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SUSTAINABLE HEALTHY DIETS GUIDING PRINCIPLES SUSTAINABLE HEALTHY DIETS GUIDING PRINCIPLES Food and agriculture organization oF the united nations World health organization rome, 2019 The designations employed and the presentation of material in this information product do not imply the expression of any opinion whatsoever on the part of the Food and Agriculture Organization of the United Nations (FAO) or World Health Organization (WHO) concerning the legal or development status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or products of manufacturers, whether or not these have been patented, does not imply that these have been endorsed or recommended by FAO or WHO in preference to others of a similar nature that are not mentioned. The views expressed in this information product are those of the author(s) and do not necessarily reflect the views or policies of FAO or WHO. ISBN 978-92-5-131875-1 (FAO) ISBN 978-92-4-151664-8 (WHO) © FAO and WHO, 2019 Some rights reserved. This work is made available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, this work may be copied, redistributed and adapted for non-commercial purposes, provided that the work is appropriately cited. In any use of this work, there should be no suggestion that FAO or WHO endorses any specific organization, products or services. The use of the FAO or WHO logo is not permitted. If the work is adapted, then it must be licensed under the same or equivalent Creative Commons licence. If a translation of this work is created, it must include the following disclaimer along with the required citation: “This translation was not created by the Food and Agriculture Organization of the United Nations (FAO) or WHO. FAO/WHO are not responsible for the content or accuracy of this translation. The original English edition shall be the authoritative edition. Disputes arising under the licence that cannot be settled amicably will be resolved by mediation and arbitration as described in Article 8 of the licence except as otherwise provided herein. The applicable mediation rules will be the mediation rules of the World Intellectual Property Organization and any arbitration will be conducted in accordance with the Arbitration Rules of the United Nations Commission on International Trade Law (UNCITRAL). Third-party materials. Users wishing to reuse material from this work that is attributed to a third party, such as tables, figures or images, are responsible for determining whether permission is needed for that reuse and for obtaining permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. Sales, rights and licensing. FAO information products are available on the FAO website ( and can be purchased through [email protected] Requests for commercial use should be submitted via: Queries regarding rights and licensing should be submitted to: [email protected] Required citation: FAO and WHO. 2019. Sustainable healthy diets – Guiding principles. Rome. 3 CoNTENTS Foreword ..........................................................................................................................................................5 Introduction ......................................................................................................................................................7 Aims of Sustainable Healthy Diets ..................................................................................................................9 Guiding Principles for Sustainable Healthy Diets .........................................................................................11 Actions for the implementation of Sustainable Healthy Diets ...................................................................13 SUMMARY PAPERS FROM THE INTERNATIONAL CONSULTATION .............................................. 15 SUMMARY PAPER 1: Background paper on healthy diets ........................................................... 17 SUMMARY PAPER 2: The role of healthy diets in creating environmentally sustainable food systems ............................................................................ 21 SUMMARY PAPER 3: The Role of culture, economics, and food environment in shaping choices for sustainable diets ........................................................ 25 SUMMARY PAPER 4: Territorial Diets ............................................................................................ 29 SUMMARY PAPER 5: Background paper on food safety ............................................................. 33 Annex 1: Contributors to the consultation ................................................................................... 37 © FAO/Hoang Dinh Nam 5 Two of the major challenges of our times are malnutrition in all its forms and the degradation of environmental and natural resources. Both are happening at an accelerated pace. The State of Food Security and Nutrition in the World Report (SOFI 2019) shows that the number of the undernourished has been slowly increasing for several years in a row, and at the same time the number of overweight and obese people all over the world is increasing at an alarming rate. More than 820 million people go to bed hungry every night. In 2018, 1.3 billion people experienced food insecurity at moderate levels, meaning they did not have regular access to nutritious and sufficient food. Overweight and obesity and their associated diet-related non-communicable diseases (NCDs) are contributing to 4 million deaths globally. Today, 2 billion adults and over 40 million children under five are overweight. Moreover, over 670 million adults and 120 million girls and boys (5-19 years) are obese. Malnutrition is costly to the health of individuals, their wellbeing and productivity. It also has high socio-economic costs for societies in all regions of the world. Poor diets are a major contributory factor to the rising prevalence of malnutrition in all its forms. Moreover, unhealthy diets and malnutrition are among the top ten risk factors contributing to the global burden of disease. In addition, the way we produce and consume food is taking a toll on the environment and natural resource base. For example, food production accounts for the use of 48 percent and 70 percent of land and fresh water resources respectively at the global level. Social, demographic and economic factors are also contributing to changing lifestyles and eating patterns, and subsequently putting pressure on resources for food production. In 2014, the FAO/WHO Second International Conference on Nutrition (ICN2) acknowledged that: “current food systems are being increasingly challenged to provide adequate, safe, diversified and nutrient rich food for all that contribute to healthy diets due to, inter alia, constraints posed by resource scarcity and environmental degradation, as well as by unsustainable production and consumption patterns”. To address these challenges, the UN Decade of Action on Nutrition 2016 – 2025 puts a specific focus on the transformation of food systems to promote healthy diets that are sustainably produced and improve nutrition to achieve the global nutrition and diet-related NCD targets in line with commitments of ICN2 and the Sustainable Development Goals (SDGs). Considering the detrimental environmental impact of current food systems, and the concerns raised about their sustainability, there is an urgent need to promote diets that are healthy and have low environmental impacts. These diets also need to be socio-culturally acceptable and economically accessible for all. Acknowledging the existence of diverging views on the concepts of sustainable diets and healthy diets, countries have requested guidance from the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) on what constitutes sustainable healthy diets. The two organisations jointly held an international expert consultation on Sustainable and Healthy Diets from 1 to 3 July 2019 at FAO headquarters in Rome, Italy, to address these issues. The Consultation agreed on guiding principles for what constitutes “Sustainable Healthy Diets”. This comes at a time when the debate around the sustainability of diets is high on the agenda of governments, international organisations, civil society organisations, the private sector and academia. FoREwoRD 6 These guiding principles take a holistic approach to diets; they consider international nutrition recommendations; the environmental cost of food production and consumption; and the adaptability to local social, cultural and economic contexts. At the Consultation the experts agreed on the term “Sustainable Healthy Diets” which encompasses the two dimensions – sustainability and healthiness of diets. Countries should decide on the trade-offs according to their situations and goals. These guiding principles emphasize the role of food consumption and diets in contributing to the achievement of the SDGs at country level, especially Goals 1 (No Poverty), 2 (Zero Hunger), 3 (Good Health and Well-Being), 4 (Quality Education), 5 (Gender Equality) and 12 (Responsible Consumption and Production) and 13 (Climate Action). This publication aims to support the efforts of countries as they work to transform food systems to deliver on sustainable healthy diets. We take this opportunity to acknowledge the experts who drafted the background papers and/or contributed to the Expert Consultation leading to the elaboration of the Guiding Principles: Seth Adu-Afarwuah, Ashkan Afshin, Sutapa Agrawal, Mary Arimond, Michael Clark, Namukolo Covic, Saskia de Pee, Adam Drewnowski, Jessica Fanzo, Edward A. Frongillo, Mario Herrero, Lea S. Jakobsen, Andrew D. Jones, Shiriki Kumanyika, Pulani Lanerolle, Mark Lawrence, Duo Li, Jennie Macdiarmid, Sarah McNaughton, Sara Monteiro Pires, Veronika Molina, Carlos Monteiro, Eva Monterrosa, Luis Moreno, Morten Poulsen, Modi Mwatsama, Maarten Nauta, Janet Ranganathan, Satoshi Sasaki, Shelly Sundberg, Sofie Thomsen, Stefanie Vandevijvere, and Davy Vanham (affiliations of the experts are provided in Annex 1). This publication has been made possible by the sustained efforts of the FAO-WHO Secretariat: Anna Lartey, Nancy Aburto, Fatima Hachem, Ramani Wijesinha-Bettoni, Tomas Buendia, Eleonora Dupouy, Francesco Branca, Chizuru Nishida and Marzella Wüstefeld. Inputs from Kim Petersen, Angelika Maria Tritscher, Jason Montez, Kaia Engesveen and Kazuaki Miyagishima from WHO to the technical content of the Expert Consultation are warmly acknowledged. Valuable review comments were received on the draft papers from Tim Lang and Gretel Pelto, and FAO staff Markus Lipp, Alice Green and Kang Zhou. The Guiding Principles have benefited from the inputs of Ana Islas, Maria A. Tuazon, Patrizia Fracassi, Pilar Santacoloma, Giulia Palma and Melissa Vargas. This work would not have been achieved without the support of the following FAO staff: Dalia Mattioni, Maria Xipsiti, Ahmed Raza, Trudy Wijnhoven, Margaret Wagah, Chiara Deligia, Giuseppina Di Felice, Michele Rude, Cristiana Fusconi, Donna Kilcawley and Diana Calderon, and Fabienne Maertens from WHO. Anna Lartey Director Nutrition and Food Systems Division FAO Francesco Branca Director Department of Nutrition for Health and Development WHO 7 The UN Committee on Economic, Social and Cultural rights has recognized that the right to adequate food is of crucial importance for the enjoyment of all human rights. The committee considers that “the right to adequate food implies: “The availability of food in a quantity and quality sufficient to satisfy the dietary needs of individuals, free from adverse substances, and acceptable within a given culture; The accessibility of such food in ways that are sustainable and that do not interfere with the enjoyment of other human rights”1. The Committee on the Rights of the Child has also recognized the obligation of States to ensure access to nutritionally adequate, culturally appropriate and safe food to combat malnutrition in all its forms2. Nonetheless, many individuals do not have year-round access to safe, affordable, healthy diets needed to promote health and wellbeing.3 As a result, malnutrition in all its forms is a problem of global proportion, and no country is free from its effects. One in three individuals is currently affected by at least one form of malnutrition such as hunger, stunting, wasting, micronutrient deficiencies, overweight and/or obesity as well as resulting diet-related, non-communicable diseases (NCDs). The consequences of malnutrition include avoidable ill-health and premature death, as well as enormous economic and societal costs. Global estimates suggest that malnutrition in all its forms costs society up to USD 3.5 trillion per year, 1 UN Economic and Social Council. 1999. Committee on Economic, Social and Cultural Rights (CESCR) The right to adequate food (Art.11) : 12/05/99. E/C.12/1999/5 (General Comments). library/ja/kokusai/humanrights_library/treaty/data/ CESCR_GC_12e.pdf 2 UN Convention of the Rights of the Child. 2013. Committee on the Rights of the Child (CRC) General Comment No. 15 2013 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24). http://www. 3 FAO & WHO. 2015. Second International Conference on Nutrition (ICN2). Report of the Joint FAO/WHO Secretariat on the Conference. pdf © FAO/Ubirajara Machado INTRoDUCTIoN 8 with overweight and obesity alone costing USD 500 billion per year4. While the causes of malnutrition around the world are complex, unhealthy diets remain one of the main contributors to the global burden of disease. Unhealthy diets were identified as the second-leading risk factor for deaths and disability-adjusted life-years (DALYs) globally in 2016,5 while in 2017 they accounted for approximately 11 million deaths and 255 million DALYs6. To address malnutrition, diets must improve. However, the task is challenging, as drivers to changing diets are numerous and include urbanization, globalization of agricultural markets and trade, incomes, supermarket penetration and mass food marketing. Thus to improve diets, the entire food system – which encompasses the range of actors (and institutions) involved in the production, aggregation, processing and packaging, distribution, marketing, consumption and disposal of food products – must be considered. Food systems are simultaneously a leading cause of environmental degradation and depletion of natural resources. Currently, food systems are responsible for a significant share (20-35 percent) of greenhouse gas (GHG) emissions, and are a major driver of land conversion, deforestation and loss of biodiversity. Agriculture alone accounts for roughly 70 percent of global freshwater withdrawals, and causes water pollution.7 With the world’s population 4 Global Panel. 2016. The Cost of Malnutrition: Why Policy Action is Urgent. London, UK: Global Panel on Agriculture and Food Systems for Nutrition. default/files/pictures/CostOfMalnutrition.pdf 5 GBD 2016 Risk Factors Collaborators. 2017. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 390(10100):1345-1422. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(17)32366-8/ fulltext 6 GBD 2017 Diet Collaborators. 2019. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 393: 1958–1972. 6736(19)30041-8/fulltext 7 FAO. 2017. Water for Sustainable Food and Agriculture: A report produced for the G20 Presidency of Germany. predicted to expand to 9.7 billion individuals by 2050, these environmental pressures and impacts do not make current food systems sustainable. The Intergovernmental Panel on Climate Change (IPCC) in their most recent report recognized that “Consumption of healthy and sustainable diets presents major opportunities for reducing GHG emissions from food systems and improving health outcomes”8. Furthermore, the environmental impacts of agricultural production are a source of morbidity and mortality. In 2014, the FAO/WHO Second International Conference on Nutrition (ICN2) recognized that: “current food systems are being increasingly challenged to provide adequate, safe, diversified and nutrient rich food for all that contribute to healthy diets due to, inter alia, constraints posed by resource scarcity and environmental degradation, as well as by unsustainable production and consumption patterns, food losses and waste, and unbalanced distribution”9. Therefore, shaping food systems for Sustainable Healthy Diets also requires consideration of the environment. Additionally, current food systems are characterized by inequitable power concentration and imbalance, with some actors profiting greatly while others remain impoverished. These systems are failing to deliver equitable benefits for all, and are leaving the most vulnerable behind. Food systems across the globe are embedded in unique historical, religious, social, cultural and economic contexts, and are thus very diverse. Though healthy diets are described through dietary goals defined in terms of nutrient adequacy, or the desirable intake of specified food groups, or adherence to a dietary pattern, diets are more than the sum of nutrients and foods consumed or the dietary patterns associated with them. They are a way of life that 8 IPCC. 2019. Climate Change and Land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and greenhouse gas fluxes in terrestrial ecosystems. 9 FAO & WHO. 2015. Second International Conference on Nutrition (ICN2). Report of the Joint FAO/WHO Secretariat on the Conference. 9 shapes and is shaped by the way food is produced, procured, distributed, marketed, chosen, prepared and consumed. The social/cultural aspects and the economic impacts of food and food systems must be taken into account in the dialogue on responses to improve diets and eliminate hunger and all forms of malnutrition. Each context is unique and poses specific challenges to address availability, accessibility, and consumption of diets, and therefore requires a tailored solution for support to optimal health and sustainability. Though the solutions vary, the objectives of diets that address health and environmental, social/cultural and economic concerns are the same for all healthy individuals. Articulating those objectives can facilitate defining, developing and delivering specific actions that respond to contextual needs. Therefore, under the auspices of the UN Decade of Action on Nutrition, FAO and WHO jointly organized an international expert consultation on sustainable healthy diets. The consultation was held from 1 to 3 July, 2019 at the FAO headquarters in Rome, Italy. Prior to the consultation, FAO and WHO commissioned five background papers covering i) the elements and definitions of healthy diets; ii) the role of healthy diets in environmentally sustainable food systems; iii) the role of culture, economics and food environment in shaping choices for sustainable diets; iv) territorial diets; and v) food safety implications of Sustainable Healthy Diets. A two page summary of each paper is published as an appendix to this report. Thirty-three experts knowledgeable in the various dimensions of healthy diets and aspects of sustainability, representing low, middle and high-income countries, participated in the consultation and/or contributed to drafting the background papers. The objective of the consultation was to develop Guiding Principles around what constitutes Sustainable Healthy Diets, to be further translated into clear, non-technical information and messaging to be used by governments and other actors in policy-making and communications. The Guiding Principles for Sustainable Healthy Diets are food based, and take into account nutrient recommendations while considering environmental, social/cultural and economic sustainability. The following Guiding Principles for Sustainable Healthy Diets were the outcomes of the consultation. AImS oF SUSTAINABLE HEALTHY DIETS Sustainable Healthy Diets are dietary patterns that promote all dimensions of individuals’ health and wellbeing; have low environmental pressure and impact; are accessible, affordable, safe and equitable; and are culturally acceptable. The aims of Sustainable Healthy Diets are to achieve optimal growth and development of all individuals and support functioning and physical, mental, and social wellbeing at all life stages for present and future generations; contribute to preventing all forms of malnutrition (i.e. undernutrition, micronutrient deficiency, overweight and obesity); reduce the risk of diet-related NCDs; and support the preservation of biodiversity and planetary health. Sustainable healthy diets must combine all the dimensions of sustainability to avoid unintended consequences. © FAO/Filipe Branquinho 10 15 16 … are accessible and desirable. … avoid adverse gender-related impacts, especially with regard to time allocation (e.g. for buying and preparing food, water and fuel acquisition). 10 … preserve biodiversity, including that of crops, livestock, forest-derived foods and aquatic genetic resources, and avoid overfishing and overhunting. 9 … maintain greenhouse gas emissions, water and land use, nitrogen and phosphorus application and chemical pollution within set targets. 7 … are consistent with WHO guidelines to reduce the risk of diet- related NCDs, and ensure health and wellbeing for the general population.12 8 … contain minimal levels, or none if possible, of pathogens, toxins and other agents that can cause foodborne disease. 2 … are based on a great variety of unprocessed or minimally processed foods, balanced across food groups, while restricting highly processed food and drink products.10 1 …start early in life with early initiation of breastfeeding, exclusive breastfeeding until six months of age, and continued breastfeeding until two years and beyond, combined with appropriate complementary feeding. SUSTAINABLE HEALTHy DIETS... REGARDING THE HEALTH ASPECT REGARDING ENVIRONMENTAL IMPACT REGARDING SOCIOCULTURAL ASPECTS 10 Food processing can be beneficial for the promotion of high quality diets; it can make food more available as well as safer. However, Some forms of processing can lead to very high densities of salt, added sugar and saturated fats and these products, when consumed in high amounts, can undermine diet quality. (Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK. getfile/collection/p15738coll5/id/5516/filename/5517.pdf) 11 Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables. 11 14 … are built on and respect local culture, culinary practices, knowledge and consumption patterns, and values on the way food is sourced, produced and consumed. 13 …reduce food loss and waste. 12 … minimize the use of plastics and derivatives in food packaging. 11 …minimize the use of antibiotics and hormones in food production. 5 … include safe and clean drinking water as the fluid of choice. 6 … are adequate (i.e. reaching but not exceeding needs) in energy and nutrients for growth and development, and to meet the needs for an active and healthy life across the lifecycle. 4 … can include moderate amounts of eggs, dairy, poultry and fish; and small amounts of red meat. 3 … include wholegrains, legumes, nuts and an abundance and variety of fruits and vegetables.11 GUIDING PRINCIPLES FoR SUSTAINABLE HEALTHY DIETS 12 They include up to 30-35 percent of total energy intake from fats, with a shift in fat consumption away from saturated fats to unsaturated fats and towards the elimination of industrial trans fats; less than 10 percent of total energy intake from free sugars (possibly less than 5 percent) and not more than 5 g per day of salt (to be iodized). WHO. 2018. Healthy diet. WHO fact sheet No. 394 (updated August 2018). Geneva, World Health Organization, 2018. 12 Create an enabling environment through government mechanisms, incentives and disincentives; legal frameworks; and regulatory instruments to promote the production, processing, distribution, labelling and marketing, and consumption of a variety of foods that contribute to Sustainable Healthy Diets. Establish a representative baseline of current diets, when needed conducting individual dietary assessment by age, gender, income, ethnic group, and geography. Use these data to identify which shifts in diet could potentially have the greatest positive impact on both health and environment. Analyze existing food systems to identify potential changes needed to encourage the production, processing, packaging, storage, distribution, marketing and retailing, and consumption of a diversity of foods needed for Sustainable Healthy Diets. Identify, in any given context, which foods are available and accessible in terms of quantity and quality and where and why mismatches in food supply and demand exist. Ensure policy coherence by aligning policies across all sectors (agriculture, health, education, environment, water, trade, etc.) from local to national to international level and discussing with all actors of society. 13 In order to make Sustainable Healthy Diets available, accessible, affordable, safe and desirable, food system changes are needed and could be guided by the following actions: ACTIoNS FoR THE ImPLEmENTATIoN oF SUSTAINABLE HEALTHY DIETS Promote capacity development strategies for behaviour change, including consumer empowerment, and effective food and nutrition education. Ensure that affordable and desirable foods for a Sustainable Healthy Diet are available and accessible for the most vulnerable. Address inequities and inequalities, and consider the perspective of people who experience poverty and deprivation. Develop national food-based dietary guidelines that define context-specific Sustainable Healthy Diets by taking into account the social, cultural, economic, ecological and environmental circumstances. Quantify and balance the potential trade-offs to make Sustainable Healthy Diets available, accessible, affordable, safe and appealing for all.

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