A conceptual framework for understanding the environmental impacts of ultra-processed foods and implications for sustainable food systems (2022)

K. Anastasiou, P. Baker, M. Hadjikakou, G.A. Hendrie, M. Lawrence. A conceptual framework for understanding the environmental impacts of ultra-processed foods and implications for sustainable food systems. Journal of Cleaner Production. Volume 368, 2022, 133155, ISSN 0959-6526, https://doi.org/10.1016/j.jclepro.2022.133155 (paywall).

Relevant to: 

Dietitians interested in understanding the environmental impacts of UPFs.

Question: 

Research aim: to determine the types of environmental impacts resulting from each stage of UPF production, and the magnitude of these impacts in the context of dietary consumption patterns

Bottom line for nutrition practice: 

  • The findings highlight that environmental degradation associated with UPFs is of significant concern due to the substantial resources used in the production and processing of such products, and also because UPFs are superfluous to basic human needs.

Abstract: 

  • Minimising environmental impacts and prioritising the production of nutritious foods are essential qualities of a sustainable food system. Ultra-processed foods (UFPs) are potentially counterproductive to these objectives.
  • This review aims to summarise the magnitude and types of environmental impacts resulting from each stage of the UPF supply chain and to develop a conceptual framework to display these impacts. It also aims to identify the terms used to describe UPFs in the sustainability literature, and the methods used to measure the associated environmental impacts.
  • A narrative review approach with a systematic search strategy was used. Fifty-two studies were included that either described or quantified the environmental impacts of UPFs.
  • This review found that UPFs are responsible for significant diet-related environmental impacts.
    • Included studies reported that UPFs accounted for between 17 and 39% of total diet-related energy use, 36–45% of total diet-related biodiversity loss, up to one-third of total diet-related greenhouse gas emissions, land use and food waste and up to one-quarter of total diet-related water-use among adults in a range of high-income countries.
    • These results varied depending on the scope of the term used to describe UPFs, stages of the lifecycle included in the analyses and country.
    • Studies also identified that UPF production and consumption has impacts on land degradation, herbicide use, eutrophication and packaging use, although these impacts were not quantified in relation to dietary contribution.
  • The findings highlight that environmental degradation associated with UPFs is of significant concern due to the substantial resources used in the production and processing of such products, and also because UPFs are superfluous to basic human needs.
  • The conceptual framework and findings presented can be used to inform food policy and dietary guideline development, as well as provide recommendations for future research.

Details of results: 

From a resource-use perspective, UPFs are not a necessary component of diets and therefore environmental impacts are avoidable. Environmental impacts from UPFs occur across the entire supply chain. These impacts range in magnitude, but research on Australian discretionary food consumption indicates that they are significant; approximately one-third of diet-related energy, greenhouse gas emissions, land use, and water use was driven by the production of discretionary foods in Australia.

UPFs reliance on low-cost, high-yield commodities is a driver of diet-related greenhouse gas emissions and biodiversity loss, intensive processing technologies is a driver of diet-related energy use and reliance on packaging drives plastic pollution.

Meat-based UPFs appear to be significant drivers of UPF-related greenhouse gas emissions. Plant-based UPFs also contribute to greenhouse gas emissions but their impacts on biodiversity and deforestation are perhaps more concerning.

Of additional interest: 

The ways in which foods were classified in the original research articles influenced study findings. This highlights the importance of considering the most relevant food classification system, and the potential impacts of the classification on the findings. Specifically, some outcomes, such as greenhouse gas emissions and land use, appeared to be driven by whether or not studies included processed meats in their ‘unhealthy food’ category.None

Conflict of interest/ Funding:  

none

External relevant links:  

Ultra-processed foods should be central to global food systems dialogue and action on biodiversity (2022) – The contribution of ultra-processed foods to agrobiodiversity loss is significant, but so far has been overlooked in global food systems summits, biodiversity conventions and climate change conferences. Ultra-processed foods need to be given urgent and high priority in the agendas of such meetings, and policies and action agreed. 

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

Corresponding author: 

Kim Anastasiou, Ms, kim.anastasiou@adelaide.edu.au

Conceptualising the drivers of ultra-processed food production and consumption and their environmental impacts: A group model-building exercise (2023)

Kim Anastasiou, Phillip Baker, Gilly A. Hendrie, Michalis Hadjikakou, Sinead Boylan, Abhishek Chaudhary, Michael Clark, Fabrice A.J. DeClerck, Jessica Fanzo, Anthony Fardet, Fernanda Helena Marrocos Leite, Daniel Mason-D’Croz, Rob Percival, Christian Reynolds, Mark Lawrence. Conceptualising the drivers of ultra-processed food production and consumption and their environmental impacts: A group model-building exercise. Global Food Security, Volume 37, 2023, 100688, ISSN 2211-9124. https://doi.org/10.1016/j.gfs.2023.100688 (paywall)

Relevant to: 

Policy makers and dietitians interested in system-wide policy change.

Question: 

This study aimed to develop and validate a conceptual model of the known and potential environmental impacts across ultra-processed food (UPF) systems.

Bottom line for nutrition practice: 

  • UPFs are associated with a wide range of environmental harms, driven by a profit-based, corporatized food system and enforced by product design and a food environment structured to encourage UPF consumption. Effectively reducing UPF production and consumption would require a suite of policies acting on the political economy, food environment and production system.

Abstract: 

  • Using group model building we developed a series of causal loop diagrams identifying the environmental impacts of ultra-processed food (UPF) systems, and underlying system drivers, which was subsequently validated against the peer-reviewed literature.
  • The final conceptual model displays the commercial, biological and social drivers of the UPF system, and the impacts on environmental sub-systems including climate, land, water and waste. It displays complex interactions between various environmental impacts, demonstrating how changes to one component of the system could have flow-on effects on other components. Trade-offs and uncertainties are discussed.
  • The model has a wide range of applications including informing the design of quantitative analyses, identifying research gaps and potential policy trade-offs resulting from a reduction of ultra-processed food production and consumption.

Details of results: 

There are a range of mechanisms by which UPFs harm the environment. Impacts do not occur in isolation and many are cumulative, whereby one type of environmental damage acts to further degrade other forms of environmental damage. Impacts include climate change, land and soil degradation, water scarcity, biodiversity and agrobiodiversity loss, eutrophication, food loss and waste, plastic waste and air pollution.

Drivers of environmental degradation include a political economy system which acts to reinforce profits of UPF corporations, drive corporate political power and ultimately weaken protective food policies. Other drivers include product design, whereby UPFs are designed to be as palatable as possible and a food environment which enables access to inexpensive UPFs around the globe.

Ultimately a shift in production is required to meet the goals of healthy, sustainable and equitable food systems. However, policies which encourage a shift away from UPF production towards unprocessed, minimally processed and processed foods, need to account for trade-offs. Trade-offs relate to production efficiency, time pressures, food loss and waste, land use, cost and convenience (see Table 1).

Of additional interest: 

The model highlights research gaps which could be used by future researchers to determine UPF-related research studies. Furthermore, the model can be used to guide researchers on designing quantitative environmental impact assessments, as well as to provide a guide for interpreting quantitative findings in the context of complex and dynamic food systems.

Conflict of interest/ Funding:  

This research received no specific grant from any funding agency, commercial or not-for-profit sectors. KA was funded by a Deakin University Postgraduate Research Scholarship.

External relevant links:  

Ultra-processed foods should be central to global food systems dialogue and action on biodiversity (2022) – The contribution of ultra-processed foods to agrobiodiversity loss is significant, but so far has been overlooked in global food systems summits, biodiversity conventions and climate change conferences. Ultra-processed foods need to be given urgent and high priority in the agendas of such meetings, and policies and action agreed.

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

Corresponding author: 

Kim Anastasiou, Ms – kim.anastasiou@adelaide.edu.au

Ultra-processed foods should be central to global food systems dialogue and action on biodiversity (2022)

Leite FHM, Khandpur N, Andrade GC, et al. Ultra-processed foods should be central to global food systems dialogue and action on biodiversity. BMJ Global Health 2022;7:e008269. doi:10.1136/bmjgh-2021-008269

This commentary highlights the impact of global diets characterised by a high intake of ultra-processed foods on agrobiodiversity. It calls for prioritising and addressing ultra-processed foods in global food system dialogues and policy, and country-level action.

Summary box

► The global industrial food system and consequent rapid rise of ultra-processed foods is severely impairing biodiversity. Yet although the impacts of existing land use and food production practices on biodiversity have received much attention, the role of ultra-processed foods has been largely ignored.

► An increasingly prominent ‘globalised diet’, characterised by an abundance of branded ultra-processed food products made and distributed on an industrial scale, comes at the expense of the cultivation, manufacture and consumption of traditional foods, cuisines and diets, comprising mostly fresh and minimally processed foods.

► Ultra-processed foods are typically manufactured using ingredients extracted from a handful of high-yielding plant species, including maize, wheat, soy and oil seed crops. Animal-sourced ingredients used in many ultra-processed foods are often derived from confined animals fed on the same crops.

► The contribution of ultra-processed foods to agrobiodiversity loss is significant, but so far has been overlooked in global food systems summits, biodiversity conventions and climate change conferences. Ultra-processed foods need to be given urgent and high priority in the agendas of such meetings, and policies and action agreed.

Conclusion

The very rapid rise of ultra-processed foods in human diets will continue to place pressure on the diversity of plant species available for human consumption. Future global food systems fora, biodiversity conventions and climate change conferences need to highlight the destruction of agrobiodiversity caused by ultra-processed foods, and to agree on policies and actions designed to slow and reverse this disaster. Relevant policymakers at all levels, researchers, professional and civil society organisations, and citizen action groups, need to be part of this process.

Environmental sustainability in national food-based dietary guidelines: a global review (2022)

Citation: James-Martin G, Baird DL, Hendrie GA, et al. Environmental sustainability in national food-based dietary guidelines: a global review. Lancet Planet Health 2022; 6: e977–86. https://doi.org/10.1016/S2542-5196(22)00246-7

Summary

Food-based dietary guidelines (FBDGs) provide country-specific guidance on what constitutes a healthy diet. With increasing evidence for the synergy between human and planetary health, FBDGs have started to consider the environmental sustainability of food choices. However, the number of countries that discuss environmental sustainability in their guidelines is unknown.

The purpose of this Review was to identify countries with government-endorsed FBDGs that made explicit mention of environmental sustainability and to examine the breadth and depth of the inclusion of sustainability in FBDGs. The Food and Agriculture Organization of the UN identified 95 countries with FBDGs.

We assessed 83 countries against our inclusion criteria, of which 37 mentioned environmental sustainability. Relevant content was assessed against a set of criteria based on the Food and Agriculture Organization’s guiding principles for sustainable healthy diets.

The depth to which environmental sustainability was discussed varied and it was often restricted to general explanations of what a sustainable diet is. Few FBDGs addressed why sustainability is important, how dietary changes can be made, or provided quantified advice for implementing sustainable diets.

Key messages

  • Food-based dietary guidelines (FBDGs) are increasingly including content to address the relationship between dietary intake and environmental sustainability. At present, this information is more likely to be reported in background documents than consumer documents, restricting its visibility to users of the consumer documentation.
  • The principles most commonly addressed in FBDGs are associated with culture, inclusion of animal-based and plant-based foods in the diet, environmental effect, biodiversity, and food waste. However, information is general, and practical, specific advice, or quantified recommendations for action are scarce.
  • To achieve the transformation to food systems needed to curb the accelerating environmental decline globally, more countries need to commit to developing FBDGs that explicitly emphasise the crucial link between diet and planetary health and provide specific and practical advice to address these issues.

37 countries with environmental sustainability in their FBDG:

  1. Argentina
  2. Australia
  3. Belgium‡
  4. Brazil
  5. Canada
  6. Colombia
  7. Costa Rica
  8. Denmark
  9. Ecuador
  10. El Salvador
  11. Estonia
  12. Finland
  13. France
  14. Germany
  15. Greece
  16. Guatemala
  17. Iceland
  18. Italy
  19. Japan
  20. Kenya
  21. Malta
  22. Mexico
  23. Netherlands
  24. New Zealand
  25. North Macedonia
  26. Norway
  27. Peru
  28. Poland
  29. Qatar
  30. Sierra Leone
  31. South Africa
  32. Sweden
  33. Switzerland
  34. Türkiye
  35. UK
  36. Uruguay
  37. Venezuela

Nutrition and Dietetics Professionals Sustainable Food Systems Knowledge Seeking Behaviour (2024)

Citation: Powell, R., Carlsson, L., & Callaghan, E. (2024). Nutrition and Dietetics Professionals Sustainable Food Systems Knowledge Seeking Behaviour. Journal of Hunger & Environmental Nutrition, 1–17. https://doi.org/10.1080/19320248.2024.2321231 (paywall)

Abstract

Sustainable food system (SFS) competence is a new and recognized knowledge area for nutrition and dietetics professionals (NDP). This research seeks to describe the SFS knowledge-seeking behavior of NDP.

Secondary data analysis of 231 anonymous self-assessments collected between September 2020 to December 2021 indicate a high proportion (41%) of self-assessed “beginners” in this topic at a mixture of career stages.

There was a preference for learning about topics that already have significant public attention globally. More advanced practitioners sought more applied information.

These results are informative for updating education and professional development tools for NDP.

Availability and Accessibility of Healthy and Unhealthy Foods in Neighborhood and their Association with Noncommunicable Diseases: A Scoping Review (2024)

Sachdeva B, Puri S, Aeri BT. Availability and accessibility of healthy and unhealthy foods in neighborhood and their association with noncommunicable diseases: A scoping review. Indian J Public Health 2024;68:95-105. DOI: 10.4103/ijph.ijph_436_23

Abstract

Worldwide, 7 million mortalities and 187.7 million morbidities have been associated with dietary risks. Poor diets emerge because of an obesogenic environment. However, clear evidence indicating an association between food environment and noncommunicable diseases (NCDs) is inconclusive.

The present review was conducted to study the associations between the availability/accessibility of healthy/unhealthy foods and the risk of NCDs among adults of the age group above 18. Studies published between 2012 and 2022 were retrieved using three databases – PubMed, Google Scholar, and Science Direct.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), (2018) guidelines and based on the selection criteria, 3034 studies were retrieved, of which 64 were included in this review. Maximum studies were conducted in high-income countries and adopted a cross-sectional study design.

Overall, the results of the review illustrate mixed findings.

  • Compared to healthy food, direct associations between obesity and the availability/accessibility of unhealthy foods were reported (n = 12).
  • In the case of diabetes, supermarket availability was more likely to be protective (4 positive) compared to a negative association with unhealthy food stores (3 associations in 11 studies).
  • For cardiovascular diseases, an increased number of cases with fast-food outlets (n = 6) outnumbered positive associations with healthy food (n = 3).
  • Studies concerning multiple NCDs reported direct associations with unhealthy food outlets (n = 5) while inconclusive associations with healthy food.

Despite a large number of studies, a weak, inconclusive relationship between food environment and NCDs was found. The use of standardized tools and longitudinal and interventional studies are warranted to rationalize the execution of the policies related to the food environment.

Sustainability and food systems concepts in dietetic training standards in speaking Spanish countries (2023)

Carvajal Useche KC, Rangel Palacio N, Carlsson L. Sustainability and food systems concepts in dietetic training standards in speaking Spanish countries. Rev Esp Nutr Hum Diet. 2023; 27(4): 315-24. doi: https://doi.org/10.14306/renhyd.27.4.1939 (open source)

Follow the link to read the full article in both Spanish and English.

Key Messages

  • Four Spanish-speaking nations include at least partial coverage of sustainable food systems dimensions in their dietetic training and practice standards: Colombia, Mexico, Paraguay and Peru. This is 66% of those for which standards exist, and similar to international content.
  • Mexican and Peruvian standards require robust commitment to social and environmental sustainability in practice (values). Mexican education is guided by relatively low level of cognitive complexity (knowledge of, “understand”); Peruvian practice standards required a higher level (up to “create”).
  • The standards in Paraguay and Colombia contribute to food systems sustainability competence through primarily food and nutrition security-related standards, concepts inseparable from sustainable food systems. Colombia explicitly recognizes the purview of nutritionists as throughout food systems (production to consumption).
  • Opportunities exist for increasing the focus on food systems sustainability as a guiding paradigm for food and nutrition work, in the context of urgent global priorities to climate change and sustainable development.

Abstract

Introduction: Global calls for action to support sustainable development through food systems and nutrition provide context to examine to what degree nutrition and dietetics professionals are equipped for this challenge. The purpose of this research is to investigate content related to sustainable food systems in training standards from Spanish-speaking countries and examine what level of knowledge is required.

Methodology: Researchers conducted a content analysis of documents informing nutrition and dietetics training standards for content related to sustainable food systems, including dimensions of these complex topics. Relevant content was then analyzed according to the level of cognitive complexity per Bloom’s Revised Taxonomy.

Results: Of 21 eligible countries, documents describing competencies, standards or codes of ethics were found for six, four of which included relevant standards: Colombia, Mexico, Paraguay, and Peru. Overall, there was minimal comprehensive inclusion of sustainable food systems, but partial inclusion of one or more important sustainability dimensions. These were required at a mix of levels of cognitive complexity.

Conclusions: This research adds to a small body of evidence documenting the state of readiness of nutrition and dietetics professionals to contribute to sustainable development. It highlights a moderate level of readiness in four Spanish-speaking countries, and opportunities for increased emphasis on comprehensive sustainability-informed education and training standards, which can help prepare practitioners for effective practice.

Funding: MITACS Global Research Internship.

Co-production of research for food systems transformation: mapping and exploring examples of co-production activities across Transforming the UK Food System (TUKFS) projects (2024)

About this project

Led by Dr Clare Pettinger (University of Plymouth, FoodSEqual) and Professor Charlotte Hardman (University of Liverpool, FIO FoodBeanMeals), this interdisciplinary, cross-project collaboration has engaged researchers from multiple academic institutions in order to better understand how to facilitate, support, and invest in future co-produced research for food systems transformation. 

There is an urgent need for transformation of the UK food system. The ways in which food is currently produced, accessed, and eaten are having significant negative impacts on human health and causing damage to our environment.

To address these issues, there has been a recent shift towards the use of creative and participatory methods of research, including co-production. In line with this, “co-producing research across disciplines and stakeholders to provide evidence for coherent policymaking” is a key strategic aim of the UK Research and Innovation (UKRI) Transforming UK Food Systems (TUKFS) SPF Programme.  

As part of the TUKFS Annual Synergy Fund, this research project identified and mapped examples of where co-production, co-design or co-creation methods are being employed for food system transformation across six TUKFS projects.

This toolkit shares the outputs of this research project, including 11 case studies of co-production, a ‘messy map’ representing our key findings, as well as practical considerations intended for researchers, academic institutions, and funders engaging with these innovative methodological approaches.

Partial substitutions of animal with plant protein foods in Canadian diets have synergies and trade-offs among nutrition, health and climate outcomes (2024 Feb)

Auclair, O., Eustachio Colombo, P., Milner, J. et al. Partial substitutions of animal with plant protein foods in Canadian diets have synergies and trade-offs among nutrition, health and climate outcomes. Nat Food (2024). https://doi.org/10.1038/s43016-024-00925-y (Paywall)

The study was published in Nature Food in February 2024 and was conducted by researchers at McGill University and the London School of Hygiene & Tropical Medicine. It analyzed the impacts of partially replacing red and processed meat or dairy with plant protein foods in Canadian diets on nutrition, health and climate outcomes.

Key findings include:

  • Replacing 50% of red and processed meat with plant proteins could reduce diet-related greenhouse gas emissions by 25% and increase life expectancy by up to 8.7 months
  • Replacing 50% of dairy with plant proteins had smaller benefits, reducing emissions by only 5% and increasing life expectancy by 7.6 months
  • Replacing dairy increased calcium inadequacy by up to 14%

Abstract

Dietary guidelines emphasize the consumption of plant protein foods, but the implications of replacing animal with plant sources on a combination of diet sustainability dimensions are unknown.

Using a combination of data from a national nutrition survey, greenhouse gas emissions from dataFIELD and relative risks from the Global Burden of Disease Study 2017, we assess the impact of partially substituting red and processed meat or dairy with plant protein foods in Canadian self-selected diets on nutrition, health and climate outcomes.

The study provides evidence that partially substituting animal with plant proteins, especially red meat, can have synergistic benefits for human and planetary health in Canada.

The substitutions induced minor changes to the percentage of the population below requirements for nutrients of concern, but increased calcium inadequacy by up to 14% when dairy was replaced. Replacing red and processed meat or dairy increased life expectancy by up to 8.7 months or 7.6 months, respectively. Diet-related greenhouse gas emissions decreased by up to 25% for red and processed meat and by up to 5% for dairy replacements.

Co-benefits of partially substituting red and processed meat with plant protein foods among nutrition, health and climate outcomes are relevant for reshaping consumer food choices in addressing human and planetary health.

Sustainable diets and risk of overweight and obesity: A systematic review and meta-analysis (2024)

Citation: Reger C, Leitzmann MF, Rohrmann S, Kühn T, Sedlmeier AM, Jochem C. Sustainable diets and risk of overweight and obesity: A systematic review and meta-analysis. Obesity Reviews. 2024;1‐11. doi:10.1111/obr.13707

Summary

Sustainable diets are gaining interest as a possible approach to tackle climate change and the global extent of obesity. Yet, the association between sustainable diets and adiposity remains unclear.

We performed a systematic review and meta-analysis, calculating summary relative risks and 95% confidence intervals (CI). We pooled maximally adjusted risk estimates, assessed heterogeneity and publication bias, calculated the E-value, and evaluated the risk of bias across the included studies.

A total of eight studies were eligible for analysis. Comparing the highest versus the lowest levels of adherence to sustainable diets, the pooled effect estimate was 0.69 (95% CI = 0.62–0.76) for overweight and 0.61 (95% CI = 0.47–0.78) for obesity.

These results suggest that sustainable diets may decrease the risk of overweight/ obesity and therefore could serve as enablers for improving both public and planetary health. An agreed-upon clear definition of sustainable diets would enhance the comparability of future studies in this area.

Key Notes extracted from the paper:

  • Of the 798 potential studies, after exclusion, 8 studies were eligible (four cohort and four cross-sectional studies) and were included in the systematic review and meta-analysis. Those studies yielded a total of 438,020 participants at baseline and ultimately 170,923 participants in the analytic sample. Six studies originated from Europe, one from North America, and one from South America.
  • Studies were considered eligible for inclusion if they (1) were observational studies, including cohort, case–control, or cross-sectional studies; (2) were carried out in generally healthy participants; (3) defined sustainable diets as exposure in a reasonable and reproducible way using a sustainability measure and considered BMI-defined overweight/obesity as the primary outcome; (4) provided a relative risk (RR) or odds ratio (OR) and 95% confidence intervals (CI) for the highest versus the lowest levels of sustainable diet/organic food consumption; (5) were published before November 23, 2023; and (6) were written in English language.
  • They use the definition by Willett et al. of sustainable diets being diets that promote health and well-being while reducing the environmental impact of food production and consumption. Besides mostly plant-based diets such as the Planetary Health Diet (PHD), organic food consumption meets several of the dimensions that characterize sustainable diets. Sustainable diets aim to ensure adequate nutrition of people worldwide while maintaining planetary boundaries and are thereby positively contributing to planetary health.
  • Sustainability itself lacks a universally agreed-upon definition. Therefore, every study included utilized a different method to classify sustainable diet, and organic agriculture was assumed to be sustainable, potentially resulting in high between-study heterogeneity. Although organic food consumption seems to be associated with more sustainable diets, the higher monetary costs of organic food is not in line with the Food and Agriculture Organization definition of sustainable diets. Furthermore, the sustainability of organic food can vary depending on factors such as location, crop type, and farming methods. Water and arable land requirements might even be higher than conventional farming methods.
  • To evaluate sustainability, studies used various indices or scores. The PHD Index assesses adherence to a reference diet proposed by the EAT-Lancet Commission. The Sustainability Diet Index is a score with a maximum of 20 points summed up using four subindices encompassing environmental, nutritional, economic, and sociocultural aspects. Kesse-Guyot et al. utilized an Organic Score ranging between 0 and 32 points across 18 food groups, and Andersen et al. used an overall organic food score ranging from 6 to 24 points.