October 2021 Issue
Sustainability and Planetary Health
By KC Wright, MS, RDN
Today’s Dietitian
Vol. 23, No. 8, P. 32
Dietitians are poised to advance this cause and begin with the use of extensive resources.
Most nutrition professionals didn’t anticipate that the word “pandemic” would become part of their daily lexicon over the past 18 months—and counting. But some may not realize that, aside from COVID-19, there are three prevalent pandemics within the scope of nutrition and dietetics: obesity, undernutrition, and climate change. These are considered pandemics that represent some of the gravest threats to human health and survival.1 Together, they compose a cluster referred to as The Global Syndemic, occurring simultaneously with interactions that affect most people worldwide.
There are substantial societal drivers underlying this syndemic, including red meat consumption, as the world now produces more than three times the quantity of meat than it did 50 years ago. Globally, average annual per capita red meat consumption is almost 25 lbs, ranging from more than 80 lbs in the United States to less than half that in both the United Kingdom and Portugal.2 Livestock production comprises approximately 20% of all greenhouse gas emissions, uses 70% of global agricultural land, and is a prime driver of deforestation.1 Regions with intensive livestock production systems also contribute heavily to localized pollution through effluents and air pollution.
Ultraprocessed foods are another driver of the global syndemic, reliant on inexpensive commodity ingredients, including sugar, flours, and oils, often with multiple preservatives, colorings, and flavorings. These products typically are energy dense and nutrient poor, containing excess amounts of fat, sugar, and sodium. High consumption of ultraprocessed foods is linked to poor diet quality, obesity, and diet-related disease risks, while perhaps also contributing to undernutrition and micronutrient deficiencies by displacing more nutritious whole foods. This double burden of malnutrition—the dichotomy of too many nutrient-poor calories causing simultaneous undernutrition and obesity—is increasing, especially in low-income populations.3
Many people don’t recognize that food choices and agricultural food production affect both human and planetary health. Yet, it has become indisputable that diet significantly impacts risk of chronic disease, and how we produce food has put the environment in peril. When the EAT-Lancet Report on Planetary Health debuted in 2019, it demonstrated that human health is intimately intertwined with environmental health.4 Shifting global dietary patterns of high animal food consumption to nutrient-dense, plant-based diets has the potential to mitigate health risks and environmental burdens.5 RDs and DTRs have the skills and access to a plethora of excellent resources to promote planetary health with clients, patients, and consumers.
Sustainable Diets Defined
The Food and Agriculture Organization of the United Nations (UN) defines sustainable diets as those with low environmental impact that contribute to food and nutrition security and health for present and future generations.6 Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, economically fair and affordable, nutritionally adequate, accessible, safe, and healthful, while optimizing natural and human resources.
Sustainability is interrelated with resilience, which is the ability of a system to withstand disturbances and continue to function in a sustainable manner. Issues of sustainability and resilience apply to all aspects of nutrition and dietetics practice; they can be practiced at both the program and systems level and are broader than any one specific practice setting or individual intervention.7 According to Irana Hawkins, PhD, MPH, RDN, faculty of doctoral programs in public health at Walden University in Minneapolis, sustainability isn’t necessarily an outcome. “We don’t ‘achieve’ sustainability ... we continuously create plans to simultaneously do more to improve planetary health. We take action, and we always search for better ways to do things,” Hawkins says. “And RDNs have been trained to do just that.”
The planetary health diet, developed by the EAT-Lancet Commission, is a global reference diet for adults, symbolically represented by half a plateful of fruits, vegetables, and nuts, while the other half of the plate consists primarily of whole grains, plant proteins (eg, beans, lentils, pulses), unsaturated plant oils, and modest amounts of meat and dairy, with some added sugars and starchy vegetables. The diet is quite flexible and allows for adaptation to dietary needs, personal preferences (including vegetarian and vegan diets), and cultural traditions. It’s based on an ideal reference diet that reduces risk of heart disease, diabetes, obesity, cancer, and mortality, with the distinction of recognizing that most current food production methods contribute to poor nutrition worldwide as well as environmental degradation.4
For decades, Americans have failed to meet the recommendations of the Dietary Guidelines for Americans (DGAs), with almost 90% of the population missing the suggested vegetable intake, 80% lacking in fruit consumption, 98% falling below recommendations for whole grains, and 74% exceeding limits for refined grains.8 Meanwhile, about 75% of Americans meet or exceed the recommended intake for meat, poultry, and eggs. In fact, when researchers applied the 2010 Healthy Eating Index to the US food supply, they found that all the food we produce and import had a score of 55 out of an optimal 100, demonstrating a significant disconnect.9 This explains why so often dietitians hear that our food system is “broken.”
The 2020–2025 DGAs are devoid of discussion on sustainability and mention of ultraprocessed foods.10 This is despite the fact that the 2020 Dietary Guidelines Advisory Committee, a group of experts charged with developing dietary guidance for the US population, released their scientific report with a section devoted to the issue of food sustainability. The final DGAs were released with no mention of these issues. The Society for Nutrition Education and Behavior and others in the scientific research community have stated that environmental sustainability should be inherent in dietary practice, specifically in future DGAs.11
Initiatives to include sustainability within dietary guidelines aren’t new. In 1986, nutrition professors Joan Dye Gussow, EdD, of Teachers College at Columbia University, and Kate Clancy, PhD, from Syracuse University jointly published the Dietary Guidelines for Sustainability, which emphasized the need for sustainable agriculture and sustainable food choices to be included in nutrition curricula.12 Gussow and Clancy identified the food system as problematic because it lacked nutrition, was wasteful, relied on cheap fossil fuels, and depleted natural resources. They encouraged consumers to choose minimally processed and minimally packaged foods and, when possible, buy locally produced foods to support regional agriculture.
Sustainable Development Goals
Because obesity, undernutrition, and climate change are intertwined in planetary health, it’s important for dietetics professionals to be knowledgeable about the Sustainable Development Goals (SDGs)—a collection of 17 interlinked global goals announced by the UN General Assembly in 2015 as a call to action by all countries, intended to achieve a better and more sustainable future for all by the year 2030.13 The SDGs recognize that ending poverty and other deprivations are linked with strategies to improve health and education, reduce inequality, and spur economic growth while tackling climate change.
Some of the SDGs focus definitively on nutrition, but “all of these SDGs have clear linkages with nutrition and come into our practice in real ways,” says Marie Spiker, PhD, MSPH, RDN, an assistant professor of epidemiology in the nutritional sciences program at the University of Washington, who served as the Health and Sustainable Food Systems Fellow with the Academy of Nutrition and Dietetics Foundation from 2018 to 2020. Spiker suggests that, perhaps unknowingly, many dietetics professionals already are supporting the SDGs in state and federal food and nutrition programs, for example. In September, the UN Food Systems Summit 2021 convened in New York to generate action and progress on the SDGs, amid significant criticism about corporate control, conflicts of interest, and lack of transparency in the proceedings.14,15
Dietary Factors Impacting Sustainability
Each SDG is closely linked with diet, such as reduced poverty (SDG 1), reduced hunger (SDG 1), and reduced inequities (SDG 10). The social determinants of health within the food system, including the food environment, have the potential to influence diet behavior. For example, residential segregation and land-use zoning can result in low-income people living in food deserts, characterized by a relative lack of healthful and nutritious food options, or food swamps, characterized by an excess of fast food chains and food outlets selling ultraprocessed foods. Research demonstrates that adults living near many fast food restaurants were twice as likely to have obesity than those who lived in areas that had much fewer fast food places to patronize.16 Moreover, the current food system is riddled with health disparities, inequitable access to education and health care, exposure to violence and crime, and systemic discrimination and racism.17
And then there’s price, which remains one of the strongest influences on choice. In the United States, processed, energy-dense foods are abundant, convenient, and cheap, whereas unprocessed healthful foods are less accessible in many areas and often more costly.16 Food prices have risen at rates higher than wages, and the COVID-19 pandemic has only exacerbated this trend.
Unfortunately, the economic burden of The Global Syndemic has become significant, with the heaviest burden on the poorest of the 8.5 billion that will compose the world’s population by 2030. Each year, global obesity, malnutrition, and climate change cost trillions of dollars. Continued inaction towards the global mitigation of climate change is predicted to cost 5% to 10% of the global gross domestic product, whereas 1% of this figure could arrest the increase in climate change.1
Another concern is the nutritional quality and sustainability of plant-based diets. Clients and patients should be aware that not all plant-based diets are nutritionally equivalent. For example, vegetarian diets high in fruit juices, refined grains, potatoes, sugar-sweetened beverages, and sweets and desserts have been shown to increase risk of coronary heart disease.18 This diet is high in ultraprocessed foods, which are highly palatable, cheap, ubiquitous, and aggressively marketed, and they have a long shelf life due to their preservative content. Ultraprocessed foods are highly profitable products in the global food system, mostly run by conglomerates given policy incentives that subsidize commodity ingredients. These conglomerates enjoy deregulated business operating environments, lack of oversight for human health and environmental effects, and industry’s privileged access to policymakers.
RDs are in a unique and dynamic position to promote sustainable food systems regardless of their role or practice within the profession. Examples include procurement of sustainable products in foodservice, nutrition security screening in the clinic, connecting those in need with community resources, evaluating packaging or ingredient sourcing in business and industry, and working to reduce food waste and promote recycling programs in workplaces.
The Academy of Nutrition and Dietetics (the Academy) envisions people thriving with proper food and nutrition and is committed to a global, systemwide collaboration to solve both present and future food and nutrition challenges. Therefore, supporting sustainable food and water systems really isn’t a specialized practice; it’s at the center of the dietetics profession.19 Nutrition is at the core of sustainability—considering how to feed more people healthfully with less land, water, and environmental degradation.
Although many RDs and DTRs were trained to provide diet recommendations solely in terms of nutritional merit, Hawkins says, “we have a diverse skill set, and planetary health lands right on our plates.” One-half of dietetics program directors indicate that their programs connect vegetarian and vegan diets to climate change mitigation and resource conservations, while nearly 60% of programs review flexitarian/semivegetarian/low-meat diets and/or reducing animal products in the diet.20,21
Resources on Sustainable Diets and Planetary Health
RDs often are on the frontlines of the food system, faced with diet-related health issues from unsustainable practices. The Academy’s newly revised Standards of Professional Performance (SOPP) on sustainable, resilient, and healthy food and water systems for RDs demonstrate a variety of ways RDs can leverage knowledge and skills to address underlying drivers of sustainability within the food system.17 “This SOPP is really an underutilized resource,” says Spiker, coauthor of the SOPP. “It provides so much rich information to orient dietetics professionals about the interdependency of nutrition and sustainability.” Because the SOPP is rather lengthy due to an extensive resource table, Spiker suggests first reading through the text. Practical examples of different RD roles also are provided “to help practitioners incorporate the principles of sustainable food systems into their respective areas of practice,” Spiker adds.
The Academy’s “Sustainable Food Systems Primer for RDNs and DTRs” was released in January 2021 to demonstrate the importance of food systems for nutrition practice, as well as provide foundational knowledge, vocabulary, and critical thinking skills so dietetics professionals are equipped to address sustainable, resilient, and healthful food and water systems.22 Spiker emphasizes that the primer mentions the connections between the SDGs and sustainable food systems.
Another avenue RDs can explore is the Future of Food, an education, communications, and research initiative addressing domestic and global food and nutrition security and consumers’ interest in a safe and healthful food supply. It was cocreated by the Academy, Feeding America, and the National Dairy Council to engage hunger relief professionals on issues surrounding agriculture, nutrition, and health. In 2018, Future of Food launched a Sustainable Food Systems Dietetic Internship Concentration to help programs incorporate sustainable food systems training into dietetics education.
The Academy’s Vegetarian Nutrition Dietetic Practice Group has developed two versions of the resource “Plant-Based Diets to Combat Climate Change and to Protect Planetary Health,” one for RDs and DTRs and one for consumer education.
Menus of Change, a partnership between the Culinary Institute of America and Harvard’s T.H. Chan School of Public Health, developed evidence-based tools to educate chefs and foodservice professionals about issues surrounding planetary health. Protein Flip and Protein Plays are Menus of Change resources that include a 12-page infographic highlighting how meat can be harmful to humans and the planet, as well as a toolkit with culinary techniques for shifting the value around meat, increasing flavor while reducing meat, and moving toward more plant protein.
Strategies for Promotion
In addition to learning about sustainability and planetary health, the following tips will help dietitians trumpet the cause:
1. Practice what you preach. According to Hawkins, “Sustainability means little unless you live it.” Dietitians should become proficient in and demonstrate the planetary health principles they want others to emulate.
2. Clarify definitions with clients. If someone hears the words “plant-based,” they may think they’re being encouraged to become vegetarian or vegan. It’s important to keep in mind that the goal for planetary health is reduction—not necessarily total exclusion—of meat and other animal food products, unless the individual chooses. Hawkins stresses that this is the time to convey the importance of consuming whole plant foods that are sustainably grown.
3. Activate systems thinking skills to tie nutrition principles to their impact on producers, livelihoods, and communities. “When we’re thinking about the resource-intensiveness of foods, we need to consider both sustainability and the specific nutritional needs of populations we work with,” Spiker says.
4. Provide nutrition recommendations based on a population’s needs. Dietitians can translate population-level research to subgroups and individuals to promote planetary health whenever they counsel different populations. For example, an RD working with patients at a long term care facility may not want to recommend reducing animal food intake due to this population’s need for vitamin B12 and difficulty maintaining lean body mass. “Due to the specific nutritional needs of this population, we might make different food procurement or menu planning recommendations than if we were working with college students,” Spiker says. Research shows that when dietitians interact with people from different cultures and population subgroups, they can develop awareness of other worldviews to improve efficacy of targeted interventions.23
Hawkins advises RDs to be “patient, yet tenacious” when discussing food sustainability and planetary health, as changing systems and creating new connections about food may involve risk-taking and diplomacy.24
5. Educate clients on how food production and food choices impact nutrition, obesity, undernutrition, and climate change. For example, “identify ways that hospital gardens, community gardens, and urban farms can support both human nutrition and sustainability,” Spiker says.
6. Give clients options to boost intake of plant foods. The Meatless Monday campaign can be helpful in reducing animal food intake. Flexitarianism, or part-time meat consumption, may appeal to a certain subset of consumers. The EAT-Lancet, DASH, Mediterranean, and Healthy Vegetarian diet patterns all have been shown to reduce lifestyle-related disease while promoting sustainability.25 Global lifecycle analysis of emissions data demonstrates that a move to a Mediterranean, pescatarian, or vegetarian diet can reduce greenhouse gas emissions from food production by 30% to 55%.26
7. Network with other stakeholders for planetary health to learn more and support the cause as a foundation of your practice.
Leading the Charge
Sustainable food systems are fundamental to the practice of nutrition and dietetics, and all RDs have the opportunity, and indeed the responsibility, to align their work with these principles.17 RDs comprise the world’s largest organization of food and nutrition professionals who have the distinct expertise and focus to promote planetary health in the kitchen, clinic, and community. Certainly, promoting planetary health requires collective action from many stakeholders, and dietitians can help to catalyze positive change. “It’s clear to me that sustainability is within our scope of practice—we can’t wait for another profession to do it,” Spiker says.
— KC Wright, MS, RDN, is a research dietitian advocating for sustainable foods and planetary health at wildberrycommunications.com.
References
1. Swinburn BA, Kraak VI, Allender S, et al. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet. 2019;393(10173):791-846.
2. Ritchie H, Roser M. Meat and dairy production. Our World in Data website. https://ourworldindata.org/meat-production. Updated November 2019. Accessed July 27, 2021.
3. World Health Organization. The double burden of malnutrition: policy brief. https://apps.who.int/iris/bitstream/handle/10665/255413/WHO-NMH-NHD-17.3-eng.pdf;jsessionid=40F79D006990D6B731F8F50B4E55E95A?sequence=1. Accessed June 30, 2021.
4. Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447-492.
5. Hemler EC, Hu FB. Plant-based diets for personal, population, and planetary health. Adv Nutr. 2019;10(Suppl_4):S275-S283.
6. Food-based dietary guidelines: dietary guidelines and sustainability. Food and Agriculture Organization of the United Nations website. http://www.fao.org/nutrition/education/food-dietary-guidelines/background/sustainable-dietary-guidelines/en/. Accessed June 30, 2021.
7. Tagtow A, Robien K, Bergquist E, et al. Academy of Nutrition and Dietetics: standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in sustainable, resilient, and healthy food and water systems. J Acad Nutr Diet. 2014;114(3):475-488.e24.
8. US Department of Agriculture; US Department of Health and Human Services. 2020–2025 Dietary Guidelines for Americans. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf. Published December 2020. Accessed June 15, 2021.
9. Miller PE, Reedy J, Kirkpatrick SI, Krebs-Smith SM. The United States food supply is not consistent with dietary guidance: evidence from an evaluation using the Healthy Eating Index-2010. J Acad Nutr Diet. 2015;115(1):95-100.
10. Nestle M. Dietary Guidelines Advisory Committee releases report. Food Politics website. https://www.foodpolitics.com/2020/07/dietary-guidelines-advisory-committee-releases-report/. Published July 16, 2020. Accessed June 30, 2021.
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12. Gussow JD, Clancy K. Dietary guidelines for sustainability. J Nutr Ed. 1986;18(1):1-5.
13. Sustainable Development Goals. Food and Agriculture Organization of the United Nations website. http://www.fao.org/sustainable-development-goals/overview/en/. Accessed June 15, 2021.
14. Canfield M, Anderson MD, McMichael P. UN Food Systems Summit 2021: dismantling democracy and resetting corporate control of food systems. Front Sustain Food Syst. 2021;5:661552.
15. Nestle, M. The UN summit on food systems 2: the critique. Food Politics website. https://www.foodpolitics.com/2021/07/the-un-summit-on-food-systems-2-the-critique/. Published July 14, 2021. Accessed July 14, 2021.
16. Bhupathiraju SN, Hu FB. Epidemiology of obesity and diabetes and their cardiovascular complications. Circ Res. 2016;118(11):1723-1735.
17. Spiker M, Reinhardt S, Meg Bruening M. Academy of Nutrition and Dietetics: revised 2020 standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in sustainable, resilient, and healthy food and water systems. J Acad Nutr Diet. 2020;120(9):1568-1885.
18. Dunn CG, Soto MJ, Hua SV, et al. Availability and nutrient composition of vegetarian items at US fast-food restaurants. J Acad Nutr Diet. 2021;121(7):1306-1311.
19. Spiker ML, Knoblock-Hahn A, Brown K et al. Cultivating sustainable, resilient, and healthy food and water systems: a nutrition-focused framework for action. J Acad Nutr Diet. 2020;120(6):1057-1067.
20. Hawkins IW, Mangels AR, Goldman R, Wood RJ. Dietetics program directors in the United States support teaching vegetarian and vegan nutrition and half connect vegetarian and vegan diets to environmental impact. Front Nutr. 2019;6:123.
21. Hawkins IW, Mangels AR. Resources used and innovations in teaching vegetarian and vegan nutrition in accredited dietetics programs in the United States. Int J Dis Rev Prev. 2021;3(2):1-13.
22. Sustainable food systems primer for RDNs and NDTRs. Academy of Nutrition and Dietetics Foundation website. https://www.eatrightfoundation.org/why-it-matters/public-education/future-of-food/sustainable-food-systems-primer-for-rdns-and-ndtrs/
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24. Hawkins IW, Balsam AL, Graves D. A qualitative study of the skills that enabled the pro-environmental behaviors of registered dietitians. J Hunger Environ Nutr. 2015;10(1):60-71.
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26. Tilman D, Clark M. Global diets link environmental sustainability and human health. Nature. 2014;515(7528):518-522.