García et al. Environmental Health (2023) 22:1 Environmental Health https://doi.org/10.1186/s12940-022-00956-7 RESEARCH Open Access Carbon dioxide ­(CO2) emissions and adherence to Mediterranean diet in an adult population: the Mediterranean diet index as a pollution level index Silvia García1,2,3, Cristina Bouzas1,2,3, David Mateos1,2,3, Rosario Pastor2,4, Laura Álvarez5,6, María Rubín5,6, Miguel Ángel Martínez‑González1,7,8, Jordi Salas‑Salvadó1,9, Dolores Corella1,10, Albert Goday1,11,12, J. Alfredo Martínez1,13,14, Ángel M. Alonso‑Gómez1,15, Julia Wärnberg1,16, Jesús Vioque4,17, Dora Romaguera1,3, José Lopez‑Miranda1,18, Ramon Estruch1,19, Francisco J. Tinahones1,20, José Lapetra1,21, Lluís Serra‑Majem1,22, Blanca Riquelme‑Gallego4,23, Xavier Pintó1,24, José J. Gaforio4,25, Pilar Matía26, Josep Vidal27, Clotilde Vázquez28, Lidia Daimiel29, Emilio Ros1,30, Maira Bes‑Rastrollo1,7, Patricia Guillem‑Saiz1,10, Stephanie Nishi1,9,31,32, Robert Cabanes1,11, Itziar Abete1,14, Leire Goicolea‑Güemez1,15, Enrique Gómez‑Gracia1,33, Antonio José Signes‑Pastor5,17, Antoni Colom1,3, Antonio García‑Ríos1,18, Sara Castro‑Barquero1,19, Jose C. Fernández‑García1,20, José Manuel Santos‑Lozano1,21, Zenaida Vázquez1,7, José V. Sorlí10, Maria Pascual9, Olga Castañer1,11, Maria Angeles Zulet1,14, Jessica Vaquero‑Luna1,15, F. Javier Basterra‑Gortari7,34, Nancy Babio1,9, Ramon Ciurana1,11, Vicente Martín‑Sánchez5,6 and Josep A. Tur1,2,3* Abstract Background Research related to sustainable diets is is highly relevant to provide better understanding of the impact of dietary intake on the health and the environment. Aim To assess the association between the adherence to an energy-restricted Mediterranean diet and the amount of ­CO2 emitted in an older adult population. Design and population Using a cross-sectional design, the association between the adherence to an energy- reduced Mediterranean Diet (erMedDiet) score and dietary ­CO2 emissions in 6646 participants was assessed. Methods Food intake and adherence to the erMedDiet was assessed using validated food frequency questionnaire and 17-item Mediterranean questionnaire. Sociodemographic characteristics were documented. Environmental impact was calculated through greenhouse gas emissions estimations, specifically C ­ O2 emissions of each participant diet per day, using a European database. Participants were distributed in quartiles according to their estimated C ­ O2 emissions expressed in kg/day: Q1 (≤2.01 kg ­CO2), Q2 (2.02-2.34 kg C ­ O2), Q3 (2.35-2.79 kg ­CO2) and Q4 (≥2.80 kg ­CO2). Results More men than women induced higher dietary levels of ­CO2 emissions. Participants reporting higher con‑ sumption of vegetables, fruits, legumes, nuts, whole cereals, preferring white meat, and having less consumption of *Correspondence: Josep A. Tur pep.tur@uib.es Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. García et al. Environmental Health (2023) 22:1 Page 2 of 10 red meat were mostly emitting less kg of ­CO2 through diet. Participants with higher adherence to the Mediterranean Diet showed lower odds for dietary ­CO2 emissions: Q2 (OR 0.87; 95%CI: 0.76-1.00), Q3 (OR 0.69; 95%CI: 0.69-0.79) and Q4 (OR 0.48; 95%CI: 0.42-0.55) vs Q1 (reference). Conclusions The Mediterranean diet can be environmentally protective since the higher the adherence to the Medi‑ terranean diet, the lower total dietary ­CO2 emissions. Mediterranean Diet index may be used as a pollution level index. Keywords Greenhouse gas emissions, Mediterranean diet, Carbon dioxide, Sustainability, Sustainable diets, Environment Introduction reducing the incidence on major cardiovascular events Despite law regulations issued in the last few dec- in a high-risk population [6]. Nowadays, cardiovascular ades, greenhouse gas (GHG) emissions have increased, diseases are the main cause of death in developed coun- affecting climate change as well as the way of life. Car- tries as well as in Spain [7]. According to the World Heart bon dioxide (­ CO2) represents one of the main GHG. As Federation, tobacco, hypertension, hypercholesterolemia, such, its reduction is part of the United Nations agenda obesity, diabetes, physical inactivity, and inadequate diet 2030 which, in general terms, aims to eradicate poverty are the main cardiovascular disease risk factors [8]. Due and promote sustainable and equalitarian development to its beneficial effects on cardiovascular health, Mediter- by 2030 following 17 sustainable development goals [1]. ranean diet is commonly recommended. Global dietary patterns have changed too, and a The Mediterranean Diet is characterized by a high new lifestyle characterized as quick and stressful has consumption of fruits and vegetables, unrefined cereals, affected our way of purchasing and eating food, caus- plant-origin proteins, and healthy fats such as olive oil, ing a detrimental impact on our health. This new way nuts, and fatty fish. A low consumption of animal prod- of living has also changed due to the increasing demand ucts, mainly red and processed meat, which is one of the of meat protein, driven by the increasing of annual main contributors to C ­ O2 emissions, is also one of the incomes in the last decades. A demand of empty calo- key traits of the characteristic points of the Mediterra- ries found in products like refined cereals, refined sug- nean diet. Limiting overconsumption and energy intakes ars, alcohol, and oils was another of the global changes. to an amount that meets recommendations was pro- Finally, the total per capita caloric demand increased as posed as another possible beneficial aspect for reducing well [2]. the impact on the ecosystems, and this also may help to New food habits and dietary changes have affected the decrease the obesity epidemic [9]. amount of ­CO2 in the atmosphere, since food system People following the Mediterranean Diet are already emissions are around 1/3 of the global GHG emissions, beneficiated for its protective effects on health. It would representing 34% of total ­CO2 equivalents in 2015 [3]. be interesting to study if people following the Mediter- Each increased step in the food chain has an added impact ranean Diet are also protecting the environment while on the degradation of the environment. The production reducing ­CO2 emissions. The present study offers an step has a particular impact, and this is the reason why the opportunity to assess the association between the adher- Eat Lancet Commission established that major changes ence to an energy-restricted Mediterranean diet and the must be made on both the way we eat and the way we amount of ­CO2 emitted in an older adult population. produce our food to stop this detrimental situation [4]. Accordingly, there is a diet-environmental-health tri- Methodology lemma and research on how to be more sustainable and Study design reduce those impacts has been increasing. Sustainable The present research was a cross-sectional analysis of diets are those with low environmental impacts which baseline data within an ongoing 8-year multicenter, par- contribute to food and nutrition security and to a healthy allel-group, randomized trial, conducted in 23 Spanish life for present and future generations. These types of recruiting centers aiming to assess the effect of weight- diets are protective and respectful of biodiversity and loss induced by a hypocaloric traditional Mediterranean ecosystems, culturally acceptable, accessible, economi- Diet combined with physical activity promotion and cally fair, and affordable; nutritionally adequate, safe and behavioral support on cardiovascular disease and mortal- healthy, while optimizing natural and human resources [5]. ity. The study protocol can be found elsewhere [10]. The The traditional Mediterranean diet is a well-studied trial was registered in 2014 at the International Standard model in terms of healthfulness being researched for its Randomized Controlled Trial (ISRCT; http://​www.​isrctn.​ protective effects on cardiometabolic risk factors and com/​ISRCT​N8989​8870) with number 89898870. García et al. Environmental Health (2023) 22:1 Page 3 of 10 Participants, recruitment, and ethics on available information from Spanish food composition A total of 9677 participants were contacted; 6874 par- tables [16, 17]. The results were used to determine the ticipants met the inclusion criteria including men aged specific amount of food (in grams) each participant had 55-76 and women aged 60-75, with overweight or obese eaten per day. (body mass index between 27 and 40 kg/m2) and meeting at least three criteria for metabolic syndrome according CO2 emitted per kg of food to the Association and National Heart, Lung and Blood The amount of ­CO2 emitted per kg of consumed food Institute [11]. Finally, 6646 participants were included per participant and day was calculated using a European in the analysis after excluding those with incomplete database from 2016 that described kg of ­CO2 emitted per FFQ data and reporting extreme energy intakes (< 500 kg of food consumed. This database was based on life or > 3500 kcal/day in women or < 800 or > 4000 kcal/day cycle assessment (LCA) of recent studies and included in men) [12]. A flow-chart of eligible participants was agricultural production and processing steps (consider- shown in Fig. 1. ing defaults for cooking, storing, and packing and letting Informed written consent was provided by all par- transportation out of the calculations) [18]. Kilograms ticipants and the study protocol and procedures were of ­CO2 emitted per consumed food were calculated by approved by ethical committees according to the ethi- multiplying g of each consumed food reported from the cal standards of the Declaration of Helsinki by all the 23 FFQ per kg of C ­ O2 emitted per kg of each food from the participating institutions. database. The sum of all kilograms of ­CO2 emitted for all the products was done to determine the total emis- Assessment of dietary intake sions a day from diet. Once the C ­ O2 emitted for each Registered dietitians assessed dietary habits, at baseline, participant was known, an adjustment per 1 kg of food through a semi quantitative 143-item food frequency consumed was completed. The adjustment was done to questionnaire (FFQ) [13] which has been previously consider the energy intake cofounder. Depending on the validated in Spanish population [13–15]. For each item, individual needs, the dietary intake could be higher in a regular portion size was established, and consumption terms of quantity meaning higher emissions, even when frequencies were registered according to 9 categories, comparing diets based on the same products. Therefore, ranging from “never or almost never” to “≥6 times/day”. an adjustment per 1 kg of food product per person offers Energy and nutrient intakes were calculated as frequency a better comparison between the emissions of the par- multiplied by nutrient composition of specified portion ticipants’ diets and avoids bias for people who could eat size for each food item, using a computer program based higher amounts due to their personal needs. Fig. 1 Flow chart of eligibility of participants García et al. Environmental Health (2023) 22:1 Page 4 of 10 Assessment of adherence to the erMedDiet were distributed in quartiles: quartile 1 (Q1); participants Adherence to energy-reduced Mediterranean diet was with the lowest emissions (≤2.01 kg ­CO2/day), quartile assessed using a 17-item Mediterranean Diet validated 2 (Q2); participants with low-moderate emissions (2.02- questionnaire [19]. 2.34 kg ­CO2/day), quartile 3 (Q3); participants with mod- erate-high emissions (2.35-2.79 kg ­CO2/day) and quartile Other health variables 4 (Q4); participants with the highest emissions (≥2.80 kg Information related to sociodemographic characteris- ­CO2/day). Q1 was considered as the reference. A linear tics such as sex, age, and scholar level were self-reported. prediction with a 95% confidence interval (CI) was cal- Anthropometric measurements (including weight, height, culated between quartiles of dietary C­ O2 and the erMed- waist, and hip circumference) were obtained. Diet adherence score. Statistical analyses Results Analyses were performed using SPSS statistical soft- Table 1 shows the association between sex, age, scholar ware package version 27.0 (SPPS Inc., Chicago, IL, USA). level, and adherence to the erMedDiet according to the Data are shown as mean and standard deviation (SD), kg ­CO2 emissions per kg of food. More men than women except for prevalence data, which was expressed as sam- were classified into quartiles 3 (Q3) and 4 (Q4), which ple size and percentage. Chi-squared test was used for shows higher levels of C ­ O2 emissions in men’s diets. categorical variables and one-way ANOVA and Bonfer- Compared to those in the lowest quartile of kg ­CO2 emis- roni’s post-hoc was used for continuous variables. To sions per kg of food, participants in the top quartile were assess the linear trend, the median value of each quartile more likely to be men, younger and with lower education of ­CO2 emissions was assigned and used as a continuous level. variable in the logistic regression model. Logistic regres- The association between the adherence to the erMed- sion was fitted to assess association between each one of Diet and its components across of quartiles of kg C ­ O2 the 17-items of erMedDiet questionnaire and the mean emissions per kg of food are showed in Table 1. Adher- adherence to the Mediterranean Diet (as dependent vari- ence to the erMedDiet was inversely associated across ables) and quartiles of dietary ­CO2 emitted (as independ- quartile of kg C­ O2 emissions per kg of food. A higher ent variable) calculating Odds Ratio (OR) value, crude number of participants reporting higher adherence to and adjusted (by sex, age, and educational level). Data the Mediterranean Diet were found in Q1 and Q2. on the amount of ­CO2 emissions per participant and day Table 1 Sex, scholar level, age, and adherence to the Mediterranean Diet according to C ­ O2 emissions (quartiles) Q1 § n = 1661 Q2 § n = 1662 Q3 § n = 1663 Q4 § n = 1660 p-value Sex Men 788 (47.4) 824 (49.6) 884 (53.2) 932 (56.1) < 0.001 Women 873 (52.6) 838 (50.4) 779 (46.8) 728 (43.9) Highest scholar level Bachelor’s degree 201 (12.1) 202 (12.2) 214 (12.9) 241 (14.5) < 0.001 College School Technician 143 (8.6) 164 (9.9) 138 (8.3) 155 (9.3) Secondary School 415 (25) 456 (27.4) 499 (30) 548 (33) Primary School 902 (54.3) 840 (50.5) 812 (48.8) 716 (43.1) Age (years) 65.2 (4.9)c 65.1 (4.9) 64.8 (4.9) 64.8 (4.9)c 0.02 bc b Weight (kg) 85.4 (12.8) 86.1 (12.8) 86.8 (12.8) 87.8 (13.4)c < 0.001 BMI (kg/m2) 32.5 (3.5)c 32.5 (3.4) 32.5 (3.5) 32.7 (3.5)c 0.039 Energy intake (Kcal/day) 2329 (582.2)c 2358.4 (527.8) 2368.6 (538.1) 2404.8 (554)c 0.001 MedDiet Adherence Low adherence (0-8) 715 (43) 771 (46.4) 869 (52.3) 1013 (61) < 0.001 High adherence (9-17) 946 (57) 891 (53.6) 794 (47.7) 647 (39) Data are expressed in n (%) or mean (standard deviation) Abbreviations: BMI Body Mass Index, MedDiet Mediterranean Diet §Kg of ­CO2 per consumed food = Kg of each consumed food from FFQ*Kg ­CO2 emitted per kg of each food (EU data base 2016). Four groups were considered according to ­CO2 emissions: Q1: ≤2.01 kg ­CO2/day; Q2: 2.02-2.34 kg ­CO2/day; Q3: 2.35-2.80 kg ­CO2/day; Q4: > 2.80 kg ­CO2/day. Differences between groups were assessed by chi-square for categorical variables and difference in means between groups were tested by one-way ANOVA and Bonferroni’s post-hoc for age Bonferroni’s post-hoc differences: b: Q1 vs Q3; c: Q1 vs Q4 García et al. Environmental Health (2023) 22:1 Page 5 of 10 Crude and adjusted OR for adherence to Mediterra- and Q4 (0.48 0.42-0.55) than in Q2 (OR 0.87 0.76-1.00), nean Diet is shown in Table 2. Q1 (≤2.01 kg ­CO2) was the which means that participants high followers of Mediter- reference, and the adjustment was done by sociodemo- ranean Diet showed lower amount of CO2 emissions. graphic characteristics (sex, age, and scholar level). Crude Figure 2 shows that there was lower adherence to the and adjusted OR values on total Mediterranean Diet Mediterranean diet in those participants with higher adherence were lower in both Q3 (OR 0.69 0.60-0.79) ­CO2 emissions. Table 2 Association (Odd Ratio and 95% Confidence interval) between the adherence to the energy restricted Mediterranean diet components (dependent variables) and quartiles of dietary kg ­CO2 emissions (independent variables) Q1 § Q2 § Q3 § Q4 § p for trend ≤2.01 kg ­CO2/day 2.02-2.34 kg ­CO2/day 2.35-2.80 kg ­CO2/day > 2.80 kg ­CO2/day n = 1661 n = 1662 n = 1663 n = 1660 erMedDiet 17-items 1.EVOO for cooking Crude OR 1.00 (Ref.) 1.00 (0.84-1.18) 0.95 (0.80-1.13) 0.94 (0.79-1.11) 0.821 Adjusted OR 1.00 (Ref.) 0.98 (0.83-1.16) 0.93(0.78-1.10) 0.89 (0.75-1.05) 0.507 2.Vegetables Crude OR 1.00 (Ref.) 0.98 (0.86-1.13) 0.84 (0.73-0.96) 0.75 (0.65-0.87) < 0.001 Adjusted OR 1.00 (Ref.) 0.99 (0.86-1.14) 0.85 (0.74-0.98) 0.77 (0.67-0.89) 0.001 3.Fruits Crude OR 1.00 (Ref.) 0.81 (0.71-0.93) 0.61 (0.54-0.71) 0.47 (0.41-0.55) < 0.001 Adjusted OR 1.00 (Ref.) 0.82 (0.72-0.94) 0.64 (0.55-0.73) 0.50 (0.43-0.57) < 0.001 4.Red and processed meat Crude OR 1.00 (Ref.) 0.65 (0.56-0.74) 0.46 (0.40-0.52) 0.29 (0.25-0.33) < 0.001 Adjusted OR 1.00 (Ref.) 0.65 (0.57-0.75) 0.47 (0.41-0.54) 0.30 (0.26-0.35) < 0.001 5.Butter, margarine, cream Crude OR 1.00 (Ref.) 1.18 (0.99-1.40) 1.05 (0.89-1.25) 1.11 (0.94-1.31) 0.275 Adjusted OR 1.00 (Ref.) 1.18 (0.99-1.40) 1.05 (0.89-1.24) 1.10 (0.92-1.30) 0.305 6.Sugar sweetened bever‑ Crude OR 1.00 (Ref.) 1.05 (0.89-1.23) 0.95 (0.81-1.11) 0.97 (0.83-1.13) 0.610 ages Adjusted OR 1.00 (Ref.) 1.06 (0.90-1.24) 0.97 (0.83-1.13) 1.00 (0.85-1.17) 0.758 7.Legumes Crude OR 1.00 (Ref.) 0.75 (0.67-0.89) 0.62 (0.52-0.73) 0.65 (0.54-0.77) < 0.001 Adjusted OR 1.00 (Ref.) 0.75 (0.64-0.89) 0.62 (0.52-0.73) 0.65 (0.55-0.77) < 0.001 8.Fish and seafood Crude OR 1.00 (Ref.) 1.41 (1.23-1.61) 1.39 (1.21-1.59) 1.46 (1.27-1.67) < 0.001 Adjusted OR 1.00 (Ref.) 1.41 (1.23-1.62) 1.41 (1.23-1.62) 1.48 (1.29-1.70) < 0.001 9.Sweets and pastries Crude OR 1.00 (Ref.) 0.92 (0.80-1.06) 0.92 (0.80-1.06) 0.92 (0.80-1.05) 0.538 Adjusted OR 1.00 (Ref.) 0.92 (0.80-1.06) 0.92 (0.80-1.06) 0.92 (0.80-1.06) 0.557 10.Nuts Crude OR 1.00 (Ref.) 0.97 (0.85-1.11) 0.93 (0.81-1.07) 0.77 (0.67-0.88) 0.001 Adjusted OR 1.00 (Ref.) 0.96 (0.84-1.10) 0.92 (0.80-1.06) 0.75 (0.65-0.86) < 0.001 11.Preference white over Crude OR 1.00 (Ref.) 0.85 (0.71-1.01) 0.56 (0.47-0.66) 0.27 (0.23-0.31) < 0.001 red meat Adjusted OR 1.00 (Ref.) 0.86 (0.72-1.03) 0.58 (0.49-0.69) 0.28 (0.24-0.33) < 0.001 12.Sofrito Crude OR 1.00 (Ref.) 0.96 (0.83-1.10) 0.93 (0.81-1.07) 0.68 (0.59-0.77) < 0.001 Adjusted OR 1.00 (Ref.) 0.96 (0.83-1.10) 0.93 (0.81-1.07) 0.68 (0.59-0.78) < 0.001 13.Adding sugar to bever‑ Crude OR 1.00 (Ref.) 1.02 (0.89-1.18) 0.91 (0.79-1.05) 1.07 (0.93-1.23) 0.171 ages Adjusted OR 1.00 (Ref.) 1.03 (0.89-1.19) 0.94 (0.81-1.08) 1.10 (0.96-1.28) 0.161 14.White bread Crude OR 1.00 (Ref.) 0.92 (0.80-1.05) 0.85 (0.74-0.98) 0.87 (0.76-1.00) 0.099 Adjusted OR 1.00 (Ref.) 0.92 (0.80-1.06) 0.87 (0.76-1.00) 0.90 (0.78-1.03) 0.243 15.Whole grains Crude OR 1.00 (Ref.) 0.91 (0.79-1.06) 0.74 (0.64-0.86) 0.54 (0.46-0.64) < 0.001 Adjusted OR 1.00 (Ref.) 0.91 (0.79-1.06) 0.75 (0.65-0.88) 0.55 (0.47-0.64) < 0.001 16.Refined cereals Crude OR 1.00 (Ref.) 0.93 (0.80-1.07) 0.90 (0.78-1.04) 0.80 (0.69-0.93) 0.029 Adjusted OR 1.00 (Ref.) 0.93 (0.80-1.08) 0.92 (0.80-1.07) 0.82 (0.71-0.95) 0.080 17.Wine Crude OR 1.00 (Ref.) 1.48 (1.25-1.75) 1.51 (1.27-1.78) 1.34 (1.14-1.59) < 0.001 Adjusted OR 1.00 (Ref.) 1.47 (1.24-1.75) 1.44 (1.21-1.71) 1.23 (1.03-1.46) < 0.001 MedDiet Adherence Crude OR 1.00 (Ref.) 0.87 (0.76-1.00) 0.69 (0.60-0.79) 0.48 (0.42-0.55) < 0.001 AdjustedOR 1.00 (Ref.) 0.87 (0.76-1.00) 0.71 (0.61-0.81) 0.49 (0.43-0.56) < 0.001 Abbreviations: erMedDiet energy-reduced Mediterranean diet, EVOO Extra Virgin Olive Oil, MedDiet Mediterranean Diet, OR Odds Ratio, Adjusted OR Odds Ratio adjusted by sociodemographic characteristics (sex, scholar level and age). §Kg of ­CO2 per consumed food = Kg of each consumed food from FFQ*Kg ­CO2 emitted per kg of each food (EU data base 2016) García et al. Environmental Health (2023) 22:1 Page 6 of 10 Fig. 2 Predictive margins of kg ­CO2 quartiles and the Mediterranean Diet adherence score with 95%CI Discussion Other studies have calculated the environmental The current study showed that ­ CO2 emissions were impact of different dietary scenarios, mainly based on inversely associated with the adherence to the Mediter- healthy recommendations or food based dietary guide- ranean Diet. It also opened the idea of using the erMed- lines [26–28] or trying to represent a specific diet of Diet index as a pollution level index. Studies in younger a country [29, 30]. A reduction in premature mortal- populations have already shown how a Mediterranean ity and a reduction in GHG emissions were seen in the Diet could be proposed as a sustainable dietary model in healthy and sustainable diets [26, 29]. A common factor terms of food production and processing. Better adher- of those dietary scenarios was the reduction in animal- ence to the Mediterranean Diet has been associated with based products with an increase focus on plant-based lower land use, water consumption, energy consumption foods [25–29]. This is relevant to the present analyses, as and GHG emissions [20]. Another study in Italian chil- the Mediterranean Diet is a plant-forward dietary pattern dren compared the ­CO2 emissions of the Mediterranean because it emphasizes consumption of fruits and vegeta- Diet between winter and spring; impacts were higher in bles, healthy fats, whole cereals, as well as a preference winter than in spring, and meat products were the major for fish and white meat, with an overall reduction in red contributors to GHG emissions in both seasons, followed and processed meat [31]. by milk and dairy products [21]. Several studies have evaluated the environmental The scope of several studies has compared the Mediter- impact of a diet related to a specific country or a region, ranean Diet with other dietary patterns. A Western Diet for instance, Switzerland [32], China [33–35], France, (WD), characterized by a high consumption of meat, United Kingdom, Finland, and Sweden [36], Italy [36, 37], sweets, and beverages, appears to be the unhealthiest Netherlands [38], Uganda [39], India [40], Germany [41] and the most detrimental pattern in terms of the environ- and the Atlantic region [42, 43]. In European countries, a ment, but the most affordable [22]. Compared to a West- transition towards a healthier diet following the recom- ern Dietary pattern, the Mediterranean Diet in Spain mended guidelines and achieving nutritional adequacy would substantially reduce GHG emissions, land use has resulted to be the most sustainable option. Reduc- and energy consumption, and lower extent water con- tions in consumption of animal-based products are sumption [23]. Moreover, GHG emissions were lower for needed with differences according to country, sex, and Mediterranean Diet pattern with a consistent emission food [32, 36–38, 41–43]. Major decreases in consump- 14.55% below to an Italian average diet and 6.74% below tion of meat, snacks, and butter are needed in the Neth- the Mediterranean Diet [24]. Compared to the DASH or erlands in conjunction with an increase in consumption Nordic Diets, higher adherence to the Mediterranean of legumes, fish, nuts, and vegetables [38]. The Atlantic Diet has been associated with lower GHG emissions [25]. region diet has high GHG emissions, since it is based García et al. Environmental Health (2023) 22:1 Page 7 of 10 in livestock products and shellfish; however, it appears seasonal vegetables from other countries in Europe has to have a high nutritional score mainly because of a low a lower impact than UK vegetables cultivated in heated intake of sodium, added sugars and saturated fats [42, greenhouses, despite the required transportation [49]. 43]. In Italy, changes towards a healthier diet in young The environmental impacts of baby foods have also been population showed a reduction in ­CO2 emissions larger assessed showing that meat-based ingredients cause than 50% [37]. In Germany, 14-20% of the environmental almost 30% of the impacts [50]. burdens resulted from food losses along the value chain, Apart from the type of food used, the total amount out-of-home consumption was responsible for 8-28% of energy intake consumed must be considered when impact, and animal products were shown to have caused assessing sustainability, as it has done in this study when the highest environmental burdens [41]. adjusting CO2 emissions per 1 kg of food products. With respect to countries outside of Europe, findings Murakami et al. showed how considering energy intake, differ. In the last few years, China has transitioned from the inverse relation between the diet quality and de staple-foods to non-staple foods and from plant-sourced greenhouse gas emissions became stronger, specifically foods to animal-sourced foods. Diets have suffered from when measurements were done with the Mediterranean globalization and become unhealthier and less sustain- Diet score [51]. able, with meat and grains being the two dominant con- While the relationship between food consumption and tributors to the carbon footprint. It has been proposed sustainability is acknowledged, many are still not willing that returning to traditional dietary patterns would be to change. It is for this reason that the consumer percep- a beneficial strategy to reduce environmental concerns, tion has been investigated by several studies [52–54]. such as land use, GHG, etc. in China [33–35]. A similar Possible strategies to increase adherence to sustainable situation has been observed in Uganda were urban resi- dietary practices and meet the United Nations agenda dency and non-traditional dietary patterns have been 2030 goal, such as supporting vegetarian dietary prac- negatively associated with environmentally sustainabil- tices [55, 56], increasing the consumption of pulses [57], ity compared to a more traditional (plant-based) dietary sustainable food systems in schools [58] and other strate- pattern [39]. On the contrary, in India, shifting to healthy gies [59], have been put in practice. However, the United guidelines has increased GHG emissions because the Nations agenda 2030 goals, specifically the target for initial energy intake of the population was below rec- GHG emissions, has not yet been reached. Future studies ommendations, nonetheless, decreased environmental investigating optimal dietary patterns for both health and impacts were seen among those who currently meet die- the environment, as well as strategies for how to increase tary recommendations [40]. awareness and consciousness to support population- There are several studies focused on comparing the based change are warranted to achieve the needed goals impact of changes in specific food products. Some to be more sustainable and respectful with others and studies have shown how diets with less animal prod- with the planet. ucts (beef, pork, poultry, and dairy products) and more plant-based products are beneficial for the environment Strengths and limitations [44–47] without compromising the health of the popula- Recently, there has been an increase in research focus- tion and still meeting dietary recommendations [45, 46]. ing on diet and sustainability. The current study con- Women are more likely to consume ≤1 portion of meat tributes to the growing knowledge about an issue that is a day compared with men and, also, females and older getting more importance every day. This is a strength of respondents (> 60 years) were more likely to hold posi- the present analyses, as it provides evidence to reinforce tive attitudes towards animal welfare [44]. Studies that the health and sustainable impact of the Mediterranean assessed specific foods founded that whole grain cereals, diet. The large sample size used to calculate the dietary fruits, vegetables, legumes, nuts, and olive oil have been ­CO2 emissions is another strength. Moreover, once the associated with improved health and have the lowest ­CO2 calculations were done for each participant, an environmental impacts. Fish was associated with good adjustment per kg of food product was done. This is a health but was not simultaneously associated with less strength because it avoids the effect of the energy intake environmental impact, although it had a markedly lower confounder. Calculating only the parameter of C ­ O2 emis- impacts than red and processed meats which were asso- sions for assessing the sustainability of a diet allows ciated with the largest increases in disease risk and envi- the impact to be observed independently from other ronmental concerns [48]. Specifically, vegetables have parameters. been seen as one of the lowest impact food products, but Limitations in relation to the present study also must it has been highlighted that the place where they are cul- be noted. This present analysis represents a cross- tivated is important. For example, in the UK, importing sectional study, and thus causal interferences cannot García et al. Environmental Health (2023) 22:1 Page 8 of 10 be established. Even though assessing ­CO2 alone is a PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728, PI13/01090, PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, strength, it can also be a limitation because of the lack PI14/01919, PI14/00853, PI14/01374, PI14/00972, PI14/00728, PI14/01471, of information representing the use of energy, land and PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, water use, or other parameters which could be also used PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, to assess sustainability. Finally, the population in this PI17/01441, PI17/00508, PI17/01732, PI17/00926, PI19/00957, PI19/00386, study was between 55 and 75 years old which might not PI19/00309, PI19/01032, PI19/00576, PI19/00017, PI19/01226, PI19/00781, make possible to extrapolate the results to a younger PI19/01560, PI19/01332, PI20/01802, PI20/00138, PI20/01532, PI20/00456, PI20/00339, PI20/00557, PI20/00886, PI20/01158); the Especial Action Project population. entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-Plus grant to JS-S; the European Conclusions Research Council (Advanced Research Grant 2014–2019; agreement #340918) granted to MÁM-G.; the Recercaixa (number 2013ACUP00194) grant to JS-S; The current study shows that Mediterranean Diet can grants from the Consejería de Salud de la Junta de Andalucía (PI0458/2013, also be environmental protective since it appeared to be PS0358/2016, PI0137/2018); the PROMETEO/2017/017 grant from the Gen‑ inversely related with GHG emissions, specifically ­CO2 eralitat Valenciana; the SEMERGEN grant. J.S-S is partially supported by ICREA under the ICREA Academia programme. S.K.N. is supported by a postdoctoral emissions. In general, the higher the adherence to the fellowship from the Canadian Institutes of Health Research (CIHR, # MFE- Mediterranean Diet, the lower the total ­CO2 emissions 171207). None of the funding sources took part in the design, collection, showing that the erMedDiet index could be used pollu- analysis, interpretation of the data, or writing the report, or in the decision to submit the manuscript for publication. tion level index in the future. Findings may help inform and support public health initiative and dietary guide- Availability of data and materials lines, such that recommendations continue to encourage Data described in the manuscript, code book, and analytic code will be made available upon request pending application and approval of the PREDIMED- making changes to food choices to achieve a healthier Plus Steering Committee. There are restrictions on the availability of data for diet for both the population and the environment. the PREDIMED-Plus trial, due to the signed consent agreements around data sharing, which only allow access to external researchers for studies following the project purposes. Requestors wishing to access the PREDIMED-Plus trial Abbreviations data used in this study can make a request to the PREDIMED-Plus trial Steering BMI Body mass index Committee chair: jordi.​salas@​urv.​cat. The request will then be passed to mem‑ CO2 Carbon Dioxide bers of the PREDIMED-Plus Steering Committee for deliberation. EVOO Extra Virgin Olive Oil FFQ Food frequency questionnaire Declarations GHG Greenhouse gas GHGs Greenhouse gases Competing interests MedDiet The Mediterranean Diet S.K.N. is a volunteer member of the not-for-profit group Plant-Based Canada OR Odds Ratio J.S.-S. reported receiving research support from the Instituto de Salud Carlos SD Standard deviations III, Ministerio de Educación y Ciencia, the European Commission, the USA Q1 Quartile 1 National Institutes of Health; receiving consulting fees or travel expenses from Q2 Quartile 2 Eroski Foundation, and Instituto Danone, Spain, receiving nonfinancial support Q3 Quartile 3 from Hojiblanca, Patrimonio Comunal Olivarero, Almond Board of California, Q4 Quartile 4 and Pistachio Growers; serving on the board of and receiving grant support 17-item erMedDiet 17-item energy-restricted Mediterranean dietary through his institution from the International Nut and Dried Foundation and questionnaire the Eroski Foundation; and personal fees from Instituto Danone; Serving in the Board of Danone Institute International. D.C. reported receiving grants from Acknowledgements Instituto de Salud Carlos III. R.E. reported receiving grants from Instituto de We thank all PREDIMED-Plus participants and investigators. CIBEROBN, Salud Carlos III, Fundación Dieta Meditarránea and Cerveza y Salud and olive CIBERESP, and CIBERDEM are initiatives of the Instituto de Salud Carlos III oil for the trial from Fundación Patrimonio Comunal Olivarero and personal (ISCIII), Madrid, Spain. The Hojiblanca (Lucena, Spain) and Patrimonio Comunal fees from Brewers of Europe, Fundación Cerveza y Salud, Interprofesional del Olivarero (Madrid, Spain) food companies donated extra-virgin olive oil. Aceite de Oliva, Instituto Cervantes in Albuquerque, Milano and Tokyo, Pernod The Almond Board of California (Modesto, CA), American Pistachio Growers Ricard, Fundación Dieta Mediterránea (Spain), Wine and Culinary International (Fresno, CA), and Paramount Farms (Wonderful Company, LLC, Los Angeles, Forum and Lilly Laboratories; non-financial support from Sociedad Española CA) donated nuts for the PREDIMED-Plus pilot study. de Nutrición and Fundación Bosch y Gimpera; and grants from Uriach Labora‑ tories. The rest of the authors have declared that no competing interests exist. Authors’ contributions The funders had no role in the design of the study; in the collection, analyses, All the principal PREDIMED-Plus investigators contributed to study con‑ or interpretation of data; in the writing of the manuscript, or in the decision to cept and design and to data extraction from the participants. SG, and CB publish the results. performed the statistical analyses. SG, CB, and JAT drafted the manuscript. All authors reviewed the manuscript for important intellectual content and Author details approved the final version to be published. 1 CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain. 2 Research Group on Community Funding Nutrition & Oxidative Stress, University of Balearic Islands-IUNICS, Guillem This work was supported by the official Spanish Institutions for funding Colom Bldg, Campus, E‑07122 Palma de Mallorca, Spain. 3 Health Research scientific biomedical research, CIBER Fisiopatología de la Obesidad y Nutrición Institute of the Balearic Islands (IdISBa), 07120 Palma de Mallorca, Spain. (CIBEROBN) and Instituto de Salud Carlos III (ISCIII), through the Fondo 4 Faculty of Health Sciences, Catholic University of Avila, 05005 Avila, Spain. de Investigación para la Salud (FIS), which is co-funded by the European 5 CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III Regional Development Fund (six coordinated FIS projects leaded by JS-S and (ISCIII), 28029 Madrid, Spain. 6 Institute of Biomedicine (IBIOMED), University JVi, including the following projects: PI13/00673, PI13/00492, PI13/00272, of León, 24071 Leon, Spain. 7 Department of Preventive Medicine and Public García et al. Environmental Health (2023) 22:1 Page 9 of 10 Health, IDISNA, University of Navarra, 31008 Pamplona, Spain. 8 Depart‑ Mediterranean diet and exercise on weight loss and cardiovascular ment of Nutrition, Harvard T. H. Chan School of Public Health, Boston, USA. risk factors: one-year results of the PREDIMED-plus trial. 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