foods

Review
Indicators and Recommendations for Assessing Sustainable
Healthy Diets
Maite M. Aldaya 1, * , Francisco C. Ibañez 1 , Paula Domínguez-Lacueva 2 , María Teresa Murillo-Arbizu 1 ,
Mar Rubio-Varas 3 , Beatriz Soret 1 and María José Beriain 1

1 Institute on Innovation & Sustainable Development in the Food Chain (IS-FOOD), Public University of
Navarra (UPNA), Jerónimo de Ayanz Building, Arrosadia Campus, 31006 Pamplona, Spain;
pi@unavarra.es (F.C.I.); mariateresa.murillo@unavarra.es (M.T.M.-A.); soret@unavarra.es (B.S.);
mjberiain@unavarra.es (M.J.B.)
2 School of Sciences, University of Navarra, 31080 Pamplona, Spain; pdominguez.7@alumni.unav.es
3 Institute for Advanced Research in Business and Economics (INARBE), Public University of Navarra (UPNA),
Jerónimo de Ayanz Building, Arrosadia Campus, 31006 Pamplona, Spain; mar.rubio@unavarra.es
* Correspondence: maite.aldaya@unavarra.es; Tel.: +34-948-16-6245

Abstract: Research coupling human nutrition and sustainability concerns is a rapidly developing
field, which is essential to guide governments’ policies. This critical and comprehensive review
analyzes indicators and approaches to “sustainable healthy diets” published in the literature since
this discipline’s emergence a few years ago, identifying robust gauges and highlighting the flaws
of the most commonly used models. The reviewed studies largely focus on one or two domains
such as greenhouse gas emissions or water use, while overlooking potential impact shifts to other



sectors or resources. The present study covers a comprehensive set of indicators from the health,


environmental and socio-economic viewpoints. This assessment concludes that in order to identify
Citation: Aldaya, M.M.; Ibañez, F.C.;
the best food option in sustainability assessments and nutrition analysis of diets, some aspects
Domínguez-Lacueva, P.; Murillo-
such as the classification and disaggregation of food groups, the impacts of the rates of local food
Arbizu, M.T.; Rubio-Varas, M.; Soret,
consumption and seasonality, preservation methods, agrobiodiversity and organic food and different
B.; Beriain, M.J. Indicators and
Recommendations for Assessing
production systems, together with consequences for low-income countries, require further analysis
Sustainable Healthy Diets. Foods 2021, and consideration.
10, 999. https://doi.org/10.3390/
foods10050999 Keywords: sustainable healthy diet; food environmental sustainability; socioeconomic sustainability;
indicators; constraints; costs
Academic Editor: Isabel Ferreira

Received: 28 March 2021

Accepted: 30 April 2021 1. Introduction
Published: 2 May 2021
Environmental degradation and malnutrition, in all its forms, are both occurring at an
accelerated pace around the world. While the causes are complex, unhealthy diets coupled
Publisher’s Note: MDPI stays neutral
with unsustainable food systems can be considered among the main contributors to these
with regard to jurisdictional claims in
global burdens [1].
published maps and institutional affil-
Referring to environmental sustainability, currently, the global food system is the
iations.
largest freshwater user: agriculture alone accounts for 70% of freshwater withdrawn in
the world [2]. Agriculture is also responsible for 21–37% of total greenhouse gas (GHG)
emissions [3] and covers approximately 49–51% of global ice-free land surface, with grazing
land representing 37% and croplands representing approximately 12–14% [4]. Intensive and
Copyright: © 2021 by the authors. unsustainable agricultural practices and pollution can also trigger biodiversity loss [5].
Licensee MDPI, Basel, Switzerland.
In regard to the health component, currently, an estimated 821 million people are
This article is an open access article
undernourished, 151 million children under five years of age are stunted, 613 million
distributed under the terms and
women and girls aged 15 to 49 suffer from iron deficiency, and, on the other side, 2 billion
conditions of the Creative Commons
adults are overweight or obese [3]. Nowadays, unhealthy and unbalanced diets pose an
Attribution (CC BY) license (https://
increased risk to morbidity and mortality.
creativecommons.org/licenses/by/
4.0/).

Foods 2021, 10, 999. https://doi.org/10.3390/foods10050999 https://www.mdpi.com/journal/foods

Foods 2021, 10, 999 2 of 31

The challenge of achieving healthy diets is coupled with the challenge of attaining
sustainable food systems [6]. While food production contributes to natural resource deple-
tion and diets should improve to overcome malnutrition, sustainable food consumption
and production could also be considered an opportunity for enhancing human health and
environmental sustainability.
In 2011, Riley and Buttriss raised the question on “which dietary patterns are both
healthy and sustainable?”, although they were not able to provide a complete answer due
to the complexity of the issue [7]. Given the divergence of approaches, in 2019, the FAO
and WHO held a consultation and coined the concept “sustainable healthy diets”. This was
defined as:
“dietary patterns that promote all dimensions of individuals’ health and wellbeing;
have low environmental pressure and impact; are accessible, affordable, safe and equitable;
and are culturally acceptable” [1]
Sustainable healthy diets must combine all the dimensions of sustainability to avoid
unintended consequences. However, currently, a few dietary guidelines take environmen-
tal sustainability into account, such as those of the Netherlands [8], Nordic countries [9],
Germany [10], Brazil [11], Sweden [12], Qatar [13] and France [14]. Furthermore, the papers
published in the literature generally focus on specific aspects of health, environmental
or socioeconomic sustainability, sometimes leaving out one or two of the three compo-
nents. Further development of encompassing indicators and data on all dimensions of
sustainability is needed to make this concept complete, useful and effective.
In recent years, there has been an increase in the number of systematic reviews focused
on sustainable and healthy diets, most of which also have a specific scope. For instance,
some of the reviews have a limited geographical reach, focusing on one country such as
the UK [15] or the USA [16]. Other reviews focus on a specific domain such as mathe-
matical optimization studies [17] or labeling schemes [18]. Most reviews have a specific
environmental scope, analyzing a single environmental aspect [19,20] or two or three
environmental resources [15,21,22]. Some leave socioeconomic aspects out of the scope of
review, instead focusing on the interlinkages between the environment and diets [23,24].
Few reviews combine socioeconomic and environmental performance with nutritional and
health indicators [17,25,26], and only three of these compile [27] and recommend [28,29]
criteria. There has been no comprehensive review highlighting a complete set of indicators
coupled with an analysis of the gaps of knowledge and misconceptions from a multidis-
ciplinary perspective. Thus, limited evidence is available on the trade-offs involved in
selecting sustainable healthy diets.
The current critical review paper aims to identify a comprehensive set of indicators
for assessing sustainable healthy diets, analyzing the most common shortcomings from
a health, environmental and socio-economic perspective. First, a literature search is per-
formed to identify frequently used indicators and approaches in these three domains.
Second, a section is devoted to outlining some of the gaps in knowledge and frequent
misconceptions around sustainable healthy diets. Third, a comprehensive collection of in-
terdisciplinary indicators is provided, proposing, among other actions, further research on
the classification of food groups, impacts of different production systems and consequences
for low-income countries to develop a complete understanding for decision-making.

2. Materials and Methods

The literature search was carried out using three bibliographical databases: Scopus,
Web of Science and PubMed. The search was limited to items written in English between
2000 and 28 February 2021. Editorials, corrections, author responses, notes, and confer-
ence papers were discarded. An initial screening was performed using the keywords
“healthy and sustainable diet”, “sustainable and healthy diet”, “sustainable diet” and
“healthy diet”, “sustainable healthy diet”, and “healthy sustainable diet”. Figure 1 shows
the results of this screening. Records identified through these main keyword search
amounted to 197,482 if including duplicates and exclusions. Additionally, other keywords
Foods 2021, 10, x FOR PEER REVIEW 3 of 32

“healthy and sustainable diet”, “sustainable and healthy diet”, “sustainable diet” and
Foods 2021, 10, 999 “healthy diet”, “sustainable healthy diet”, and “healthy sustainable diet”. Figure 1 shows 3 of 31
the results of this screening. Records identified through these main keyword search
amounted to 197,482 if including duplicates and exclusions. Additionally, other keywords
were
wereused
usedforfor deepening
deepening in specific indicators
in specific indicators(Table
(Table1),1),identifying
identifying 171
171 additional
additional rec-
records.
ords. Each of these keywords was combined with the “sustainable
Each of these keywords was combined with the “sustainable diet” term. In addition,diet” term. In addition,
the
thefilters
filters “review”, “systematicreview”,
“review”, “systematic review”,“meta-analysis”,
“meta-analysis”, and
and “human
“human species”
species” werewere
used
used for the domain “nutrition and health”. The abstracts were first reviewed
for the domain “nutrition and health”. The abstracts were first reviewed before moving before mov-
ing to the
to the fullfull text.
text. TwoTwo researchers
researchers (M.M.A.
(M.M.A. andand F.C.I.)
F.C.I.) reviewed
reviewed the the papers
papers andand coordi-
coordinated
nated with the different field experts (M.R.-V., B.S., M.T.M.-A. and P.D.).
with the different field experts (M.R.-V., B.S., M.T.M.-A. and P.D.). Any discrepancies Any discrepan-
cies
werewere resolved
resolved by consulting
by consulting a third
a third reviewer
reviewer (M.J.B.).
(M.J.B.). Articles
Articles withwith no clearly
no clearly identi-
identifiable
fiable indicators or approaches for assessing sustainable healthy diets
indicators or approaches for assessing sustainable healthy diets or food systems were ex- or food systems
were excluded.
cluded. Selected Selected
articlesarticles were de-duplicated
were de-duplicated by a search
by a search tool in tool in Zotero
Zotero citing man-
citing manager [30]
ager [30] 2).
(Figure (Figure 2).

Figure 1. Trend in the number of publications using the search terms “healthy and sustainable diet”,
Figure 1. Trend in the number of publications using the search terms “healthy and sustainable
“sustainable and healthy diet”, “sustainable diet” and “healthy diet”, “sustainable healthy diet”,
diet”, “sustainable and healthy diet”, “sustainable diet” and “healthy diet”, “sustainable healthy
“healthy sustainable diet” published from 2000–2020, excluding 2021, and listed on Scopus, Web of
diet”, “healthy sustainable diet” published from 2000–2020, excluding 2021, and listed on Scopus,
Science
Web and PubMed
of Science (28 February
and PubMed 2021). 2021).
(28 February

1. Specific
Table Table keywords
1. Specific used inused
keywords the different domains
in the different in the literature
domains review.review.
in the literature

Nutrition and HealthNutrition and Health Environmental

Environmental Socioeconomic
Socioeconomic
Nutrient requirementNutrient requirement
Bioavailability Bioavailability
Nutritional quality Environmental sustainability
Nutritional quality
Food intake / food consumption Environmental sustainability
Footprint Socioeconomic costs
Food intake / food
Animal food / plant-based food Footprint Socioeconomic
Life cycle analysis Economicscosts
Processed food consumption Life cycle analysis Economics
Enriched food
Agrobiodiversity Trade
Animal food / plant-based food Agrobiodiversity Trade
Dietary supplement Greenhouse
Greenhouse gas emissions
gas emissions Productivity
Productivity
Processed food
Serving size WaterWater consumption
consumption Affordability
Affordability
Dietary recommendation Enriched food Soil health
Soil health Consumer preferences
Consumer preferences
Dietary guideline Dietary supplement Biodiversity Culture
Biodiversity Culture
Healthy diet Serving size Energy
Diet quality/diet quality index Energy
Dietary recommendation
Disease risk
Sustainable diet
Dietary guideline
 Healthy diet
Diet quality / diet quality index
Foods 2021, 10, 999 Disease risk 4 of 31
Sustainable diet

Figure 2. PRISMA flow diagram of the selection process of indicators for assessing research papers
Figure 2. PRISMA flow diagram of the selection process of indicators for assessing research papers
on on sustainable
sustainable healthy
healthy diets.
diets. MainMain keywords:
keywords: “healthy
“healthy and sustainable
and sustainable diet”, “sustainable
diet”, “sustainable and and
healthy
healthy diet”,
diet”, “sustainable
“sustainable diet”
diet” and
and “healthy
“healthy diet”,
diet”, “sustainable
“sustainable healthy
healthy diet”,
diet”, “healthy
“healthy sustainable
sustaina-
blediet”.
diet”. Other
Other keywords:
keywords: see
see Table
Table11(28
(28February
February2021).
2021).

3. Healthy Sustainable Diets in the Literature

3. Healthy Sustainable Diets in the Literature
3.1. Healthy Diet
3.1. Healthy Diet
Some of the latest studies point to the following dietary recommendations in promot-
ingSome of the
overall latest studies
wellbeing and lowpoint
risktoofthe following
major chronic dietary recommendations
disease: (1) protein sourcesin promot-
primarily
ingfrom
overall wellbeing
plants, includingandsoylowfoods;
risk of major
other chronicand
legumes; disease: (1) protein
nuts, fish sourcessources
or alternative primarily
of n-3
from plants, including soy foods; other legumes; and nuts, fish or
polyunsaturated fatty acids (PUFA) consumed several times per week with optional mod-alternative sources of
n-3est
polyunsaturated fatty acids (PUFA) consumed several times per week
consumption of poultry and eggs and low intakes of red meat, if any, and especially of with optional
modest consumption
processed meat; (2) offat poultry
obtainedand eggsfrom
mostly and unsaturated
low intakes plant
of redsources
meat, ifwith
any,low
andintakes
espe- of
cially of processed meat; (2) fat obtained mostly from unsaturated plant
saturated fats and no consumption of partly hydrogenated oils; (3) carbohydrates primarily sources with low
intakes
from of saturated
whole grains fats
withand lowno consumption
intake of partly
of refined grains andhydrogenated
less than 5% ofoils; (3) carbohy-
energy from sugar;
drates
(4) atprimarily
least fivefrom
dailywhole grains
servings with fruits
of fresh low intake of refined grains
and non-starchy and less
vegetables; andthan 5% of
(5) optional
energy from dairy
moderate sugar;consumption
(4) at least five daily servings
[6,31–33]. of fresh fruitscan
These components andbenon-starchy
combined in vegeta-
various
bles; and (5) optional moderate dairy consumption [6,31–33]. These
types of omnivore, vegetarian, and vegan diets [6]. This nutritional guidance improves components can be
combined in various types of omnivore, vegetarian, and vegan diets [6].
the intake of most nutrients. However, specific cases of dietary inadequacies require ob- This nutritional
guidance
taining improves the intake
nutrients from of supplements
dietary most nutrients. or However, specific
enriched foods cases The
[34–41]. of dietary inad-
most accepted
equacies require
nutritional obtaining
criteria proposednutrients
for a from
healthydietary supplements
diet are summarized or enriched
in Table 2.foods [34–41].
The most accepted
Some studiesnutritional
analyzingcriteria proposedbetween
the association for a healthy
healthdiet
andaredietsummarized
are based oninprecon-
Ta-
bleceived
2. concepts and established hypotheses that do not support the cause–effect results
and do not take into consideration the sustainability of the assessed diets. A balanced
and healthy diet should be based on available, accessible, affordable, safe and culturally
acceptable food and allow guaranteeing socio-economic and environmental sustainability.
Foods 2021, 10, 999 5 of 31

Table 2. Accepted nutritional criteria for defining a healthy diet (according to mainstream science) *.

Criteria Rationale Relevance and Comments References

Dietary sugars are not more harmful than
Dietary sugars have been excess of dietary energy. However, if the
linked to dental caries, obesity, energy is excessive, a higher intake of added
Reduce intake of sugars and cardiometabolic diseases, sugar (especially from sugar-sweetened [42–46]
including type 2 beverages) might be associated with poorer
diabetes (T2DM). diet quality and might increase the risk of
caries, overweight, and T2DM.
Cardiovascular diseases (CVDs) have been
linked to saturated fat intake based on
observational studies with contradictory
Cardiovascular diseases results. Some studies question further limiting
Reduce intake of saturated fat (CVDs) have been linked to the intake of such fats. Effect of a specific
[47–54]
as much as possible saturated fat intake based on saturated fatty acid should be considered and
observational studies. not “generic saturated fat”.
It is the higher intake of trans-fatty acids that is
associated with greater risk of CVDs in a
dose–response fashion.
Anti-inflammatory and The same ratio can be obtained with different
anti-aggregatory activities are individual amounts of n-3 and n-6 PUFAs.
linked to n-3 PUFA. The ratio is about 9.3 when linoleic,
Reach a low n-6:n-3 ratio Conversely, the n-6 PUFAs are arachidonic, a-linolenic, docosahexaenoic, [55–58]
considered precursors of and eicosapentaenoic acids are only
pro-inflammatory and considered. This ratio is based on data
pro-aggregatory mediators. association and not cause–effect studies.
Evidence from observational studies
conducted in different countries does not
indicate a significant association with
cardiovascular disease risk. Findings from
intervention trials prove that dietary
From the 1960s,
cholesterol does not increase plasma
epidemiological studies have
cholesterol. Likewise, the impact of dietary
Reduce intake of cholesterol suggested that dietary [59–70]
cholesterol on the immune response
cholesterol contributes to the
remains unclear.
increased risk of CVD.
Not all subjects respond equally to
dietary cholesterol.
Dietary guidance focused on dietary patterns
is more effective in improving diet quality and
promoting cardiovascular health.
The recommended protein intake level
(0.8 g/kg) was derived as a minimum amount
to avoid the loss of body nitrogen.
Higher protein intake can help maximize
health benefits, particularly in older
The recommended protein
individuals. Amounts of protein above
intake level (0.8 g/kg) was
recommended do not appear to have
derived as a minimum
harmful effects.
amount to avoid the loss of
It is unclear whether the relation animal
Protein amount and source body nitrogen. [71–85]
proteins–diseases (cancer, CVD, T2DM,
Animal proteins have been
osteoporosis, etc.) is indicative of a causative
linked to increased risk of
effect or due to other diet and lifestyle factors.
many diseases (cancer, CVD,
The role of plant or animal proteins in diseases
diabetes, osteoporosis, etc.)
or mortality is difficult to isolate. If there is a
difference, it is reduced. Evidence to date is
inconclusive. Globally, plant protein
consumption is not more advantageous than
animal protein consumption and vice versa.
Foods 2021, 10, 999 6 of 31

Table 2. Cont.

Criteria Rationale Relevance and Comments References

Several dietary guidelines,
The reduction in blood pressure is clinically
health organizations and
relevant in the hypertensive population,
government policies
especially in the elderly and Black ethnicity
recommend population-wide
Reduce intake of salt populations. There is not enough scientific [86–90]
sodium restriction to prevent
evidence to recommend salt reduction in the
hypertension and related
general population. Health policies should
comorbidities such as
focus on the target population.
heart failure.
Colon cancer (CC) is an entity with different
Observational studies suggest molecular subtypes. Epidemiological studies
a protective role of dietary can mask these subtypes. Few studies consider
Intake of dietary fiber [91–95]
fiber intake in colon environmental and molecular factors together.
cancer risk. Regarding CC patients, increased fiber intake
does not reduce the risk of recurrence.
Consumption of PO is associated with an
increase in LDL cholesterol, but irrelevant
PO contains a high amount of
clinically. Insignificant effects on fasting
saturated fat (40–50% of total
glucose and insulin. The studies to date do not
Reduce intake of palm oil (PO) fat). Their low consumption [96–102]
establish strong evidence for or against PO
has been proposed as a policy
consumption relating to cardiovascular disease
to reduce deaths due to CVD.
risk and cardiovascular
disease-specific mortality.
Butter consumption was weakly associated
with all-cause mortality in prospective studies.
A theoretical analysis suggests that
substituting butter with tub margarine may be
Butter and margarine contain
associated with reduced risk of myocardial
Reduce intake of dietary fats high amount of saturated fats.
infarction. Beef fat was more effective in [103–105]
(butter and margarine) Saturated fats have been
reducing LDL-cholesterol as compared with
linked to high CVD risk.
butter according to randomized trials.
The number of studies remains insufficient to
conclude a cause–effect relationship between
fats and CVD.
Intake of dairy products was associated with a
neutral or reduced risk of T2DM and a reduced
risk of CVD, particularly stroke. The evidence
suggested a beneficial effect of dairy intake on
Saturated fats from whole
bone mineral density but no association with
dairy derivatives have been
risk of bone fracture. Among cancers,
associated with increased risk
Reduce intake of whole dairy dairy intake was inversely associated with
of chronic diseases including [106–122]
products CRC, bladder cancer, gastric cancer, and breast
obesity, metabolic syndrome,
cancer, and not associated with risk of
T2DM, CVD, osteoporosis,
pancreatic cancer, ovarian cancer, or lung
and cancers.
cancer, while the evidence for prostate cancer
risk was inconsistent. Consumption of dairy
products was not associated with
all-cause mortality.
Foods 2021, 10, 999 7 of 31

Table 2. Cont.

Criteria Rationale Relevance and Comments References

After multivariate adjustment for dietary and
non-dietary risk factors, total, unprocessed,
and processed red meat intake were each
associated with a modestly higher risk of CVD.
Meats, meat products and meat derivatives are
From the 1970s,
inconsistently classified or misclassified into
epidemiological studies have
food groups when dietary questionnaires
suggested that cancer and
are applied.
CVD risks are linked to red
Reduce or suppress intake of Studies examining the relation between the
meat. Saturated fat, heme iron, [123–135]
red meat consumption or avoidance of meat and
N-nitroso compounds,
psychological health varied substantially in
and sialic acid have been
methodologic rigor, validity of interpretation,
implicated as causes of the
and confidence in results. Most studies,
increased risk.
and especially the higher quality studies,
showed that those who avoided meat
consumption had significantly higher rates or
risk of depression, anxiety, and/or
self-harm behaviors.
From the 1990s, 50 more indices have been
proposed based on nutrients, foods or
combining the two. Most recent proposals
include inflammatory or cardiovascular
risk biomarkers.
The main limitations of these indices include:
a non-standard methodology, “a priori”
An index combining the
scoring, estimation of nutrient and
above criteria would allow the
biocompound intakes by questionnaires,
objective assessment of diet
Dietary quality index failing to distinguish between some food types, [136–142]
quality. Such indices would
difficulty in establishing a strong dose–effect
facilitate the implementation
relationship, inclusion of subrogated
of dietary guidelines.
biomarkers, exclusion of different ethnic
groups and phenotype/genotype profiles,
poorly defined “lifestyle”, etc.
Some recommendations obtained from these
indices are unrealistic since they propose food
substitutions that nutritionally are
not interchangeable.
* The details of the nutritional and healthy indicators used to assess a sustainable healthy diet are provided in Table S1.

3.2. Environmentally Sustainable Diet

The two main approaches used to address the environmental sustainability of diets
and food systems are life cycle analysis (LCA) and environmental footprints. LCA as-
sesses the environmental impact of a product from resource extraction, manufacturing,
and transport to use and end-of-life disposal [143]. Ideally, LCA studies cover every rel-
evant environmental category. However, in the case of diet-related impact assessments,
only a few environmental indicators are generally used to perform analyses. The most
common and recurrent impact categories applied in these studies are climate change,
freshwater use, land use, acidification, ecotoxicity, eutrophication, human toxicity, ioniz-
ing radiation, ozone depletion, particulate matter, photochemical ozone formation and
resource depletion [144–150]. There are no standardized methodologies to perform LCAs
for diets. Thus, authors add and discriminate environmental indicators in different ways,
leading to a wide variety of studies that differ in scale and sets of environmental indicators,
hindering data comparisons.
Environmental footprint approaches are able to pair food-production estimates with
country-specific environmental footprints and compare them with planetary boundar-
Foods 2021, 10, 999 8 of 31

ies [151,152]. The footprint indicators used in sustainable diet studies are GHG emissions,
freshwater use, land use and nitrogen, phosphorus application, biodiversity, energy and
the ecological footprint [153–161]. However, many authors do not adopt these methodolo-
gies from a holistic perspective to assess the environmental impact from diets. The vast
majority of studies take into consideration a single or few environmental aspects or im-
pact categories (Table 3). Therefore, the results obtained from these kinds of assessments
have to be interpreted rigorously as they may show a reductionist outlook of the whole
environmental impact.
Recommendations from wealthier countries such as Europe include reducing the
consumption of certain products, such as red meat and sugar, particularly by reducing
excessive consumption, and increasing the consumption of fruits, vegetables, nuts and
legumes [6,162]. Beyond these relevant global trends, a deeper understanding of the
impacts of different production systems would be useful to improve and facilitate the
decision-making. Furthermore, these methodologies do not generally consider aspects
such as the rate of local/regional food consumption and seasonality, agrobiodiversity and
organic/eco-friendly production and consumption [163]. These approaches are discussed
in detail in Section 4.2.

Table 3. Indicators of an environmentally sustainable diet *.

Environmental Concern Indicators and Definition Relevance and Comments References

Land conversion for crop and animal
agriculture is the main driver of habitat
loss, which currently continues to be the
Biodiversity footprint: leading threat to biodiversity.
Biodiversity loss biodiversity loss related to Increasing crop yields, reducing [164–168]
products and processes. deforestation and reducing meat
consumption may be the most effective
means to prevent biodiversity loss in
future years.
Energy use: energy used in the
Food production, transport and
production and/or cooking of a [169]
consumption require large inputs of energy
product or process.
that have a significant environmental
Energy consumption and GHG emissions: release of impact. Energy consumption is commonly
greenhouse gas (GHG) greenhouse gases into linked to GHG emissions, as energy [170–181]
emissions the atmosphere. generation methods are some of the main
Carbon footprint: total GHG emission sources.
emissions caused by a product or Global carbon emissions have increased by
nearly 50% since 1990. Food production is [182]
process, expressed as carbon
dioxide equivalent. one of the main causes of climate change.
Globally, 30% of food is wasted annually
(IPCC, 2019). In fact, avoidable food waste
represents the largest fraction of overall
Food waste and losses: decrease food waste. The environmental footprints
Food waste in the quantity or quality of food. of an average person’s daily food waste are: [4,154,183,184]
Daily food waste per capita. 124 g CO2 eq., 58 L of freshwater use,
0.36 m2 of cropland use, 2.90 g of nitrogen
use and 0.48 g of phosphorus use.
Foods 2021, 10, 999 9 of 31

Table 3. Cont.

Environmental Concern Indicators and Definition Relevance and Comments References

Agrobiodiversity: variety and
variability of animals, plants and
micro-organisms that are
necessary for sustaining key
functions of the agro-ecosystem.
There is currently no agreed,
standard way of measuring
agrobiodiversity in diets, food Species richness and diversity scores are
production or genetic resources. usually related to adequate levels of
Indices include the Simpson’s micronutrients and presented as a
Food and vegetable diversity, Shannon’s diversity, promising solution for food security issues.
biodiversity and Dietary Species Richness. Furthermore, maintaining genetic diversity [185–194]
(agrobiodiversity) Beyond conventional measures, is key for agricultural crops and livestock
the Agrobiodiversity Index to be able to adapt—naturally or with
(ABD Index) is a method of human intervention—to future needs and
measuring agrobiodiversity in a challenges and be resilient to disturbances.
consistent, long-term manner to
be applied across all pillars of
sustainable food systems.
The ABD Index assesses diversity
in production, food markets,
consumption, conservation,
and seed systems.
Land use change: the acquisition
of natural resources for human
needs (croplands and pastures), [195]
often at the expense of degrading
environmental conditions.
Land use: agricultural land
required to produce crops for
direct human consumption, According to FAOSTAT, in 2017, 50% of
as feed and for usage in industry habitable land was used for agricultural [196,197]
and the energy sector, plus the purposes, of which 77% was used for
area needed to produce the animal feed. Land and soil degradation is a
commodities’ packaging material. global challenge that may contribute to
Human carrying capacity: food insecurity, higher food prices and
climate change in the near future. Overall, [198]
persons fed per unit land area.
changing land use, high-yield cultivars and
Land footprint: amount of land meat products are the main triggers of
Land use needed to produce food land deterioration.
(grasslands, croplands used to
[199,200]
produce feed crops,
and croplands used to produce
crops for human food).
Forest cover loss: areas of forest
cover removed related to land [201]
use changes.
Ecological footprint: biologically
productive area people use for
their consumption and pollution
(i.e., crop-, grazing-, forest-, fish-,
[202,203]
built-up and carbon-uptake land)
to the biologically productive area
available within a region or
the world.
Chemical footprint: all chemical Pesticides used in the agricultural
substances released into the production phase are the main contributors
Pesticide use environment which may to ecotoxicity and human toxicity episodes. [149]
ultimately lead to ecotoxicity and The use of such chemicals is not commonly
human toxicity impacts. addressed by sustainability approaches.
Foods 2021, 10, 999 10 of 31

Table 3. Cont.

Environmental Concern Indicators and Definition Relevance and Comments References

N footprint: total amount of N
released into the environment
during the food chain as
emissions of nitrous oxide,
nitric oxide, ammonia or
molecular nitrogen to the
atmosphere, or as nitrate or [183,184,204,205]
A 50% increase in the N and P input to
organic nitrogen to the
Nitrogen (N) application agricultural fields from 2010 levels will be
hydrosphere before the food
required by 2050. N and P losses,
product is supplied to the
agriculture intensification and dietary
consumer. In some studies, it has
been considered equal to N use. choices are responsible for eutrophication
in many parts of the world and are
N loss: nitrogen losses to the endangering many freshwater and
environment from agriculture coastal ecosystems. [206]
(croplands and animal
manure management).
P footprint: total amount of P
Phosphorus (P) released into the environment as a
result of food consumption. [205,207]
application
In some studies, it has been
considered equal to P use.
Green water footprint: volume of
rainwater consumed during the
production process.
Blue water footprint: volume of
surface and groundwater
consumed as a result of the
production of a good or service. [184,208–214]
Grey water footprint: the grey
water footprint of a product is an
indicator of freshwater pollution
that can be associated with the
production of a product over its Agriculture (including irrigation, livestock
full supply chain. and aquaculture) accounts for
Water use and/or scarcity Water use efficiency: approximately 70% of total freshwater use.
and pollution micronutrient output per liter Actual population growth and climate [215]
consumptive water use. change scenarios are substantially
Blue water scarcity footprint: increasing levels of water stress globally.
equivalent amount of water Some of the most promising means to
improve water use efficiency involve a [157,199,216]
withdrawn from a waterbody at
the global average level of stress. combination of plant-based dietary choices
and reducing food loss and waste.
Green-blue water (GBW) scarcity
index: ratio of GBW availability
and water resource requirements
for producing a country-specific [210,211]
3000 kcal/cap/day model diet
with 20% of the energy from
animal products.
Blue water scarcity: blue WF
amounts in relation to local blue [213]
water availability.
* The details of the studies on the environmental sustainability indicators used to assess a sustainable healthy diet are presented in Table S2.

3.3. Socioeconomic Approach to a Sustainable Healthy Diet

Food security remains the most significant challenge to the development of sustainable
and healthy diets. Over 2 billion people, mostly in low- and middle-income countries,
do not have regular access to safe, nutritious and sufficient food [217]. However, irregu-
lar access is also a challenge for high-income countries, including for 8% of the populations
of North America and Europe. Most environmental studies on sustainable diets neglect
or minimize socioeconomic factors, rendering their recommendations empirically unfeasi-
Foods 2021, 10, 999 11 of 31

ble. Furthermore, there is a bias in the geographical focus of studies towards high- and
middle-income countries. Of the country-specific studies analyzed, 121 address high-
/middle-income countries, while only 26 focus on low-income countries. Dietary choices
have macroeconomic and microeconomic implications for both the producer (supply) and
consumer (demand) sides. Most studies identify criteria affecting consumer behavior—
either affordability and/or acceptability (Table 4 and Table S3). A small number of studies
consider the distinct constraints that food producers face when adopting the production of
healthy food and using methods that minimize environmental damage. Another strand
of literature analyzes the value chains that take products from suppliers to the consumer.
What is missing from the literature are comprehensive socioeconomic approaches based on
criteria that affect supply and demand and the necessary value chains that connect them.

Table 4. Socioeconomic indicators for a sustainable healthy diet*.

Criteria Comments References

Supply side indicators Those affecting the production and distribution of food
Many of the assumptions of sustainable diet models are too rigid to resist
empirical testing:
• Perfect substitutability among foods;
• Perfect substitutability of land for different forms of
Scalability and feasibility agrarian production; [218,219]
• Constant yield growth rates;
• Resistance of organic agriculture to pests and climate patterns.
A key question for any sustainable diet concerns whether it can be
empirically implemented on a large scale.
Value chains consist of involved actors (including public organizations and
private firms) and the sequence of activities performed to bring a product
from production to the consumer. Functioning supply chains require not
Value chain approach only cooperation among supply chain actors (including farmers and [219–222]
between producers and other firms) but also rely on other supporting
functions such as transport networks, standards and regulation
enforcement, and credit markets.
Local and organic agriculture is less productive per hectare and more
vulnerable to climate patterns and pests. These risks elevate production
Production costs costs and must be considered for producers to undertake modes of [223–226]
production beneficial for both the environment and producers’ long-term
business survival (especially in low-income countries).
It is necessary to consider the impact on farmers’ livelihoods, especially for
Ethical and societal factors smaller operators and those in underdeveloped economies reliant on [219]
livestock production for income and wealth.
Demand side indicators Those affecting consumer food choices
Availability The availability of sufficient quantities of food of appropriate quality. [219]
Locally grown, organic, non-processed food lasts fewer days and must be
more often purchased close to the production date. Such limitations must
Resilience (stability) be accounted for to encourage the consumer to undertake dietary changes [224]
beneficial for the environment and guaranteeing the supply of food
(especially in low-income countries).
A healthy/sustainable diet is more costly than a conventional diet.
Affordability The environmental costs associated with a conventional diet are not high [156,227–230]
enough to compensate for the difference.
Beyond costs, consumer preferences are affected by a host of factors such
as cultural values, family habits, religious beliefs, physical adaptations
Acceptability including those of digestibility and intolerance (different populations show [231–233]
different degrees of tolerance for certain foods), convenience (time to cook),
etc., affecting what is acceptable for different consumers.
Income inequality increases the likelihood of severe food insecurity.
Access equality The likelihood of being food insecure is higher for women than men in [217]
every continent.
* The details of the studies on the socioeconomic indicators used to assess a sustainable healthy diet are presented in Table S3.
Foods 2021, 10, 999 12 of 31

4. Dispelling the Misconceptions

4.1. Nutrition and Health Approaches
The WHO establishes that a healthy diet protects against malnutrition and forms
the basis for health and development, preventing the development of diseases including
diabetes, cardiovascular diseases, some cancers and other conditions linked to obesity [234].
However, defining a global healthy diet is a challenge given the multiple factors to consider
as people have different nutritional needs according to their age, sex, disease status and
physical activity levels, and the particularities of vulnerable populations, such as young
children and pregnant women, must also be taken into account [6]. In line with the WHO,
in some countries and social classes the excessive consumption of low nutritional quality
foods, which are generally inexpensive, and of certain animal products among some coun-
tries and social classes, can lead to excessive sugar, salt, fat and energy intakes. This section
brings to light several concepts mentioned in Table 2 of this work that are sometimes
unclear and considered important to achieve a balanced and high-quality nutrition.

4.1.1. Nutritional and Healthy Properties of Foods

Dietary sugars have two sources, either as naturally contained sugar or as added
sugar during formulation or processing steps. Correlating the sugar occurrence in foods,
either rich or poor in nutrients, with diet quality is challenging in those studies that focus
on products with added sugar but do not assess the total sugar, and the food intake is
generally concomitant with other foodstuffs that, may or may not, have sugar too [45].
A certain amount of fat in the diet is essential for the development of nervous system
tissues, for the assimilation of fat-soluble vitamins and for maintaining an energy balance in
healthy individuals. For years, dietary fat was assumed to increase blood cholesterol levels,
leading to an elevated risk of cardiovascular diseases. However, current evidence, based on
intervention trials and epidemiological studies, does not support the “diet cholesterol—
heart disease” hypothesis [52,62,235].
Therefore, edible fats in a balanced diet must be obtained from plant and animal
sources. Nevertheless, several studies suggest a relationship between “red” meat intake
and illnesses such as cardiovascular diseases, diabetes and cancer [236–238]. However,
inflammatory processes that trigger these diseases are due to multiple factors such as
environmental pollution, lifestyle (stress, sedentarism, and smoking), and unbalanced diet
(especially overeating takeaway meals and fast-food consumption). Neutral findings have
been obtained as regards the n-6 to n-3 PUFA ratio and cardiovascular disease protection.
The critical aspect is to intake indispensable polyunsaturated fatty acids (n3 and n-6) in
minimal quantities, not considering their relative proportions. This, together with the fact
that n-3 PUFA and n-6 PUFA involve different components, has given rise to the suggestion
of the obsolescence of this index [57].
Proteins are considered the sources of amino acids needed to maintain muscle health
and, in some way, to have a beneficial role in the prevention of osteoporosis [79,83]. Pro-
tein digestion velocity, other macronutrients’ intake and absorption rates would determine
the body protein use and therefore the protein requirements of each individual [84]. In this
connection, meat intake prevents the loss of muscle mass (i.e., sarcopenia) and promotes
bone health since eating foods rich in protein of high biological value stimulates muscle
formation joined to physical activity, even if moderate [239,240].
Many edible algae, mushrooms and plants predominately contain an inactive corrinoid
named pseudovitamin B12 [241]. Vitamin B12 deficiency is common in approximately
6–12% adults under 60 years old, mainly due to limited dietary intake of animal foods
or poor absorption of the vitamin. Vegans as well as other population groups with low
intake of animal foods or those with restrictive dietary patterns are at risk of vitamin B12
deficiency and are recommended to take supplements [242–245].
The rising prevalence of vitamin D deficiency (serum 25(OH)D < 50 nmol/L) affects
both low- and high-income countries [246]. Very few foods found in nature are good
sources of cholecalciferol (animal foods high in fat). Therefore, it is needed to obtain
Foods 2021, 10, 999 13 of 31

sufficient sunlight for endogenous synthesis of vitamin D, and even then, there will be
population groups that do not meet their requirements in sunny regions. The fortification
of staple foods provides the majority of vitamin D for those with low sun exposure, low fat
intake and plant-based diets. Milk, margarines and cereals are fortified with vitamin D in
countries of Northern latitudes [247]. Many types of fermented milks and most alternative
vegetable beverages are also enriched with vitamin D but may contain excess sugar and
must be evaluated as regards their consideration as healthy food.
Regarding dietary iron, there are two types of compounds, heme iron (derived from
myoglobin contained in meat and fish) and non-heme iron (derived from plant foods,
eggs and dairy products). While heme iron is well absorbed in the human digestive tract
(15–35%), non-heme iron is generally poorly absorbed (5–10%), although co-ingestion with
vitamin C can improve it [248,249]. Plant-based foods provide non-heme iron. Iron intake
is higher among adults following plant-based diets, but they have lower iron body stores
compared to omnivores [250,251].
The foods richest in zinc are meats from different animals, milk and dairy products
and eggs. Several dietary factors can influence zinc absorption. Phytic acid is the main
dietary factor known to limit the bioavailability of zinc by binding strongly to zinc in the
gastrointestinal tract. This acid is the main phosphorus storage compound found in plant
seeds and especially in cereals and legumes, which makes up a high percentage of foods
consumed through vegetarian diets and are food staples in developing countries. Diets not
rich in animal origin foods must evaluate levels of this essential element to ensure that the
required daily intake levels are achieved [252]. Additionally, selenium content in foods
and beverages varies geographically between countries. The selenium content of foods of
animal origin reflects selenium levels in animal diets, while the selenium content of plants
is directly determined by selenium levels found in the soils in which they are grown [253].
As regards sodium as coming from salt intake through food consumption, the spread
idea that this must be reduced needs a second thought. The decrease in salt intake offers
health benefits when assigned to hypertensive people. However, the same results were
not obtained with the normotensive population. Even so, salt reduction can have potential
side effects on hormones, lipids, and heart rate of people’s health [89].
In October 2015, the WHO’s International Agency for Research on Cancer [254]
classified processed meat as carcinogenic to humans (Group 1) based on sufficient evidence
in humans that the consumption of processed meat causes colorectal cancer. Meanwhile,
red meat is classified as likely carcinogenic (Group 2A). The state of epidemiological science
on red meat consumption and colorectal cancer is characterized by weak associations,
heterogeneity, an inability to discriminate the effects of other dietary and lifestyle factors,
a lack of dose–response effects, and evidence that weakens over time [255,256]. This can
also be applied to many other areas of nutritional epidemiology due to the food intake
complexity, with substantial difficulties in isolating the action of single foods or nutrients.
Regarding egg, intervention trials prove that egg intake increases the total choles-
terol, LDL-cholesterol and HDL-cholesterol, but not triacylglycerides [68]. This highly
accepted idea by consumers is dependent on the plasma reaction to the additional dietary
cholesterol provided.

4.1.2. Nutrition Requirements in Different Population Groups

Together with an unhealthy diet, a lack of physical activity is a leading global risk to
health. Sustainable physical activities have low environmental impact and are culturally
and economically acceptable and accessible [257]. Returning to basic approaches using less
equipment and appliances for everyday tasks could contribute to energy balance through
increased physical activity and could also decrease resource use. Balancing food intake with
energy expenditure will require less food production with accompanying energy savings.
Nutrient intakes should be tailored to meet the needs of different population groups [258].
In this way, due to experiencing a period of rapid growth for infants, this group has
more significant nutritional requirements than any other age group and physiological
Foods 2021, 10, 999 14 of 31

classification. Breast feeding provides ideal nutrition for 4–6 month aged ones, after which a
complementary diet is necessary. The high nutritional demand for children and insufficient
diets can result in inadequate development. The adolescents’ requirements are like those of
adults, with increased intake of protein of animal origin (eggs, meat and fish), consumption
of high-energy foods due to increased energy demands, and intake of calcium and iron due
to high levels of deficiency [259,260]. Heterogeneous physiological characteristics of elderly
people and few studies make it difficult to establish nutritional requirements. Their needs
are like those of young adults, with increased vitamin and mineral intake. In the case of
pregnant women, almost all nutrients should be increased, especially protein, n-3 PUFA,
vitamins A and C and folate. Gradual bone loss is common with aging, especially women,
irrespective of their ethnicity. Inadequate intake of calcium and vitamin D3 increases
the osteoporosis risk; thus, 400–800 IU of vitamin D is recommended in menopausal
women [261].

4.1.3. Food Classification

The term “meat” is heterogeneously described in regulatory, consumer and scientific
environments [135]. Muscle food descriptors and categories are broad and disparately
described, which has a big impact on the epidemiological studies’ comparative conclusions.
Indeed, the terms “red meat” and “white meat” are not sufficiently informative to precisely
classify meat sources. The myoglobin concentration in meat is what defines it as red or
white. However, the erroneous myth exist as regards the association of red meat with high
levels of saturated fats. As, for example, beef versus veal meats are sometimes considered
red and white meat, respectively, yet they come from the same animal. In general, poultry
meat is classified as white meat, but turkey legs, although classified as white meat, have a
nutritional composition that varies long compared with the breast. These inconsistencies,
together with the fact that different parts of the same animal can have different levels of
nutrients, may lead to discrepancies in the population estimated intakes [134].
Currently, the classification of food types as “minimally processed”, “processed” and
“ultraprocessed” does not properly describe the impact of food processing on health. How-
ever, food processing and packaging do have an impact on the environment (see Section 4.2.2).
This kind of food classification allows different interpretations. There is not an international
definition for unprocessed or minimally processed foods, processed culinary ingredients,
processed foods, and ultra-processed foods and drinks (UPFDs), as can be seen in the
different NOVA and EPIC (European Prospective Investigation into Cancer and Nutrition)
classifications [262]. Nutritional adequacy in industrialized food can be achieved by chang-
ing formulations and not the processing levels [263]. Food formulations often increase the
energy density of food through “ultraprocessing”, with the addition of added fat, sugar and
saturated fats [263]. However, food formulation may also be intended to obtain nutritional
benefits. Food processing can lead to improvements in the food security attributes, having a
minimum effect on its nutritional attributes. Both fresh and processed foods make up vital
parts of the food supply for the consumers, when the aim of processed food is to ensure
that sufficient food is available, and the food quality meets human nutrient needs [264].
Since there is no scientific consensus nor legal regulation about the concept of “func-
tional food” [265], it is necessary to clarify and regulate the definition of nutraceuticals and
their specific role in the prevention and treatment of pathological conditions, supporting
their potential medical use in prevention and therapy only when proven by scientific
and clinical data [266]. Therefore, fortified foods are only effective in subjects with spe-
cial needs [267,268].

4.2. Environmental Approaches

As made relevant in Section 3, the environmental impacts of food production and con-
sumption affect air, water, soil, and biodiversity, deriving toxicity for humans, other living
beings and the planet. Nevertheless, the high diversity of the studies and research makes
it difficult to compare data and extract general conclusions that can guide the definition
Foods 2021, 10, 999 15 of 31

of environmental sustainability indicators. In this section, some of the most important

approaches detected through the reviewed literature that need to be analyzed in depth
are discussed.

4.2.1. Holistic Approaches to Environmental Challenges

Both environmental footprint and LCA approaches are useful when analyzing the
environmental sustainability of diets. However, in practice, most of the analyzed studies fo-
cus on a single or few environmental aspects and hardly any adopt a holistic environmental
approach [146,147,152,155,156,163]. Furthermore, these studies do not generally consider
aspects such as the rate of local/regional food consumption and seasonality, agrobiodi-
versity, organic production and consumption or different types of livestock production
systems in their approaches, which might be important in avoiding unintended environ-
mental consequences of the recommended dietary shift [6,146,147,155,163,269]. A systems
approach integrating the different environmental domains is needed to build resilient
food systems [270].
At the European level, a harmonized environmental footprint (EF) methodology
is being developed at the product and organization levels based on LCA to quantify
environmental impacts [271]. Guidelines are provided to consider different impact-type
categories when addressing different product groups and sectors. However, there are
some impact categories and aspects not addressed by this method, such as biodiversity,
agrobiodiversity and the rate of local/regional foods and seasonality.
At the global level, there are some systemic approaches, commonly used, focusing on
the sustainability of food and agriculture systems, such as the SAFA (Sustainability Assess-
ment of Food and Agriculture systems) [272] and the MEMIS framework (Framework for
Assessing the Sustainability of Natural Resource Management Systems) [273], which in-
clude not only environmental but also socioeconomic attributes and criteria, defined in a
case-to-case basis in the latter.
To date, these three methods have not been applied to diets. However, it might be
interesting to assess the product options and to explore and adapt their application to diets.

4.2.2. Rate of Local/Regional Food Consumption and Seasonality

“Local/regional food” is produced within a short distance of where it is consumed
(up to 100 km or miles) and purchased directly from the producer or with one intermedi-
ate between the consumer and producer. Production “in season” refers to the minimum
artificial conditions used to grow products, without heated greenhouses in the local agro-
environmental conditions and no long-term cold storage [163]. The origins and seasonality
of food are important factors to consider in developing sustainable approaches [274,275].
Air-transported and out-of-season produced vegetables and fruits have considerably higher
carbon footprints than those produced and consumed locally [276]. Moreover, local prod-
ucts are usually associated with more sustainable agricultural practices [161]. According
to the database of the French Environment and Energy Management Agency [277], 1 kg
of lettuce produced in a French heated greenhouse emits 11 kg of CO2eq , whereas 1 kg of
lettuce produced in season generates almost 34 times fewer emissions (0.3 kg of CO2eq ).
Considering that 1 kg of bovine calf produced in a conventional manner emits 6.4 kg CO2eq ,
in this particular case, 1 kg of beef is more environmentally beneficial in terms of GHG
emissions than 1 kg of greenhouse-produced lettuce. Nevertheless, the trade-offs between
local and seasonal food production need to be analyzed on a case-by-case basis. For in-
stance, Hospido et al. [278] estimate that importing Spanish lettuce to the UK during
the winter months results in three to eight times fewer emissions than producing lettuce
locally. The same applies for other foods: tomatoes produced in greenhouses in Sweden
use 10 times as much energy as tomatoes imported from Southern Europe when in sea-
son [279]. Furthermore, the food preservation methods add variability and complexity to
the above. Food processing and packaging can cause significant air pollution, water use
and, if not properly treated, could be a source of environmental waste production and lead
Foods 2021, 10, 999 16 of 31

to increasing disposal and pollution problems [280,281]. In summary, local food production
is necessary but not sufficient to ensure the best choice from an environmental point of
view. Seasonality and preservation methods are also key variables to be considered in
the assessment.

4.2.3. Agrobiodiversity and Organic Production and Consumption

Agrobiodiversity, or agricultural biodiversity, encompasses the variety and variability
of animals, plants and micro-organisms that are necessary for sustaining key functions of
the agro-ecosystem, including its structure and processes for, and in support of, food pro-
duction and food security [282]. It refers to interactions between agricultural management
practices, farmers’ resource endowments, bio-physical resources, and species [283]. Agro-
biodiversity conservation and promotion are essential to achieving food security and nutri-
tional, environmental and socioeconomic goals [185,187–194,284–287]. Some authors have
proposed including agrobiodiversity indexes in diet sustainability assessments [187,193]
(Table S2). Even if the relationships between agrobiodiversity and human interactions have
been clearly identified [194,286], a wide variety of ecosystem services and environmental
benefits could be further analyzed and accounted [193].
Today, organic agriculture based on agro-ecological principles is well characterized,
controlled, certified and labeled [163]. These food production methods refrain from using
synthetic fertilizers and pesticides, GMOs, and intensive animal husbandry and promote
crop rotation focused on soil fertility and closed nutrient cycles [163,269]. The feasibility
of organic agriculture has been contested at a global scale, as a conversion to organic
agriculture implies lower yields and requires more land than conventional agriculture.
However, in combination with complementary measures such as reductions in food waste
and food-competing animal feed from arable land, with a corresponding reduced produc-
tion and consumption of animal products, organic agriculture can help provide sufficient
food for the population while simultaneously reducing environmental impacts [269].
To sum up, adopting agrobiodiversity approaches and related indexes knowledge
and research, as the basis for a healthy environment, would lead the way to develop more
comprehensive diet sustainability assessments and ultimately to more sustainable diets.

4.2.4. Livestock Production Systems

Current data show a substantial contribution of the livestock sector to environmental
resource use and pollution. It is estimated that this sector is responsible for approximately
13% of global GHG emissions [288,289], for occupying 26% of the total ice-free land surface
area (22% through pastures and rangelands and 4% of cropland used for feed) [289,290]
and for 29% of the water footprint [291].
However, the different types of livestock production systems, including extensive
grassland-based systems, intensive landless systems, and mixed farming systems, vary con-
siderably in terms of environmental pressure [292]. For instance, extensive grassland-based
systems and silvopastoral systems with appropriate stoking rates, which generally use
land not suitable for other purposes (i.e., there is not feed–food competition), can help
store carbon in the soil and lower livestock emissions [293]. The blue water footprint and
nitrogen-related grey water footprint are also reduced [294], and the supporting biodi-
versity and ecosystem services are improved [295,296]. Based on a land use optimization
model, Van Kernebeek et al. [297] concluded that moderate meat consumption is more
beneficial to the environment than vegan and vegetarian diets. Their results contradict the
conclusions of previous LCA studies because the latter did not consider the unsuitability of
marginal lands for growing crops, the suitability of animals for human-inedible products
and the coproduction of meat and milk [147]. On the other hand, besides being fed by
biomass produced from marginal lands, livestock can also take advantage of crop residues
and food waste, improving the circularity of the food systems [298].
Context-specific holistic assessments of a harmonized scope are needed to evaluate
the trade-offs and win-win solutions that could arise from different animal production
Foods 2021, 10, 999 17 of 31

practices and systems [6]. These considerations highlight the need to take into account the
production model and the role of livestock in the agroecosystems.

4.3. Socioeconomic Approaches

4.3.1. Supply
From the supply side, any proposal for a sustainable diet must have its feasibility and
scalability evaluated, that is, whether it can be empirically implemented on a large scale
to feed the world at affordable prices. Any action to promote more sustainable farming
techniques must lower risks for producers of undertaking modes of production that benefit
the environment but also guarantee producer’s long-term business survival (especially in
low-income countries). In addition, the availability of functioning supply chains requires
not only cooperation among supply chain actors (including farmers, producers and other
firms) but also reliance on other supporting functions such as transport networks, standards
and regulation enforcement, and credit markets.
The sustainability of the food supply chain is affected by several factors, such as
(1) the length of food supply chain networks with shorter or larger distances and more or
less direct relationships between producers and consumers, (2) the effects of technology
improvements in increasing the efficiency of the food supply chain, and (3) possibilities
for food supply chain optimization via increased productivity or waste reduction. Addi-
tional research efforts to reduce food loss through preservation, reduce transit times and
benefit local and seasonal production are important to avoid unintended consequences of
recommended dietary shifts [299].
In line with the reviewed literature, the projected increase in the world’s population,
coupled with rising incomes, will contribute to an increase in global demand for livestock
products to obtain proteins of high biological value [4,20]. In this context, it will be
necessary to seek new ways to supply protein from a variety of sources. There is growing
research and development focused on alternative protein-based foods using edible insects,
algae or cell culture production [219]. Only the creation of new production models based
on energy efficiency, the robotization of the agrifood industries and the use of renewable
energy could achieve both sustainability and high nutritional value for many of the foods
in our diet which need to be provided to the markets at reasonable costs.

4.3.2. Demand
Food demand studies have often been conducted with a focus on diets and populations
in developed countries and lower income groups, where evidence also suggests that
healthier diets may be costlier than less healthy diets, which, along with knowledge,
accessibility and other factors, most likely presents a barrier to the adoption of healthier
diets [300–305].
Some aspects about the potential for cultural or birthplace bias should be considered.
Low-income populations generally cannot afford healthy food and base their diet mainly
on vegetables. In relation to plant-based dietary patterns, vegetarian diets show a modest
cardiovascular benefit. However, vegetarians are more likely to have lower iron stores than
non-vegetarians [251,306]. Vegan mothers present increased risks of delivering newborns
with low birth weight than omnivorous mothers [307–310]. Scientific data do not allow us to
draw firm conclusions on the health benefits or risks of present-day vegan diets relating to
the nutritional or health status of children and adolescents in industrialized countries [309].
Owing to birthplace bias, rice is a staple food for over half the world’s population,
with Asia being a high rice-consuming continent [311]. The contribution of rice to estimated
zinc intake is very low coupled with thiamine deficiency. Therefore, this population
will need to consume foods rich in this element, such as meat, milk and dairy products,
pulses and seafood [312].
Individual preferences, beliefs and cultural traditions are key in shaping food con-
sumption patterns [313]. For instance, insects are part of the food culture in some coun-
tries, while in other countries, such as Western countries, populations are reluctant to
Foods 2021, 10, 999 18 of 31

accept insects as food because they are usually considered pests and sources of contami-
nation [219]. Gaining a deeper understanding of consumers’ attitudes, purchase behavior
and buying motives regarding different sustainability attributes is recommended for fu-
ture studies [147].
Consumers are seeking new foods that offer variety, hedonic experiences, welfare,
safety and especially health benefits, but they also consider environmental impacts by se-
lecting foods developed based on concepts of sustainability and the circular economy [314].
In recent years, vegan alternatives have emerged, transforming plants into products
named like those used for meat source products but without using animal resources.
These “meat analogues” are intended to serve as substitutes for minced meat such as in
burgers. These foods are composed of legumes, cereals, spices and food additives to create
foods of acceptable organoleptic quality, as shown by an increase in the consumption of
such foods [315]. The emergence of new sensitivities related to food and diet configura-
tions has led to the emergence of plant-based diets. However, plant-based diets, when not
planned properly, may increase risks of health problems emerging from nutritional deficien-
cies of minerals such as iron, iodine, and zinc or vitamins A, D, and B12 and folate, among
others. This has led to the development of novel food products, such as fortified plant
foods or “nutritional supplements’” to prevent nutritional deficiencies in the vegan diet.

5. Indicators for a Sustainable Healthy Diet

After an exhaustive and critical literature review, the published studies show great
heterogeneity in their methods and results. Great advances have been made during the
last few years, but, hitherto, they are still insufficient to obtain conclusive results.
Based on the above analysis and reflection process, a comprehensive set of indicators
is recommended from environmental, health and socioeconomic perspectives (Table 5).
The proposed indicators include not only frequently used indicators such as the carbon
footprint, water footprint or land footprint but also other elements generally missing from
sustainable healthy diet assessments, such as agrobiodiversity and organic certified food
criteria. This harmonized set of indicators could be a step forward for the assessment and
comparison of diets in different countries and contexts.
Finally, there are some fields in need of further research in order to arrive at robust
scientific conclusions, such as the environmental impacts of the different production systems,
including those of alternative proteins, packaging systems or dietary supplements [316,317].

Table 5. Proposed indicators for assessing sustainable healthy diets.

Nutrition and Health Indicators Environmental Indicators Socioeconomic Indicators

• Carbon footprint (climate change)

• Water footprint
• Land footprint, land use
• Rate of local/regional foods
• Nutritional requirements according to age, sex,
and seasonality
and ethnicity (genetic profile could
• Agrobiodiversity
be considered)
• Physical activity/sedentarism prevalence • Nitrogen footprint
• Phosphorus footprint • Availability
• Balance achieved between energy intake from
• Chemical footprint and ecotoxicity • Resilience (stability)
sustainable sources and energy needs
• Acidification • Affordability
• Food diversity and properly typified foods
• Eutrophication • Acceptability
(according to composition, formulation
and processing) • Material footprint (use of fossil fuels, • Access equality
• Food rations adjusted to nutrient/energy metal ores, minerals, • Scalability and feasibility
requirements (serving size according to age and and biotic resources) • Production costs
• Biodiversity footprint • Impacts on farmers’ livelihoods
physical activity)
• Ozone depletion
• Commonly consumed food’s contribution to
• Particulate matter (PM2.5 and
energy, nutrient and biocompound requirements
PM10 footprint)
• Diet-related morbidity/mortality prevalence
• Human toxicity (cancer and non-cancer)
• Ionizing radiation (human health)
• Photochemical ozone formation
(human health)
Foods 2021, 10, 999 19 of 31

6. Conclusions
The recent and growing literature on sustainable healthy diets addresses several
aspects related to the economic, social and environmental dimensions of nutrition and
health. This body of work covers a wide range of approaches, from LCA to environmental
footprint assessment, and countries, mainly developing but also some developed countries.
This literature has and will continue to inform policy, business decisions and dietary
guidelines with increasing influence.
Feeding the world in a sustainable manner will entail two strands of work. First, it will
be important to use a uniform set of parameters and harmonized scopes that properly
integrate economic, social, and environmental aspects when defining sustainable and
healthy diets in dietary guidelines. This will curtail potential environmental burdens or
impacts transferring to other sectors or resources. Second, achieving sustainable diets
implies considering culturally sensitive and context-specific approaches using different
practices and production systems.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/

10.3390/foods10050999/s1, Table S1: The nutritional indicators proposed for defining a healthy
diet according to mainstream science, Table S2: The environmental indicators used for assessing a
sustainable and healthy diet, Table S3: The socioeconomic indicators used for assessing a sustainable
and healthy diet.
Author Contributions: M.M.A., P.D.-L. and B.S.: Conceptualization, review and writing of the
sustainability aspects. M.J.B., F.C.I. and M.T.M.-A.: Conceptualization, review and writing of the
nutrition and health aspects. M.R.-V.: Conceptualization, review and writing of the socioeconomic
aspects. All authors have read and agreed to the published version of the manuscript.
Funding: The project leading to these results has received funding from “la Caixa” and Caja Navarra
Foundation, under agreement LCF/PR/PR13/51080004.
Acknowledgments: The authors are grateful for the administrative support of the IS-FOOD (Pub-
lic University of Navarre).
Conflicts of Interest: The authors declare no conflict of interest.

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