The intervention group altered food intake toward MedDiet; however, this effect resulted in no change in GHGs emissions, land use, and pReCiPe score, and a relative increase in the use of fossil energy.

Grosso et al. The authors found that, except for DASH, the adherence to healthy dietary patterns MedDiet and Nordic diet and higher diet quality indices AHEI and DQI-I were associated with higher sustainability scores.

They also found that higher adherence to MedDiet and AHEI was associated with lower GHGs emissions. The environmental impact of the Western dietary pattern was also compared with MedDiet in a study from Fresán et al. Rosi et al. Similar results were observed by Grosso et al.

The authors explained these results by the relatively high consumption of vegetables within the Lebanese MedDiet and the fact that the production of vegetables requires more energy use and GHGs emissions than grains and fruits.

In a later study 27 , it was reported that red meat was the greatest contributor to water use, sugar-sweetened beverages were the main contributors to energy use, and red meat was the food group with the highest contributions to GHGs emissions. Economic sustainability was assessed through the monetary cost.

Llanaj et al. Seconda et al. The health-nutrition pillar of sustainability was assessed by the study by Fresán et al. Using the overall sustainable diet index, the authors showed that MedDiet was the most sustainable option in comparison with Western and Provegetarian dietary patterns.

Out of the 28 articles included in this review, 11 analyzed MedDiet sustainability based on the models of dietary patterns or recommendations dietary scenarios 31 — Relevant information from these articles is summarized in Table 3.

Table 3. Summary of studies reporting MedDiet sustainability using dietary scenarios. Studies were conducted using the recommendations or dietary patterns from countries located in the Mediterranean basin, Netherlands, and the United States; briefly, one study was conducted in the Netherlands 37 , three studies in the United States 34 , 35 , 39 , seven studies in the Mediterranean basin 32 , 33 , 36 , 38 — 41 , and one study with no specific location discernible Most of the studies compared the MedDiet scenario with other dietary patterns or recommendations, such as, the European dietary pattern 31 , the Western dietary pattern 31 , EAT-Lancet reference diet 32 , the Southern European Atlantic Diet SEAD 33 , the Spanish Dietary Guidelines NAOS 33 , Healthy US diet 34 , 35 , Lacto-ovo vegetarian diet 34 , typical American diet 34 , 39 , healthy vegetarian dietary pattern 35 , New Nordic diet 36 , 37 , optimized Low Lands diet 37 , Italian average diet 40 , healthy consumption pattern 40 , vegetarian consumption pattern 40 , status-quo diet Iran 41 , WHO recommended diet 41 , and the diet recommended by World Cancer Research Fund WCRF One study explored the sustainability of different MedDiet scenarios, such as Healthy MedDiet, healthy pesco-vegetarian MedDiet, and healthy vegetarian MedDiet Most of the studies reported environmental sustainability indicators, including land use 31 , 37 , water use 31 , 35 , GHGs emissions 31 , 36 , 37 , eutrophication potential 31 , water footprint WF 32 , 33 , 39 , CF 33 , 40 , global warming potential 34 , 35 , freshwater eutrophication 35 , marine eutrophication 35 , particulate matter or respiratory organics 35 , and energy use The WF is an indicator of freshwater consumption from rainfall, surface, and groundwater that looks at direct and indirect water use of a producer or consumer and water resources appropriation expressed in liters One study used a combined GHGs emissions-land use GHGE-LU score that was defined as the average of the GHGs emissions and LU score per diet 37 , One study reported the variation in environmental load emission of GHGs, such as CO 2 , CH 4 , and N 2 O expected in case of change for different dietary scenarios Sustainability was also assessed in the dimensions of economy and health nutrition.

One study assessed the nutritional quality through the Nutrient Rich Foods Index 9. van Dooren et al. Studies using dietary scenarios consistently found MedDiet as a sustainable pattern; although, it was not always considered superior to other healthy dietary patterns.

Vanham et al. The authors reported that the EAT-Lancet reference diet consistently reduces the current WF of the analyzed countries while MedDiet reduces WF to a smaller extent or even increases it. In a previous study, Vanham et al. Blas et al. The authors also reported that a shift to the Mediterranean diet would decrease the WF in the US, while a shift toward an American diet in Spain will increase the WF.

Despite presenting a lower WF when compared to a typical American diet, the MedDiet presented a higher water depletion, and higher freshwater and marine eutrophication when compared with the Healthy US-style dietary pattern and the healthy vegetarian dietary pattern according to the study by Blackstone et al.

In this study 35 , MedDiet presented a slightly lower global warming potential and land use, and slightly higher particulate matter than the Healthy US-style dietary pattern; however, MedDiet presented the worst environmental performance in all indicators when compared to healthy vegetarian dietary pattern.

The authors mentioned that reliance on plant-based protein and eggs in the healthy vegetarian dietary pattern vs. emphasis on animal-based protein in the other patterns was a key driver of differences. A lacto-ovo vegetarian diet also performed better than other dietary patterns analyzed in the United States, including the MedDiet.

Chapa et al. Considering the nutritional quality and satiety, the authors concluded that high satiety foods can help prevent overconsumption and thus improve dietary CF.

The authors also identified animal products, including meat and dairy, and discretionary foods as the specific food categories that contributed the most to the global warming potential. Similarly, Pairotti et al. Despite that, compared to the Italian average diet, the best overall environmental performance was found with the vegetarian diet in which energy use was 3.

Gonzalez-García et al. The SEAD presented the higher CF and WF explained by the greater animal source food content present in that dietary pattern. Belgacem et. al 31 compared three dietary scenarios and found that a shift from the European or Western dietary pattern to the MedDiet would lead to land and water savings, reduction in GHGs emissions, and eutrophication potential.

Ulaszewska et al. On the other hand, Rahmani et al. Van Dooren et. al 37 noticed that an optimized low lands diet would result in a lower environmental impact lower GHGs emissions, lower land use, and higher combined GHGE-LU score with similar nutritional characteristics measured by the health score as the MedDiet.

Pairotti et al. Out of the 28 articles included in this review, 4 analyzed MedDiet sustainability based on the models of dietary patterns or recommendations dietary scenarios in comparison with the national food consumption surveys 42 — Relevant information from these articles is summarized in Table 4.

Table 4. Summary of studies reporting MedDiet scenario sustainability vs. other scenarios or dietary consumption. Studies were conducted in countries located in the Mediterranean Basin and north of Europe; briefly, two studies were conducted in Spain, one study in Italy, and one study in the Netherlands.

All the studies compared MedDiet and other dietary patterns or recommendations with dietary consumption data obtained from national representative surveys. The dietary consumption patterns, obtained from the national representative samples, correspond to the Spanish dietary pattern 42 , 45 , the Dutch diet 43 , and the real consumption of the Italian population Environmental sustainability indicators included WF 42 , 44 , GHGs emissions 43 , 45 , land use 43 , 45 , CF 44 , EF 44 , and WF 42 , One study used a combined GHGE-LU score Two studies included a health-nutrition indicator, the health score 43 , and the multidimensional nutritional analysis One study used an index that combines water use and nutritional values, the nutritional-water productivity One study included the monetary cost MedDiet was consistently found to be a more sustainable option when a mixed approach, using dietary scenarios and data from food consumption surveys, was used.

Furthermore, MedDiet presents better nutritional-water productivity than Spanish dietary consumption. The environmental sustainability of the Spanish dietary consumption was also compared with the sustainability of the adoption of a MedDiet pattern and a Western dietary pattern.

Sáez-Almendros et al. Vegetarian diet and the vegan diet were the options with higher sustainability scores closely followed by MedDiet, which was the dietary pattern with the higher health score.

MedDiet was considered, by the authors, the health focus option with a high GHGE-LU score. When comparing the sustainability of the dietary consumption obtained through the Italian National Food Consumption Survey INRAN-SCAI —06 with MedDiet recommendations, Germani et al.

Despite the lower environmental impact, it was also shown that adherence to the MedDiet recommendations would result in a slightly higher cost when compared to the expenditure allocated to food by the Italian population, which may dampen the economic sustainability of MedDiet.

Out of the 28 studies identified through our strategy, four were proposals of methodological approaches to assess the MedDiet nutritional sustainability.

Two studies were proposals of methodological approaches to assess the nutritional sustainability of the MedDiet 46 , 47 , and two studies were methodological proposals to assess the nutritional sustainability of MedDiet typical agro-food 48 , The identified proposals were published between and Relevant information is summarized in Tables 5 , 6.

Table 5. Summary of proposed methodological approaches to assess MedDiet sustainability. Table 6. Summary of proposed methodological approaches to assess the sustainability of MedDiet's typical agro-food products.

Dernini et al. The methodological approach was based on the results of the participatory process, conducted in and by the International Centre for Advanced Mediterranean Agronomic Studies-Mediterranean Agronomic Institute of Bari CIHEAM MAI-Bari and FAO in collaboration with the National Agency for New Technologies, Energy and Sustainable Economic Development, Italy ENEA , Italian National Research Council CNR , the National Institute for Research on Food and Nutrition, Italy INRAN , the International Interuniversity Study Centre on Mediterranean Food Cultures CIISCAM , Bioversity International, and World Wildlife Fund for Nature, Italy WWF-Italy , in which the three dimensions of sustainability economic, social, and environmental were added to nutrition and health.

Within these, four thematic areas were identified as sets of sustainability indicators. The list of sustainability indicators for each criterion that was established is reviewed in Table 5. On the environment thematic area, the sustainability indicators aggregated WF, CF, nitrogen footprint, and biodiversity.

The set of sustainability indicators on the economy thematic area were food consumer price index, cost of living index related to food expenditures, distribution of household expenditure per food group, food self-sufficiency, intermediate consumption in the agricultural sector nitrogen fertilizers , and food losses and waste.

Identified indicators in the thematic area of society and culture were the proportion of meals consumed outside the home, the proportion of already prepared meals, consumption of traditional products e.

Later, in , Donini et al. Five main thematic areas were identified and included biochemical characteristics of food, food quality, environment, lifestyle, and clinical aspects. Among those areas, 13 nutrition indicators of sustainability were identified and the definition, the methodology, the background, data sources, limitations, and references for each indicator were provided.

A methodological approach to assess the environmental, economic, socio-cultural, and health-nutrition sustainability of Apulian agro-food products was proposed by Capone et al. Azzini et al. Two main aspects of health-nutrition sustainability were considered: 1 the business distinctiveness of agro-food companies and food safety and 2 the nutritional quality of foodstuffs.

It is important to mention that this work seems to be a refinement of the indicators identified in the nutrition-health principle published in the work of Capone et al. The proposed indicators for health-nutrition sustainability are reviewed in Table 6. It includes indicators that are not specific to a single product and depend on the whole management of the agro-food company.

To evaluate a company's distinctiveness and food safety, the application of different regulations and standards regarding food safety together with statutory, regulatory, and voluntary requirements, the origins of the raw materials used, and marketing and labeling were considered.

The second aspect, the nutritional quality, refers to each individual product product-based approach. The selection criteria for nutritional indicators in the nutritional quality aspect were based on secondary data from scientific literature and other relevant sources.

This is the first scoping review of the methodological assessment of MedDiet nutritional sustainability. A previous study 18 systematically reviewed the studies on sustainable diets to identify the components of sustainability that were measured and the methods applied to do so.

In this work, we reviewed the scientific literature to identify the main components of the nutritional sustainability of MedDiet and the methods that have been applied to assess those components.

The concept of nutritional sustainability is broad and complex and encompasses the three dimensions of sustainability, environmental, economic, and socio-cultural, and also the health-nutrition dimension 8.

Through our search strategy, we identified 28 articles; 24 studies exploring the dimensions of nutritional sustainability of the MedDiet 22 — 45 , and 4 proposing the methodological approaches to assess the nutritional sustainability of MedDiet 46 , 47 or the sustainability of typical agro-foods of MedDiet 48 , One of the methodological proposals to assess the nutritional sustainability of MedDiet 47 contemplated the four dimensions of nutritional sustainability, as well as one of the methodological proposals to assess the sustainability of typical agro-foods of MedDiet Nevertheless, no study was identified, through our search strategy or through the list of citing articles, applying those methodological proposals.

The remaining methodological proposals 46 , 48 were further characterizations of the health-nutrition dimension of sustainability from the previously mentioned studies. From the research articles, several sustainability indicators were identified.

Most of the identified research articles reported sustainability indicators pertaining to the environmental dimension of nutritional sustainability 23 — 29 , 31 — Six studies 22 , 26 , 33 , 40 , 41 , 44 reported economic sustainability indicators and six studies 26 , 30 , 34 , 37 , 42 , 43 reported the sustainability indicators of the health-nutrition dimension of nutritional sustainability.

Two studies used indices that combined indicators from the environmental and health-nutrition components of sustainability 26 , No studies have reported indicators regarding the socio-cultural dimension.

These results are not surprising, due to the large attention that the environmental dimension of sustainability has received over time and are in line with the results obtained in the systematic review of Jones et al.

Two of the leading threats to global health are climate change and non-communicable diseases, both of which are inextricably linked to diet 20 , 50 ; in this sense, nutritional sustainability goes along with the One Health concept where human, animal, and the environmental health are intimately linked The One Health approach, by definition, encompasses many fields, including, but not limited to, health, ecology, agriculture and sustainability, economics, anthropology, and the social sciences All those disciplines are also included in the assessment of nutritional sustainability.

Assessing the environmental dimension of sustainability is of utmost importance. Recently, the report of the EAT-Lancet Commission on healthy diets from sustainable food systems 1 indicated that food systems are the major driver of environmental degradation and further food production should use no additional land, safeguard existing biodiversity, reduce consumptive water use and manage water responsibly, substantially reduce nitrogen and phosphorus pollution, produce zero carbon dioxide emissions, and cause no further increase in methane and nitrous oxide emissions.

Sustainability indicators to assess those recommendations were found in the articles included in this review. Among the indicators cited, the most used were related to global warming potential GHGs emissions and CF 23 — 29 , 31 , 33 , 35 — 37 , 40 , 41 , 43 — 45 , followed by water 25 — 29 , 31 — 33 , 35 , 38 , 39 , 42 , 44 , 45 , land 23 , 25 , 26 , 29 , 31 , 35 , 37 , 43 , 45 , and energy use 23 , 25 — 29 , 40 , Our findings are in line with the previous studies where the global warming potential of diets was by far the most commonly measured environmental sustainability indicator, with land, energy, and water use also frequently assessed Considering the detrimental impacts that food systems have on the environment, it is not surprising to observe the abundance of those sustainability indicators in the identified literature.

Most of the studies used the life cycle assessment LCA approach to obtain environmental sustainability indicators. This finding is consistent with the literature on the subject, where LCA is the most commonly used approach 18 — 20 , Despite being the most commonly used approach, LCA methodology is not free from limitations 55 , and other methodologies to assess sustainability, such as the modeling approaches, integrated analytical frameworks, and the proposed adaptive, participatory methods, have been proposed From the environmental perspective, many of the identified studies consistently found that MedDiet is a sustainable option 25 — 31 , 33 , 38 — 40 , 42 — Nevertheless, some studies relying on dietary consumption data or dietary scenarios reported that in some cases, other dietary patterns had a similar or better environmental performance 22 , 25 , 26 , 28 , 32 , 34 — 37 , 41 , while the mixed studies, based on dietary consumption and dietary scenarios, indicated MedDiet as the most environmentally friendly option 42 — Studies examining the impact of foods on environmental sustainability reported animal food sources as the food category with the most deleterious environmental effects 25 , 34 , As previously mentioned, MedDiet is a dietary pattern characterized by moderate consumption of eggs, poultry, and dairy products cheese and yogurt and low consumption of red meat 13 , Furthermore, in its present update, the MedDiet pyramid reflected multiple environmental concerns and strongly emphasizes a lower consumption of red meat and bovine dairy products 13 , Six studies 22 , 26 , 33 , 40 , 41 , 44 measured the cost associated with the adherence to MedDiet as a measure of economic sustainability.

Those studies shed some light on the economic tradeoffs of adhering to MedDiet. In two of the studies 26 , 44 , adherence to the MedDiet, compared to other patterns of dietary consumption, was associated with a higher cost; yet, in one study 33 , it was proposed that isocaloric diets have approximately the same cost.

These results may be explained by the different methodological approaches used in each study but are most likely explained by the dietary patterns compared to the MedDiet. The MedDiet was more expensive than the Western dietary pattern and the Provegetarian dietary pattern 26 , slightly more expensive than the dietary consumption of the Italian population 44 ; no significant differences were observed between the MedDiet, the SEAD, and the NAOS Monetary cost is one of the key factors in food choice and it is the main factor in shaping the consumer demand; therefore, it will affect consumer preferences and options for a sustainable dietary pattern 18 , Food prices condition the affordability of sustainable diets.

Low prices reduce the income of producers, reduce their ability to invest, and may hinder the development of a sustainable food system. From the sustainability point of view, price is ambivalent; therefore, it is important to guarantee the accessibility and affordability to food choices in order to ensure economic sustainability but at the same time, the affordability may have negative environmental impacts by not discouraging food waste In line with our findings, there is evidence indicating that MedDiet is not necessarily associated with higher overall dietary costs The health-nutrition dimension of nutritional sustainability of MedDiet was assessed in six studies 26 , 30 , 34 , 37 , 42 , The NRF9.

Regardless of the methodological differences, MedDiet was associated with a better performance in the health-nutrition dimension. MedDiet has been consistently shown to be a healthy dietary pattern that may reduce risk related to non-communicable diseases 60 ; and therefore, adherence to the MedDiet or other healthy dietary patterns may be associated with the sustainability of healthcare systems.

The absence of exploration regarding the socio-cultural dimension of sustainability in the identified literature is particularly important, given the critical role of society and culture in the MedDiet. The relevance of this dimension is so clear that MedDiet was acknowledged by UNESCO as an intangible cultural heritage According to UNESCO, MedDiet is a way of life that encompasses a set of skills, knowledge, rituals, symbols, and traditions, ranging from landscape to the table.

Eating together is the foundation of the cultural identity and continuity of communities throughout the Mediterranean Basin. The MedDiet emphasizes values of hospitality, neighborliness, intercultural dialogue and creativity, and a way of life guided by respect for diversity Despite its increasing popularity worldwide, adherence to the MedDiet is decreasing due to multifactorial influences, such as globalization, population growth, and socio-economic changes.

Food chain modernization has increased productivity and resulted in a substantial transformation of lifestyles as a consequence of rising incomes, urbanization, and changes in the agricultural and food sectors. Those changes threaten seriously the transmission and preservation of the MedDiet heritage to present and future generations Measuring the sustainability of the socio-cultural dimension is paramount for the preservation of MedDiet.

The development of indices that combine all the dimensions of nutritional sustainability may facilitate its assessment and the comparability of different dietary patterns or food products. We did not identify studies that used methodological approaches covering all the conceptual framework of nutritional sustainability of MedDiet; instead, we identified studies that assessed some dimensions of MedDiet nutritional sustainability.

Heterogeneity in the indicators used was found, particularly in the environmental dimension. Studies on the economic and health-nutrition dimensions are less frequent and absent in the socio-cultural dimension. Our findings call for the development of harmonized methodologies for the assessment of MedDiet nutritional sustainability.

Indeed, the methodological approach proposed by Dernini et al. Despite being comprehensive and complete, no indication is given regarding the weight of each dimension or the indicator for a sustainability score; although the authors mention that the methodological approach requires to be tested and further refined in a group of selected Mediterranean countries, indicating that this is an ongoing work.

Traditional and typical agro-food products are at the core of MedDiet A typical agro-food product is characterized by historical and cultural features and by physical attributes that are deep-rooted to the territory of origin encompassing much more than organoleptic qualities.

In the last years, we have observed a deep transformation in consumer perception and in the demand for typical agro-food products. The retrieval of typical and traditional foods represents an attempt to recover the safety and social aspects of eating habits.

To form positive attitudes and expectations toward food, consumers need to be assured and informed about the production and transformation processes as well as about their origin and the symbolic values they encompass Typical agro-food products contribute directly and indirectly to the sustainability of the MedDiet in the Mediterranean basin Considering those aspects, we identified two works related to the sustainability of typical agro-food products 48 , Capone et al.

This methodological proposal englobes all the dimensions of sustainability that are explored in our study. The identified work of Azzini et al.

In this work, sustainability was assessed in the environmental, economic, sociocultural, and health-nutrition dimensions. Considering the included literature, environmental sustainability was assessed and defined as the ability to use fewer resources 23 , 25 — 29 , 31 — 33 , 35 , 37 — 40 , 42 — 45 to produce less byproducts 23 — 29 , 31 , 33 — 37 , 40 , 41 , 43 — Economic sustainability was defined as the ability to promote economic growth 41 or the accessibility to the consumers 22 , 26 , 33 , 40 , The Heath-nutrition dimension was defined as the capability to provide adequate nutrition 30 , 37 , 42 , 43 , promote health, and prevent disease Despite not being assessed, the socio-cultural dimension of sustainability encompasses historical remains and values, local culture, and traditions; therefore, it was defined as the ability to preserve them Nutritional sustainability is an umbrella term that can take several meanings depending on the dimension that is assessed.

Several considerations must be made regarding the findings of this study. Most of the studies identified are from the countries located in the Mediterranean basin and the remaining are from Northern Europe and the United States.

While it is not surprising to find studies regarding MedDiet sustainability in the countries of its origin, MedDiet is recommended worldwide as a sustainable dietary option 64 ; therefore, studies on other regions are needed. Comparisons are difficult due to the heterogeneity of the indicators used in the identified studies and no studies used a comprehensive approach that explores nutritional sustainability in all dimensions.

Harmonization is essential for the comparison of results; yet, a significant degree of flexibility is also needed to allow for the wide application of an instrument to assess the nutritional sustainability of diets or food products that are, by nature, dynamic.

Identified studies did not provide examples of approaches to combine all the indicators of sustainability. Identified articles were published between and , highlighting the recent interest in the subject.

Despite a significant body of literature that meets the inclusion criteria for this review, more work is needed to establish a consensual approach to assess the nutritional sustainability of MedDiet and to compare it with other dietary patterns.

Our scoping review has some limitations. A search was performed only in two electronic databases Scopus and PubMed ; therefore, relevant works may have been missed. Gray literature could be an informative source of evidence to this study; however, the sizable amount of gray literature in the field could have dumped the feasibility of the work.

The search strategy was broad enough to capture a significant body of literature in the area, yet it is possible that studies assessing the sustainability indicators but not mentioning the word sustainability or related words have not been captured.

Our study reviewed for the first time the assessment of the nutritional sustainability of MedDiet. From a general perspective, there is sufficient evidence to state that MedDiet is a nutritional sustainable option. Methodological assessment of nutritional sustainability is challenging and involves multidisciplinary approaches.

In its concept, nutritional sustainability is differentiated from other concepts combining nutrition and sustainability; it does not contradict with other similar concepts sustainable diet and sustainable food systems but aggregates concepts from them.

MedDiet nutritional sustainability needs to attract sufficient political attention and become a core priority in the shaping of agriculture, food, and nutrition policies; for that, research needs, in a comprehensive way, to reflect the complexity of the nutritional sustainability concept.

CP-N wrote the first draft of the manuscript. The data acquisition of the article and analysis of its content has been made by a consensus between CP-N and CG. CS and CG conceived and designed the study. All the authors had revised the manuscript. The CP-N is supported by an AgriFood XXI project post-doctoral fellowship.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Eur J Clin Nutr. Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomised trials. The Greek scientists behind the study add that agricultural production occupies approximately 40 per cent of the global land.

Livestock and growing food for livestock represent 75 per cent of all agricultural land. As such, the use of irrigation, fertilisers and pesticides could cause a depletion of natural resources and environmental degradation, the researchers say. In response to this critical situation, the study has looked at the relative benefits of different diets for sustainable development and food security.

Their research concluded that the Mediterranean diet is the best for our planet. Used in countries such as Italy, Cyprus and Greece, it was found to be the most favourable for biodiversity and food-plant diversity.

The Mediterranean diet is rich in plant-based foods like vegetables, fruits and grains - although it has many variations between countries.

It is also generally low in the consumption of animal products. This means that it has advantages for our health, such as reducing the risk of chronic diseases, as well as having a low environmental impact. The study showed that the agricultural biodiversity and the diversity in food plant varieties and species were higher in the Mediterranean diet than in western-type dietary patterns.

The study concludes that adopting the Mediterranean diet could help establish a more biodiverse environment and put less pressure on natural resources. To follow a Mediterranean diet, you should make fruit and vegetables your core foods, along with whole grains like oats, brown rice and whole wheat bread.

Legumes like beans, lentils and chickpeas are a great source of protein. You should also include healthy fats like olive oil and avocados.

The analysis presented in this paper joins a limited number of studies that have identified this gap 4 , 5 , By analyzing data from a diverse sample of people in Israel, we evaluated real consumption data in regard to adherence to healthy and sustainable diets.

These findings are the integrative product of both the studied population's consumption habits and the environmental factors of each studied commodity. Our findings indicate that the main contributors to water use were fruits, vegetables, and dairy.

The main contributors to land use were meat and poultry, and the main contributor to GHG emissions was dairy products. We found that the highest tertiles of adherence to the MED and the EAT-Lancet reference diet 6 , 9 were associated with the lowest GHG emissions and land use.

On the other hand, the highest tertiles of adherence to the MED and EAT-Lancet were associated with higher water use. To expand our view on sustainability beyond the environmental footprint, adjoining sociocultural, economic, and health aspects we used the SHED index 7.

The need to develop methods to include all 4 dimensions of sustainability of the diet in their case MED were acknowledged in a recent review by Portugal et al. The results of the SHED index analysis were similar to those obtained for the MED and EAT-Lancet dietary pattern.

The health value of the MED is well established. During the last 20 years MED was shown to benefit health and function, reducing mortality rates 9 , 10 , The EAT-Lancet as a theoretical dietary pattern targets both health and the environment using evidence based data, indicating that healthy and sustainable diet is achievable 11 , In a review by Aleksandrowicz et al.

Our findings parallel those of prior studies. In studies from Italy and Spain that used real consumed diet, high adherence to MED pattern was associated with lower GHG emissions and land use 4 , 5. The contribution of animal products meat, poultry, dairy, egg, and fish constituted the greatest contributor to GHG emissions 19 , 21 , 22 , Higher adherence to the MED or the EAT-Lancet recommended diet was associated with lower GHG emissions in other studies In Spain the SUN cohort better adherence to the Spanish MED was associated with decreased environmental pressures in all assessed dimensions including GHG, land and water 5.

Likewise, a cross-sectional study among Italian adults showed that omnivorous dietary choices or low adherence to the MED correlated with higher GHG emissions, land, and water use 4 , Results in the same direction were found in a non-MED country.

Data from the European Prospective Investigation into Cancer and Nutrition—Netherlands EPIC-NL 28 cohort showed that the WHO and Dutch dietary guidelines lower the risk of all-cause mortality and moderately lower the environmental impact, while the DASH diet Dietary Approaches to Stop Hypertension diet , despite leading to similar health outcomes, was associated with higher GHG emissions due to high dairy product consumption in the Netherlands Another study conducted on Italian adults showed that omnivorous dietary choices generated worse carbon, water, and ecological footprints than other plant-based diets, while no differences were found for the environmental impacts of ovo-lacto-vegetarians and vegans Unlike the above studies, in our findings water footprint was higher in the third tertiles of MED, EAT-Lancet and SHED and was connected tofruit intake.

This unique aspect revealed in our analysis needs further discussion. Since fruits and vegetables are more dependent on irrigation than animal-based foods, reducing animal-based foods and increasing plant-based foods do not always correspond with lower water use, as shown by Harris et al.

Plant-based foods were major contributors to dietary blue-water footprints. Grosso et al. Higher fruit consumption was also associated with higher water footprints in the United States, particularly the blue-water footprint However, theoretical dietary models show different results indicating that shifting to a more plant-based diet would reduce the water footprint Other studies also demonstrate that the contribution of fruits and vegetables does not exceed the meat contribution for both blue and green water Indeed, we found that sustainable diets like MED or the EAT-Lancet reference diet are characterized by higher water consumption, but several considerations need to be taken into account.

One is that most fruits and vegetables consumed in Israel are grown locally. It follows that given the climatic conditions, most are irrigated, so they would have relatively high rates of blue-water footprints.

Nevertheless, it is important to note that not all blue water is the same as most of the fruit-related water footprint relies on treated wastewater, which reduces environmental pressure Other solutions such as the use of desalinated water and efficient and cost-effective irrigation techniques already exist in Israel, but our findings emphasize the importance of further development of water management, including advanced technologies, reducing water losses, and improving data quality and monitoring for water—food system linkages 32 , Management of the local food systems can also reduce water consumption.

There are substantial differences of 2—fold in water consumption between different fruit crops Prioritizing certain types of crops that are less burdensome in terms of water requirements while considering their health benefits could be another future direction to increase the health and sustainability of food systems.

As for dairy intake in Israel, the mean intake in our study is ± g per day. This value is higher than the estimated intake in Europe and North America, where the average daily intake is Since most dairy products consumed in Israel are domestically produced, and the production system is based on non-grazing cows, production can occur in a relatively small area 19 , In addition, the productivity of Israeli dairy cows is very high, which reduces the footprint per unit of milk Nevertheless, the high demand for dairy products identified in our analysis led to high rates of dairy-related footprints.

According to the EAT-Lancet commission 6 and in accord with the national dietary recommendations, the requirement for different food groups is calculated based on healthy dietary intake within global boundaries. For example, the reference intake is 29 g per day for poultry, g per day for vegetables, g per day for fruits, and g per day for dairy.

In our data Table 2 , the actual consumption in the lowest tetiles of land GHG and water was nearly similar to the EAT-Lancet recommended diet.

The main difference was fruit consumption. Thus, a shift, toward less animal based and more plant-based diets, is beneficial for both health and the environment. The Isocaloric Substitution of Plant-Based and Animal-Based Protein was related with Aging-Related Health Outcomes A recent paper by Eisen and Brown, 37 show that, following a phaseout of livestock production will independently provide persistent drops in atmospheric methane and nitrous oxide levels, and slower carbon dioxide accumulation.

This reduction through the end of the century, have the same cumulative effect on the warming potential of the atmosphere as a 25 gigaton per year reduction in anthropogenic CO2 emissions. This level of reduction will provide half of the net emission reductions necessary to limit warming to 2C.

Based on our data, which originate from the FFQ results of participants, it seems that there is no conflict between a healthy and sustainable diet, but there is a need to adjust and optimize dietary patterns in light of recommendations for various populations with different dietary needs.

For example, Israel is characterized with mixed Jewish and non-Jewish population, locals and new and established immigrants; and a significant young population alongside a growing share of elderly population. It is important to note that the EAT-Lancet reference diet stems from a theoretical model for a healthy and sustainable diet, whereas our data represent actual dietary patterns of the Israeli population.

The results may be a proof of concept that the EAT-Lancet reference diet is indeed feasible. One strength of this study is its ability to assign environmental-footprint values to the FFQ lines.

The Israeli FFQ was created based on h recall information that was collected in the Israeli National Health and Nutrition Survey MABAT The results of MABAT were available to our group, so we could assign Environmental Footprint values to most of the food items that were on the basic list for the FFQ.

The final lines of the FFQ were extracted from the food items. In many cases, when the FFQ is used, the data behind the questionnaire are not available to the researchers.

We believe that the use of this basic method results in a more accurate long-term assessment of EF exposure of our participants 8 , Our footprint analysis was based on local supply coefficients. It follows that each analyzed food commodity footprint is considered in terms of whether it was supplied from local sources or imported from several other parts of the world.

The footprint was then calculated to reflect the amount of land and water related to the supply from each source 14 , 27 , 32 , 39 , Our study also has several limitations that need to be addressed.

One is the use of a convenience sample that was restricted to people who have access to web-based platforms. However, we made an effort to recruit a representative sample including all sectors in Israel.

Our sample consists of a high number of educated participants who practice a healthy lifestyle, which may partially limit the generalizability of the results to the general population. While the footprint figures included detailed place-based data and calculations, for some commodities, we had to make some assumptions or exclude some footprint categories.

For example, in the case of fish-related footprints, we included only global averages of GHG data and not the other footprint coefficients. Our analysis of consumed diets revealed that animal protein is associated with the highest GHG emissions and land use, while fruits and vegetables were associated with the highest water consumption.

Nevertheless, most of them are grown using treated wastewater, which reduces environmental pressure. The differences in water consumption for different fruit crops support the need to prioritize certain types of crops, which should be less burdensome in terms of water requirements while considering their health benefits.

Given these findings, we suggest that adherence to MED and EAT-Lancet dietary patterns should be included in national dietary guidelines and encouraged for consumption by all. Furthermore, our data could be used as a database to create healthy and sustainable diet recommendations while adjusting for nutritional needs and health status, as well as maintaining diversity within dietary patterns.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. ST planned and conducted the research and wrote the first draft of the manuscript.

MK calculated the environmental footprints and co-authored the manuscript. DS created the combined database and co-authored the manuscript. KA analyzed the data and co-authored it. All authors contributed to the article and approved the submitted version.

This study was supported by Ben-Gurion University's internal fund for nutritional research, MIGAL - Galilee Research Institute grant, and Tel-Hai College research fund. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Department for Innovation in Biological, Agro-Food and Forestry Systems, University of Tuscia, Via Camillo de Lellis 4, , Viterbo, Italy. Department of Ecology, Russian Timiryazev State Agrarian University, Timiryazevskaya st. You can also search for this author in PubMed Google Scholar.

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Reprints and permissions. Castaldi, S. The positive climate impact of the Mediterranean diet and current divergence of Mediterranean countries towards less climate sustainable food consumption patterns. Sci Rep 12 , Download citation. Received : 28 May Accepted : 04 May Published : 25 May Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. In response to this critical situation, the study has looked at the relative benefits of different diets for sustainable development and food security.

Their research concluded that the Mediterranean diet is the best for our planet. Used in countries such as Italy, Cyprus and Greece, it was found to be the most favourable for biodiversity and food-plant diversity.

The Mediterranean diet is rich in plant-based foods like vegetables, fruits and grains - although it has many variations between countries. It is also generally low in the consumption of animal products.

This means that it has advantages for our health, such as reducing the risk of chronic diseases, as well as having a low environmental impact. The study showed that the agricultural biodiversity and the diversity in food plant varieties and species were higher in the Mediterranean diet than in western-type dietary patterns.

The study concludes that adopting the Mediterranean diet could help establish a more biodiverse environment and put less pressure on natural resources. To follow a Mediterranean diet, you should make fruit and vegetables your core foods, along with whole grains like oats, brown rice and whole wheat bread.

Environmental Health volume 12 , Article number: Cite this article. Metrics details. Dietary patterns can substantially vary the resource consumption and environmental impact of a given population. Dietary changes such as the increased consumption of vegetables and reduced consumption of animal products reduce the environmental footprint and thus the use of natural resources.

The adherence of a given population to the Mediterranean Dietary Pattern MDP through the consumption of the food proportions and composition defined in the new Mediterranean Diet pyramid can thus not only influence human health but also the environment.

The aim of the study was to analyze the sustainability of the MDP in the context of the Spanish population in terms of greenhouse gas emissions, agricultural land use, energy consumption and water consumption. Furthermore, we aimed to compare the current Spanish diet with the Mediterranean Diet and in comparison with the western dietary pattern, exemplified by the U.

food pattern, in terms of their corresponding environmental footprints. The environmental footprints of the dietary patterns studied were calculated from the dietary make-up of each dietary pattern, and specific environmental footprints of each food group. The dietary compositions were obtained from different sources, including food balance sheets and household consumption surveys.

The specific environmental footprints of food groups were obtained from different available life-cycle assessments. The adherence of the Spanish population to the MDP has a marked impact on all the environmental footprints studied. The MDP is presented as not only a cultural model but also as a healthy and environmentally-friendly model, adherence to which, in Spain would have, a significant contribution to increasing the sustainability of food production and consumption systems in addition to the well-known benefits on public health.

Peer Review reports. The environmental consequences of food systems are on public health agendas. Foods are produced, processed, distributed and consumed, these actions having consequences for both human health and the environment [ 1 ].

Furthermore, food production is also inevitably a driver of environmental pressures, particularly in relation to climate change, water use, toxic emissions and [ 2 ] greenhouse gas emissions GHG , such as CO 2 , CH 4 and N 2 O, which are responsible for global warming.

Agriculture is one of the main contributors to the emissions of two last gases mentioned whilst other parts of the food system contribute to carbon dioxide emissions due to the use of fossil fuels in processing, transportation, retailing, storage, and preparation.

Food items differ substantially in their environmental footprints, which among many other descriptors, can be measured in terms of energy consumption, agriculture land use, water consumption or GHG emissions [ 3 ]. Animal-based foods are by far the most land and energy intensive compared to foods of vegetable origin [ 4 ].

Thus, dietary patterns can substantially vary in resource consumption and the subsequent impact on the environment, as well as on the health of a given population [ 3 ]. Research has recently shown that certain dietary patterns, such as the Mediterranean Diet MDP , play a role in chronic diseases prevention [ 5 ].

Moreover, the MDP has been linked to a higher nutrient adequacy in epidemiological studies [ 6 ]. Thus, the MDP, as a plant-centred dietary pattern that does not exclude but rather admits moderately to low amounts of animal foods and meat , seems to emerge as a hypothetical dietary pattern that could address both health and environmental concerns [ 7 , 8 ].

The MDP should be understood not only as a set of foods but also as a cultural model which involves the way foods are selected, produced, processed and distributed [ 9 , 10 ].

The MDP has recently been acknowledged by UNESCO as an Intangible Cultural Heritage of Humanity [ 9 ]. Based on the latest scientific evidence it has also been represented in the new MDP pyramid [ 11 ] Figure 1.

New Mediterranean Diet pyramid. Lifestyle guidelines for adult population. Adapted from: [ 11 ]. Unfortunately, current diets in Mediterranean countries are departing from the traditional MDP which are changing in so far as the the quantities and proportions of food groups are concerned.

This is due to the widespread dissemination of a Western-type culture, along with the globalisation of food production and consumption which is related to the homogenisation of food behaviours in the modern era [ 12 ].

The concepts of the sustainable diet and human ecology have been neglected in favour of intensification and industrialisation of agricultural systems. More recently, the growing concern over food safety has motivated a renewed interest in sustainable foods, particularly in the Mediterranean area [ 13 ].

The aim of the present study was to analyse the sustainability of the MDP in the context of the Spanish population, whilst also comparing, in terms of their environmental footprints, the current Spanish diet with both the MDP and a typical Western dietary pattern WDP.

Several sources of data were used to analyse the environmental footprints linked to the three dietary patterns studied. These were defined by defined by a mean consumption of the different food groups. Dietary composition of the MDP reference pattern was obtained from the new MDP pyramid [ 11 ].

For the analysis the minimum servings of the several food groups recommended in the MDP pyramid Figure 1 were taken into account. We assumed that the recommended servings from the MDP pyramid applied to the entire population, despite these being addressed to adult population.

This limitation, and the resulting uncertainty, also apply to the other dietary patterns considered, and respond to the lack of data on specific dietary composition for different age groups.

Using only the adult population would change the absolute footprints, but would in any case, only be a partial assessment of the true total footprint, and would not in fact substantially change our results concerning the relative comparison of the environmental footprints between dietary patterns.

The current Spanish dietary pattern SCP was estimated from the FAO food balance sheets for [ 14 ] SCP FB. The WDP was exemplified by the U.

food pattern, and data was also obtained from the FAO food balance sheets. This data was provided by FAOSTAT database [ 15 ]. These values reflect national per capita supply at retail level for human consumption. At the same time, the SCP was estimated from the Household Consumption Surveys of the Spanish Ministry of Agriculture, Food and Environment [ 16 ] SCP CS.

The data set consisted of a representative sample of the Spanish population from households, food service sector centres and institutions in , following a stratified random selection process which recorded daily food purchases in the first case and monthly purchases in the other two cases [ 16 ].

A comparison between the two independent estimates of SCP from food balance sheets, SCP FB , and from consumption surveys, SCP CS was used as a quality control for the estimates. The calories from the different patterns were calculated through food composition tables and stated as comparable ranging around kcal.

The methodological limitations of the consumption surveys [ 17 ] and food balance sheets [ 18 ] should be taken into consideration when interpreting the results.

Despite food purchases and food consumption being fully equivalent, mostly due to food waste that may occur at household level, the amount of food purchased reasonably corresponds to that consumed [ 19 ].

Furthermore data on foods available for human consumption obtained from the food balance sheets, generally overestimate food consumption compared to individual dietary surveys [ 20 ]. Footprints analysed include GHG emissions and use of resources such as agricultural land use, energy consumption and water consumption.

Specific footprints for each food group were obtained from several Life Cycle Assessment LCA sources conducted in Spain and elsewhere Additional file 1. The three phases analyzed in the food system were the agricultural production, processing and packaging, transportation and retail.

These three phases were considered key, where information was available. Some specific footprint values for water consumption and GHG emissions, were not available for some of the food groups cereals, fruits, vegetables, vegetable oils, nuts, etc.

This occurred mainly in the area of processing and transportation. The uncertainties associated with the lack of data for specific footprint values and with the assumption of constant footprints in general imply that the environmental footprint estimates discussed here should be considered as conservative.

Regarding the limitations linked to environmental food data; there were a limited number of food items included in the analysis as data on the different processes was lacking for some food-items. It was assumed that each food category was represented by some representative food items. Furthermore, post retailing distribution from stores to households, storing and cooking and alternative ways of production eco-friendly were not taken into account, only conventional agriculture processes were included.

Thus, neither the environmental impact of intensive resource-consuming processed foods, nor the energy savings related to a higher contribution by fresh, local, eco-friendly and seasonal products could be evaluated in the study.

Land use included both the land used for crops and livestock production, implying an inherent bias in our estimates of this environmental pressure. In the case of fish, data on land use were not available. For comparison, the level of current real environmental pressure was estimated.

The current footprint for each environmental pressure was taken into consideration. Thus, current land use was defined as the agricultural area, including cultivated arable and permanent crops and pasture areas. Data was obtained from the FAOSTAT database in [ 15 ].

Current energy consumption was estimated using data on the energy consumed by the agricultural, fishing and food-production sectors for [ 21 , 22 ]. Current water consumption was defined as the total amount of water consumed by the agricultural sector in and by food industries in [ 23 ].

The current GHG emissions correspond to the total gas emissions of agricultural and food industries in grams of CO 2 equivalent. The MDP showed the lowest footprints in all the environmental pressures taken into consideration, whereas the WDP showed the highest Table 1.

The footprint estimates for the SCP showed considerable differences when evaluated using food balance sheets and consumption surveys estimates, the former always being higher than the latter.

The Land Use and Water Consumption footprint estimates for the SCP agreed with the current real environmental pressures, i. the current real pressure fell between the SCP FB and SCP CS values. However, the Energy Consumption and GHG emissions footprint estimates for the SCP were higher than the current real pressures for both SCP FB and SCP CS.

The adherence of the Spanish population to the MDP would decrease all the considered environmental footprints Figure 2. Changes in environmental footprints of the Mediterranean white and Western grey dietary patterns in relation to the Spanish current diet.

The relative change of each dietary pattern in relation to the Spanish current diet is shown for data derived from food-balance sheets boxes and from household consumption surveys dots. Animal products contributed significantly to increasing diet patterns footprints.

Therefore, diet patterns such as WDP and SCP, with a high contribution of animal products such as meat and dairy products present higher footprint values. The food products with the highest contribution to energy intake are dairy products followed by meat for the WDP, fish for the SCP and vegetables for the MDP Figure 3.

Environmental footprints energy consumption, water consumption, GHG emissions and agricultural land use mean annual contribution of each food group to the dietary pattern. In the WDP dairy products have a slightly higher contribution to water use and as do vegetable oils in the case of the MDP and SCP.

In the WDP sugars and sweets occupy the fourth place in contribution to water use Figure 3. Regarding GHG emissions, undoubtedly meat stands as the food item that most contributes to emissions; a large difference compared to other foods emerges, both in the WDP and SPC.

However, dairy products are the main contributor to GHG emissions in the MDP. In second place, we find dairy products in both the WDP and SCP, and meat in the MDP. In third place, comes fish in all the dietary patterns Figure 3.

A WDP would account for double the GHG emissions compared with the SCP whilst WDP would produce 6 times greater emissions than the MDP. Meanwhile dairy products in the MDP show the highest contribution to land use.