Health and Sustainable Nutritional Choices from Childhood: Dietary Pattern and Social Models

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Key insights

The implications of a “healthy diet” go beyond the simple provision of nutrients to prevent malnutrition and avoid disease. A lifestyle underpinned by poor dietary choices is linked to a reduction in longevity and in years of healthy life. Today, increasing attention is focused not just on the promotion of healthy dietary patterns, but also on reducing the burden of human nutrition on the planet. The preservation of the Earth's resources and the impact of food supply and production on the climate are key considerations for present and future generations. This review summarizes the evidence that links children's nutritional status and dietary habits with environmental sustainability. 

Current knowledge

Dietary patterns have been shown to emerge in early life and to become established by age 3 years, beyond which they tend to stabilize throughout childhood. Early intervention is, therefore, essential for improving lifelong dietary patterns. Today, there is avid interest in designing diets that are not only healthy, but also ecologically sustainable. Every country has specific eating habits affected by various levels of development and food security, as well as cultural and regional preferences. When analyzing dietary regimens such as the Mediterranean, Atlantic, New Nordic, and vegetarian diets, several key principles emerge. Diets rich in plantbased foods, legumes, nuts, and unrefined cereals are beneficial for health and have a lower ecological footprint.

Practical implications

A switch in dietary habits to emphasize plant-based products represents an important strategy, particularly if started in early life. Successful inter-ventions must begin with the parents and family, but also encompass schools and the community. When considering vegetarian or vegan diets, special attention should be paid to certain micronutrients such as iron, zinc, vitamin B12, and calcium. The combination of a varied diet and fortified foods or supplements can be beneficial for avoiding deficiencies, particularly during the weaning period. Another key step towards fostering healthy food choices for life is teaching children the value of selecting local and environmentally friendly products.

Recommended reading

Fresán U, Sabaté J. Vegetarian diets: planetary health and its alignment with human health. Adv Nutr. 2019;10(Suppl 4):S380-8.
 

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Key Messages

•    A healthy diet considers either the preservation of a healthy status and the prevention of future diseases while preserving the integrity of environmental resources.
•    The most common sustainable dietary patterns adopted worldwide are plant-based to a large extent.
•    Parents and schools are the main role models in shaping healthy nutritional habits in children, contrasting the risk of obesity and the planet degradation at the same time.

Keywords

Sustainability • Nutrition • Environment • Dietary patterns • Nutritional habits

Abstract

Background: The role of diet in the pediatric age for optimal development, achievement, and maintenance of a healthy status is well recognized. Increasing attention is nowadays also paid to reducing the burden of human nutrition on the planet's health for present and future generations. Summary: Beyond environmental sustainability, the transition to diets rich in animal and processed foods contributes to an overall unhealthy nutritional status leading to an increased preva-lence of obesity- and diet-related noncommunicable diseas-es. Childhood overweight and obesity are a growing public health crisis worldwide. The aim of this narrative review was to summarize evidence of the nutritional status and dietary habits in children and the link with environmental sustainabil-ity. Key Message: Optimizing nutrition in infancy and estab-lishing healthy lifestyles from the preschool years might help to reduce the risk of overweight, and all the disorders related, respecting the sustainability dimension.

Introduction

The role of diet in the achievement and maintenance of a healthy status is well recognized [1, 2]. This is especially im-portant in the pediatric age since children need an adequate intake of energy and nutrients for growth and development of their full potential.

To date, the concept of a “healthy diet” has a broader meaning than the simple provision of nutrients in a quality and quantity that prevents malnutrition and chronic diseases. A lifestyle with poor dietary choices is linked to a reduction both in longevity and in years of healthy life [3]. Together with the promotion of healthy dietary patterns, increasing attention is nowadays paid to reducing the burden of human nutrition on the planet's health. The concern about the Earth's resources preservation and the impact on climate of activities associ-ated with food production and processing is of growing inter-est for present and future generations. The aim of this narra-tive review was to summarize evidence on the link of the nu-tritional status and dietary habits of children with environmental sustainability.

Sustainable Nutrition

The food supply chain is a complex system that includes dif-ferent phases, such as agricultural and livestock activities, processing, manufacturing, distribution, preparation, con-sumption, and waste management [2]. All these stages could have negative environmental impacts, mainly associated with greenhouse gases (GHGs) emission, water requirements, pri-mary energy, and land use, at different levels according to the dietary resources [4]. Diets high in food products of animal origin are undoubtedly associated with higher GHG emissions per gram of protein. On the other hand, plant-based foods may present advantages in storage, safety, and waste management. Accordingly, a shift from animals to products such as fruits, vegetables, legumes, cereals, seeds, and nuts is the best option for reducing GHG emissions [5]. Legumes have GHG emissions per gram of protein around 250 times lower than those of ruminant meats [6]. Replacing most meat proteins with alternative foods, such as mushrooms, or the so- called superfoods, such as quinoa, could also be considered as an improvement [7].

In this geological epoch named Anthropocene, food pro-duction practices represent the main source of planet degra-dation impacting the global climate change and therefore sea-level rise and extreme weather events, animal and plant species extinction causing biodiversity loss, land system change, and freshwater consumption [8]. Considering a pro-jected population increase to about 10 billion by 2050, this footprint is likely to grow [9]. Beyond environmental sustain-ability, transition to diets rich in animal and not natural foods contributes to an overall unhealthy nutritional status, leading to an increased prevalence of obesity and diet-related non-communicable diseases [8].

The definition of “sustainable diets,” by the Food and Agri-culture Organization (FAO) of the United Nations in 2010, highlights the importance of different aspects that a nutritional pattern must consider: respect of biodiversity and eco-systems, cultural acceptance, accessibility, affordability; nu-tritional adequacy, safety, and health [10]. Of course, not in every country worldwide there are geographical characteristics (e.g., soil, climate, and water accessibility), economical systems, or religious or cultural values fully in line with this definition. Especially in low- and middle-income countries, urban populations have lower access to healthy options because of expensive prices. Moreover, in these areas, income losses due to the COVID-19 pandemic have markedly worsened the affordability gap [11].

Principal Models of Sustainable Diet

There is a growing interest and effort in designing healthy and sustainable diets worldwide. Every country has specific eating habits affected by different levels of development and food security, as well as cultural and regional preferences [2].

Researchers have focused their attention on understand-ing which dietary patterns can realistically support the planet. In Figure 1, the sustainable diet is summarized in terms of features, main foods included, and the most common dietary patterns adopted worldwide.


The Mediterranean diet represents one of the most impor-tant models of sustainable diet, and it has been recognized as an Intangible Cultural Heritage of Humanity by the United Nations Educational, Scientific and Cultural Organization (UNESCO) in 2010, not only for the positive effects on health but also for its impact on the planet [12]. This nutritional pattern is rich in plant-based foods being based on seasonal vegetables and fruits, unrefined cereals, nuts, legumes, and extra virgin olive oil as the primary source of fat [13]. Furthermore, it shows a preference for traditional and local products, lowering the ecological footprint [14]. On the other hand, the ingestion of food ingredients, such as meat, eggs, fish, dairy products, and sweets, is limited [13]. A typical graphic representation of the Mediterranean pattern is the diet pyramid, and recently, a new illustration has been presented to emphasize the concept of sustainability, highlighting the importance of consumption of traditional, local, and eco-friendly products [9].

The Atlantic dietary pattern is a dietary model typical in Northern Portugal and Galicia (Northwest Spain) and is con-sidered another example of healthy nutritional habits, thanks to the abundant consumption of plant-based food that is preferably natural, local, and fresh. In particular, the most rep-resentative dishes are based on vegetables, fruits, potatoes, cereals, whole nuts, legumes, and fish. As in the Mediterra-nean diet, olive oil is the main source of fat. Conversely, dairy products, meat (beef and pork), and eggs are consumed moderately [15, 16].

The New Nordic Diet concept was developed starting from 2004 to emphasize the values of health, gastronomic poten-tial, sustainability, and Nordic identity. Because of the Nordic climate, the typical foods are represented by berries, legumes, apples, pears, root vegetables, cabbage, cauliflower, curly kale, onions, and mushrooms, as well as barley, wheat, spelt, oats, buckwheat, and rye thrive. Regular fish consumption is recommended, and milk and meat from both wild and domesticated animals (beef, lamb, pork, and game) and birds (farmed and wild birds) are available [17, 18].

Lastly, throughout the world, vegetarian and vegan dietary patterns are also more and more popular and associated with a reduction in GHG emission and land use. Particularly, al-though the vegan diet is over-simplified in terms of nutrition and may present the need for professional advisors, it has been reported as the one with the lowest environmental im-pact [8]. The vegetarian model, unlike the vegan pattern, be-yond plant-based foods, could include the consumption of dairy products, eggs or fish, and other seafood [19, 20].

Children's Diet: The Burden of Overweight and Obesity

Childhood overweight and obesity are a growing public health crises worldwide. According to the WHO, in 2020, about 39 million children under the age of 5 years were overweight or obese, and this problem today is rising also in low- and middle-income countries, particularly in urban settings. In 2016, there were over 340 million children and adolescents aged 5-19 years defined as overweight or obese [21]. Until now, considering the impact of the COVID-19 pandemic on the exacerbation of all forms of malnutrition (under and over) resulting from the economic, food, education, and health system disruptions, there are no updated obesity statistics from the WHO. In this pandemic scenario, the percentage of people who are not able to afford a healthy diet has increased. Consequently, consumption of comfort food (fried, high in fat, sugar, salt) and a more sedentary lifestyle have increased [11]. Frequently, obese adolescents remain obese into adulthood, and this persistent condition predisposes them to an increased risk for many chronic diseases, such as type 2 diabetes, metabolic syndrome, cardiovascular and oncological disorders, and increased mortality and premature death [22, 23].

Obesity is a multifactorial disease. The primary cause is an imbalance between energy intake and energy expenditure that, if sustained over a long period, leads to weight gain. Be-side genetic factors, an obesogenic lifestyle characterized by unhealthy eating habits and sedentary behaviors is a major contributor to the development of obesity [23, 24].

Specifically, a diet rich in energy-dense foods and sugar- sweetened beverages is very critical for childhood obesity. Problems related to nutrition are even amplified during ado-lescence because of the higher susceptibility to influence of marketing of unhealthy foods, peer pressure, and perceptions of ideal body image [25]. Furthermore, adolescents may have more freedom in eating choices, placing them at greater risk for dietary patterns directly linked to overweight and obesity [26].

Number, regularity, and duration of meals are also tradi-tionally considered as obesity-related eating behavior. Dietary patterns have been shown to emerge early in life and to be-come established by age 3 years; then, they tend to remain stable and are maintained through childhood [27]. Maintaining of unhealthy dietary patterns is therefore likely to increase this risk.

Considering these aspects, the family and then school represent the primary education influencing children's behavior regarding food choices (type and amount, meal time, dining out) and lifestyle (whether they are sedentary or physically active). This is quite relevant, starting from birth and even during intrauterine life. Since early-life exposures may contribute to the risk of obesity, the topic is recognized to be of social and public health interest [28].

Health and Sustainability: How to Act? The Role of Family and School

Parents act as promoters and role models in all aspects of child education, including health promotion [29]. Nutrition is part of this, and the family's dietary attitudes influence the child's life. Particularly, the advent of a child and the connect-ed responsibility was found to be a turning point in many adults' consumption patterns [30]. Feeding behavior starts early in a child's life. Nutritional preferences begin to be built from the amniotic fluid through the mother's diet and, later, through human milk [31]. For this reason, and to support ad-equate child growth, mothers should maintain a good nutri-tional status and consume a variety of foods. Later on, at the beginning of complementary feeding, the choice and the amount of the food eaten by the child are offered by the fam-ily. Caregivers are responsible for the food offered to a child to reach his/her nutritional needs, in terms of quality and quantity of micronutrients and macronutrients and in terms of variety of choices [32]. Children love what they know, and the beginning of the complementary feeding period through the first thousand days of life is the perfect time to introduce a huge variety of foods and flavors, to let the child explore and get used to different tastes [33]. This healthy attitude toward food, if started early in life, will remain later in adulthood [34]. Recently, in this context, based on the “Planetary Health Diet” plate proposed by the EAT-Lancet Commission, our research group has developed two schemes of diets for infants aged 6 and 24 months to promote practical advice highlighted to im-prove a sustainable behavior during this critical period. Both proposals have been conceived respecting EFSA nutritional recommendations for each respective age, encouraging, be-side human milk consumption (when possible), preferences for local foods that are natural, not packaged, and plantbased [33].

Besides, the child's life includes family and peers, both in-fluenced by community, society, media, and food offering. Children model themselves on their parents' eating behaviors, lifestyle, eating-related thoughts, and satisfaction or dissatisfaction regarding body image [35].

Beyond the family, school represents the second most im-portant context to gain and establish options for a healthy lifestyle. Since children spend many hours of their day at school and consume one of the main meals (lunch) and at least one small snack (typically in the late morning) in the in-stitute, educational programs to promote healthy eating habits from preschool age are now part of the academic plan. School meals, in line with dietary recommendations, repre-sent a way to transmit food routines, contributing significantly to overall eating behaviors [36, 37]. Nutritional programs are a good approach to promoting changes in food choice, re-shaping habits that consider planet sustainability linked to food consumption. Thus, nowadays, planning of school meals needs to take different aspects into account. First, they must cover all the nutritional needs in terms of macro- and micronutrients according to age, and second, they should consider the environmental impact of the ingredients. Lastly, to be a winning and effective strategy, meals should be acceptable to and appreciated by children and affordable to providers. Acceptability plays an important role in food choices. This concept relies both on palatability of foods and, as seen above, on eating habits that, in turn, are determined by tradition and cultural and religious factors [38].

In Spain, a case study was performed to test a model built on optimal menus for school children considering nutritional, climate change, and economic aspects. From combinations of 20 starters, 20 main dishes, and 7 desserts, a 20-day plan-ning period was created with the purpose of meeting nutrient requirements and reducing the carbon footprint (CFP) and the lunch budget. The results showed reductions of the average CFP (between -13% and -24%) and the average costs (be-tween -10% and -15%), while maintaining the nutritional as-pects similar to the proposed menus. Therefore, this work is an example of how it is possible to design diets with a select-ed group of economically, environmentally, and nutritionally sustainable dishes [39].

Similarly, encouraging findings were obtained in an Italian study assessing either water or CFP as a proxy for the impact of primary school lunch menus based on a prespecified set of Mediterranean recipes. Results from a schedule obtained to minimize the GHG emissions showed a saving of more than 40% of CO2eq and more than 20% in water consumption. Other results from a schedule obtained to minimize the water consumed showed a saving of more than 35% in H2O consumption and more than 20% of the GHG emissions [40].

In the OPTIMATTM intervention study performed in Sweden in 2019, the authors assessed in three schools the effects of a 4-week lunch menu optimized in terms of GHG emission re-duction, nutritional adequacy, and affordability. They also tested the effects on food waste and consumption and the pupils' satisfaction compared to the current food supply. Their findings showed that this optimization strategy resulted in a food list that was 40% lower in GHG emissions, met all nutri-ent recommendations for school meals, and with 11% lower costs compared to the original menu [41].

Another study conducted in Italy presented the results of a mathematical model for the development of a school lunch monthly plan that combines nutritional adequacy and accept-ability criteria, while minimizing environmental impact in terms of GHG emissions. For this model, a national sample of 52 Italian school menus was collected, and a total number of 194 recipes were included in a database containing 70 first courses, 83 second courses, 39 vegetables, 1 portion of fruit, and 1 portion of bread. General acceptability of the menu was accomplished by making a trade-off between promoting healthy recipes based on fruit, vegetables, and legumes and making menus attractive for children by avoiding monotony of food choices [42].

Beyond the importance of the construction of a sustain-able plate, a recent systematic review has summarized and pointed out all the principle feeding policies and the sustain-ability practices adopted in schools and reported in the litera-ture [43]. Specifically, 16 governmental and nongovernmental programs were identified. The most frequently cited strate-gies were the involvement with school gardens and the adop-tion of measures such as buying local and short-chain foods and reducing waste (e.g., recycling, composting). All these ac-tions are conceived in order to enable students to become aware of the impact of their dietary choices in a more holistic way, not only considering food consumption.

Discussion

To date, nutritional choices not only deal with different as-pects mainly related to the preservation of a healthy status and the prevention of future diseases, but also consider the environmental resources' integrity and pay attention to the socio-economic conditions. There is more and more evi-dence that certain foods are better for the human, planet, and economic health.

Optimizing nutrition in infancy and establishing healthy lifestyles from the preschool years could help to reduce the risk of overweight and all the related disorders, respecting the sustainability dimension. Family, school, and community are the crucial environments where educational interventions can be instituted, starting from maternal nutrition and continuing through infancy, childhood, and adolescence. First, parents play the major role in dietary behavior habits, representing the principal model to pursue. Second, school contributes to raising students' awareness of health and nutrition, hence it enables them to make more well-informed and healthier food choices.
Intervention programs of diet optimization at school could translate nutrient-based recommendations into acceptable dietary patterns for children, determining moreover a positive impact on the planet's health. A common feature of the prin-cipal sustainable dietary patterns known is a preference for plant-based recipes because of their low negative influence both on chronic diseases risk and environmental degradation. At the same time, when considering restrictive dietary pat-terns such as vegetarian and, above all, vegan diets, it is im-portant to consider all the nutritional needs to be met, espe-cially in a vulnerable population such as children and adoles-cents. Several nutrients require special attention in the planning of nutritionally adequate diets for young vegetarians. Special attention should not only be paid to iron, zinc, iodine, and vitamin B12, but also to calcium and vitamin D. In some cases, having a varied diet is sufficient to avoid deficiencies, but fortified foods and/or supplements should be used as needed, especially during the beginning of the complementary feeding period, particularly for vitamin B12 [44].
Another issue, beside dietary requirement satisfaction, concerns adolescents and their attitudes to and perceptions of plant-based foods. In this population category, the ap-proach to these nutritional patters is more difficult, because they are influenced by their peers when choosing food, and usually, they tend to consume much more meat than the rec-ommended portions, as well as products high in fat, sugar, and salt. Moreover, an important determinant to adopt a diet including more vegetables and fruits is the taste, which is per-ceived to be as good as the one of animal-based foods [45].

Lastly, the neighborhood, and the schools' neighborhoods, represents another important environmental factor determining either individual behavior or child nutritional sta-tus [46]. The presence of green urban areas around schools could positively influence BMI and body fat percentage in children [47]. To this aim, approaches ensuring environmental integrity and public health should be developed, shaping food habits and lifestyle toward more sustainable choices from early life, when the possibility of a successful intervention is greater.

Conclusions

Many children with obesity maintain this condition until adult-hood. Since obesity is associated with increased morbidity and mortality later in life, normalization of body weight during childhood is of great importance. Efforts should be made to counteract this noncommunicable pandemic and related consequences in terms of human health and planet preserva-tion. Within this context, a switch of dietary habits toward plant-based products, with limited inclusion of animal sourc-es, starting in early life, may represent a successful interven-tion.

Conflict of Interest Statement

The writing of this article was supported by Nestlé Nutrition Institute and the authors declare no other conflicts of interest.

Author Contributions

Alessandra Mazzocchi, Valentina De Cosmi, and Gregorio Paolo Mi- lani drafted the manuscript; Carlo Agostoni and Gregorio Paolo Mi- lani supervised the work and proofread. All the authors contributed significantly to the paper and agreed to the manuscript in its current form. All the authors have read and agreed to the published version of the manuscript.

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