{"paper_id":"d7b9ffd2-d17e-45d8-9bf8-be2cd853302f","body_text":"Many diets for many people: planetary health diets and their health and environmental impacts at global, regional, national, and demographic levels | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Social Sciences - Article Many diets for many people: planetary health diets and their health and environmental impacts at global, regional, national, and demographic levels Marco Springmann, Olivia Auclair, Sumati Bajaj, Thomas Burke, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6474232/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract Without dietary changes towards healthier and more sustainable diets, there is little chance of addressing the growing burden of non-communicable diseases, avoiding dangerous levels of climate change, and staying within key planetary boundaries that define a safe operating space for humanity. Global reference values for healthy and sustainable eating exist, but consistent adaptations to local contexts are limited, which impacts food-related planning and decision-making. Here we develop a diverse set of “planetary health diets” that are adapted to the nutritional needs and preferences of populations at global, regional, national, and demographic levels. The set includes distinct dietary patterns (flexitarian, pescatarian, vegetarian, vegan) that differ across countries, age groups, and sexes. Using impact assessments, we show that adoption of these diets would be associated with substantial improvements in nutritional adequacy and simultaneous reductions in diet-related mortality and environmental resource demand, in each case across a wide range of regional and demographic scales. Our findings also indicate large differences to current diets, suggesting the need for dedicated initiatives and support for dietary change. We integrated the estimates of food intake and the associated impacts into interactive analysis tools to facilitate dietary planning and decision-making across dietary preferences at regional and demographic levels. Scientific community and society/Social sciences/Interdisciplinary studies Earth and environmental sciences/Environmental sciences/Environmental impact Health sciences/Risk factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The health and environmental challenges that are posed by unhealthy and unsustainable diets, and the food system underpinning those, have emerged as key public and planetary health concerns 1,2 . Unhealthy diets are a leading risk factor for non-communicable diseases (NCDs), responsible for one in five deaths globally 3,4 . The food systems producing those diets are major drivers of environmental resource use and pollution, including climate change, land use and biodiversity loss, and water use and pollution 2,5,6 . Without dietary changes towards healthier and more sustainable diets, there is little chance of addressing the growing burden of NCDs, avoiding dangerous levels of climate change, and staying within key planetary boundaries that define a safe operating space for humanity 7 . Despite general agreement on the importance of dietary change, a clear and comprehensive description is lacking of how healthy and sustainable diets can look like at various scales, including at country and population levels 2 . Although dietary guidelines exist for some countries, many of them have been found to be inconsistent with global health and environmental targets, often due to vague recommendations for foods important for public and planetary health 8 . In response, a set of global recommendations for a “planetary health diet” has been developed to be both healthy and sustainable 2 , but their global scope has raised issues of adaptability to national circumstances and preferences, as well as their nutritional suitability for all segments of society 9 , especially as their main illustration was for the energy needs of a specific population group 2 . Here we develop a diverse and nutritionally balanced set of options of healthy and sustainable dietary patterns for all countries and population groups within those. Our analysis – undertaken as part of the (second) EAT-Lancet Commission on Healthy, Sustainable, and Just Food Systems 10 – expands the planetary health diet into four distinct and compatible dietary patterns to provide additional choice whilst combining nutritional adequacy at the population level with environmental sustainability at the global level. The dietary patterns include flexitarian diets with low to moderate amounts of animal source foods, pescatarian diets which include seafood but no other meat, vegetarian diets which include dairy and eggs but no meat or fish, and vegan diets which do not include any animal source foods. For each dietary pattern, we developed specific dietary options that are adapted to the demographic (age and sex) groups within each country based on nutritional needs and dietary preferences. To further characterise the dietary patterns and to inform decision making on dietary change, we estimated the health and environmental impacts of adopting the different dietary patterns across scales. We quantified impacts on nutritional adequacy, dietary risks and mortality, and environmental resource use and pollution. Our analysis advances the characterisation of healthy and sustainable diets by substantially expanding the level of regional, demographic, and dietary detail and by improving methods for assessing their impacts. This includes using a biophysically grounded proxy for food intake in developing the dietary patterns, estimating the nutritional adequacy of populations across regions and demographic groups, quantifying the burden of dietary risks related to both composition and overall intake, and tracking food-related environmental impacts consistently across the food system and environmental domains. To ease the use of our analysis in the planning of dietary policies and food-related initiatives by various actors and at different scales, we compiled a set of supplementary datafiles that contain the full details and estimated impacts of all dietary patterns for each country (184 in total) and population group (up to 22 age groups, 5 age classes, and 2 sexes). The assessment tools, data, and results will be also made available as part of the World Health Organization’s Dietary Impact Assessment (DIA) model 11 , version 2.0. Healthy and sustainable dietary patterns We based the development of healthy and sustainable dietary patterns on a comprehensive review of the scientific evidence on healthy eating conducted as part of the first and second EAT-Lancet Commissions on Healthy Diets from Sustainable and Just Food Systems 2,10 . Reference values identified to be in line with optimal health outcomes in adults include a balanced energy intake and at least five servings of vegetables and fruits per day, one to two servings of legumes and nuts per day each, a preference for whole grains over refined grains, and for oils high in unsaturated fatty acids over those high in saturated fats and animal fats, up to one serving of red meat per week, two servings of poultry, fish, and eggs per week each, and one serving of dairy and starchy roots per day each. The reference values are compatible with several dietary patterns, including flexitarian diets with low to moderate levels of animal source foods, pescatarian diets which include seafood but no other meat, vegetarian diets which include dairy and eggs but no meat or fish, and vegan diets which do not include any animal source foods. Starting with flexitarian diets, we developed population-specific diets by following several steps ( Methods ). First, we implemented the reference values as ceilings and floors (Fig. 1A), which ensured that populations whose intake already fulfilled the recommendations were not penalised from reductions in encouraged foods or increases in discouraged ones. For a sensitivity analysis, we also implemented the reference values without adjustment. Second, we further regionalised the diets by preserving the dietary preferences within general food groups, e.g. of the types of grains, red meat, fish, and fruits. Third, we adjusted first grain intake and then oil intake to fulfil the recommended energy intake of adults across countries and regions, and we scaled overall food intake to fulfil the recommended energy intake across sexes and age groups (Fig. 1B). For a sensitivity analysis, we used only grain intake for balancing energy intake. Fourth, we generated the full set of dietary patterns by replacing either meat (pescatarian), meat and fish (vegetarian), or all animal source foods (vegan) with a mix of fruits, vegetables, and legumes, informed by observed patterns of substitution in specialised dietary patterns 12 . Lastly, we balanced the intake of micronutrients for each population group by adjusting the intake of nutrition-sensitive foods within general food groups (e.g., of green-leafy vegetables and soybeans for iron, and including a small portion of algae for B vitamins 13 ). The set of dietary patterns differ across regions and population groups (Fig. 2, Fig S3). For example, flexitarian diets in North America contained mostly wheat as grains (70%), beef as red meat (55%), and shellfish as seafood (40%), whereas diets in East Asia contained mostly rice as grain (70%), pork as red meat (70%), and freshwater fish as seafood (40%). Across age groups, the diets (flexitarian and others) of children contained 45% less calories as the population average and consequently less servings of foods (e.g., 3.5 servings of grains per person per day (servings/d) compared to 6), whereas those of adults contained about 10% more calories and foods (e.g., 7 servings/d of grains). Across sexes, the diets of women contained 10% less calories as the average (e.g., 5.5 servings/d of grains), whereas the diets of men contained 10% more calories (e.g., 7 servings/d of grains). Compared to flexitarian diets, pescatarian, vegetarian, and vegan diets contained gradually lower amounts of animal source foods, but also gradually more fruits and vegetables (+ 10–30%, or 6.5-8 servings/d compared to 6) and more legumes (+ 10–50%, or up to 2 servings/d compared to 1.5). Difference to current intake The dietary patterns differ substantially from current dietary intake (Fig. 2, Fig S6). On average, they contain larger amounts of fruits (+ 40–80% across the dietary patterns, ranging from flexitarian diets to vegan ones), vegetables (+ 70–120%), legumes (+ 230–380%), nuts and seeds (+ 270%), and vegetable oils (+ 75%), and lower amounts of beef and lamb (-70-100%), pork (-80-100%), poultry (-35-100%), dairy (-40-100%), eggs (-55-100%), fish (-35-100%), oils high in saturated fat (-45%), sugar (-50%), roots (-70%), and grains (-20%). The changes expressed in servings ranged from less than 0.5 servings/d on average for animal source foods to 2–3 for vegetables, vegetable oils, and sugar (Figs S4-S5). To describe the degree of dietary change across regions and demographic groups, we calculated the overall percentage change in the intake of all encouraged foods with minimum intake targets and that of all to-be-limited foods with maximum targets. Across regions and for the example of flexitarian diets (Figs S7-S8), the overall percentage change in encouraged foods ranged from 45% in East Asia (primarily driven by whole grains) to 145% in Sub-Saharan Africa (driven by both vegetables and whole grains). The change in to-be-limited foods ranged from 30% in South Asia (driven by refined grains) to 50% in North America (driven by milk). Across demographic groups, the absolute changes in intake were generally larger in groups with higher energy needs such as men and adults, whereas the proportional changes were often larger in groups with lower energy needs such as children. Nutritional impacts The dietary patterns are associated with improvements in nutritional balances (Fig. 3A, Fig S9). On average, they increased mineral intake, including calcium (+ 10–30%), iron (+ 40–70%), and zinc (+ 10–20%), in each case primarily driven by more vegetables and legumes. They also increased the intake of most vitamins, including vitamin C (+ 70–110%) and vitamin A (+ 230–290%), again driven by vegetables; and vitamin B12 (+ 110–180%), driven by algae rich in B12 (with some varieties of tempeh, i.e., fermented soybeans as another plant-based alternative 13 ). In addition, macronutrient composition improved due to greater intake of protein (+ 5%), fibre (+ 70–110%), and poly-unsaturated fatty acids (+ 90–100%), and lower intake of carbohydrates (-15-25%) and saturated fat (-10-40%). By construction, the dietary patterns meet the nutritional requirements of each population group and attained full nutrient adequacy scores across regions, age groups, and sexes (Figs S10-S11). We calculated the adequacy scores by averaging nutrient adequacy ratios (i.e., the ratio between estimated and recommended intake capped at one) of nutrients with recommendations to avoid deficiency ( Methods ). According to our estimates (Fig. 3A), the dietary patterns increased average nutrient adequacy by 6% globally, which was driven by improving low intakes of riboflavin, iodine, and iron, followed by vitamins C, A, B12, as well as folate and zinc. Across regions, the average improvements in nutrient adequacy ranged from 4% in East Asia to 12% in Sub-Saharan Africa where current adequacy of vitamin B12 is particularly low. Across demographic groups, they ranged from 5% in men to 8% in women who have greater iron needs and current deficiencies, and from 5% in young adults to 8% in senior adults who have greater current deficiencies in vitamin C. Health impacts The dietary patterns are associated with reductions in diet-related disease risk and mortality across regions and population groups (Fig. 3B). For our assessment of long-term health impacts, we conducted a comparative risk assessment of diet and weight-related risks based on cause-specific mortality rates and established risk-disease relationships ( Methods ). According to our analysis, the dietary patterns are associated with reductions in mortality of 18–20%, corresponding to 10–11 million avoided deaths globally (Fig S12). Most of the reductions in mortality were from coronary heart diseases (45%), followed by cancer (30%), type-2 diabetes (5%), and respiratory disease (5%), with similar contributions from improvements in risks related to dietary composition and risks related overall food intake and energy imbalances that affect weight levels (Fig S13). The health impacts differed by dietary pattern, region, and demographic groups (Fig. 3B, Fig S14). Across diets, the reductions in mortality ranged from 18% for flexitarian diets to 20% in vegan diets which contained relatively more foods associated with reductions in disease risk (vegetables, fruits, and legumes), and less foods associated with increased risks (red and processed meat). Across regions and for the example of flexitarian diets, the reductions ranged from 10–11% in Sub-Saharan Africa which has a relatively young population and lower incidence of diet-related NCDs to 24–27% in Europe and Central Asia which has an older population and high incidence of NCDs. Across demographic groups, the reductions were similar in women (18–20%) and men (18–19%), by they ranged from 6–7% in young adults to 20–21% in senior adults who have higher mortality rates. Environmental pressures and impacts The dietary patterns are associated with less environmental resource use and pollution (Fig. 3C, Fig S15). For assessing the environmental impacts, we estimated changes in total food demand associated with the diet scenarios and then paired those for each food commodity with a set of trade-adjusted and regionalised environmental footprints ( Methods ). According to our analysis, the dietary patterns are associated with changes in food demand that would reduce global food-related GHG emissions by 30–50% (5–8 GtCO 2 eq), land use by 45–70% (20–35 Mkm 2 ), including cropland use by 2–10% (0.5–1.5 Mkm 2 ), as well as water use by 25–35% (850-1,100 km 3 ), and eutrophication potential by 35–55% (25–40 MtPO 3 4− eq). The reductions in most domains were primarily driven by less intake and production of animal source foods (Figs S16-S17). As a consequence, the environmental impacts were lowest in the more plant-based dietary patterns. To provide an overview of impacts across populations (Fig. 3C), we averaged the percentage changes in each domain, weighted by the importance of dietary change for mitigation in that domain ( Methods ) 7 . Across dietary patterns, the weighted reductions in environmental impacts ranged from 35% for flexitarian diets which contain moderate amounts of animal source foods to 50% for vegan diets which contain no animal sourced foods. Across regions and for the example of flexitarian diets, reductions ranged from 10% in South Asia to 50% in both North America and Latin America where diets are relatively high in animal source foods. Across age groups, reductions ranged from 25% in children who have less overall food intake to 40% in senior adults whose diets contain relatively high amounts of animal source foods, especially in low and middle-income countries. Across sexes, reductions were comparable (33–35%) but moderately less in women who have a lower intake of animal source foods and a lower overall food intake than men. The regional and demographic trends for the other dietary patterns were comparable (SI Datafiles). Sensitivity analysis In developing the dietary patterns, we implemented the reference values of healthy intake as ceilings and floors, which ensured that populations whose intake already fulfilled the recommendations were not penalised. However, there are alternative perspectives on adopting the reference values, including allowing increases in discouraged foods (e.g., of meat and dairy) up to the ceiling to not penalise potentially increasing preference for such foods, as well as a strict adherence of both floors and ceilings (especially for flexitarian diets) to provide more distinct variants of dietary patterns. In a sensitivity analysis (Fig. 4), we assessed the implications of a strict adherence to the reference values of healthy intake (Fig. 1A), which also included using grain intake for energy balance. Flexitarian diets with strict adherence contained lower amounts of previously encouraged foods (e.g., 25% less vegetables) and more of previously discouraged foods (e.g., 75% more milk, 55% more poultry and fish, and 25% more red meat). As a result, the environmental benefits decreased by 14%, but the health benefits remained comparable with small reductions (-4%). The dietary patterns were developed based on the recommended energy and food intake of populations at current levels of physical activity. However, about a third of all adults and four fifth of adolescents do not meet global health recommendations of engaging in at least moderate levels of physical activity 14,15 , something that results in increased disease burden and costs 16,17 . Ideally, dietary changes towards healthier and more sustainable dietary patterns would be accompanied by efforts to increase physical activity. In a second sensitivity analysis (Fig. 4), we therefore developed diets that accommodate the additional energy needs of meeting the World Health Organization’s recommendations on physical activity 18 . On average, an additional energy intake of 100 kcal/d was required in those diets, which could be met by, e.g., increasing the intake of whole grains and vegetable oils by a quarter to half a serving per day each. The changes in intake had no substantial impacts on the health and environment benefits identified previously (+ 2% and − 5% respectively). In a final sensitivity analysis (Fig. 4), we quantified the implications of adopting dietary recommendations developed for a different population group. We based this analysis on a common misinterpretation of the EAT-Lancet reference values, which were expressed for an energy intake of 2500 kcal/d for illustration. Although this level of intake only corresponds to the energy needs of specific population groups such as middle-aged men or physically active young adults, it has often been used as the target for energy intake of the total population 19,20 . Using 2500 kcal/d diets for all population groups increased national energy intake by 20% (400 kcal/d) on average in our sensitivity analysis. In addition, it increased the intake of some encouraged foods such as fruits and nuts by 10–15%, as well as the intake of discouraged foods such as red meat and milk by 45–110%. These changes resulted in about a third less health benefits, primarily due to less reductions in overweight and obesity, as well as a halving of the environmental benefits, primarily due to the higher intake of animal source foods. Discussion Dietary changes towards healthier and more sustainable diets across all regions and population groups are necessary for addressing major health and environmental challenges, including limiting global warming, meeting the Sustainable Development Goals related to environmental resource use and pollution, and tackling the ongoing obesity and NCD pandemics 1,2,4–6 . Here we developed a set of planetary health diets that are adapted to different regions and demographic groups which can be used to inform dietary transitions across scales and actors. By construction, the dietary patterns are nutritionally adequate and in line with food-related planetary boundaries 2,7 . Our analysis indicates that their adoption would also be associated with substantial reductions in diet-related disease risk and mortality, and in environmental resource use and pollution, in each case across a wide range of regional and demographic scales. Our findings show that there are many diets that are both healthy and sustainable, and that healthy and sustainable diets differ by region and demographic group. Providing dietary options that are tailored to the dietary preferences and nutritional requirements of different population groups can help in devising concrete pathways of dietary change, including in policy planning, civil-society initiatives, business approaches, and personal behaviour change. Explicitly including the variety of healthy and sustainable dietary patterns in such pathways allows for agency in dietary choice which increases the likelihood of adoption 21 . Variety of choice could for example be facilitated by a “common core” approach in which the dietary components common to each dietary pattern (e.g., whole grain, vegetables, legumes, nuts, fruits) are provided as a non-exclusionary default, and foods specific to a dietary pattern become an optional choice in proportion dietary reference values. The set of healthy and sustainable diets we developed are also relevant for further research. For example, including the set of dietary patterns in impact assessments can help analyse the range of mitigation options more fully than a focus on one variant, something that is supported by the substantially lower environmental impacts we identified for vegan diets compared to flexitarian ones, at similar health and nutritional benefits. The grounding of the set of diets in the nutritional and energy needs of population groups ensures biophysical consistency when using them in dietary impact assessments. This contrasts with many previous analyses that were based on misapplying the dietary reference values of a specific population group (with energy requirements of 2500 kcal/d) to the whole population 19,20 . Our analysis suggests this could have resulted in substantial deviations in quantified impacts. We hope the dietary options we developed will facilitate more biophysically grounded research on health, environmental, and social aspects not covered here 22,23 . Our findings show that current diets differ substantially from the set of healthy and sustainable dietary patterns developed here. Dietary choices are seldomly made based on the health and environmental considerations that form the basis of our analysis. Instead, they are known to be influenced by the availability, prices, tastes, and habits embodied in both local and global food environments. As such, multi-component approaches would be necessary to encourage and enable dietary changes towards healthier and more sustainable dietary patterns 24,25 . They can include informational approaches (e.g., food labelling and reforms of dietary guidelines 8 ), but are thought to also require regulatory approaches, including fiscal incentives (e.g., reform of agricultural subsidies 26 and adjusting the pricing of foods according to their health or environmental impacts 27–29 ), as well as gustatory approaches, including menu and meal reformulations, so that healthy and sustainable dietary options are not only encouraged, but also available, affordable, and desirable. Our study advances the literature in several ways but is also subject to caveats. First, by developing dietary scenarios by country and population group, we explicitly accounted for regional and demographic differences in energy needs and food-group recommendations, which goes beyond assessments based on national averages 30 . We used a new and improved proxy of dietary intake, but the existing estimates of food intake with global coverage that we used for its construction have large uncertainties. They include misreporting in dietary surveys and outdated data on the amount of nationally available food that is wasted 31,32 . We used a triangulation method that normalised food intake to those levels of energy intake that are required to sustain measured levels of body weight, height, and physical activity levels in each population group 33 . Whilst this is an improvement on previous approaches, it comes with its own sources of uncertainty, including those related to anthropometric measures. Second, by coupling the construction of dietary scenarios with a nutritional assessment, we ensured that all dietary patterns attained nutritional adequacy in each population group (including in women and children), something previous country-level analyses were not able to demonstrate 30 . We improved current methods in nutritional analyses by regionalising nutritional recommendations to the demographic and weight distribution of each population group instead of applying reference weights from high-income countries. In addition, we included complementary food sources of nutrients such as vitamin B12 that are especially relevant in predominantly plant-based dietary patterns. Plant-based sources of bioavailable B12 include certain algae and fermented soybeans (tempeh) 13,34 . Algae can be grown and harvested in most coastal regions, and soybeans are a widely traded commodity, but regular intake is limited to East Asia. Targeted regulatory, business, and behavioural initiatives might be needed to increase regular consumption in other regions. Third, by including both scale and composition-related risks in our analysis of long-term health, we were able to provide a more comprehensive attribution of the diet-related disease burden than most current assessments 3 . Compared to other assessments, we only included non-overlapping and food-based dietary risks, used independently derived risk-disease associations whose quality of evidence in meta-analyses have been graded as moderate to high 35–37 , and omitted composition-related risk factors that showed high regional variability (e.g., fish) or became non-significant in fully adjusted models (e.g., milk). However, despite our conservative approach to disease attribution, residual confounding with unaccounted risk factors cannot be ruled out in the epidemiological studies that derived the disease-risk associations 38 . Fourth, by pairing regional environmental footprints with current statistics of the global food system, we were able to provide estimates of the potential environmental impacts of dietary change without making additional economic assumption (e.g., related to prices), which we think are a matter of policy. This complements analyses of existing food system models whose baseline data can be several decades old and who therefore rely on (less certain) economic projections and modelling for their estimates 39–41 . These models are based on specific behavioural economic assumptions and have a fixed regional focus which make the estimated supply and demand relationships not representative of other contexts. In contrast, our estimates can be used across scales to scope the dietary option space and related impacts, but our analysis does not resolve potential policies or pathways that would result in those changes. Identifying if and with what combination of measures large-scale dietary change can be achieved is still an active area of research 25,42,43 . Some businesses and interest groups have been promoting the adoption of meat and milk alternatives as practical solutions for reducing especially the environmental footprints of diets 44–46 . However, from environmental, health, and cost perspectives, they generally perform worse than the unprocessed plant-based foods the EAT-Lancet Commissions and other dietary guidelines recommend for regular intake 47 . We therefore did not include them in our set of diets and the related assessments. However, increasing the uptake of less marketable whole foods will likely require a shift in business approaches away from the promotion of single products towards more service and meal-oriented approaches, and an alignment of policy support, including public and private investments into healthy and sustainable meals and diets. Our analysis implies that this might be worthwhile as the health and environmental benefits of such structural changes in diets would be substantial across all geographical scales and population groups. Declarations Acknowledgements MSp, SC, and JR acknowledge funding from Wellcome Trust through a Career Development Award (Award number: 225318/Z/22/Z). MSp and OA acknowledge funding from the EU Horizon Programme through the CATALYSE project (Grant agreement number: 101057131). MSp and DH acknowledge funding from the EU Horizon Programme through the BrightSpace project (Grant agreement number: 101060075). SB acknowledges funding through an EAT-Lancet research fellowship funded by the IKEA Foundation and the Novo Nordisk Foundation. TB acknowledges funding from Germany Federal Ministry of Education and Research (BMBF) through the WeAreOne project. MSc acknowledge funding from the EU Horizon Programme through the ACT4CAP project (Grant agreement number: 101134874). All authors acknowledge helpful discussions with other members of the second EAT-Lancet Commission on Healthy Diets from Sustainable and Just Food Systems. Contributions MSp designed the study, conducted the analysis, and wrote the manuscript. All authors provided inputs to the analysis, commented on the manuscript, and approved the submission. 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Micha, R., Coates, J., Leclercq, C., Charrondiere, U. R. & Mozaffarian, D. Global Dietary Surveillance: Data Gaps and Challenges. Food Nutr Bull 39 , 175–205 (2018). Burrows, T. L., Ho, Y. Y., Rollo, M. E. & Collins, C. E. Validity of Dietary Assessment Methods When Compared to the Method of Doubly Labeled Water: A Systematic Review in Adults. Front Endocrinol 10 , 850 (2019). Springmann, M. Estimates of energy intake, requirements, and imbalances based on anthropometric measurements at global, regional, and national levels and for sociodemographic groups. BMJ Public Health (under review). Ahnan-Winarno, A. D., Cordeiro, L., Winarno, F. G., Gibbons, J. & Xiao, H. Tempeh: A semicentennial review on its health benefits, fermentation, safety, processing, sustainability, and affordability. Comprehensive Reviews in Food Science and Food Safety 20 , 1717–1767 (2021). Bechthold, A. et al. Food groups and risk of coronary heart disease, stroke and heart failure: A systematic review and dose-response meta-analysis of prospective studies. Critical Reviews in Food Science and Nutrition 59 , 1071–1090 (2019). Schwingshackl, L. et al. Food groups and risk of type 2 diabetes mellitus: a systematic review and meta-analysis of prospective studies. European Journal of Epidemiology 32 , 363–375 (2017). Schwingshackl, L. et al. Food groups and risk of colorectal cancer. International Journal of Cancer 142 , 1748–1758 (2018). Satija, A., Yu, E., Willett, W. C. & Hu, F. B. Understanding Nutritional Epidemiology and Its Role in Policy. Advances in Nutrition 6 , 5–18 (2015). Valin, H. et al. The future of food demand: understanding differences in global economic models. Agricultural Economics 45 , 51–67 (2014). Robinson, S. et al. Comparing supply-side specifications in models of global agriculture and the food system. Agricultural Economics 45 , 21–35 (2014). von Lampe, M. et al. Why do global long-term scenarios for agriculture differ? An overview of the AgMIP Global Economic Model Intercomparison. Agricultural Economics 45 , 3–20 (2014). Afshin, A. et al. The prospective impact of food pricing on improving dietary consumption: A systematic review and meta-analysis. PLOS ONE 12 , e0172277 (2017). Andreyeva, T., Marple, K., Moore, T. E. & Powell, L. M. Evaluation of Economic and Health Outcomes Associated With Food Taxes and Subsidies: A Systematic Review and Meta-analysis. JAMA Network Open 5 , e2214371 (2022). Mylan, J., Andrews, J. & Maye, D. The big business of sustainable food production and consumption: Exploring the transition to alternative proteins. Proceedings of the National Academy of Sciences 120 , e2207782120 (2023). Rubio, N. R., Xiang, N. & Kaplan, D. L. Plant-based and cell-based approaches to meat production. Nat Commun 11 , 6276 (2020). Sexton, A. E., Garnett, T. & Lorimer, J. Framing the future of food: The contested promises of alternative proteins. Environment and Planning E: Nature and Space 2 , 47–72 (2019). Springmann, M. A multicriteria analysis of meat and milk alternatives from nutritional, health, environmental, and cost perspectives. Proceedings of the National Academy of Sciences 121 , e2319010121 (2024). Methods Development of planetary health diets We constructed the dietary patterns by adjusting current intake to meet minimum and maximum recommended values for healthy eating. Estimates of current intake were derived by combining estimates of food composition from waste-adjusted food availability data 48,49 with demographic trends in intake from dietary surveys 50 , and normalised to estimates of total energy intake required to sustain measured levels of body weight, height, and physical activity 33 . The estimates capture complete diets aggregated into 36 primary foods and 7 processed foods for 184 countries, 22 age groups in five-year intervals, and two sexes (Table S1, SI section S1). They are regionally and demographically comparable and follow observed trends in over and underconsumption (Fig. 1B). For this study, we aggregated the dietary resolution to 24 food commodities to align with the detail of dietary recommendations, and we summarised the demographic detail to ten groups for presentational purposes (whilst keeping the full detail in our computations). The values of recommended intake were based on a comprehensive review of the literature on healthy eating conducted by the EAT-Lancet Commissions on Healthy Diets from Sustainable and Just Food Systems, which is available in the EAT-Lancet reports 2,10 . The reference values describe healthy food intake for physically active adults, which can be interpreted as minimum and maximum recommendations that allow for a variety of dietary patterns (Fig. 1A). Starting with flexitarian diets, we adjusted current intake amongst adults to meet both minimum and maximum recommendations, without reducing intake if it was above minimum values (e.g., for fruits and vegetables) or increasing intake if it was below maximum values (e.g., for red meat and sugar). We preserved regional preferences of specific types of foods within the general categories of grains, red meat, fish, and fruits by using the current distribution of intake within those categories (Table S1). We then adjusted energy intake in adults to those energy requirements that are in line with healthy body weights by changing grain and oil intake (whose recommended values were also initially determined by energy and macronutrient balances). Estimates of healthy body weights by country and population group (Fig. 1B) were derived by using predictive equations for estimating energy requirements for healthy body weights that minimise mortality risk at current levels of body heights and physical activity 33 . For attaining energy balance, we first adjusted grain intake but switched to oils when grain intake exceeded maximum recommendations (six servings per day, 270 g/d), whilst ensuring oil intake stayed within the range recommended for macronutrient balance (40–80 g/d). We constructed diets for other and more specific age groups (at five-year intervals) by scaling food intake by recommended energy intake in that age group. We developed the full set of dietary patterns by substitution. We replaced either meat (pescatarian), meat and fish (vegetarian), or all animal source foods (vegan) with a mix of fruits and vegetables and of legumes and fish (pescatarian diets), or with a mix of fruits and vegetables and legumes (vegetarian and vegan diets). The pattern of substitution was based on dietary recommendations and observed patterns of substitution in specialised dietary patterns 12 . The mix of fruits and vegetables constituted one third of replaced calories in each case, and the mix of legumes and fish in pescatarian diets was determined based on increasing fish intake up to its recommended value (Fig. 1A) and increasing legumes thereafter. In a final adjustment, we balanced the intake of micronutrients for each population group by adjusting the composition of nutrient-rich foods within general food groups (e.g., increasing green-leafy vegetables and soybeans within vegetables and legumes for increasing iron intake), and of adding a plant-based source of vitamin B12. For the latter, we used a small serving of algae with bioavailable B12 13 , but note that other options exist, including certain types of tempeh (i.e., fermented soybeans), a range of fortified foods (e.g., soymilks and nutritional yeast), as well as targeted nutrient supplementation, each associated with different food-system implications. For comprehensively describing the set of planetary health diets, we used several metrics of food intake. They included intake in weight (grams per person per day), energy content (kilocalories per person per day), and servings (servings per person per day) which were based on amounts customarily consumed (Fig. 1A). We also assessed the sensitivity of impacts on the content and construction of the diets. For the sensitivity analyses, we developed and assessed dietary variants with strict adherence to the reference values (i.e., without allowing overfulfilling recommendations), and with levels of energy intake that are in line with meeting recommendations for physical activity (instead of using current activity levels). Nutritional assessment We assessed the nutrient adequacy of the dietary patterns by estimating nutrient intake and requirements by region and population group. For estimating nutrient intake, we paired food intake in the different diets with the nutrient densities of foods. We sourced most nutrient densities from the Global Expanded Nutrient Supply (GENuS) model 51 , and supplemented them for nutrients and food groups not comprehensively covered by GENuS (e.g., B12 and phytate) by estimates from the Harvard Nutrient Database and specialised food composition tables 52 . To estimate nutrient requirements, we used a set of harmonised nutrient reference values that specify the average nutrient requirements of populations by age and sex 53 , paired those with detailed population estimates from the United Nations Population Division 54 , and adjusted the specified reference weights to the average body weight of each population group in each country 55 . We accounted for changes in the bioavailability of zinc and iron by using established dependencies with dietary modulators (e.g., phytate) 56–58 . In addition to estimating changes in nutrient intake, we combined the estimates of intake with nutrient requirements to calculate nutrient adequacy scores 59 . For each nutrient with an estimated average requirement (EAR) related to adequacy, we calculated nutrient adequacy ratios by dividing estimated intake by recommended intake capped at one, so that a NAR of one represents full adequacy for a population group on average. We then summed all NARs and divided by the number of deficiency-related nutrients to calculate overall nutrient adequacy scores (mean adequacy ratios). This calculation included 14 out of the 26 nutrients we assessed intake of because not all nutrients had requirements established in relation to adequacy (Table S2 and SI section S2). Nutrients without adequacy-related EARs included most macronutrients (carbohydrates, fatty acids, and fibre) except for protein, as well as calcium, copper, magnesium, and pantothenate whose EARs were determined by balance studies and observed intake in high-income countries 60,61 . Comparative risk assessment We assessed the impacts on dietary risks and mortality of the adopting the dietary patterns by using a comparative risk assessment framework with eight diet and weight-related risk factors and five disease endpoints 8 . For parameterizing the comparative risk assessment, we used data on cause-specific mortality from the Global Burden of Disease project 62 , body weight from the NCD Risk Factor Collaboration 55 , and relative risk estimates that relate change in risk factors to changes in disease mortality from meta-analyses of epidemiological cohort studies (Table S3). We focused on adults aged 20 year or older in our assessment due to low mortality rates of NCDs in younger age groups, and we adjusted the relative risks for attenuation with age based on a pooled analysis of cohort studies focussed on metabolic risk factors in line with other studies 63 . The selection of risk-disease associations was supported by available criteria used to judge the certainty of evidence (Table S4). They were graded as moderate or high with NutriGrade 35–37 , and assessed as probable or convincing by the Nutrition and Chronic Diseases Expert Group (NutriCoDe) 64 , and by the World Cancer Research 65 . For each risk factor, we constrained the maximum attainable risk reduction to minimal risk exposure values established by NutriCoDe and available meta-analyses (SI section S3). We differentiated between composition and weight-related risks in our main analysis. As weight-related risks are associated with imbalanced energy intake, we also conducted a sensitivity analysis in which we attributed weight-related risks to the over and underconsumption of foods (measured in kcal/d) relative to their dietary reference values (Fig. 1A). Environmental assessment For calculating environmental impacts, we first converted the estimates of dietary intake to total food demand, and then paired the demand estimates with a set of trade-adjusted and regionalised environmental footprints. To calculate total food demand, we added estimates of food waste to the estimates of dietary intake, and then multiplied the per-person values by the population in the specific demographic group 54 . Waste estimates of specific foods were based on estimates of the Food and Agriculture Organization of the United Nations (FAO) 49 and harmonised to the difference between total calorie intake (derived from anthropometric measures 33 as used in our estimates of intake, Table S1) and total calorie demand (as reported by the FAO 48 ). This harmonisation accounts for changes in waste fractions from their initial year of analysis and ensures total food demand in the baseline matches the values reported by the FAO. The environmental footprints were obtained from a comprehensive meta-analysis of life cycle assessments (LCAs) of 40 foods produced by 38,700 farms in 119 countries, covering GHG emissions, land use, freshwater use, and soil and water pollution as measured by eutrophication potential. The LCAs were standardised by harmonising system boundaries (from inputs to retail) and gap-filling missing steps along the supply chain, which made use of auxiliary estimates (e.g., of post-farm processes) and dedicated process-based models (e.g., of nitrate leaching). FAO data on food production and yields were used to scale and regionalise estimates 48 , and FAO data on trade were used to derive consumption-based footprints by commodity and region (Table S5, SI section S4). In addition to reporting changes in environmental impacts for each domain, we also calculated an overall indicator of food-related environmental impacts. Because the importance of diets and dietary changes for reducing environmental impacts varies for each domain, we used a weighing scheme that accounts for that, with weights assigned based on the needed contribution of dietary changes for staying within food-related environmental limits (or planetary boundaries) while also considering contributions from other food-system measures, including changes in technologies and management practices, food loss and waste, and socio-economic development (Fig S1) 7 . This meant weighing the changes in GHG emissions relatively more (46%) than changes in eutrophication potential (30%), and land and water use (12% each) (SI section S4). Using simple averages resulted in the same ordering across dietary patterns, regions, and demographic groups, and we included those and the detailed set of estimated impacts in the SI Datafiles. Data Availability All results produced in this study will be made available as Supplementary Datafiles and uploaded to a public repository. Code availability The code used in this study will be made available on GitHub and as part of the second version of the World Health Organization’s Dietary Impact Assessment (DIA) model 11 . Methods references Food and Agriculture Organization of the United Nations. FAOSTAT Statistical Database . (2022). Gustavsson, J., Cederberg, C., Sonesson, U., Van Otterdijk, R. & Meybeck, A. Global Food Losses and Food Waste: Extent, Causes and Prevention . (FAO Rome, 2011). Miller, V. et al. Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide. BMJ Global Health 6 , e003585 (2021). Smith, M. R., Micha, R., Golden, C. D., Mozaffarian, D. & Myers, S. S. Global expanded nutrient supply (GENuS) model: a new method for estimating the global dietary supply of nutrients. PLOS ONE 11 , e0146976 (2016). Wessells, K. R., Singh, G. M. & Brown, K. H. Estimating the Global Prevalence of Inadequate Zinc Intake from National Food Balance Sheets: Effects of Methodological Assumptions. PLOS ONE 7 , e50565 (2012). Allen, L. H., Carriquiry, A. L. & Murphy, S. P. Perspective: Proposed Harmonized Nutrient Reference Values for Populations. Advances in Nutrition 11 , 469–483 (2020). United Nations Department of Economic and Social Affairs, Population Division. World Population Prospects 2024: Data Sources . https://population.un.org/wpp/assets/Files/WPP2024_Data_Sources.pdf (2024). NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. Lancet 403 , 1027–1050 (2024). Miller, L. V., Krebs, N. F. & Hambidge, K. M. A mathematical model of zinc absorption in humans as a function of dietary zinc and phytate. J Nutr 137 , 135–141 (2007). Hambidge, K. M., Miller, L. V., Westcott, J. E., Sheng, X. & Krebs, N. F. Zinc bioavailability and homeostasis. Am J Clin Nutr 91 , 1478S-1483S (2010). Armah, S. M., Carriquiry, A., Sullivan, D., Cook, J. D. & Reddy, M. B. A complete diet-based algorithm for predicting nonheme iron absorption in adults. J Nutr 143 , 1136–1140 (2013). Tufts University. Data4Diets: Building Blocks for Diet-related Food Security Analysis, Version 2.0. (2023). Bajaj, S. & Springmann, M. A review of the quality of evidence of nutrient reference values. Lancet Planetary Health (under review). European Food Safety Authority (EFSA). Dietary Reference Values for nutrients Summary report. EFS3 14 , (2017). GBD 2021 Causes of Death Collaborators. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 403 , 2100–2132 (2024). Singh, G. M. et al. The Age-Specific Quantitative Effects of Metabolic Risk Factors on Cardiovascular Diseases and Diabetes: A Pooled Analysis. PLOS ONE 8 , e65174 (2013). Micha, R. et al. Etiologic effects and optimal intakes of foods and nutrients for risk of cardiovascular diseases and diabetes: Systematic reviews and meta-analyses from the Nutrition and Chronic Diseases Expert Group (NutriCoDE). PLOS ONE 12 , e0175149 (2017). World Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: A Global Perspective. Continuous Update Project Expert Report. (2018). Additional Declarations There is NO Competing Interest. Supplementary Files manydietsSI041725.docx Additional Information Supplementary Information and Datafiles are available for this paper. Correspondence and requests for materials should be addressed to Marco Springmann ( [email protected] or [email protected] ). Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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maximum targets for dietary intake (shown for adults, \\u003cstrong\\u003eA\\u003c/strong\\u003e), estimates of current dietary intake (shown by country, \\u003cstrong\\u003eB\\u003c/strong\\u003e), and estimates of recommended energy intake (also shown by country, \\u003cstrong\\u003eC\\u003c/strong\\u003e).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/ce427a5fbba7f4a4424eea13.png\"},{\"id\":90895812,\"identity\":\"f56d3b6d-422d-4bf3-8958-a9f52b79804b\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 11:35:15\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":36822,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eVariation in planetary health diets. \\u003c/strong\\u003ePlanetary health diets vary across dietary patterns, regions, and demographic scales (\\u003cstrong\\u003eA\\u003c/strong\\u003e), in each case with substantial differences to current intake (\\u003cstrong\\u003eB\\u003c/strong\\u003e). Food intake in the different diets is expressed in kilocalories per person per day (kcal/d) and for primary commodities. Intake expressed in other measures (grams and servings) and for processed foods are reported in the Supplementary Information (Figs S3-S5). Although total grain intake decreases in most planetary health diets, whole grain intake increases (Figs S5-S6). The variation across regions, age groups, and sexes are shown for the example of flexitarian diets. The SI Datafiles contain the complete set of planetary health diets by dietary pattern, country, and demographic group.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/cc77d66c4862b15fd91fe213.png\"},{\"id\":90897422,\"identity\":\"b0e7842e-928b-4cb2-9c72-6036fd614285\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 11:43:15\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":29584,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eImpact assessment of adopting planetary health diets across scales. \\u003c/strong\\u003eThe assessments quantify changes in nutritional adequacy (\\u003cstrong\\u003eA\\u003c/strong\\u003e), mortality from diet-related diseases (\\u003cstrong\\u003eB\\u003c/strong\\u003e), and environmental resource use and pollution (\\u003cstrong\\u003eC\\u003c/strong\\u003e). The changes denote overall percentage changes compared to current impacts, and they include proportional contributions from relevant subcomponents, including nutrients (\\u003cstrong\\u003eA\\u003c/strong\\u003e), diseases (\\u003cstrong\\u003eB\\u003c/strong\\u003e), and environmental indicators (\\u003cstrong\\u003eC\\u003c/strong\\u003e). The variation across regions, age groups, and sexes are shown for the example of flexitarian diets. The\\u003cstrong\\u003e \\u003c/strong\\u003eSI Datafiles contain the complete set of planetary health diets by dietary pattern, country, and demographic group.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/3033c213ebc4707f6362d28f.png\"},{\"id\":90893998,\"identity\":\"c2f2cc1e-ba5a-43b6-ad89-c892940f4054\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 11:27:15\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":17248,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eSensitivity analysis of developing planetary health diets. \\u003c/strong\\u003eThe sensitivity analysis compares four ways of developing flexitarian dietary patterns (\\u003cstrong\\u003eA\\u003c/strong\\u003e) and the associated impacts on mortality by risk factor (\\u003cstrong\\u003eB\\u003c/strong\\u003e) and environmental resource demand by food group (\\u003cstrong\\u003eC\\u003c/strong\\u003e). They include the main variant which regionalises dietary recommendations without penalising greater than recommended intake of encouraged foods and lower than recommended intake of to-be-limited foods (\\u003cem\\u003emain\\u003c/em\\u003e), a static variant with strict adherence to the dietary reference values (\\u003cem\\u003estatic\\u003c/em\\u003e), a variant that is regionalised as the main and adapted to the energy requirements of populations that meet recommended levels of physical activity (\\u003cem\\u003eactive\\u003c/em\\u003e), and a variant that includes static adherence to the reference values and illustrates the impacts of misapplying the energy requirements of one population group with energy requirements of 2500 kcal/d to all other groups (\\u003cem\\u003eadult\\u003c/em\\u003e). The sensitivity analysis for other dietary patterns shows similar trends as flexitarian diets (Fig S19).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/b81caf950c95ec29ea5caed3.png\"},{\"id\":90897855,\"identity\":\"199a118e-0c5b-4be8-9514-1882f84f5095\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 11:51:15\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1056694,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/4736e1ca-d595-4a34-bba9-47bb3495c879.pdf\"},{\"id\":90894001,\"identity\":\"0ec4d2be-89e5-46c9-859b-fb1245fc70a8\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 11:27:15\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":3441077,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eAdditional Information\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSupplementary Information and Datafiles are available for this paper. Correspondence and requests for materials should be addressed to Marco Springmann (m.springmann@ucl.ac.uk or marco.springmann@ouce.ox.ac.uk).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"manydietsSI041725.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6474232/v1/0853905d0b2a71cf6e381a0a.docx\"}],\"financialInterests\":\"There is \\u003cb\\u003eNO\\u003c/b\\u003e Competing Interest.\",\"formattedTitle\":\"Many diets for many people: planetary health diets and their health and environmental impacts at global, regional, national, and demographic levels\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe health and environmental challenges that are posed by unhealthy and unsustainable diets, and the food system underpinning those, have emerged as key public and planetary health concerns \\u003csup\\u003e1,2\\u003c/sup\\u003e. Unhealthy diets are a leading risk factor for non-communicable diseases (NCDs), responsible for one in five deaths globally \\u003csup\\u003e3,4\\u003c/sup\\u003e. The food systems producing those diets are major drivers of environmental resource use and pollution, including climate change, land use and biodiversity loss, and water use and pollution \\u003csup\\u003e2,5,6\\u003c/sup\\u003e. Without dietary changes towards healthier and more sustainable diets, there is little chance of addressing the growing burden of NCDs, avoiding dangerous levels of climate change, and staying within key planetary boundaries that define a safe operating space for humanity \\u003csup\\u003e7\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eDespite general agreement on the importance of dietary change, a clear and comprehensive description is lacking of how healthy and sustainable diets can look like at various scales, including at country and population levels \\u003csup\\u003e2\\u003c/sup\\u003e. Although dietary guidelines exist for some countries, many of them have been found to be inconsistent with global health and environmental targets, often due to vague recommendations for foods important for public and planetary health \\u003csup\\u003e8\\u003c/sup\\u003e. In response, a set of global recommendations for a \\u0026ldquo;planetary health diet\\u0026rdquo; has been developed to be both healthy and sustainable \\u003csup\\u003e2\\u003c/sup\\u003e, but their global scope has raised issues of adaptability to national circumstances and preferences, as well as their nutritional suitability for all segments of society \\u003csup\\u003e9\\u003c/sup\\u003e, especially as their main illustration was for the energy needs of a specific population group \\u003csup\\u003e2\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eHere we develop a diverse and nutritionally balanced set of options of healthy and sustainable dietary patterns for all countries and population groups within those. Our analysis \\u0026ndash; undertaken as part of the (second) EAT-Lancet Commission on Healthy, Sustainable, and Just Food Systems \\u003csup\\u003e10\\u003c/sup\\u003e \\u0026ndash; expands the planetary health diet into four distinct and compatible dietary patterns to provide additional choice whilst combining nutritional adequacy at the population level with environmental sustainability at the global level. The dietary patterns include flexitarian diets with low to moderate amounts of animal source foods, pescatarian diets which include seafood but no other meat, vegetarian diets which include dairy and eggs but no meat or fish, and vegan diets which do not include any animal source foods. For each dietary pattern, we developed specific dietary options that are adapted to the demographic (age and sex) groups within each country based on nutritional needs and dietary preferences.\\u003c/p\\u003e\\u003cp\\u003eTo further characterise the dietary patterns and to inform decision making on dietary change, we estimated the health and environmental impacts of adopting the different dietary patterns across scales. We quantified impacts on nutritional adequacy, dietary risks and mortality, and environmental resource use and pollution. Our analysis advances the characterisation of healthy and sustainable diets by substantially expanding the level of regional, demographic, and dietary detail and by improving methods for assessing their impacts. This includes using a biophysically grounded proxy for food intake in developing the dietary patterns, estimating the nutritional adequacy of populations across regions and demographic groups, quantifying the burden of dietary risks related to both composition and overall intake, and tracking food-related environmental impacts consistently across the food system and environmental domains.\\u003c/p\\u003e\\u003cp\\u003eTo ease the use of our analysis in the planning of dietary policies and food-related initiatives by various actors and at different scales, we compiled a set of supplementary datafiles that contain the full details and estimated impacts of all dietary patterns for each country (184 in total) and population group (up to 22 age groups, 5 age classes, and 2 sexes). The assessment tools, data, and results will be also made available as part of the World Health Organization\\u0026rsquo;s Dietary Impact Assessment (DIA) model \\u003csup\\u003e11\\u003c/sup\\u003e, version 2.0.\\u003c/p\\u003e\"},{\"header\":\"Healthy and sustainable dietary patterns\",\"content\":\"\\u003cp\\u003eWe based the development of healthy and sustainable dietary patterns on a comprehensive review of the scientific evidence on healthy eating conducted as part of the first and second EAT-Lancet Commissions on Healthy Diets from Sustainable and Just Food Systems \\u003csup\\u003e2,10\\u003c/sup\\u003e. Reference values identified to be in line with optimal health outcomes in adults include a balanced energy intake and at least five servings of vegetables and fruits per day, one to two servings of legumes and nuts per day each, a preference for whole grains over refined grains, and for oils high in unsaturated fatty acids over those high in saturated fats and animal fats, up to one serving of red meat per week, two servings of poultry, fish, and eggs per week each, and one serving of dairy and starchy roots per day each. The reference values are compatible with several dietary patterns, including flexitarian diets with low to moderate levels of animal source foods, pescatarian diets which include seafood but no other meat, vegetarian diets which include dairy and eggs but no meat or fish, and vegan diets which do not include any animal source foods.\\u003c/p\\u003e\\u003cp\\u003eStarting with flexitarian diets, we developed population-specific diets by following several steps (\\u003cem\\u003eMethods\\u003c/em\\u003e). First, we implemented the reference values as ceilings and floors (Fig.\\u0026nbsp;1A), which ensured that populations whose intake already fulfilled the recommendations were not penalised from reductions in encouraged foods or increases in discouraged ones. For a sensitivity analysis, we also implemented the reference values without adjustment. Second, we further regionalised the diets by preserving the dietary preferences within general food groups, e.g. of the types of grains, red meat, fish, and fruits. Third, we adjusted first grain intake and then oil intake to fulfil the recommended energy intake of adults across countries and regions, and we scaled overall food intake to fulfil the recommended energy intake across sexes and age groups (Fig.\\u0026nbsp;1B). For a sensitivity analysis, we used only grain intake for balancing energy intake. Fourth, we generated the full set of dietary patterns by replacing either meat (pescatarian), meat and fish (vegetarian), or all animal source foods (vegan) with a mix of fruits, vegetables, and legumes, informed by observed patterns of substitution in specialised dietary patterns \\u003csup\\u003e12\\u003c/sup\\u003e. Lastly, we balanced the intake of micronutrients for each population group by adjusting the intake of nutrition-sensitive foods within general food groups (e.g., of green-leafy vegetables and soybeans for iron, and including a small portion of algae for B vitamins \\u003csup\\u003e13\\u003c/sup\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe set of dietary patterns differ across regions and population groups (Fig.\\u0026nbsp;2, Fig S3). For example, flexitarian diets in North America contained mostly wheat as grains (70%), beef as red meat (55%), and shellfish as seafood (40%), whereas diets in East Asia contained mostly rice as grain (70%), pork as red meat (70%), and freshwater fish as seafood (40%). Across age groups, the diets (flexitarian and others) of children contained 45% less calories as the population average and consequently less servings of foods (e.g., 3.5 servings of grains per person per day (servings/d) compared to 6), whereas those of adults contained about 10% more calories and foods (e.g., 7 servings/d of grains). Across sexes, the diets of women contained 10% less calories as the average (e.g., 5.5 servings/d of grains), whereas the diets of men contained 10% more calories (e.g., 7 servings/d of grains). Compared to flexitarian diets, pescatarian, vegetarian, and vegan diets contained gradually lower amounts of animal source foods, but also gradually more fruits and vegetables (+\\u0026thinsp;10\\u0026ndash;30%, or 6.5-8 servings/d compared to 6) and more legumes (+\\u0026thinsp;10\\u0026ndash;50%, or up to 2 servings/d compared to 1.5).\\u003c/p\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eDifference to current intake\\u003c/h2\\u003e\\u003cp\\u003eThe dietary patterns differ substantially from current dietary intake (Fig.\\u0026nbsp;2, Fig S6). On average, they contain larger amounts of fruits (+\\u0026thinsp;40\\u0026ndash;80% across the dietary patterns, ranging from flexitarian diets to vegan ones), vegetables (+\\u0026thinsp;70\\u0026ndash;120%), legumes (+\\u0026thinsp;230\\u0026ndash;380%), nuts and seeds (+\\u0026thinsp;270%), and vegetable oils (+\\u0026thinsp;75%), and lower amounts of beef and lamb (-70-100%), pork (-80-100%), poultry (-35-100%), dairy (-40-100%), eggs (-55-100%), fish (-35-100%), oils high in saturated fat (-45%), sugar (-50%), roots (-70%), and grains (-20%). The changes expressed in servings ranged from less than 0.5 servings/d on average for animal source foods to 2\\u0026ndash;3 for vegetables, vegetable oils, and sugar (Figs S4-S5).\\u003c/p\\u003e\\u003cp\\u003eTo describe the degree of dietary change across regions and demographic groups, we calculated the overall percentage change in the intake of all encouraged foods with minimum intake targets and that of all to-be-limited foods with maximum targets. Across regions and for the example of flexitarian diets (Figs S7-S8), the overall percentage change in encouraged foods ranged from 45% in East Asia (primarily driven by whole grains) to 145% in Sub-Saharan Africa (driven by both vegetables and whole grains). The change in to-be-limited foods ranged from 30% in South Asia (driven by refined grains) to 50% in North America (driven by milk). Across demographic groups, the absolute changes in intake were generally larger in groups with higher energy needs such as men and adults, whereas the proportional changes were often larger in groups with lower energy needs such as children.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Nutritional impacts\",\"content\":\"\\u003cp\\u003eThe dietary patterns are associated with improvements in nutritional balances (Fig.\\u0026nbsp;3A, Fig S9). On average, they increased mineral intake, including calcium (+\\u0026thinsp;10\\u0026ndash;30%), iron (+\\u0026thinsp;40\\u0026ndash;70%), and zinc (+\\u0026thinsp;10\\u0026ndash;20%), in each case primarily driven by more vegetables and legumes. They also increased the intake of most vitamins, including vitamin C (+\\u0026thinsp;70\\u0026ndash;110%) and vitamin A (+\\u0026thinsp;230\\u0026ndash;290%), again driven by vegetables; and vitamin B12 (+\\u0026thinsp;110\\u0026ndash;180%), driven by algae rich in B12 (with some varieties of tempeh, i.e., fermented soybeans as another plant-based alternative \\u003csup\\u003e13\\u003c/sup\\u003e). In addition, macronutrient composition improved due to greater intake of protein (+\\u0026thinsp;5%), fibre (+\\u0026thinsp;70\\u0026ndash;110%), and poly-unsaturated fatty acids (+\\u0026thinsp;90\\u0026ndash;100%), and lower intake of carbohydrates (-15-25%) and saturated fat (-10-40%).\\u003c/p\\u003e\\u003cp\\u003eBy construction, the dietary patterns meet the nutritional requirements of each population group and attained full nutrient adequacy scores across regions, age groups, and sexes (Figs S10-S11). We calculated the adequacy scores by averaging nutrient adequacy ratios (i.e., the ratio between estimated and recommended intake capped at one) of nutrients with recommendations to avoid deficiency (\\u003cem\\u003eMethods\\u003c/em\\u003e). According to our estimates (Fig.\\u0026nbsp;3A), the dietary patterns increased average nutrient adequacy by 6% globally, which was driven by improving low intakes of riboflavin, iodine, and iron, followed by vitamins C, A, B12, as well as folate and zinc. Across regions, the average improvements in nutrient adequacy ranged from 4% in East Asia to 12% in Sub-Saharan Africa where current adequacy of vitamin B12 is particularly low. Across demographic groups, they ranged from 5% in men to 8% in women who have greater iron needs and current deficiencies, and from 5% in young adults to 8% in senior adults who have greater current deficiencies in vitamin C.\\u003c/p\\u003e\"},{\"header\":\"Health impacts\",\"content\":\"\\u003cp\\u003eThe dietary patterns are associated with reductions in diet-related disease risk and mortality across regions and population groups (Fig.\\u0026nbsp;3B). For our assessment of long-term health impacts, we conducted a comparative risk assessment of diet and weight-related risks based on cause-specific mortality rates and established risk-disease relationships (\\u003cem\\u003eMethods\\u003c/em\\u003e). According to our analysis, the dietary patterns are associated with reductions in mortality of 18\\u0026ndash;20%, corresponding to 10\\u0026ndash;11\\u0026nbsp;million avoided deaths globally (Fig S12). Most of the reductions in mortality were from coronary heart diseases (45%), followed by cancer (30%), type-2 diabetes (5%), and respiratory disease (5%), with similar contributions from improvements in risks related to dietary composition and risks related overall food intake and energy imbalances that affect weight levels (Fig S13).\\u003c/p\\u003e\\u003cp\\u003eThe health impacts differed by dietary pattern, region, and demographic groups (Fig.\\u0026nbsp;3B, Fig S14). Across diets, the reductions in mortality ranged from 18% for flexitarian diets to 20% in vegan diets which contained relatively more foods associated with reductions in disease risk (vegetables, fruits, and legumes), and less foods associated with increased risks (red and processed meat). Across regions and for the example of flexitarian diets, the reductions ranged from 10\\u0026ndash;11% in Sub-Saharan Africa which has a relatively young population and lower incidence of diet-related NCDs to 24\\u0026ndash;27% in Europe and Central Asia which has an older population and high incidence of NCDs. Across demographic groups, the reductions were similar in women (18\\u0026ndash;20%) and men (18\\u0026ndash;19%), by they ranged from 6\\u0026ndash;7% in young adults to 20\\u0026ndash;21% in senior adults who have higher mortality rates.\\u003c/p\\u003e\"},{\"header\":\"Environmental pressures and impacts\",\"content\":\"\\u003cp\\u003eThe dietary patterns are associated with less environmental resource use and pollution (Fig.\\u0026nbsp;3C, Fig S15). For assessing the environmental impacts, we estimated changes in total food demand associated with the diet scenarios and then paired those for each food commodity with a set of trade-adjusted and regionalised environmental footprints (\\u003cem\\u003eMethods\\u003c/em\\u003e). According to our analysis, the dietary patterns are associated with changes in food demand that would reduce global food-related GHG emissions by 30\\u0026ndash;50% (5\\u0026ndash;8 GtCO\\u003csub\\u003e2\\u003c/sub\\u003eeq), land use by 45\\u0026ndash;70% (20\\u0026ndash;35 Mkm\\u003csup\\u003e2\\u003c/sup\\u003e), including cropland use by 2\\u0026ndash;10% (0.5\\u0026ndash;1.5 Mkm\\u003csup\\u003e2\\u003c/sup\\u003e), as well as water use by 25\\u0026ndash;35% (850-1,100 km\\u003csup\\u003e3\\u003c/sup\\u003e), and eutrophication potential by 35\\u0026ndash;55% (25\\u0026ndash;40 MtPO\\u003csub\\u003e3\\u003c/sub\\u003e\\u003csup\\u003e4\\u0026minus;\\u003c/sup\\u003eeq). The reductions in most domains were primarily driven by less intake and production of animal source foods (Figs S16-S17). As a consequence, the environmental impacts were lowest in the more plant-based dietary patterns.\\u003c/p\\u003e\\u003cp\\u003eTo provide an overview of impacts across populations (Fig.\\u0026nbsp;3C), we averaged the percentage changes in each domain, weighted by the importance of dietary change for mitigation in that domain (\\u003cem\\u003eMethods\\u003c/em\\u003e) \\u003csup\\u003e7\\u003c/sup\\u003e. Across dietary patterns, the weighted reductions in environmental impacts ranged from 35% for flexitarian diets which contain moderate amounts of animal source foods to 50% for vegan diets which contain no animal sourced foods. Across regions and for the example of flexitarian diets, reductions ranged from 10% in South Asia to 50% in both North America and Latin America where diets are relatively high in animal source foods. Across age groups, reductions ranged from 25% in children who have less overall food intake to 40% in senior adults whose diets contain relatively high amounts of animal source foods, especially in low and middle-income countries. Across sexes, reductions were comparable (33\\u0026ndash;35%) but moderately less in women who have a lower intake of animal source foods and a lower overall food intake than men. The regional and demographic trends for the other dietary patterns were comparable (SI Datafiles).\\u003c/p\\u003e\"},{\"header\":\"Sensitivity analysis\",\"content\":\"\\u003cp\\u003eIn developing the dietary patterns, we implemented the reference values of healthy intake as ceilings and floors, which ensured that populations whose intake already fulfilled the recommendations were not penalised. However, there are alternative perspectives on adopting the reference values, including allowing increases in discouraged foods (e.g., of meat and dairy) up to the ceiling to not penalise potentially increasing preference for such foods, as well as a strict adherence of both floors and ceilings (especially for flexitarian diets) to provide more distinct variants of dietary patterns. In a sensitivity analysis (Fig.\\u0026nbsp;4), we assessed the implications of a strict adherence to the reference values of healthy intake (Fig.\\u0026nbsp;1A), which also included using grain intake for energy balance. Flexitarian diets with strict adherence contained lower amounts of previously encouraged foods (e.g., 25% less vegetables) and more of previously discouraged foods (e.g., 75% more milk, 55% more poultry and fish, and 25% more red meat). As a result, the environmental benefits decreased by 14%, but the health benefits remained comparable with small reductions (-4%).\\u003c/p\\u003e\\u003cp\\u003eThe dietary patterns were developed based on the recommended energy and food intake of populations at current levels of physical activity. However, about a third of all adults and four fifth of adolescents do not meet global health recommendations of engaging in at least moderate levels of physical activity \\u003csup\\u003e14,15\\u003c/sup\\u003e, something that results in increased disease burden and costs \\u003csup\\u003e16,17\\u003c/sup\\u003e. Ideally, dietary changes towards healthier and more sustainable dietary patterns would be accompanied by efforts to increase physical activity. In a second sensitivity analysis (Fig.\\u0026nbsp;4), we therefore developed diets that accommodate the additional energy needs of meeting the World Health Organization\\u0026rsquo;s recommendations on physical activity \\u003csup\\u003e18\\u003c/sup\\u003e. On average, an additional energy intake of 100 kcal/d was required in those diets, which could be met by, e.g., increasing the intake of whole grains and vegetable oils by a quarter to half a serving per day each. The changes in intake had no substantial impacts on the health and environment benefits identified previously (+\\u0026thinsp;2% and \\u0026minus;\\u0026thinsp;5% respectively).\\u003c/p\\u003e\\u003cp\\u003eIn a final sensitivity analysis (Fig.\\u0026nbsp;4), we quantified the implications of adopting dietary recommendations developed for a different population group. We based this analysis on a common misinterpretation of the EAT-Lancet reference values, which were expressed for an energy intake of 2500 kcal/d for illustration. Although this level of intake only corresponds to the energy needs of specific population groups such as middle-aged men or physically active young adults, it has often been used as the target for energy intake of the total population \\u003csup\\u003e19,20\\u003c/sup\\u003e. Using 2500 kcal/d diets for all population groups increased national energy intake by 20% (400 kcal/d) on average in our sensitivity analysis. In addition, it increased the intake of some encouraged foods such as fruits and nuts by 10\\u0026ndash;15%, as well as the intake of discouraged foods such as red meat and milk by 45\\u0026ndash;110%. These changes resulted in about a third less health benefits, primarily due to less reductions in overweight and obesity, as well as a halving of the environmental benefits, primarily due to the higher intake of animal source foods.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eDietary changes towards healthier and more sustainable diets across all regions and population groups are necessary for addressing major health and environmental challenges, including limiting global warming, meeting the Sustainable Development Goals related to environmental resource use and pollution, and tackling the ongoing obesity and NCD pandemics\\u0026nbsp;\\u003csup\\u003e1,2,4–6\\u003c/sup\\u003e. Here we developed a set of planetary health diets that are adapted to different regions and demographic groups which can be used to inform dietary transitions across scales and actors. By construction, the dietary patterns are nutritionally adequate and in line with food-related planetary boundaries\\u0026nbsp;\\u003csup\\u003e2,7\\u003c/sup\\u003e. Our analysis indicates that their adoption would also be associated with substantial reductions in diet-related disease risk and mortality, and in environmental resource use and pollution, in each case across a wide range of regional and demographic scales.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOur findings show that there are many diets that are both healthy and sustainable, and that healthy and sustainable diets differ by region and demographic group. Providing dietary options that are tailored to the dietary preferences and nutritional requirements of different population groups can help in devising concrete pathways of dietary change, including in policy planning, civil-society initiatives, business approaches, and personal behaviour change. Explicitly including the variety of healthy and sustainable dietary patterns in such pathways allows for agency in dietary choice which increases the likelihood of adoption\\u0026nbsp;\\u003csup\\u003e21\\u003c/sup\\u003e. Variety of choice could for example be facilitated by a “common core” approach in which the dietary components common to each dietary pattern (e.g., whole grain, vegetables, legumes, nuts, fruits) are provided as a non-exclusionary default, and foods specific to a dietary pattern become an optional choice in proportion dietary reference values.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe set of healthy and sustainable diets we developed are also relevant for further research. For example, including the set of dietary patterns in impact assessments can help analyse the range of mitigation options more fully than a focus on one variant, something that is supported by the substantially lower environmental impacts we identified for vegan diets compared to flexitarian ones, at similar health and nutritional benefits. The grounding of the set of diets in the nutritional and energy needs of population groups ensures biophysical consistency when using them in dietary impact assessments. This contrasts with many previous analyses that were based on misapplying the dietary reference values of a specific population group (with energy requirements of 2500 kcal/d) to the whole population\\u0026nbsp;\\u003csup\\u003e19,20\\u003c/sup\\u003e. Our analysis suggests this could have resulted in substantial deviations in quantified impacts. We hope the dietary options we developed will facilitate more biophysically grounded research on health, environmental, and social aspects not covered here\\u0026nbsp;\\u003csup\\u003e22,23\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eOur findings show that current diets differ substantially from the set of healthy and sustainable dietary patterns developed here. Dietary choices are seldomly made based on the health and environmental considerations that form the basis of our analysis. Instead, they are known to be influenced by the availability, prices, tastes, and habits embodied in both local and global food environments. As such, multi-component approaches would be necessary to encourage and enable dietary changes towards healthier and more sustainable dietary patterns\\u0026nbsp;\\u003csup\\u003e24,25\\u003c/sup\\u003e. They can include informational approaches (e.g., food labelling and reforms of dietary guidelines\\u0026nbsp;\\u003csup\\u003e8\\u003c/sup\\u003e), but are thought to also require regulatory approaches, including fiscal incentives (e.g., reform of agricultural subsidies\\u0026nbsp;\\u003csup\\u003e26\\u003c/sup\\u003e and adjusting the pricing of foods according to their health or environmental impacts\\u0026nbsp;\\u003csup\\u003e27–29\\u003c/sup\\u003e), as well as gustatory approaches, including menu and meal reformulations, so that healthy and sustainable dietary options are not only encouraged, but also available, affordable, and desirable.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOur study advances the literature in several ways but is also subject to caveats. First, by developing dietary scenarios by country and population group, we explicitly accounted for regional and demographic differences in energy needs and food-group recommendations, which goes beyond assessments based on national averages\\u0026nbsp;\\u003csup\\u003e30\\u003c/sup\\u003e. We used a new and improved proxy of dietary intake, but the existing estimates of food intake with global coverage that we used for its construction have large uncertainties. They include misreporting in dietary surveys and outdated data on the amount of nationally available food that is wasted\\u0026nbsp;\\u003csup\\u003e31,32\\u003c/sup\\u003e. We used a triangulation method that normalised food intake to those levels of energy intake that are required to sustain measured levels of body weight, height, and physical activity levels in each population group\\u0026nbsp;\\u003csup\\u003e33\\u003c/sup\\u003e. Whilst this is an improvement on previous approaches, it comes with its own sources of uncertainty, including those related to anthropometric measures.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSecond, by coupling the construction of dietary scenarios with a nutritional assessment, we ensured that all dietary patterns attained nutritional adequacy in each population group (including in women and children), something previous country-level analyses were not able to demonstrate\\u0026nbsp;\\u003csup\\u003e30\\u003c/sup\\u003e. We improved current methods in nutritional analyses by regionalising nutritional recommendations to the demographic and weight distribution of each population group instead of applying reference weights from high-income countries. In addition, we included complementary food sources of nutrients such as vitamin B12 that are especially relevant in predominantly plant-based dietary patterns. Plant-based sources of bioavailable B12 include certain algae and fermented soybeans (tempeh)\\u0026nbsp;\\u003csup\\u003e13,34\\u003c/sup\\u003e. Algae can be grown and harvested in most coastal regions, and soybeans are a widely traded commodity, but regular intake is limited to East Asia. Targeted regulatory, business, and behavioural initiatives might be needed to increase regular consumption in other regions.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThird, by including both scale and composition-related risks in our analysis of long-term health, we were able to provide a more comprehensive attribution of the diet-related disease burden than most current assessments \\u003csup\\u003e3\\u003c/sup\\u003e. Compared to other assessments, we only included non-overlapping and food-based dietary risks, used independently derived risk-disease associations whose quality of evidence in meta-analyses have been graded as moderate to high\\u0026nbsp;\\u003csup\\u003e35–37\\u003c/sup\\u003e, and omitted composition-related risk factors that showed high regional variability (e.g., fish) or became non-significant in fully adjusted models (e.g., milk). However, despite our conservative approach to disease attribution, residual confounding with unaccounted risk factors cannot be ruled out in the epidemiological studies that derived the disease-risk associations\\u0026nbsp;\\u003csup\\u003e38\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eFourth, by pairing regional environmental footprints with current statistics of the global food system, we were able to provide estimates of the potential environmental impacts of dietary change without making additional economic assumption (e.g., related to prices), which we think are a matter of policy. This complements analyses of existing food system models whose baseline data can be several decades old and who therefore rely on (less certain) economic projections and modelling for their estimates\\u0026nbsp;\\u003csup\\u003e39–41\\u003c/sup\\u003e. These models are based on specific behavioural economic assumptions and have a fixed regional focus which make the estimated supply and demand relationships not representative of other contexts. In contrast, our estimates can be used across scales to scope the dietary option space and related impacts, but our analysis does not resolve potential policies or pathways that would result in those changes. Identifying if and with what combination of measures large-scale dietary change can be achieved is still an active area of research\\u0026nbsp;\\u003csup\\u003e25,42,43\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSome businesses and interest groups have been promoting the adoption of meat and milk alternatives as practical solutions for reducing especially the environmental footprints of diets\\u0026nbsp;\\u003csup\\u003e44–46\\u003c/sup\\u003e. However, from environmental, health, and cost perspectives, they generally perform worse than the unprocessed plant-based foods the EAT-Lancet Commissions and other dietary guidelines recommend for regular intake\\u0026nbsp;\\u003csup\\u003e47\\u003c/sup\\u003e. We therefore did not include them in our set of diets and the related assessments. However, increasing the uptake of less marketable whole foods will likely require a shift in business approaches away from the promotion of single products towards more service and meal-oriented approaches, and an alignment of policy support, including public and private investments into healthy and sustainable meals and diets. Our analysis implies that this might be worthwhile as the health and environmental benefits of such structural changes in diets would be substantial across all geographical scales and population groups.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMSp, SC, and JR acknowledge funding from Wellcome Trust through a Career Development Award (Award number: 225318/Z/22/Z). MSp and OA acknowledge funding from the EU Horizon Programme through the CATALYSE project (Grant agreement number: 101057131). MSp and DH acknowledge funding from the EU Horizon Programme through the BrightSpace project (Grant agreement number: 101060075). SB acknowledges funding through an EAT-Lancet research fellowship funded by the IKEA Foundation and the Novo Nordisk Foundation.\\u0026nbsp;TB acknowledges funding from Germany Federal Ministry of Education and Research (BMBF) through the WeAreOne project. MSc acknowledge funding from the EU Horizon Programme through the ACT4CAP project (Grant agreement number: 101134874). All authors acknowledge helpful discussions with other members of the second EAT-Lancet Commission on Healthy Diets from Sustainable and Just Food Systems.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eContributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMSp designed the study, conducted the analysis, and wrote the manuscript. All authors provided inputs to the analysis, commented on the manuscript, and approved the submission.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u0026nbsp;\\u003c/p\\u003e\\n\"},{\"header\":\" References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWhitmee, S. \\u003cem\\u003eet al.\\u003c/em\\u003e Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health. \\u003cem\\u003eThe Lancet\\u003c/em\\u003e \\u003cstrong\\u003e386\\u003c/strong\\u003e, 1973\\u0026ndash;2028 (2015).\\u003c/li\\u003e\\n\\u003cli\\u003eWillett, W. \\u003cem\\u003eet al.\\u003c/em\\u003e Food in the Anthropocene: the EAT\\u0026ndash;Lancet Commission on healthy diets from sustainable food systems. \\u003cem\\u003eThe Lancet\\u003c/em\\u003e \\u003cstrong\\u003e393\\u003c/strong\\u003e, 447\\u0026ndash;492 (2019).\\u003c/li\\u003e\\n\\u003cli\\u003eGBD 2017 Diet Collaborators \\u003cem\\u003eet al.\\u003c/em\\u003e Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. \\u003cem\\u003eThe Lancet\\u003c/em\\u003e \\u003cstrong\\u003e0\\u003c/strong\\u003e, (2019).\\u003c/li\\u003e\\n\\u003cli\\u003eSpringmann, M., Mozaffarian, D., Rosenzweig, C. \\u0026amp; Micha, R. 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A multicriteria analysis of meat and milk alternatives from nutritional, health, environmental, and cost perspectives. \\u003cem\\u003eProceedings of the National Academy of Sciences\\u003c/em\\u003e \\u003cstrong\\u003e121\\u003c/strong\\u003e, e2319010121 (2024).\\u003cstrong\\u003e\\u003cbr\\u003e \\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eDevelopment of planetary health diets\\u003c/h2\\u003e\\n \\u003cp\\u003eWe constructed the dietary patterns by adjusting current intake to meet minimum and maximum recommended values for healthy eating. Estimates of current intake were derived by combining estimates of food composition from waste-adjusted food availability data \\u003csup\\u003e48,49\\u003c/sup\\u003e with demographic trends in intake from dietary surveys \\u003csup\\u003e50\\u003c/sup\\u003e, and normalised to estimates of total energy intake required to sustain measured levels of body weight, height, and physical activity \\u003csup\\u003e33\\u003c/sup\\u003e. The estimates capture complete diets aggregated into 36 primary foods and 7 processed foods for 184 countries, 22 age groups in five-year intervals, and two sexes (Table S1, SI section S1). They are regionally and demographically comparable and follow observed trends in over and underconsumption (Fig.\\u0026nbsp;1B). For this study, we aggregated the dietary resolution to 24 food commodities to align with the detail of dietary recommendations, and we summarised the demographic detail to ten groups for presentational purposes (whilst keeping the full detail in our computations).\\u003c/p\\u003e\\n \\u003cp\\u003eThe values of recommended intake were based on a comprehensive review of the literature on healthy eating conducted by the EAT-Lancet Commissions on Healthy Diets from Sustainable and Just Food Systems, which is available in the EAT-Lancet reports \\u003csup\\u003e2,10\\u003c/sup\\u003e. The reference values describe healthy food intake for physically active adults, which can be interpreted as minimum and maximum recommendations that allow for a variety of dietary patterns (Fig.\\u0026nbsp;1A). Starting with flexitarian diets, we adjusted current intake amongst adults to meet both minimum and maximum recommendations, without reducing intake if it was above minimum values (e.g., for fruits and vegetables) or increasing intake if it was below maximum values (e.g., for red meat and sugar). We preserved regional preferences of specific types of foods within the general categories of grains, red meat, fish, and fruits by using the current distribution of intake within those categories (Table S1).\\u003c/p\\u003e\\n \\u003cp\\u003eWe then adjusted energy intake in adults to those energy requirements that are in line with healthy body weights by changing grain and oil intake (whose recommended values were also initially determined by energy and macronutrient balances). Estimates of healthy body weights by country and population group (Fig. 1B) were derived by using predictive equations for estimating energy requirements for healthy body weights that minimise mortality risk at current levels of body heights and physical activity \\u003csup\\u003e33\\u003c/sup\\u003e. For attaining energy balance, we first adjusted grain intake but switched to oils when grain intake exceeded maximum recommendations (six servings per day, 270 g/d), whilst ensuring oil intake stayed within the range recommended for macronutrient balance (40\\u0026ndash;80 g/d). We constructed diets for other and more specific age groups (at five-year intervals) by scaling food intake by recommended energy intake in that age group.\\u003c/p\\u003e\\n \\u003cp\\u003eWe developed the full set of dietary patterns by substitution. We replaced either meat (pescatarian), meat and fish (vegetarian), or all animal source foods (vegan) with a mix of fruits and vegetables and of legumes and fish (pescatarian diets), or with a mix of fruits and vegetables and legumes (vegetarian and vegan diets). The pattern of substitution was based on dietary recommendations and observed patterns of substitution in specialised dietary patterns \\u003csup\\u003e12\\u003c/sup\\u003e. The mix of fruits and vegetables constituted one third of replaced calories in each case, and the mix of legumes and fish in pescatarian diets was determined based on increasing fish intake up to its recommended value (Fig.\\u0026nbsp;1A) and increasing legumes thereafter.\\u003c/p\\u003e\\n \\u003cp\\u003eIn a final adjustment, we balanced the intake of micronutrients for each population group by adjusting the composition of nutrient-rich foods within general food groups (e.g., increasing green-leafy vegetables and soybeans within vegetables and legumes for increasing iron intake), and of adding a plant-based source of vitamin B12. For the latter, we used a small serving of algae with bioavailable B12 \\u003csup\\u003e13\\u003c/sup\\u003e, but note that other options exist, including certain types of tempeh (i.e., fermented soybeans), a range of fortified foods (e.g., soymilks and nutritional yeast), as well as targeted nutrient supplementation, each associated with different food-system implications.\\u003c/p\\u003e\\n \\u003cp\\u003eFor comprehensively describing the set of planetary health diets, we used several metrics of food intake. They included intake in weight (grams per person per day), energy content (kilocalories per person per day), and servings (servings per person per day) which were based on amounts customarily consumed (Fig.\\u0026nbsp;1A). We also assessed the sensitivity of impacts on the content and construction of the diets. For the sensitivity analyses, we developed and assessed dietary variants with strict adherence to the reference values (i.e., without allowing overfulfilling recommendations), and with levels of energy intake that are in line with meeting recommendations for physical activity (instead of using current activity levels).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eNutritional assessment\\u003c/h2\\u003e\\n \\u003cp\\u003eWe assessed the nutrient adequacy of the dietary patterns by estimating nutrient intake and requirements by region and population group. For estimating nutrient intake, we paired food intake in the different diets with the nutrient densities of foods. We sourced most nutrient densities from the Global Expanded Nutrient Supply (GENuS) model \\u003csup\\u003e51\\u003c/sup\\u003e, and supplemented them for nutrients and food groups not comprehensively covered by GENuS (e.g., B12 and phytate) by estimates from the Harvard Nutrient Database and specialised food composition tables \\u003csup\\u003e52\\u003c/sup\\u003e. To estimate nutrient requirements, we used a set of harmonised nutrient reference values that specify the average nutrient requirements of populations by age and sex \\u003csup\\u003e53\\u003c/sup\\u003e, paired those with detailed population estimates from the United Nations Population Division \\u003csup\\u003e54\\u003c/sup\\u003e, and adjusted the specified reference weights to the average body weight of each population group in each country \\u003csup\\u003e55\\u003c/sup\\u003e. We accounted for changes in the bioavailability of zinc and iron by using established dependencies with dietary modulators (e.g., phytate) \\u003csup\\u003e56\\u0026ndash;58\\u003c/sup\\u003e.\\u003c/p\\u003e\\n \\u003cp\\u003eIn addition to estimating changes in nutrient intake, we combined the estimates of intake with nutrient requirements to calculate nutrient adequacy scores \\u003csup\\u003e59\\u003c/sup\\u003e. For each nutrient with an estimated average requirement (EAR) related to adequacy, we calculated nutrient adequacy ratios by dividing estimated intake by recommended intake capped at one, so that a NAR of one represents full adequacy for a population group on average. We then summed all NARs and divided by the number of deficiency-related nutrients to calculate overall nutrient adequacy scores (mean adequacy ratios). This calculation included 14 out of the 26 nutrients we assessed intake of because not all nutrients had requirements established in relation to adequacy (Table S2 and SI section S2). Nutrients without adequacy-related EARs included most macronutrients (carbohydrates, fatty acids, and fibre) except for protein, as well as calcium, copper, magnesium, and pantothenate whose EARs were determined by balance studies and observed intake in high-income countries \\u003csup\\u003e60,61\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eComparative risk assessment\\u003c/h2\\u003e\\n \\u003cp\\u003eWe assessed the impacts on dietary risks and mortality of the adopting the dietary patterns by using a comparative risk assessment framework with eight diet and weight-related risk factors and five disease endpoints \\u003csup\\u003e8\\u003c/sup\\u003e. For parameterizing the comparative risk assessment, we used data on cause-specific mortality from the Global Burden of Disease project \\u003csup\\u003e62\\u003c/sup\\u003e, body weight from the NCD Risk Factor Collaboration \\u003csup\\u003e55\\u003c/sup\\u003e, and relative risk estimates that relate change in risk factors to changes in disease mortality from meta-analyses of epidemiological cohort studies (Table S3). We focused on adults aged 20 year or older in our assessment due to low mortality rates of NCDs in younger age groups, and we adjusted the relative risks for attenuation with age based on a pooled analysis of cohort studies focussed on metabolic risk factors in line with other studies \\u003csup\\u003e63\\u003c/sup\\u003e.\\u003c/p\\u003e\\n \\u003cp\\u003eThe selection of risk-disease associations was supported by available criteria used to judge the certainty of evidence (Table S4). They were graded as moderate or high with NutriGrade \\u003csup\\u003e35\\u0026ndash;37\\u003c/sup\\u003e, and assessed as probable or convincing by the Nutrition and Chronic Diseases Expert Group (NutriCoDe) \\u003csup\\u003e64\\u003c/sup\\u003e, and by the World Cancer Research \\u003csup\\u003e65\\u003c/sup\\u003e. For each risk factor, we constrained the maximum attainable risk reduction to minimal risk exposure values established by NutriCoDe and available meta-analyses (SI section S3). We differentiated between composition and weight-related risks in our main analysis. As weight-related risks are associated with imbalanced energy intake, we also conducted a sensitivity analysis in which we attributed weight-related risks to the over and underconsumption of foods (measured in kcal/d) relative to their dietary reference values (Fig.\\u0026nbsp;1A).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eEnvironmental assessment\\u003c/h2\\u003e\\n \\u003cp\\u003eFor calculating environmental impacts, we first converted the estimates of dietary intake to total food demand, and then paired the demand estimates with a set of trade-adjusted and regionalised environmental footprints. To calculate total food demand, we added estimates of food waste to the estimates of dietary intake, and then multiplied the per-person values by the population in the specific demographic group \\u003csup\\u003e54\\u003c/sup\\u003e. Waste estimates of specific foods were based on estimates of the Food and Agriculture Organization of the United Nations (FAO) \\u003csup\\u003e49\\u003c/sup\\u003e and harmonised to the difference between total calorie intake (derived from anthropometric measures \\u003csup\\u003e33\\u003c/sup\\u003e as used in our estimates of intake, Table S1) and total calorie demand (as reported by the FAO \\u003csup\\u003e48\\u003c/sup\\u003e). This harmonisation accounts for changes in waste fractions from their initial year of analysis and ensures total food demand in the baseline matches the values reported by the FAO.\\u003c/p\\u003e\\n \\u003cp\\u003eThe environmental footprints were obtained from a comprehensive meta-analysis of life cycle assessments (LCAs) of 40 foods produced by 38,700 farms in 119 countries, covering GHG emissions, land use, freshwater use, and soil and water pollution as measured by eutrophication potential. The LCAs were standardised by harmonising system boundaries (from inputs to retail) and gap-filling missing steps along the supply chain, which made use of auxiliary estimates (e.g., of post-farm processes) and dedicated process-based models (e.g., of nitrate leaching). FAO data on food production and yields were used to scale and regionalise estimates \\u003csup\\u003e48\\u003c/sup\\u003e, and FAO data on trade were used to derive consumption-based footprints by commodity and region (Table S5, SI section S4).\\u003c/p\\u003e\\n \\u003cp\\u003eIn addition to reporting changes in environmental impacts for each domain, we also calculated an overall indicator of food-related environmental impacts. Because the importance of diets and dietary changes for reducing environmental impacts varies for each domain, we used a weighing scheme that accounts for that, with weights assigned based on the needed contribution of dietary changes for staying within food-related environmental limits (or planetary boundaries) while also considering contributions from other food-system measures, including changes in technologies and management practices, food loss and waste, and socio-economic development (Fig S1) \\u003csup\\u003e7\\u003c/sup\\u003e. This meant weighing the changes in GHG emissions relatively more (46%) than changes in eutrophication potential (30%), and land and water use (12% each) (SI section S4). Using simple averages resulted in the same ordering across dietary patterns, regions, and demographic groups, and we included those and the detailed set of estimated impacts in the SI Datafiles.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\n \\u003cp\\u003eAll results produced in this study will be made available as Supplementary Datafiles and uploaded to a public repository.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eCode availability\\u003c/h2\\u003e\\n \\u003cp\\u003eThe code used in this study will be made available on GitHub and as part of the second version of the World Health Organization\\u0026rsquo;s Dietary Impact Assessment (DIA) model \\u003csup\\u003e11\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eMethods references\\u003c/h2\\u003e\\u003cspan\\u003e\\n\\u003col start=\\\"48\\\"\\u003e\\n \\u003cli\\u003eFood and Agriculture Organization of the United Nations. \\u003cem\\u003eFAOSTAT Statistical Database\\u003c/em\\u003e. (2022).\\u003c/li\\u003e\\n \\u003cli\\u003eGustavsson, J., Cederberg, C., Sonesson, U., Van Otterdijk, R. \\u0026amp; Meybeck, A. \\u003cem\\u003eGlobal Food Losses and Food Waste: Extent, Causes and Prevention\\u003c/em\\u003e. (FAO Rome, 2011).\\u003c/li\\u003e\\n \\u003cli\\u003eMiller, V. \\u003cem\\u003eet al.\\u003c/em\\u003e Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide. \\u003cem\\u003eBMJ Global Health\\u003c/em\\u003e \\u003cstrong\\u003e6\\u003c/strong\\u003e, e003585 (2021).\\u003c/li\\u003e\\n \\u003cli\\u003eSmith, M. R., Micha, R., Golden, C. D., Mozaffarian, D. \\u0026amp; Myers, S. S. Global expanded nutrient supply (GENuS) model: a new method for estimating the global dietary supply of nutrients. \\u003cem\\u003ePLOS ONE\\u003c/em\\u003e \\u003cstrong\\u003e11\\u003c/strong\\u003e, e0146976 (2016).\\u003c/li\\u003e\\n \\u003cli\\u003eWessells, K. R., Singh, G. M. \\u0026amp; Brown, K. H. Estimating the Global Prevalence of Inadequate Zinc Intake from National Food Balance Sheets: Effects of Methodological Assumptions. \\u003cem\\u003ePLOS ONE\\u003c/em\\u003e \\u003cstrong\\u003e7\\u003c/strong\\u003e, e50565 (2012).\\u003c/li\\u003e\\n \\u003cli\\u003eAllen, L. H., Carriquiry, A. L. \\u0026amp; Murphy, S. P. Perspective: Proposed Harmonized Nutrient Reference Values for Populations. \\u003cem\\u003eAdvances in Nutrition\\u003c/em\\u003e \\u003cstrong\\u003e11\\u003c/strong\\u003e, 469\\u0026ndash;483 (2020).\\u003c/li\\u003e\\n \\u003cli\\u003eUnited Nations Department of Economic and Social Affairs, Population Division. \\u003cem\\u003eWorld Population Prospects 2024: Data Sources\\u003c/em\\u003e. https://population.un.org/wpp/assets/Files/WPP2024_Data_Sources.pdf (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eNCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. \\u003cem\\u003eLancet\\u003c/em\\u003e \\u003cstrong\\u003e403\\u003c/strong\\u003e, 1027\\u0026ndash;1050 (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eMiller, L. V., Krebs, N. F. \\u0026amp; Hambidge, K. M. A mathematical model of zinc absorption in humans as a function of dietary zinc and phytate. \\u003cem\\u003eJ Nutr\\u003c/em\\u003e \\u003cstrong\\u003e137\\u003c/strong\\u003e, 135\\u0026ndash;141 (2007).\\u003c/li\\u003e\\n \\u003cli\\u003eHambidge, K. M., Miller, L. V., Westcott, J. E., Sheng, X. \\u0026amp; Krebs, N. F. Zinc bioavailability and homeostasis. \\u003cem\\u003eAm J Clin Nutr\\u003c/em\\u003e \\u003cstrong\\u003e91\\u003c/strong\\u003e, 1478S-1483S (2010).\\u003c/li\\u003e\\n \\u003cli\\u003eArmah, S. M., Carriquiry, A., Sullivan, D., Cook, J. D. \\u0026amp; Reddy, M. B. A complete diet-based algorithm for predicting nonheme iron absorption in adults. \\u003cem\\u003eJ Nutr\\u003c/em\\u003e \\u003cstrong\\u003e143\\u003c/strong\\u003e, 1136\\u0026ndash;1140 (2013).\\u003c/li\\u003e\\n \\u003cli\\u003eTufts University. Data4Diets: Building Blocks for Diet-related Food Security Analysis, Version 2.0. (2023).\\u003c/li\\u003e\\n \\u003cli\\u003eBajaj, S. \\u0026amp; Springmann, M. A review of the quality of evidence of nutrient reference values. \\u003cem\\u003eLancet Planetary Health\\u003c/em\\u003e (under review).\\u003c/li\\u003e\\n \\u003cli\\u003eEuropean Food Safety Authority (EFSA). Dietary Reference Values for nutrients Summary report. \\u003cem\\u003eEFS3\\u003c/em\\u003e \\u003cstrong\\u003e14\\u003c/strong\\u003e, (2017).\\u003c/li\\u003e\\n \\u003cli\\u003eGBD 2021 Causes of Death Collaborators. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. \\u003cem\\u003eLancet\\u003c/em\\u003e \\u003cstrong\\u003e403\\u003c/strong\\u003e, 2100\\u0026ndash;2132 (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eSingh, G. M. \\u003cem\\u003eet al.\\u003c/em\\u003e The Age-Specific Quantitative Effects of Metabolic Risk Factors on Cardiovascular Diseases and Diabetes: A Pooled Analysis. \\u003cem\\u003ePLOS ONE\\u003c/em\\u003e \\u003cstrong\\u003e8\\u003c/strong\\u003e, e65174 (2013).\\u003c/li\\u003e\\n \\u003cli\\u003eMicha, R. \\u003cem\\u003eet al.\\u003c/em\\u003e Etiologic effects and optimal intakes of foods and nutrients for risk of cardiovascular diseases and diabetes: Systematic reviews and meta-analyses from the Nutrition and Chronic Diseases Expert Group (NutriCoDE). \\u003cem\\u003ePLOS ONE\\u003c/em\\u003e \\u003cstrong\\u003e12\\u003c/strong\\u003e, e0175149 (2017).\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: A Global Perspective. Continuous Update Project Expert Report. (2018).\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003c/div\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"nature-portfolio\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Nature Portfolio\",\"twitterHandle\":\"\",\"acdcEnabled\":false,\"dfaEnabled\":false,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6474232/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6474232/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eWithout dietary changes towards healthier and more sustainable diets, there is little chance of addressing the growing burden of non-communicable diseases, avoiding dangerous levels of climate change, and staying within key planetary boundaries that define a safe operating space for humanity. Global reference values for healthy and sustainable eating exist, but consistent adaptations to local contexts are limited, which impacts food-related planning and decision-making. Here we develop a diverse set of \\u0026ldquo;planetary health diets\\u0026rdquo; that are adapted to the nutritional needs and preferences of populations at global, regional, national, and demographic levels. The set includes distinct dietary patterns (flexitarian, pescatarian, vegetarian, vegan) that differ across countries, age groups, and sexes. Using impact assessments, we show that adoption of these diets would be associated with substantial improvements in nutritional adequacy and simultaneous reductions in diet-related mortality and environmental resource demand, in each case across a wide range of regional and demographic scales. Our findings also indicate large differences to current diets, suggesting the need for dedicated initiatives and support for dietary change. We integrated the estimates of food intake and the associated impacts into interactive analysis tools to facilitate dietary planning and decision-making across dietary preferences at regional and demographic levels.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Many diets for many people: planetary health diets and their health and environmental impacts at global, regional, national, and demographic levels\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-09 11:27:10\",\"doi\":\"10.21203/rs.3.rs-6474232/v1\",\"editorialEvents\":[],\"status\":\"published\",\"journal\":{\"display\":false,\"email\":\"info@researchsquare.com\",\"identity\":\"nature\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"nature\",\"sideBox\":\"Learn more about [Nature](http://www.nature.com/nature/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Nature\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"36a76f54-7818-4a9a-98c2-de79ee3447c4\",\"owner\":[],\"postedDate\":\"September 9th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":54219150,\"name\":\"Scientific community and society/Social sciences/Interdisciplinary studies\"},{\"id\":54219151,\"name\":\"Earth and environmental sciences/Environmental sciences/Environmental impact\"},{\"id\":54219152,\"name\":\"Health sciences/Risk factors\"}],\"tags\":[],\"updatedAt\":\"2025-10-17T13:37:23+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-09 11:27:10\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6474232\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6474232\",\"identity\":\"rs-6474232\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}