Environmental assessment of diets: overview and guidance on indicator choice.

Comprehensive but interpretable assessment of the environmental performance of diets involves choosing a set of appropriate indicators. Current knowledge and data gaps on the origin of dietary foodstuffs restrict use of indicators relying on site-specific information. This Personal View summarises commonly used indicators for assessing the environmental performance of diets, briefly outlines their benefits and drawbacks, and provides recommendations on indicator choices for actors across multiple fields involved in activities that include the environmental assessment of diets. We then provide recommendations on indicator choices for actors across multiple fields involved in activities that use environmental assessments, such as health and nutrition experts, policy makers, decision makers, and private-sector and public-sector sustainability officers. We recommend that environmental assessment of diets should include indicators for at least the five following areas: climate change, biosphere integrity, blue water consumption, novel entities, and impacts on natural resources (especially wild fish stocks), to capture important environmental trade-offs. If more indicators can be handled in the assessment, indicators to capture impacts related to land use quantity and quality and green water consumption should be used. For ambitious assessments, indicators related to biogeochemical flows, stratospheric ozone depletion, and energy use can be added.

A restatement of the natural science evidence base concerning grassland management, grazing livestock and soil carbon storage.

Approximately a third of all annual greenhouse gas emissions globally are directly or indirectly associated with the food system, and over a half of these are linked to livestock production. In temperate oceanic regions, such as the UK, most meat and dairy is produced in extensive systems based on pasture. There is much interest in the extent to which such grassland may be able to sequester and store more carbon to partially or completely mitigate other greenhouse gas emissions in the system. However, answering this question is difficult due to context-specificity and a complex and sometimes inconsistent evidence base. This paper describes a project that set out to summarize the natural science evidence base relevant to grassland management, grazing livestock and soil carbon storage potential in as policy-neutral terms as possible. It is based on expert appraisal of a systematically assembled evidence base, followed by a wide stakeholders engagement. A series of evidence statements (in the appendix of this paper) are listed and categorized according to the nature of the underlying information, and an annotated bibliography is provided in the electronic supplementary material.

Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials.

BACKGROUND: Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy. METHODS: MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I2 value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool. RESULTS: Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49-0.91, I2: 38.7%, p = 0.0098) and -0.07 (95% CI -0.12 to -0.03, I2: 53.6%, p = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect. CONCLUSION: The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

Does prophylactic negative pressure wound therapy prevent surgical site infection in abdominal surgery?

OBJECTIVE: To determine if prophylactic negative pressure wound therapy (pNPWT) allows for the prevention of surgical site infections (SSIs) in abdominal surgery. METHOD: A non-systematic review assessing the evidence was conducted in 2020. RESULTS: Retrospectve studies comparing patients with pNPWT with patients receiving standard wound dressing after abdominal surgery showed encouragning results in favour of pNPWT for reducing the incidence of SSIs, but randomised controlled trials have so far reported mixed results. CONCLUSION: New randomised controlled trials including a sufficient number of patients at risk of SSIs are needed for confirming the results of non-interventional studies.

Agroecological practices in combination with healthy diets can help meet EU food system policy targets.

Agroecology has been proposed as a strategy to improve food system sustainability, but has also been criticised for using land inefficiently. We compared five explorative storylines, developed in a stakeholder process, for future food systems in the EU to 2050. We modelled a range of biophysical (e.g., land use and food production), environmental (e.g., greenhouse gas emissions) and social indicators, and potential for regional food self-sufficiency, and investigated the economic policy needed to reach these futures by 2050. Two contrasting storylines for upscaling agroecological practices emerged. In one, agroecology was implemented to produce high-value products serving high-income consumers through trade but, despite 40% of agricultural area being under organic management, only two out of eight EU environmental policy targets were met. As diets followed current trends in this storyline, there were few improvements in environmental indicators compared with the current situation, despite large-scale implementation of agroecological farming practices. This suggests that large-scale implementation of agroecological practices without concurrent changes on the demand side could aggravate existing environmental pressures. However, our second agroecological storyline showed that if large-scale diffusion of agroecological farming practices were implemented alongside drastic dietary change and waste reductions, major improvements on environmental indicators could be achieved and all relevant EU policy targets met. An alternative storyline comprising sustainable intensification in combination with dietary change and waste reductions was efficient in meeting targets related to climate, biodiversity, ammonia emissions, and use of antibiotics, but did not meet targets for reductions in pesticide and fertiliser use. These results confirm the importance of dietary change for food system climate change mitigation. Economic modelling showed a need for drastic changes in consumer preferences towards more plant-based, agroecological and local foods, and for improvements in technology, for these storylines to be realised, as very high taxes and tariffs would otherwise be needed.

Sustainability of Diets in Mexico: Diet Quality, Environmental Footprint, Diet Cost, and Sociodemographic Factors.

Background: Little is known about the current intake of sustainable diets globally and specifically in middle-income countries, considering nutritional, environmental and economic factors. Objective: To assess and characterize the sustainability of Mexican diets and their association with sociodemographic factors. Design: Dietary data of 2,438 adults within the National Health and Nutrition Survey 2012 by integrating diet quality measured by the Healthy Eating Index (HEI-2015), diet cost, and four environmental indicators were analyzed: land use (LU), biodiversity loss (BDL), carbon footprint (CFP), and blue water footprint (BWFP). We defined healthier more sustainable diets (MSD) as those with HEI-2015 above the overall median, and diet cost and environmental indicators below the median. Logistic regression was used to evaluate the association of sociodemographic factors with MSD. Results: MSD were consumed by 10.2% of adults (4% of urban and 22% of rural), who had lower intake of animal-source foods, unhealthy foods (refined grains, added sugar and fats, mixed processed dishes and sweetened beverages), fruits, and vegetables, and higher intake of whole grains than non-MSD subjects. Characteristics of MSD vs. non-MSD (urban; rural) were: HEI-2015 (62.6 vs. 51.9; 66.8 vs. 57.6), diet-cost (1.9 vs. 2.8; 1.9 vs. 2.5 USD), LU (3.3 vs. 6.6; 3.2 vs. 5.9 m2), BDL (105 vs. 780; 87 vs. 586 species × 10-10), BWFP (244 vs. 403; 244 vs. 391 L), and CFP (1.6 vs. 4.4; 1.6 vs. 3.7 kg CO2eq). Adults from rural vs. urban (OR 2.7; 95% CI: 1.7, 4.1), or from the South (OR 2.1; 95% CI: 1.1, 3.9), Center (OR 2.3; 95% CI: 1.3, 4.4) vs. the North were more likely to consume MSD, while adults with high vs. low socioeconomic status were less likely (OR 0.17; 95% CI: 0.09, 0.3). Conclusions: The MSD is a realistic diet pattern mainly found in disadvantaged populations, but diet quality is still sub-optimal. Increased consumption of legumes, fruits, and vegetables, and a reduction in unhealthy foods, is required to improve nutritional quality of diets while ensuring their environmental sustainability.

Smaller farm size and ruminant animals are associated with increased supply of non-provisioning ecosystem services.

To balance trade-offs between livestock's negative environmental impacts and their positive contributions (e.g. maintaining semi-natural grasslands, varied agricultural landscapes and crop rotations), a better understanding is needed of how the supply of ecosystem services differs across farms. We analysed a suite of indicators for non-provisioning ecosystem services on a large subset of Swedish farms (71% of farms, covering 82% of agricultural land) and related these to farm type, farm size and livestock density. The analysed indicators exhibited clear geographical patterns with hotspots especially in less productive regions. Controlling for this spatial variation we still found that small-scale and ruminant farms were associated with more varied landscapes, small-scale habitats, semi-natural grasslands and better crop sequences compared to nearby farms specialised in crop production, while farms specialising in monogastric livestock were associated with less varied landscapes and inferior crop sequences. Results for cultural ecosystem services indicated that farms with more semi-natural grassland were associated with more visitors and more likely located within designated recreation or nature conservation areas.

Dietary fat intake and risk of Parkinson disease: results from the Swedish National March Cohort.

BACKGROUND: Following progressive aging of the population worldwide, the prevalence of Parkinson disease is expected to increase in the next decades. Primary prevention of the disease is hampered by limited knowledge of preventable causes. Recent evidence regarding diet and Parkinson disease is inconsistent and suggests that dietary habits such as fat intake may have a role in the etiology. OBJECTIVE: To investigate the association between intake of total and specific types of fat with the incidence of Parkinson disease. METHODS: Participants from the Swedish National March Cohort were prospectively followed-up from 1997 to 2016. Dietary intake was assessed at baseline using a validated food frequency questionnaire. Food items intake was used to estimate fat intake, i.e. the exposure variable, using the Swedish Food Composition Database. Total, saturated, monounsaturated and polyunsaturated fat intake were categorized into quartiles. Parkinson disease incidence was ascertained through linkages to Swedish population-based registers. Cox proportional hazards regression models were used to estimate hazard ratios (HR) with 95% confidence intervals (CI) of the association between fat intake from total or specific types of fats and the incidence of Parkinson disease. The lowest intake category was used as reference. Isocaloric substitution models were also fitted to investigate substitution effects by replacing energy from fat intake with other macronutrients or specific types of fat. RESULTS: 41,597 participants were followed up for an average of 17.6 years. Among them, 465 developed Parkinson disease. After adjusting for potential confounders, the highest quartile of saturated fat intake was associated with a 41% increased risk of Parkinson disease compared to the lowest quartile (HR Q4 vs. Q1: 1.41; 95% CI: 1.04-1.90; p for trend: 0.03). Total, monounsaturated or polyunsaturated fat intake were not significantly associated with Parkinson disease. The isocaloric substitution models did not show any effect. CONCLUSIONS: We found that a higher consumption of large amounts of saturated fat might be associated with an increased risk of Parkinson disease. A diet low in saturated fat might be beneficial for disease prevention.

Meat tastes good, legumes are healthy and meat substitutes are still strange - The practice of protein consumption among Swedish consumers.

Replacing some meat with grain legumes would benefit human health, the environment and agriculture. This study analysed legume and meat consumption practices by investigating consumer perceptions and competences relating to lightly processed grain legumes (LPL), legume-based meat substitutes (LBMS) and meat in Sweden, and how these (and demographic variables) influenced stated intention to change consumption. Major differences in consumer perceptions of LPL and LBMS compared with meat related to product attractiveness and status, with meat seen as more fun, popular, suitable in diets and for festive occasions, and tastier. Most consumers knew of the environmental impact of meat and health benefits of LPL. Country of origin, i.e. Swedish origin, was important for many consumers (especially for meat and women). Preferences relating to health and environmental impact were important for intention to decrease meat consumption. Perceived environmental impact was important for intention to change consumption of LPL, but taste, healthiness, weight control, ease of preparation and suitability in the diet were equally or more important. Leveraging stated consumer willingness and intention to eat more LPL by making LPL more accessible to consumers could increase their consumption. For LBMS, there are still important barriers in terms of taste, familiarity and overall attractiveness of these products that need to be overcome to increase their consumption in Sweden.

Diet cost and quality using the Healthy Eating Index-2015 in adults from urban and rural areas of Mexico.

OBJECTIVE: To assess the association between diet cost and quality by place of residence. DESIGN: We analysed cross-sectional data of the National Health and Nutrition Survey-2012. Diet cost was estimated by linking dietary data, obtained from a 7-d SFFQ, with municipality food prices, which were derived from a national expenditure survey. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). Association between quintiles of diet cost and HEI-2015 was assessed using linear regression analysis. SETTINGS: Mexico. PARTICIPANTS: 2438 adults (18-59 years). RESULTS: Diet cost was positively associated with diet quality (HEI-2015) in urban but not in rural areas. Compared with quintile (Q1) of cost, the increment in diet quality score was 1·17 (95 % CI -0·06, 4·33) for Q2, 2·14 (95 % CI -0·06, 4·33) for Q3, 4·70 (95 % CI 2·62, 6·79) for Q4 and 6·34 (95 % CI 4·20, 8·49) for Q5 (P-trend < 0·001). Individuals in rural v. urban areas on average have higher quality diets at lower cost with higher intakes of whole grains and beans and lower intakes of Na, added sugars and saturated fats. Living in the South, being indigenous and having low socio-economic status were also associated with higher quality diets. CONCLUSIONS: Diet cost was positively associated with diet quality, but only in urban areas. Further studies are needed to understand the relation between diet cost and quality in rural areas. To improve overall diet quality in Mexico, strategies that aim to reduce the cost of high-quality diets should consider the heterogeneity by place of residence.

The role of fats in the transition to sustainable diets.

In comparison with protein, dietary fat receives little attention in the food system sustainability literature, although we calculate that the average consumption of fats in many populous regions of the world is below nutritional recommendations. Animal products are the major source of dietary fat, particularly in regions with excess fat consumption. We estimate that an additional 45 Mt of dietary fat per year need to be produced and consumed for the global population to reach recommended levels of fat consumption, and we review different strategies to fill this gap sustainably. These strategies include diverting oils currently used for energy production to human consumption, increasing palm oil and peanut oil yields while avoiding further deforestation, developing sustainable cropping systems for the production of rapeseed and soybean oils, increasing the consumption of whole soybeans and derived products, and expanding the use of animal fats already produced.

Prophylactic negative-pressure wound therapy for prevention of surgical site infection in abdominal surgery: a nationwide cross-sectional survey.

Our objective was to determine current practice in Switzerland regarding the use of pNPWT in abdominal surgery. An online survey was carried out to evaluate the use of pNPWT among abdominal surgeons in Switzerland. One hundred and ten participants replied to the survey from 16.12.2019 to 15.01.2020. Eleven were excluded, leaving 99 responders for analysis. Seventy participants (70.7%) were using pNPWT, 3 (3%) have stopped using it and 26 (26.3%) have never used it. pNPWT was used on midline laparotomy by 63 responders (90%), closed stoma wounds by 21 (30%), closed perineal wounds by 20 (28.6%), Pfannenstiel incisions by 18 (23.7%), groin incisions by 16 (22.9%), subcostal incisions by 13 (18.6%), Mc Burney incisions by 3 (4.3%) and other incisions by 18 (25.7%). Forty-eight participants (68.6%) used pNPWT on less than 10% of patients, 14 (20%) on 10-25% of patients, six (8.6%) on 25-50% of patients and two (2.9%) on 75-100% of patients. Suggestions for improvement to pNPWT were: better sealing, recyclable system, better adaptation to the perineum, smaller device, reduced cost and possibility to check the surgical wound through the dressing. In conclusion, pNPWT is widely used among Swiss surgeons, mostly on midline incisions. However, most of them apply pNPWT on a small proportion of patients only. Suggestions for improvement were a better sealing for complex wounds, reduced cost and possibility to check the wound during the therapy.

Amyotrophic Lateral Sclerosis After Exposure to Manganese from Traditional Medicine Procedures in Kenya.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by motor neuron loss and widespread muscular atrophy. Despite intensive investigations on genetic and environmental factors, the cause of ALS remains unknown. Recent data suggest a role for metal exposures in ALS causation. In this study we present a patient who developed ALS after a traditional medical procedure in Kenya. The procedure involved insertion of a black metal powder into several subcutaneous cuts in the lower back. Four months later, general muscle weakness developed. Clinical and electrophysiological examinations detected widespread denervation consistent with ALS. The patient died from respiratory failure less than a year after the procedure. Scanning electron microscopy and X-ray diffraction analyses identified the black powder as potassium permanganate (KMnO4). A causative relationship between the systemic exposure to KMnO4 and ALS development can be suspected, especially as manganese is a well-known neurotoxicant previously found to be elevated in cerebrospinal fluid from ALS patients. Manganese neurotoxicity and exposure routes conveying this toxicity deserve further attention.

The role of perineal application of prophylactic negative-pressure wound therapy for prevention of wound-related complications after abdomino-perineal resection: a systematic review.

BACKGROUND: Closed perineal wounds often fail to heal by primary intention after abdomino-perineal resection (APR) and are often complicated by surgical site infection (SSI) and/or wound dehiscence. Recent evidence showed encouraging results of prophylactic negative-pressure wound therapy (pNPWT) for prevention of wound-related complications in surgery. Our objective was to gather and discuss the early existing literature regarding the use of pNPWT to prevent wound-related complications on perineal wounds after APR. METHODS: Medline, Embase, and Web of Science were searched for original publications and congress abstracts reporting the use of pNPWT after APR on closed perineal wounds. RESULTS: Seven publications were included for analysis. Two publications reported significantly lower incidence of SSI in pNPWT patients than in controls with a risk reduction of about 25-30%. Two other publications described similar incidences of SSI between the two groups of patients but described SSI in pNPWT patients to be less severe. One study reported significantly lower incidence of wound dehiscence in pNPWT patients than in controls. CONCLUSION: The largest non-randomized studies investigating the effect of pNPWT on the prevention of wound-related complications after APR showed encouraging results in terms of reduction of SSI and wound dehiscence that deserve further investigation and confirmation.

Halting European Union soybean feed imports favours ruminants over pigs and poultry.

The European Union (EU) livestock sector relies on imported soybean as a feed source, but feeding soybean to animals leads to a loss of macronutrients compared to direct human consumption, and soybean production is associated with deforestation. Here we show that 75-82% of current EU animal fat and protein production could be sustained without soybean imports while avoiding increased use of cropland for feed production within the EU. Reduced soybean feed exports, mainly from South America, would free up 11-14 million hectares outside the EU, but indirect land-use changes would increase demand for palm oil produced in southeast Asia. Avoiding imported soybean feeds would result in reduced EU pork and poultry production; increased plant-based food consumption would be required to maintain the supply of essential nutrients for human diets. Optimizing livestock production to overcome dependency on imported soybean feed can reduce cropland demand in deforestation-prone areas while supporting the nutritional requirements of EU diets-but will require progressive policies targeting all aspects of the food system.

Prophylactic Negative-pressure Wound Therapy Prevents Surgical Site Infection in Abdominal Surgery: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials and Observational Studies.

BACKGROUND: Prevention of surgical site infection (SSI) is a public health challenge. Our objective was to determine if prophylactic negative-pressure wound therapy (pNPWT) allows preventing SSI after laparotomy. METHODS: Medline, Embase, and Web of Science were searched on 6 October 2019 for original studies reporting the incidences of SSI in patients undergoing open abdominal surgery with and without pNPWT. Risk differences (RDs) between control and pNPWT patients and risk ratios (RRs) for SSI were obtained using random-effects models. RESULTS: Twenty-one studies (2930 patients, 5 randomized controlled trials [RCTs], 16 observational studies) were retained for the analysis. Pooled RD between patients with and without pNPWT was -12% (95% confidence interval [CI], -17% to -8%; I2 = 57%; P < .00001) in favor of pNPWT. That risk difference was -12% (95% CI, -22% to -1%; I2 = 69%; P = .03) when pooling only RCTs (792 patients). pNPWT was protective against the incidence of SSI with a RR of 0.53 (95% CI, .40-.71; I2 = 56%; P < .0001). The effect on pNPWT was more pronounced in studies with an incidence of SSI ≥20% in the control arm. The preventive effect of pNPWT on SSI remained after correction for potential publication bias. However, when pooling only high-quality observational studies (642 patients) or RCTs (527 patients), significance was lost. CONCLUSIONS: Existing studies suggest that pNPWT on closed wounds is protective against the occurrence of SSI in abdominal surgery, but these findings need to be confirmed by more high-quality evidence, preferentially in subgroups of patients with an incidence of SSI ≥20% in the control arm.

Mapping of aetiologies of gastroenteritis: a systematic review and meta-analysis of pathogens identified using a multiplex screening array.

OBJECTIVE: Emergence of molecular methods to screen stools could provide a more complete picture of pathogens causing gastroenteritis, allowing to adequately treat patients whenever required but, so far, no aggregate data have been released. Our objective was to report pathogens identified in patients suffering from gastroenteritis using a multiplex molecular array. DESIGN: Medline and Embase were searched for original publications reporting pathogens identified with FilmArray GI panel in patients suffering from gastroenteritis. Proportions of pathogens were extracted and pooled using a model with random effects. RESULTS: Fourteen studies (17,815 patients) were included in the analysis. Among the 7,071 patients (39.7%) with positive FilmArray, identified pathogens were EPEC (27.5%), Clostridium difficile (19.3%), Norovirus (15.1%), EAEC (15%), Campylobacter spp (11.8%), Salmonella spp (8.1%), ETEC (7.3%), Rotavirus (7.3%), Sapovirus (7.1%), STEC (5.2%), Shigella/EIEC (4.9%), Giardia lamblia (4%), Adenovirus (3.8%), Cryptosporidium spp (3.8%), Astrovirus (2.8%), Yersinia enterocolitica (1.7%), Escherichia coli O157 (1.1%), Plesiomonas shigelloides (1.1%), Cyclospora cayetanensis (0.7%), Vibrio spp (0.5%), Vibrio cholerae (0.3%) and Entamoeba histolytica (0.3%). When considering only studies with control group (microbiological examination of the stools performed by other methods), FilmArray identified at least one pathogen in 48.2% of patients versus 16.7% when using comparative diagnostic methods. CONCLUSIONS: FilmArray GI panel was positive in 39.7% of patients suffering from gastroenteritis. This proportion has to be mitigated by the carriage rates of identified organisms. Ultimately, restricted ordering of molecular panels to those patients who might benefit from specific treatment could provide medical value by swift identification of the pathogen and more targeted therapy.

The role of reducing food waste for resilient food systems.

Food waste undermines long-term resilience of the global food system by aggravating ecosystem damage. The global community must therefore work to reduce the amount of food that gets wasted. However, we should be mindful of some potential conflicts between food waste reduction and food system resilience. Over-production and over-supply are a contributing cause of waste, yet they also provide resilience in the form of redundancy. In this paper, we examine individual interventions designed to minimise food waste by scoring their impact on different aspects of resilience. We find that there are strong synergistic elements and interventions that support short- and long-term resilience, such as improved storage, which reduces the need to provide a constant flow of 'surplus food' and replaces it with a stock of 'spare' food. Some interventions carry a risk of trade-offs due to possible losses of redundancy, and investment lock-in that may reduce the ability of farmers to adapt by changing what and where they farm. Trade-offs do not mean that those interventions should not be pursuit, but they should be recognised so that can be adequately addressed with complimentary actions. This review underlines the necessity of food-systems thinking and joined-up policy.