Background: Public interest in plant-based dairy analogues is increasing; thus, their assessment by front-of-pack nutrition labelling schemes such as Keyhole and Nutri-Score can facilitate the identification of products with optimal nutritional quality. In this study, Keyhole and the latest version of Nutri-Score criteria were applied to plant-based dairy analogues (i.e., milk, yoghurt, cheese, cream, fat spread, and ice cream analogues) in the Swedish market to evaluate their nutritional quality. Methods: Nutritional data for 222 plant-based dairy analogues were collected from food manufacturers’ websites, and the eligibility of these analogues for Keyhole and Nutri-Score (A to E) were assessed. Products eligible for Keyhole and Nutri-Score A or B were deemed to have optimal nutritional quality. Results: 16% of plant-based milk analogues (from oat-, almond-, rice-, and potato-based products), 2% of plant-based yoghurt analogues and 37% of plant-based fat spread analogues were eligible for Keyhole. The plant-based cheese, cream and ice cream analogues were ineligible for Keyhole. None of the plant-based milk analogues qualified for Nutri-Score A, and 45% (mainly soy-, almond-, coconut-, pea- and mixed-based products) qualified for Nutri-Score B. 68% of plant-based yoghurt analogues (from oat-, soy-, almond- and mixed-based products) qualified for Nutri-Score A or B. The plant-based cheese, fat spread and ice cream analogues were ineligible for Nutri-Score A or B and 32% of plant-based cream analogues qualified for Nutri-Score B. A higher percentage of organic milk analogues and a lower percentage of organic yoghurt analogues were eligible for Keyhole and Nutri-Score A or B compared to their non-organic varieties. Keyhole and Nutri-Score had an agreement on classifying two plant-based dairy analogues as optimal nutritional quality products and 133 plant-based dairy analogues as suboptimal. Conclusions: There is variability in the eligibility of plant-based dairy analogues for Keyhole and Nutri-Score labelling. Eligibility for Keyhole was highest among plant-based fat spread analogues, while Nutri-Score A and B ratings were more common for plant-based yoghurt analogues. Plant-based cheese and ice cream analogues were ineligible for Keyhole and Nutri-Score A or B. Since the micronutrient content of organic and non-organic plant-based dairy analogues did not affect their evaluation by Keyhole and Nutri-Score, this limitation warrants further consideration. 

Background: Human diets account for 30% of greenhouse gas emissions (GHGE). Reporting dietary GHGE with or without energy standardization yields different outcomes, often resulting in conflicting conclusions regarding associations with micronutrient intake. Objectives: This study aims to compare methods of reporting dietary GHGE, with and without consideration of energy intake, and their respective associations with micronutrient intake. Methods: Data were sourced from the Malmö Diet and Cancer Study, a cohort involving 25,970 participants. GHGE were estimated based on life cycle assessment data. The study explores different methods of reporting dietary climate impact: GHGE per day, GHGE per 1000 kcal, and with different energy adjustments. Association with micronutrient intake was modeled as daily intake and per 1000 kcal using linear regression models. Results: Diets with higher GHGE per day were associated with a higher daily intake of all 17 examined micronutrients. When energy was included in the model, the results for GHGE per 1000 kcal aligned well with those for GHGE per day. However, using GHGE per 1000 kcal generally showed that higher GHGE were linked to lower daily micronutrient intake. Different methods of adjusting for energy intake yielded estimates with varying directions and magnitudes of associations. Conclusions: This study highlights the implications of energy intake when assessing the impact of dietary GHGE and demonstrates that the choice of GHGE modeling approach might have important consequences for the results and interpretation. The method of choice for modeling dietary GHGE in relation to micronutrient intake needs to be carefully considered in future studies.

The global food system contributes roughly one-third of global greenhouse gas emissions (GHGEs) making shifts towards more sustainable food consumption an imperative. Such diets also need to factor in nutrient requirements and cultural acceptability. Our aim was to simulate dietary changes for adolescents in Sweden to achieve the recommended intake (RI) for vitamin D while factoring in additional nutrients, cultural acceptability and keeping the diet within planetary boundaries for climate change. A baseline diet was estimated from Sweden’s national dietary survey Riksmaten Adolescents 2016–17 (n = 3099, ages 11–18 years), which provided food intake via two 24-hour recalls. Intake data were linked to the Swedish Food Agency’s food composition database and GHGE estimates from the Research Institutes of Sweden’s (RISE) Food Climate Database. Linear programming was used to optimize the baseline diet to meet the RI for vitamin D (10 µg/day), reduce GHGEs to ≤ 1.7 kg CO2-equivalents/person/day, and minimize dietary changes from baseline to factor in cultural acceptability. A second optimization included 25 additional nutrients requirements. Both optimized diets met their respective requirements reducing GHGEs by 54 % but relied heavily on milk and yoghurt (fortified by law), which provided > 60 % of vitamin D intake. Both diets also required major shifts toward plant-based foods and the second optimization demanded a five-fold greater change in diet from baseline compared to first optimization. Results suggest that adolescents in Sweden can achieve RIs for vitamin D and other nutrients while greatly reducing diet-related GHGEs, though cultural acceptability may be a challenge. 

Purpose: The risk of inadequate micronutrient intake is a concern of low-climate impact diets. This study analyzes the prevalence of iron deficiency (ID) among adolescents with varying dietary climate impact, with special reference to different types and dietary sources of iron. Methods: Data on dietary intake (n = 3099) and plasma ferritin (n = 1030) were from Riksmaten Adolescents 2016–2017 survey of Swedish girls and boys aged 11–18 years. Dietary climate impact was estimated with life cycle assessment data. Linear and logistic regression models assessed associations between dietary climate impact, intakes of iron and food groups, and ID. Results: Higher total iron and heme, but not non-heme, iron intake, was linearly associated with higher dietary climate impact. Compared to girls, boys had higher climate impact and low prevalence of ID. Girls in the highest climate impact quartile had 56% lower odds of ID (OR 0.44, 95% CI 0.24–0.81) compared to the lowest quartile, whereas no association was found in boys. Lower intake of red meat and heme iron was associated with ID in girls, while higher intake of dairy was associated with ID in boys. Menstruating girls and adolescents born outside of Sweden were identified risk groups for ID. Conclusions: Girls with a more climate-friendly diet and lower intake of red meat/heme iron may be at higher risk of ID compared to girls with higher dietary climate impact. These results highlight the importance of considering risk groups of ID, such as menstruating girls, in the transition to more plant-based diets with lower climate impact.

Different approaches have been used for translation of the EAT–Lancet reference diet into dietary scores that can be used to assess health and environmental impact. Our aim was to compare the different EAT–Lancet diet scores, and to estimate their associations with all-cause mortality, stroke incidence, and greenhouse gas emissions. We did a systematic review (PROSPERO, CRD42021286597) to identify different scores representing adherence to the EAT–Lancet reference diet. We then qualitatively compared the diet adherence scores, including their ability to group individuals according the EAT–Lancet reference diet recommendations, and quantitatively assessed the associations of the diet scores with health and environmental outcome data in three diverse cohorts: the Danish Diet, Cancer and Health Cohort (DCH; n=52 452), the Swedish Malmö Diet and Cancer Cohort (MDC; n=20 973), and the Mexican Teachers’ Cohort (MTC; n=30 151). The DCH and MTC used food frequency questionnaires and the MDC used a modified diet history method to assess dietary intake, which we used to compute EAT–Lancet diet scores and evaluate the associations of scores with hazard of all-cause mortality and stroke. In the MDC, dietary greenhouse gas emission values were summarised for every participant, which we used to predict greenhouse gas emissions associated with varying diet adherence scores on each scoring system. In our review, seven diet scores were identified (Knuppel et al, 2019; Trijsburg et al, 2020; Cacau et al, 2021; Hanley-Cook et al, 2021; Kesse-Guyot et al, 2021; Stubbendorff et al, 2022; and Colizzi et al, 2023). Two of the seven scores (Stubbendorff and Colizzi) were among the most consistent in grouping participants according to the EAT–Lancet reference diet recommendations across cohorts, and higher scores (greater diet adherence) were associated with decreased risk of mortality (in the DCH and MDC), decreased risk of incident stroke (in the DCH and MDC for the Stubbendorff score; and in the DCH for the Colizzi score), and decreased predicted greenhouse gas emissions in the MDC. We conclude that the seven different scores representing the EAT–Lancet reference diet had differences in construction, interpretation, and relation to disease and climate-related outcomes. Two scores generally performed well in our evaluation. Future studies should carefully consider which diet score to use and preferably use multiple scores to assess the robustness of estimations, given that public health and environmental policy rely on these estimates. 

Well-aligned food policies are needed at both national and international level to guide food system transformation towards sustainability. Rigorous indicator frameworks are essential in order to facilitate discussion of priorities, enable comparisons, assessment and progress monitoring, and ensure accountability. In this study, we develop a national framework for a sustainable food system, using Sweden as a case. Our framework, the Food System Sustainability House, advances the literature on sustainable food system frameworks in three distinct ways. Firstly, it is tailored to a specific national context (Sweden in our case); secondly, it distinguishes between impacts of domestic production arising within territorial boundaries and impacts related to Swedish consumption independent of country of origin; and thirdly, to facilitate policy priorities, it suggests how different dimensions of sustainability are interlinked at a conceptual level. From a scientific perspective, the Food System Sustainability House postulates the interlinkages between the societal objectives of the food system, the environmental foundations on which production takes place, and the economic system and governance which in the framework are suggested to function as enablers for an overall sustainable system. From a policy perspective, the framework provides a much-needed basis for assessing food system sustainability by suggesting indicators within a comprehensive set of sustainability themes at national level for monitoring distinct perspectives. It also provides the necessary basis for a discussion on how sustainability dimensions are interlinked. 

The market for plant-based dairy alternatives is growing; therefore, focusing on the nutritional quality of these products is important. This study evaluates the nutritional profile of plant-based alternatives to milk, yoghurt, cheese, cream, ice cream and fat spread in the Swedish market and compares them to corresponding dairy products. The nutritional quality of organic vs non-organic and plain vs flavoured plant-based milk and yoghurt alternatives was also assessed. Nutritional data for 222 plant-based dairy alternatives were collected from the manufacturers’ websites, and data for corresponding dairy products were obtained from the Swedish Food Composition Database. Plant-based dairy alternatives had higher fibre content than dairy products, while their protein content was lower, except for soy-based products. The saturated fat content of plant-based dairy alternatives was similar to or lower than dairy products, except for coconut-based yoghurt and plant-fat-based cheese. Their energy content was also similar to or lower than dairy products, except for coconut-based yoghurt, plant-based fat spread and plant-based ice cream, which contained higher energy than yoghurt, blended margarine, and ice cream, respectively. The micronutrient fortification was mainly in plant-based milk, yoghurt, and cheese alternatives; thus, compared to dairy, they had similar or higher vitamins D, B2, and B12 (except in plant-based milk alternatives), calcium and iodine content. Furthermore, organic plant-based milk and yoghurt alternatives had a lower micronutrient content (e.g., vitamins B2 and B12, iodine and calcium) except for vitamin D than non-organic varieties. Flavoured plant-based milk and yoghurt alternatives were higher in energy and total sugar than plain varieties. In summary, plant-based dairy alternatives have nutritional strengths and weaknesses compared to dairy products that should be considered when replacing dairy. 

Objective: To assess the associations between adherence to the Swedish dietary guidelines and all-cause mortality and thus assessing the index' ability to predict health outcomes, as well as levels of dietary greenhouse gas emissions (GHGEs). Design: A longitudinal study 1990-2016 within the population-based cohort Västerbotten Intervention Programme. Dietary data were based on food frequency questionnaires. Diet quality was assessed by the Swedish Healthy Eating Index for Adults 2015 (SHEIA15), based on the 2015 Swedish dietary guidelines. Dietary GHGEs were estimated from life cycle assessment data including emissions from farm to industry gate. Hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause mortality were evaluated with Cox proportional hazards regression, and differences in median GHGEs were tested using the Kruskal-Wallis one-way ANOVA test, between quintiles of SHEIA15 score. Setting: Northern Sweden. Participants: In total, 49,124 women and 47,651 men, aged 35-65 years. Results: Median follow-up times were 16.0 years for women and 14.7 years for men, during which time 3074 women and 4212 men died. A consistent trend of lower all-cause mortality HRs for both sexes with higher SHEIA15 scores was demonstrated. For women, the all-cause mortality HR was 0.81 [(95% CI 0.71-0.92); p=0.001] and for men 0.90 [(95% CI 0.81-0.996); p=0.041] between the quintile with the highest SHEIA15 score compared with the quintile with the lowest SHEIA15 score. A consistent trend of lower estimated dietary GHGEs among both sexes with higher SHEIA15 scores was also found. Conclusions: Adherence to Swedish dietary guidelines, estimated by SHEIA15, seems to promote longevity and reduce dietary climate impact. © The Authors 2023.

Background: There is a concern that pesticide residues, regularly detected in foods, might pose a health risk to the consumer, but epidemiological evidence is limited. We assessed the associations between dietary exposure to a mixture of pesticide residues and mortality. Methods: Food consumption was assessed in 68,844 participants from the Swedish Mammography Cohort and the Cohort of Swedish Men, 45–83 years at baseline (1997). Concentrations of pesticide residues detected in foods on the Swedish market (1996–1998), mainly fruits and vegetables, were obtained via monitoring programs. To assess mixture effects, we summed per food item the ratios of each single pesticide mean residue concentration divided by its acceptable daily intake to create for each participant a Dietary Pesticide Hazard Index (adjusted for energy intake and expressed per kilogram of body weight). Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HR) and 95 % confidence intervals (95 %CI). Results: During 15 years of follow-up (1998–2014), a total of 16,527 deaths occurred, of which 6,238 were caused by cardiovascular disease (CVD) and 5,364 by cancer. Comparing extreme quintiles of Dietary Pesticide Hazard Index, the highest category was inversely associated with CVD mortality HR, 0.82 (95 % CI, 0.75–0.90) and with cancer mortality HR 0.82 (95 % CI 0.75–0.91). In analyses stratified by high/low Dietary Pesticide Hazard Index, similar inverse associations were observed by increasing fruit and vegetable consumption. Conclusions: We observed no indications that dietary exposure to pesticide residue mixtures was associated with increased mortality, nor any clear indications that the benefits of fruit and vegetable consumption on mortality was compromised. Yet, our results need to be interpreted with caution. © 2023 The Author(s)

The transition towards more plant-based diets is identified as an important measure for limiting dietary climate impact. Plant-based meat analogues (PBMAs) have been proposed as a viable lower carbon alternative to meat, and its market is rapidly growing globally. However, knowledge about the climate impact of PBMAs in relation to other foods is currently limited due to the challenge of comparing life cycle assessments (LCAs) using different methods. The aim of this study was to review the climate impact of PBMAs based on LCAs published up to 2021. Original LCA data were recalculated to harmonize differences in method choices among studies and presented as the climate impact of final products at factory gate. The median climate impact of PBMAs was estimated at 1.7 kg CO2 eq./kg of product with a more than fourfold variation in impact (0.5–2.4 kg CO2 eq./kg product). Climate impact per protein content of the final product varied from 0.4 to 1.2 kg CO2 eq./100 g protein with a median impact of 0.8 kg CO2 eq./100 g protein. Cultivation of raw materials and manufacturing were identified to be responsible for a large proportion of GHG emissions up to factory gate. However, the assessment of climate impact in the production chain was challenged by the level of detail of data provided. A transparent reporting strategy regarding the specific stages in the supply chain, method choices and product information is recommended to facilitate identification of hot spots to target for improved climate performance of future PBMAs and to enable accurate comparisons between studies. It could further be concluded that current scientific knowledge on the climate impact of PBMAs is based on a limited number of LCAs that often rely on a combination of secondary data and collected data at production scale or from pilot-scale production facilities. Future LCAs of PBMAs would benefit from additional assessments of commercial production using region- and site-specific data. © 2023 The Authors