Development of an EAT-Lancet index and its relation to mortality in a Swedish population (2021 Nov)

Stubbendorff, A., E. Sonestedt, et al. (2021). “Development of an EAT-Lancet index and its relation to mortality in a Swedish population.” The American Journal of Clinical Nutrition.

Open access link to article:

Relevant to: 

Community, Dietetic Educator, Public Health, Researcher


We sought to develop a new dietary index to quantify adherence to the EAT-Lancet diet and assess its association with mortality in a large, population-based Swedish cohort.

Bottom line for nutrition practice: 

A large population study from Lund University in Sweden has shown that more sustainable dietary habits are linked to health benefits, such as a reduced risk of premature death from cardiovascular disease and cancer.


  • Background – Current global food systems threaten human health and environmental sustainability. In 2019, the EAT-Lancet Commission on healthy diets from sustainable food systems defined the first global reference diet to improve both areas, but there is no consensus on how to quantify the EAT-Lancet reference diet as a diet index, and its relation to mortality has not been widely studied.
  • Objectives – We sought to develop a new dietary index to quantify adherence to the EAT-Lancet diet and assess its association with mortality in a large, population-based Swedish cohort. We also examined food components included in the index and their individual associations with mortality.
  • Methods – We used the Malmö Diet and Cancer cohort (n = 22,421; 45–73 years old at baseline). Dietary data were collected using a modified diet history method. The EAT-Lancet index was developed based on intake levels and reference intervals of 14 food components defined in the EAT-Lancet diet (0–3 points per component; 0–42 points in total). Associations with mortality were examined based on registers during a mean of 20 years of follow-up and were adjusted for potential confounders.
  • Results – Divided into 5 adherence groups, the highest adherence to the EAT-Lancet diet (≥23 points) was associated with lower all-cause mortality (HR, 0.75; 95% CI, 0.67–0.85), cancer mortality (HR, 0.76; 95% CI, 0.63–0.92), and cardiovascular mortality (HR, 0.68; 95% CI, 0.54–0.84) than the lowest adherence (≤13 points). Several food components included in the index contributed to the observed reductions in mortality.
  • Conclusions – We developed a new dietary index to investigate adherence to the EAT-Lancet diet. The findings indicate a 25% lower risk of mortality among those with the highest adherence to the EAT-Lancet diet, as defined using our index, which adds to the evidence base for the development of sustainable dietary guidelines.

Details of results: 

Participants received between 5-35 points of the possible maximum of 42 points.

  • Mean score for women was 18.5 and 16.8 for men.
  • Less than 1% of the study population reached the target intake of the EAT-Lancet diet for legumes and nuts.
  • Less than 5% reached the target intakes for whole grains, beef and lamb, and pork.
  • Adherence was highest for poultry and fish, where 77% and 66% of the population reached the target intakes, respectively.
  • Comparing the group with the highest score to the lowest score shows a decrease in total mortality of 25%, cancer mortality of 24% and cardiovascular mortality of 32% in the fully adjusted model.
  • In the less adjusted model the magnitude of the results were even larger.
  • Adherence to each of the 14 food group components included in the EAT-Lancet index and mortality were also tested separately. High intakes of whole grains, vegetables, and fruits, compared to low intakes, were associated with lower risks of all-cause mortality, whereas high intake of eggs was associated with a higher risk.

Of additional interest: 

Scroll down👇🏽 for a pdf of an article released on this study by the author.

Editor’s comment:  


Conflict of interest/ Funding:  

The authors have no conflict of interest. The study was funded by the Swedish Heart-Lung Foundation, Crafoord Foundation, and Agenda 2030 Graduate School at Lund University.

External relevant links:

Corresponding author: 

Anna Stubbendorff

PhD student

CIDSE’s principles of Agroecology – Towards just, resilient, & sustainable food systems (2018)

CIDSE advocates for radical changes towards just, resilient and sustainable models of food systems. They strongly believe that agroecology and its principles – when firmly rooted in food sovereignty and climate justice – are the way to move away from a model that threatens present and future agricultural production and food security (biodiversity losses, soil degradation, soil erosion…) while meeting the long-term goal of 1.5°C and contributing to the full realisation of the right to food. CIDSE currently works to promote and advocate for agroecology within debates in civil society on these issues, and in high-level policy processes. They gather and share experiences and knowledge in our network on agroecological systems and with movements that are applying the principles of agroecology. To understand more about CIDSE’s position on food systems you may also consult our:

Other CIDSE Sustainable Food Systems Advocacy & Tools available in 7 languages in pdf format:

Creating Better Health for People, Animals, & the Planet: Food Systems Insights for Health Professionals.  (2022 Jun)

Insights from health sector professionals, coupled with a deeper analysis of the Case Studies, make it clear that joint initiatives and cross-sector collaboration will expand perspectives of what constitutes good health and do much to advance the case for food systems transformation.

Global Alliance for the Future of Food. Creating Better Health for People, Animals, & the Planet: Food Systems Insights for Health Professionals. n.p.: Global Alliance for the Future of Food, 2022.

Excerpts from the forward & website:

For more than a decade, the Global Alliance for the Future of Food has advocated for a truly healthy food system built on an integrated approach that includes nutrition, health, happiness, as well as social and cultural factors. The Global Alliance has been dedicated to deepening our understanding of the positive co-benefits and negative health externalities of food systems since the onset of the pandemic.

The Global Alliance in partnership with European Public Health Alliance, Global Climate and Health Alliance, International Federation of Medical Students Associations, NCD Alliance, and the World Organization of Family Doctor to survey health sector workers (doctors, nurses, medical students, dietitians and nutritionists, healthcare assistants, and policymakers, to name a few) on how food systems impact health.

More than 300 experts from over 50 countries responded saying that since the outbreak of the pandemic they:

  • have an increased understanding of the connection between food systems and health and are more concerned about these issues;
  • very strongly agreed that climate change, health, and food systems are interconnected (80% of respondents)
  • ranked the availability and marketing of ultra-processed foods the highest impact of food systems on global health;
    • followed by environmental contamination, pollution, and degradation; and
    • then the food systems’ contribution to climate change.
  • stated that it is very important to consume and/or promote healthy and sustainable diets as a way to both improve health and reduce environmental impacts of food systems (stated by 84% of respondents)

This report is about mobilizing action to transform food systems. For inspiration, they look to those who are getting it right. The 10 Case Studies feature food-focused initiatives that have taken action to promote human, ecological, and animal health and well-being. From ​Brazil, ​Canada, France, Italy, the Netherlands, Nigeria, Taiwan, Thailand, Uganda, and the United States, the case studies in this report demonstrate how the health sector can play a critical role in food systems transformation.

The initiatives profiled provide healthcare and public health professionals with evidence and ideas for how food–health action can be taken at local, regional, national, and international levels – including:

  • Public health, food, animal health, and planetary health workers’ collaboration is necessary to advance positive food–health outcomes
  • Appreciation of lived experiences and Indigenous knowledge is key to better food-health outcomes
  • Medical institutions, including hospitals, have a role to play support better availability of healthy foods
  • Healthcare professionals can influence government policy in a way that improves the health and well-being of the communities they serve.
  • Culturally appropriate nutrition education, food literacy, and skills training should be advocated for through schools, health and social services, and community settings.

Download the full report here: Creating Better Health for People, Animals, and the Planet: Food Systems Insights for Health Professionals 

Healthy and sustainable diets: Position brief of Dietitians Australia (2022 Mar, revised from 2020)

It is the position of Dietitians Australia that to promote human and planetary health, a food system transformation is needed that supports the population to adopt healthy and sustainable diet-related practices.

MEDIA RELEASE Monday 28 March 2022 (see full pdf below)

Australia eating its way to a sick planet. Six and a half planet Earths would be needed to produce food by 2050 if the world were to adopt Australia’s eating habits.

A recently published position statement by Dietitians Australia revealed that as the planet’s health continues to decline, so too does the health of Australians, as our country favours quantity over quality when it comes to food. Dietitians Australia is calling on the government for urgent intervention by strategically planning the nation’s food systems in favour of a sustainable, affordable and nutritious way forward. “Australia’s diet causes the highest per capita greenhouse gas emissions of all G20 countries and many of these foods are energy dense and nutrient poor, which are not needed for health,” said Robert Hunt, CEO of Dietitians Australia. “We need to shift away from just focusing on producing more food, and instead concentrate on how we can sustainably produce nutritious food that’s affordable.”

Dietitians Australia believes that Aboriginal and/or Torres Strait Islander knowledge is key to sustainability into the future, and that this should be captured in a National Nutrition Strategy that supports a healthy planet. “As a nation we must work in partnership with First Nations Peoples and respect their knowledge of caring for the land, waters and ecosystems. Capturing this within a National Nutrition Strategy would help lead the way for healthy and sustainable eating patterns to flow through our communities. The strategy could see sustainability incorporated into the Australian Dietary Guidelines and be accounted for in the meals served at hospitals, aged care homes, education centres and correctional facilities. It would also support the evolution of food on our supermarket shelves to meet consumer demand for healthy and sustainable options.”

The report, published in Nutrition & Dietetics, explained how Australia and New Zealand are among the highest in rates of overweight children at 16.9%, compared to a global average of 5.7%. Obesity in adults is also extraordinarily high at 30.7%, compared to a global average of 13.2%. Despite being considered ‘the lucky country’, 12.3% of Australians have trouble affording or accessing food, compared to a 7.6% average amongst other high-income countries. When comparing Australia’s food system scorecard to those in the global arena, the report found that urgent action is required to contribute to global transformative efforts.

Barbour L, Bicknell E, Brimblecombe J, Carino S, Fairweather M, Lawrence M, et al. Dietitians Australia position statement on healthy and sustainable diets. Nutrition & Dietetics. 2022;79(1). 10.1111/1747-0080.12726

Food+Planet: Empowering Nutrition Professionals to Advance Sustainable Food Systems – Paper & Action sheets (2021)

This Food+Planet white paper and website launched in 2021 provides a road map of how we might meaningfully close the gap to create a movement among nutrition professionals and catalyze change within the food system. There are also 2 useful summary sheets via the same link: Sustainability in Action: 11 Simple Steps to Start Making a Difference Today; and From Learning to Action: 4 Ways to Make Meaningful Change in Your Practice.

Consumption of Ultra-Processed Foods by Pesco-Vegetarians, Vegetarians, and Vegans: Associations with Duration and Age at Diet Initiation (2020)

Gehring J, Touvier M, Baudry J, Julia C, Buscail C, Srour B, et al. Consumption of Ultra-Processed Foods by Pesco-Vegetarians, Vegetarians, and Vegans: Associations with Duration and Age at Diet Initiation. The Journal of Nutrition. 2020;151(1):120-31. 

Relevant to: 

All Dietitians-Nutritionists.   


This study assessed the intake of ultra-processed foods (UPFs) and unprocessed foods within a group of meat eaters and vegetarians (pesco-vegetarians, vegetarians, and vegans) in France. The nutritional quality of the plant-based foods was also assessed, as well as the determinants of UPF consumption for the vegetarians.  

Bottom line for nutrition practice: 

In this study, vegetarians – and even moreso, vegans – consumed more energy from ultra-processed foods (UPFs) than meat eaters. This was driven particularly through the consumption of commercial plant-based meat and dairy alternatives, but vegetarians also had a higher UPF intake through the consumption of salty snacks and biscuits. On the other hand, the proportion of energy from unprocessed foods was higher for vegetarians than for meat eaters, and vegetarians also had lower intakes of alcoholic beverages and sweet and fatty foods.  

 The study showed that consuming UPFs is linked to a lower intake of whole plant-based foods, and could therefore decrease the nutritional quality of the diet. Those who had been vegetarians for a shorter time or had a young age when initiating the diet had an increased consumption of UPFs. In this study, vegetarians demonstrated a diversity of diets (e.g., differing in their intake of UPFs, and in the nutritional quality of their choices). The results show that all plant-based diets are not equally beneficial to health; the health benefits of a plant-based diet could be compromised if diets are composed of a high amount of processed foods. The authors therefore recommend guidelines for vegetarians and vegans to limit their consumption of UPFs, similar to those recommended for the general population.  


Background: There is a growing availability of industrial plant-based meat and dairy substitutes that can be classified as ultra-processed foods (UPFs). Very little is known about the consumption of UPFs by vegetarians. 
Objective: The aim of this cross-sectional study, from the NutriNet-Santé cohort, was to describe the contribution of UPFs to different vegetarian diets, in relation to the nutritional quality of their diet, and determinants of UPF consumption, including duration and age at vegetarian diet initiation. 
Methods: The study population (= 21,212) was divided into 4 groups: 19,812 meat eaters, 646 pesco-vegetarians, 500 vegetarians, and 254 vegans. Daily food intakes were collected using repeated 24-h dietary records. Vegetarian diets were described by the proportion of energy from UPFs and the nutritional quality of the diet using healthy and unhealthy plant-based diet indices (PDIs). In a subsample without meat eaters (= 1,400), a multivariable linear regression model was performed to study the association between UPF consumption and its determinants. 
Results: Higher avoidance of animal-based foods was associated with a higher consumption of UPFs (< 0.001), with UPFs supplying 33.0%, 32.5%, 37.0%, and 39.5% of energy intakes for meat eaters, pesco-vegetarians, vegetarians, and vegans. The nutritional quality of diets was also associated with the level of animal-based foods avoidance (< 0.001), with healthy PDIs at 53.5, 60.6, 61.3 and 67.9 for meat-eaters, pesco-vegetarians, vegetarians, and vegans. Short duration and young age at diet initiation were associated with an increased consumption of UPFs (βage at initiation = −0.003, = 0.001; βduration = −0.002, < 0.001). 
Conclusions: Not all vegetarian diets necessarily have health benefits, because of potential adverse effects of UPFs on nutritional quality and healthiness of diet. UPF consumption by vegetarians and their diet characteristics should be considered in future studies on the links between vegetarianism and health.  

Details of results: 

The authors used a cross-sectional design of over 20,000 adults sampled from the French NutriNet-Santé (a French prospective observational cohort launched in May 2009). Participants were classified into four groups according to their diets: meat eaters, pesco-vegetarians, vegetarians, and vegans.  

Foods were classified by the NOVA categories “ultra-processed foods” (UPFs) and “unprocessed or minimally processed foods” (see “of additional interest” for more details). The NOVA UPFs include a wide range of foods from industrial plant-based substitutes such as vegetable patties or nuggets and plant-based dairy alternatives to packaged snacks, frozen or shelf-stable ready to eat meals, sweetened beverages, and foods made predominantly from sugar and fat. Foods were further classified by “healthy” and “unhealthy” plant-based diet indices (PDI), which assessed the nutritional quality of the foods.  

Each participant was assigned a UPF indicator related to the proportion of energy from UPFs in the diet, as well as an indicator related to the proportion of energy from unprocessed foods. Within the group of vegetarians, the authors separated out the contribution of plant-based meat and dairy alternatives to their UPF intake (i.e., textured soy protein foods, vegetarian patties, and plant-based drinks). Participants were also assigned healthy PDI and unhealthy PDI scores.  
All vegetarian groups except for pesco-vegetarians had a higher energy intake from UPFs than meat eaters, whose UPF intake was 33% of total energy consumed. Vegans were particularly high at 39.5% of total energy consumed. Within the group of vegetarians, vegans by far consumed the most industrial plant-based milk or dairy substitutes. Vegans also had a significantly higher percentage of total energy intake from unprocessed foods (31.2%) than meat eaters (29.0%).   

When examined through the lens of a plant-based nutrition index, the study found that average healthy PDI and unhealthy PDIs scores were both significantly higher for vegetarians than meat eaters. This suggests that a higher number of vegans and vegetarians favoured unhealthy plant-based foods over healthy plant-based foods than meat eaters, but that they also favoured healthy plant-based foods over unhealthy plant-based foods. The authors suggest that this somewhat contradictory result illustrates the heterogeneity of the diets of the vegetarians studied. When the proportion of energy from UPFs was correlated with the healthy and unhealthy diet indices, results demonstrated that when UPF intake increased, the unhealthy diet index increased and the healthy diet index decreased.  

The authors suggest that the observed increased consumption of UPFs for those who had been vegetarians for a shorter time or had initiated the diet at a young age might be explained by previous studies showing that vegetarians seem to include healthier plant based foods over time. The authors conclude by suggesting that all plant-based diets are not equally beneficial to health; the health benefits of a plant-based diet could be compromised if diets are composed of a high amount of processed foods.  

Of additional interest: 

The four NOVA levels of food by level of processing include: 1. Unprocessed and minimally processed foods; 2. Processed culinary ingredients; 3. Processed foods; and 4. Ultra-processed foods. 

For more information on the NOVA classification see: Monteiro, C.A., Cannon, G., Lawrence, M., Costa Louzada, M.L. and Pereira Machado, P.2019. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome, FAO. 

Editor’s comment:  

While this study focused on vegetarians, some of the findings are relevant to those following a plant-based diet – in particular, the need to limit the consumption of UPFs.  

Additionally, while the study noted that the higher intake of UPFs by vegetarians and vegans was driven by a higher consumption of plant-based meat and dairy substitutes, it is important to note that not all meat and dairy alternatives are equally healthy (or unhealthy). Dietitians-Nutritionists can assist the population to choose the healthiest alternatives among these processed products. 

Open access link to article: 


Conflict of interest/ Funding:  

No conflicts reported 

External relevant links:  

Corresponding author: