Main difficulties of health promotion for the implementation of the planetary or reference diet
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Barriers to broader adoption of a planetary health diet in the US Food environment (cost and access) Attitudes, preferences, and norms Challenges to reducing meat consumption Complicating connections between cooking at home and sustainable diets Dr. Julia Wolfson, PhD MPP Associate Professor Department of International Health Department of Health Policy and Management
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Main difficulties of health promotion for the implementation of the planetary or reference diet
- 1. Dr. Julia Wolfson, PhD MPP Associate Professor Department of International Health Department of Health Policy and Management October 25, 2022 Main difficulties of health promotion for the implementation of the planetary or reference diet
- 2. • Barriers to broader adoption of a planetary health diet in the US – Food environment (cost and access) – Attitudes, preferences, and norms • Challenges to reducing meat consumption • Complicating connections between cooking at home and sustainable diets
- 3. The US diet
- 4. Dietary intakes compared to recommendations Source: Dietary guidelines for Americans 2020-2025 “percent of us population aged 1 and older who are below and at or above each dietary goal
- 5. Ultra-processed foods Source: Juul et al., AJCN (2021)
- 6. Poor diet quality is a longstanding problem
- 7. Barrier: Food environment • Access – Fresh fruits and vegetables, whole grains, fish – Food desert / food swamp neighborhoods • Affordability – Higher cost of more sustainable ingredients – Time costs, equipment, and effort to prepare healthier/sustainable foods
- 8. Food environment and normative eating Source: USDA, ERS
- 9. Meat consumption Source: Neff et al. Public Health Nutrition (2018) and https://www.thedailybeast.com/why-right-wingers-are-going-crazy-about-meat
- 10. Reasons Americans reduce meat consumption Source: Neff et al. Public Health Nutrition (2018)
- 11. Taste and affordability are top concerns Source: Menus of Change, 2022
- 12. Strategies to reduce meat consumption Source: Neff et al. Public Health Nutrition (2018)
- 13. Cooking at home is also associated with high GHGE Source: Wolfson et al., IJERPH, 2022
- 14. Americans who cook more often consume more meat Source: Wolfson et al., IJERPH, 2022
- 15. Cooking and climate impact (GHGE) Source: Wolfson et al., IJERPH, 2022
- 16. Conclusion Source: Fanzo et al. Nature Food (2020)
Notas del editor
- Thank you for having me, I’m very happy to be with you virtually, though I would have loved to be able to join you in person! Today I’m going to be discussing some of the main challenges of broader adoption of a planetary health diet in the context of the United States
- First, I’ll go over some of the high level trends in dietary intake in the United States and barriers to changing those trends in the direction of more healthy and sustainable diets with a particular focus on the food environment, and attitudes, preferences and behavioral norms around food. I’ll also discuss a particular focus on challenges related to reducing meat consumption and some recent research from my team about the complex relationship between cooking at home at sustainable diets.
- This figure is from the report for the 2020-2025 Dietary Guidelines for Americans. It shows that diet quality among Americans at all stages of life is quite poor. As you can see, the maximum score here is 100 indicating a dietary intake consistent with the Dietary Guidelines for Americans. So, higher scores represent heathier diets. The metric used here is the Healthy Eating Index-2015, not a planetary health reference diet, however the goals of the both are quite similar and the changes needed to improve diet quality would also represent significant shifts towards a planetary health diet.
- This figure shows more detailed information about what Americans are eating and what is driving poor diet quality. The purple striped bars on the top half of the figure represent the percentage of Americans who are at or above recommendations for consuming each food group (indicated along the x axis). The blue bars along the bottom show the percent of Americans who are not meeting recommendations for that food group. So, you can see that for total vegetable consumption, 90% of Americans 1 year old and older are not eating enough to meet recommendations by the Dietary Guidelines. For all vegetables, the overwhelming majority of Americans do not meet recommendations. Same for fruits and whole grains. In contrast, almost all Americans consume too much refined grains and about 2/3 are consuming too much meat, poultry and eggs. So, big picture, we consume far too few fruits and vegetables, too few whole grains, too much refined grains and meat and poultry. This is a diet inconsistent with the planetary health reference diet.
- One factor driving this is ultra-processed foods. These highly processed, highly palatable foods comprise the majority of caloric intake among American adults. This is data from the National Health and Nutrition Examination Survey, a large representative survey of Americans that includes two 24-hour dietary recalls. We see here in the purple line along the top of the figure that the proportion of energy intake from ultra-processed foods is growing over time among both men and women, and the difference in the proportion of energy intake from ultra-processed foods compared to minimally processed foods is becoming larger over time. This is not good news for dietary quality or for sustainable diets as ultra-processed foods are associated with numerous adverse health outcomes and are associated with environmental degradation and high greenhouse gas emissions.
- These trends in intake, particularly related to low fruit and vegetable consumption and too much consumption of meats is a long standing problem. On the left, you see here a comparison of intakes among American adults between 1970 in the orange bars and 2018 in the blue bars. You can see that little has changed over nearly 50 years. On the right, you see a figure showing an indicator of meat consumption over time among Americans. Beef is in the red, whereas chicken is in yellow. While beef consumption has declined considerably since the 1970s, beef consumption is still very high and chicken consumption has increased dramatically. These trends in dietary intake are also relevant to more sustainable diets as well. Since in order to achieve broad adoption of a more sustainable dietary pattern, a primary change that will need to take place is to reduce consumption of red meat, and increase consumption of more plant based meals.
- The food environment is a primary driver of these dietary patterns. Though this looks different in urban and rural communities, in many areas in the US, access to healthy and sustainable foods, particularly fresh and sometimes frozen fruits and vegetables, is very low. In many communities in addition to fruits and vegetables, high quality whole grain foods, fish, legumes, and other minimally processed foods are scarce. Many neighborhoods, often referred to as food deserts, lack supermarkets or grocery stores. Whereas other neighborhoods are dominated by fast food restaurants while healthy food options are also scarce. These neighborhoods are often referred to as food swamps. Affordability is also a concern particularly the relative cost between healthier and more environmentally sustainable food and ingredients compared to fast food, and ultra-processed foods which dominate small markets in urban communities as well as grocery store shelves. Affordability doesn’t only refer to the monetary cost of foods. There are also time costs and mental energy or effort costs to making certain food choices. And, making different food choices in the direction of healthier and more sustainable diets will require effort and time that often people do not have.
- In addition to foods available on grocery store shelves, the role of food away from home has increased over time and has changed normative eating behaviors. In this chart showing the proportion of household food spending over time on foods to be consumed at home in green compared to foods away from home such as restaurants in blue and fast food restaurants specifically in red. You can see that the role of food away from home, and fast food in particular, has increased since the 1950s. Whereas spending on food to be prepared and consumed at home has declined. Americans now spend 50% of all household food spending on foods away from home. On a typical day, 1/3 of Americans eat at a fast-food restaurant. This is important because away from home foods tend to have larger portion sizes and be more energy dense compared to foods prepared at home, and are often dominated by meat-based menu items as well.
- As I already mentioned, Americans consume a lot of meat! This is for a lot of reasons, not the least of which include that people really like meat, they think it tastes good, associate it with a complete meal, and in many culinary traditions in the US meals center around the main protein on the dish, which is usually a meat-based protein. This figure is from a survey we did in 2015 in which we asked people who had not reduced their meat consumption in the prior 3 years why they did not do so. Beliefs about a healthy diet including meat and meals being incomplete without meat were frequently cited. Other main reasons people cited were that meals without meat were boring, that making plant-based meals was too expensive, plant based meals were not filling, that they didn’t like meals without meat or they weren’t a big vegetable eater, and finally that they don’t know how to cook meatless meals. These attitudes and taste preferences are really intractable barriers to change. Particularly when being a ”red meat eater” is also bound up in other cultural and political identities such as one’s identity as a cultural or political conservative. That dietary choices have become politicized is an additional important barrier to broader promotion of more sustainable dietary patterns.
- In that same survey we also asked people who had reduced their meat consumption why they did so. Interestingly, cost and health concerns were the most frequently cited reasons whereas the environment ranked fourth. This is notable, and other studies are exploring whether messages about the environmental impact of food choices versus the health impact, or combined messages are more effective. This is an important area of research to better understand what kind of messages on food labels, or advertisements or public education campaigns will resonate with the public and shift behaviors towards more sustainable food choices.
- The data presented here are from a study conducted by the Menus of Change initiative at the Culinary Institute of America. They did a national online survey of 1500 adults in the US in 2022. When they asked people in the US about why they do not eat plant-based meals more often, the most commonly cited reason was taste concerns followed by affordability. More than half of people thought that plant-based meals wouldn’t taste good! Another interesting finding was that one in five adults overall, and one in four Generation Z members said that cooking plant-based meals was a barrier for them. This is consistent with other evidence that lack of confidence or knowledge about cooking is a barrier to shifting food choices and making dietary changes.
- This figure shows data from the same 2015 survey, but this time among people who had reduced their meat consumption. Most did so by reducing the amount of meat they ate either buy buying less meat or reducing their portion sizes of meat. Fewer implemented a meatless day, such as a Meatless Monday, which has been a public health campaign to promote eating more plant based meals and reducing meat consumption. Only about 1 in 10 Americans said they had fully cut meat out of their diets. Other studies have had similar findings, and this is important to think about for messages about reducing meat consumption. Perhaps taking a sort of ‘harm reduction’ approach with small steps to reduce consumption of red meat, or goals to eat a planetary health meal or day of meals will be a more achievable step for many compared to making a wholesale change to their diets, which may feel overwhelming.
- Let’s return to the barrier of cooking at home cited in the survey results I was just referring to. A growing body of research has shown that cooking confidence and self efficacy are really important drivers of cooking behavior. In some of my research I have found that cooking more frequently at home is associated with better diet quality among American adults. That led me to hypothesize that more frequent cooking at home would also be associated with lower food related greenhouse-gas emissions. In this figure we analyzed data from the National Health and Nutrition Examination Survey, and calculated the greenhouse gas emissions from the foods consumed that were reported in 24 hour dietary recalls. We then looked at associations between cooking frequency and frequency of consuming fast food with diet related greenhouse gas emissions. Interestingly, eating fast food more often was associated with higher greenhouse gas emissions. But, notably and unexpectedly, we found that more frequent cooking at home is also associated with higher greenhouse gas emissions!
- Why is this? Well, the reason is that when Americans cook at home, they are cooking a lot of meat, including beef, pork and poultry as you can see here in this figure showing the grams/2000 calories consumed associated with different levels of cooking frequency. You can see that overall, more frequently cooking at home (in the gray and yellow bars) is associated with higher intake of meat and fish.
- In fact, when we looked at the odds of being in the highest quintile of greenhouse gas emissions, we found that people who cooked dinner at home the most frequently were 28% more likely to be in the highest quintile of greenhouse gas emissions. This really underscores the complexity of the problem in that messages to cook more at home to improve diet quality might be having an unintended environmental consequence if sustainable food choices are not explicitly addressed.
- To conclude, factors across all levels of the food system influence dietary intake and are difficult to shift. In the US context, food environments make healthy and sustainable choices difficult and individual factors and cultural norms around food, and meat in particular, are resistant to change. Finally, consumer behaviors, particularly cooking practices when not eating at restaurants, are a key consideration for any effort to shift towards more sustainable diets.