
==== Front
Eur J Nutr
Eur J Nutr
European Journal of Nutrition
1436-6207
1436-6215
Springer Berlin Heidelberg Berlin/Heidelberg

38763928
3396
10.1007/s00394-024-03396-w
Original Contribution
Environmental impact of the diet of young Portuguese and its relationship with adherence to the Mediterranean Diet
Álvarez-Álvarez Laura 1
Vitelli-Storelli Facundo 1
Rubín-García María 1
Martín-Sánchez Vicente 12
García Fernández Camino 3
Carvalho Catarina 456
Araújo Joana 456
http://orcid.org/0000-0001-7146-3457
Ramos Elisabete up426486@g.uporto.pt

456
1 https://ror.org/02tzt0b78 grid.4807.b 0000 0001 2187 3167 Group of Investigation in Interactions Gene-Environment and Health (GIIGAS), Institute of Biomedicine (IBIOMED), University of León, León, Spain
2 https://ror.org/00ca2c886 grid.413448.e 0000 0000 9314 1427 CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
3 https://ror.org/02tzt0b78 grid.4807.b 0000 0001 2187 3167 Department of Food Hygiene and Technology, Veterinary Faculty, University of León, León, Spain
4 https://ror.org/043pwc612 grid.5808.5 0000 0001 1503 7226 Department of Public Health and Forensic Sciences, EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
5 https://ror.org/043pwc612 grid.5808.5 0000 0001 1503 7226 Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal
6 https://ror.org/043pwc612 grid.5808.5 0000 0001 1503 7226 Medical School, University of Porto, Porto, Portugal
19 5 2024
19 5 2024
2024
63 6 23072315
12 12 2023
16 4 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Objective

To estimate, in a cohort of young Portuguese adults, the environmental impact (greenhouse gas (GHG) emissions, land use, energy used, acidification and potential eutrophication) of diet according to adherence to the Mediterranean Diet (MD).

Methods

Data from 1554 participants of the Epidemiologic Health Investigation of Teenagers in Porto (EPITeen) were analysed. Food intake and MD adherence were determined using validated questionnaires. The environmental impact was evaluated with the EAT-Lancet Commission tables, and the link between MD adherence and environmental impact was calculated using adjusted multivariate linear regression models.

Results

Higher adherence (high vs. low) to the MD was associated with lower environmental impact in terms of land use (7.8 vs. 8.5 m2, p = 0.002), potential acidification (57.8 vs. 62.4 g SO2-eq, p = 0.001) and eutrophication (21.7 vs. 23.5 g PO4-eq, p < 0.001). Energy use decreased only in the calorie-adjusted model (9689.5 vs. 10,265.9 kJ, p < 0.001), and GHG emissions were reduced only in a complementary model where fish consumption was eliminated (3035.3 vs. 3281.2 g CO2-eq, p < 0.001). Meat products had the greatest environmental impact for all five environmental factors analysed: 35.7% in GHG emissions, 60.9% in energy use, 72.8% in land use, 70% in acidification and 61.8% in eutrophication.

Conclusions

Higher adherence to the MD is associated with lower environmental impact, particularly in terms of acidification, eutrophication, and land use. Reducing meat consumption can contribute to greater environmental sustainability.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-024-03396-w.

Keywords

Climate change
Environmental sustainability
Healthy dietary pattern
Sustainable food
Portuguese Foundation for Science and TechnologyPTDC/DTP-EPI/6506/2014 Epidemiology Research Unit – Institute of Public Health, University of PortoUID/DTP/047507/2013 Universidade do PortoOpen access funding provided by FCT|FCCN (b-on).

issue-copyright-statement© Springer-Verlag GmbH Germany, part of Springer Nature 2024
==== Body
pmcIntroduction

Climate change is one of the great problems of the twenty-first century, and there are increasing strategies aimed at reducing the impact of humans on the planet. In this sense, diet plays a key role in climate change as it is considered to be responsible for one-third of greenhouse gas (GHG) emissions [1, 2], two-thirds of fresh water use [3] and the use of about half of the planet’s ice-free surface as farmland or grasslands [4]. This is so important that, even if fossil fuel emissions were halted, GHG emissions from the food system could impede meeting the Paris Climate Agreement's goal of limiting global warming to 1.5 °C compared to pre-industrial levels [5].

Since not all foods have the same environmental impact, different food patterns are particularly relevant in terms of their relationship with environmental sustainability [4, 6, 7]. Today, the concept of sustainable diets is becoming increasingly important. The Food and Agriculture Organization defines sustainable diets as those “with low environmental impacts which contribute to food and nutrition security and to healthy life for present and future generations” with specific features, such as “protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimising natural and human resources” [8].

In 2019, the EAT-Lancet Commission published a reinforcing that use dietary patterns more sustainable than current Western patterns, in which consumption of meat and dairy products is reduced, is the most important strategy to improve the sustainability of the current food system [9].

One of the dietary patterns that meets these characteristics is the Mediterranean Diet (MD), characterised by a high intake of vegetable products and monounsaturated fatty acids (mainly olive oil); a moderate intake of fish; a low-moderate intake of meat, poultry and dairy products; and a moderate intake of wine [10]. This dietary pattern is recognised for its important benefits in cardiovascular health [11, 12] and the prevention of chronic diseases [13, 14]. Moreover, since it reduces the intake of animal products and promotes biodiversity [15, 16], this dietary model is expected to benefit environmental sustainability.

Understanding the environmental impact of diets is fundamental for developing sustainable public health policies that contribute to improving global health. Therefore, the aim of this work was to estimate, in a cohort of young Portuguese adults, the environmental impact of diet according to the adherence to the MD.

Methods

The Epidemiologic Health Investigation of Teenagers in Porto (EPITeen) is a cohort study of adolescents who were born in 1990, and attended public and private schools in Porto, Portugal, in 2003/2004, as previously described [17]. Data from the third wave of the study in 2011/2013, when participants were, on average, 21 years old, were used for the present analysis.

The study was approved by the Ethics Committee of the Hospital São João and the Ethics Committee of the Institute of Public Health of the University of Porto on July 31, 2012. Written informed consent was obtained from parents and participants at baseline, participants in the third wave. In addition, a secure standard procedure was followed to ensure confidentiality and data protection.

Participants

At 21 years, 1764 participants were evaluated, but after excluding participants without food frequency questionnaire (FFQ) information, those with total energy intake higher than three times the interquartile range, or fruit or vegetable intake more than 1.5 times the interquartile range, and those with extreme total energy intakes (< 500 or > 3500 kcal/day in women or < 800 or > 4000 kcal/day in men) [18], 1554 participants remained for the analysis.

Variables and data collection

The dietary assessment was carried out using an 86-item semi-quantitative food frequency questionnaire (FFQ) that was validated in the Portuguese adult population [19, 20]. The FFQ covered the previous 12 months, ranging from never or less than once a month to six or more times a day. Daily energy intake and dietary fibre were calculated using Food Processor Plus® software (ESHA Research, Salem, OR, USA), with the addition of values for Portuguese foods based on the Portuguese Food Composition Tables, typical recipes and previous data [19, 21].

Adherence to MD was calculated according to the Dietary Score (DS) index, developed by Panagiotakos [22], which includes 11 food groups (vegetables, legumes, fruits, fish, whole grains, potatoes, olive oil, poultry, dairy products with fat, red meat and alcohol), and ranges from 0 to 55. This index classifies adherence into tertiles, with the first tertile corresponding to low adherence and the third tertile to high adherence.

Trained interviewers used face-to-face interviews and self-administered questionnaires to collect data on sex, body mass index (BMI), parental and own education level, lifestyle, and dietary habits.

The educational level of the parents was obtained from the information of the parent with the most advanced formal education, represented as the number of years of formal education successfully completed. Schools were categorized as public if they were state-run, and as private otherwise. BMI classification was based on the World Health Organization definition [23], while sports activity was evaluated according to the frequency of dedication of at least 20 consecutive minutes to sports activities, excluding compulsory school activities.

Estimating environmental footprint

Based on the information gathered in the FFQs, GHG emissions (grams of Carbon Dioxide equivalents (g CO2-eq)), land (m2) and energy use (kJ), acidification (grams of Sulfur Dioxide equivalents (g SO2-eq)) and eutrophication potential (grams of Phosphate equivalent (g PO4-eq)) were estimated and associated with each food item. These estimations were based on the EAT-Lancet Commission tables [9], using the following steps:All FFQ food items without reference in the tables of the EAT-Lancet Commission were excluded and reduced to 63 foods (We lack information on chocolate, turkey, certain fruits, vegetables and legumes, and also on certain beverages such as soft drinks, coffee or tea);

For dishes and recipes, we calculated their environmental impact based on their ingredients and proportions, using traditional MD recipes [24, 25];

When a FFQ item did not refer to a single food (e.g., blue fish), we calculated the intake ratio based on data from the National Food and Physical Activity Survey [26].

The environmental loads of each food were obtained from the meta-analysis [27] published within the recommendations of the EAT-Lancet Commission (Supplementary material), and the environmental impact of each food was calculated by multiplying the value of the environmental burden by the daily consumption of each product;

Finally, to determine the environmental impact of each participant's diet, we summed up the individual contributions of all the foods consumed considering the information collected in the FFQs.

Statistical analysis

Descriptive statistics were used to show the general baseline characteristics of the participants. The prevalence for each category of each qualitative variable described is expressed as n and percentage. To test whether there were differences between the groups described, the chi-squared test was used, including its corresponding p value. Dietary intake values for food groups and environmental footprints were represented by means and standard deviations. Linear regression models, adjusted for sex, total energy intake and parents’ years of schooling (≤ 8 years, 9–12 years or ≥ 13 years), were performed to classify participants based on tertiles of adherence to MD, and Kruskal–Wallis tests were used to assess differences between tertiles with respect to GHG emissions, land and energy use, acidification, and eutrophication.

R software version 4.1.1 [28] was used for the calculation of individuals’ dietary environmental impact, and statistical analysis was performed using Stata software version 15.1 [29].

Results

The sample included 1554 participants of whom 51% were women, 75% had studied in public school, 42% had studied for more than 15 years and 71% of their parents had studied for 9 years or more, 69% had normal weight, 51% did sports, 63% were non-smokers or former smokers and 62% consumed alcohol less than once a week. A higher level of education, both from the participant and from the parents, the practice of sports activities, not smoking and not drinking alcohol were significantly associated (p < 0.05) with greater adherence to MD according to the DS index (Table 1).Table 1 General characteristics of the sample according to tertiles of the Dietary Score (DS)

	Overall (n = 1554)	Tertiles MD	
n	%	Low (0–28)	Medium (29–33)	High (34–54)	p-value	
Sex							
 Female	800	51.5	288 (49.8%)	270 (50.6%)	242 (54.8%)	0.130	
 Male	754	48.5	290 (50.2%)	264 (49.4%)	200 (45.3%)		
Type of schoola							
 Public	1032	75.2	388 (76.7%)	355 (75.7%)	289 (72.6%)		
 Private	270	19.7	88 (17.4%)	92 (19.6%)	90 (22.6%)	0.124	
 Professional	71	5.2	30 (5.9%)	22 (4.7%)	19 (4.8%)		
 Missing	181						
Parents’ years of schooling							
 ≤ 8 years	441	28.5	186 (32.4%)	142 (26.8%)	113 (25.6%)		
 9–12 years	607	39.3	208 (36.2%)	220 (41.6%)	179 (40.5%)	0.046	
 ≥ 13 years	497	32.2	180 (31.4%)	167 (31.6%)	150 (33.9%)		
 Missing	9						
Participant’s years of schooling							
 ≤ 12 years	530	38.0	242 (46.5%)	170 (35.6%)	118 (29.8%)		
 13–14 years	283	20.3	98 (18.8%)	107 (22.4%)	78 (19.7%)	 < 0.001	
 ≥ 15 years	581	41.7	181 (34.7%)	200 (41.9%)	200 (50.5%)		
 Missing	160						
BMI (kg/m2)							
 < 18.5	93	6.0	43 (7.4%)	23 (4.3%)	27 (6.1%)		
 ≥ 18.5 and < 25	1074	69.1	404 (69.9%)	366 (68.5%)	304 (68.8%)		
 ≥ 25 and < 30	289	18.6	96 (16.6%)	109 (20.4%)	84 (2%)	0.568	
 ≥ 30	98	6.3	35 (6.1%)	36 (6.7%)	27 (6.1%)		
Sports							
 No	758	48.8	308 (53.3%)	251 (47.0%)	199 (45.0%)		
 Yes	796	51.2	270 (46.7%)	283 (53.0%)	243 (55.0%)	0.007	
Smoking habits							
 Non-smoker	435	28.0	133 (23.1%)	156 (29.2%)	146 (33.0%)		
 Smoker	568	36.6	257 (44.5%)	183 (34.3%)	128 (29.0%)	 < 0.001	
 Former smoker	550	35.4	187 (32.4%)	195 (36.5%)	168 (38.0%)		
 Missing	1						
Alcohol consumption							
 No	39	2.5	17 (2.9%)	10 (1.9%)	12 (2.7%)		
 Yes	545	35.1	236 (40.9%)	174 (32.6%)	135 (30.5%)	0.001	
 Former drinker or < 1 time/week	969	62.4	324 (56.2%)	350 (65.5%)	295 (66.8%)		
 Missing	1						
The p values correspond to the chi-square test performed to assess whether there are differences between groups. BMI Body Mass Index, MD Mediterranean Diet

aType of school at age 21, data collected in the third wave of the study

The results highlighted in bold are those statistically significant (p < 0.05)

The results obtained in relation to environmental factors according to adherence to the MD dietary pattern by tertiles are shown in Fig. 1. In the crude model, higher adherence to MD was associated with lower acidification (high vs. low adherence: 57.8 vs. 62.4 g SO2-eq, p = 0.001), lower eutrophication (high vs. low adherence: 21.7 vs. 23.5 g PO4-eq, p = 0.001) and lower land use (high vs. low adherence: 7.8 vs. 8.5 m2, p = 0.001). However, greater adherence to MD was associated with higher GHG emissions (high vs. low adherence: 4561.7 vs. 3861.6 g CO2-eq, p < 0.001) and increased energy use (high vs. low adherence: 10,140 vs. 9840 kJ, p = 0.144).Fig. 1 Environmental footprint for different factors by tertiles of adherence to MD (Crude model)

Subsequently, different models were estimated, adjusting for total energy intake and then for sex and parents’ years of schooling (Table 2). In the model adjusted for total energy intake, higher adherence to MD was associated with lower acidification (high vs. low adherence: 54.5 vs. 65.5 g SO2-eq, p < 0.001), lower eutrophication (high vs. low adherence: 20.5 vs. 24.6 g PO4-eq, p < 0.001), lower land use (high vs. low adherence: 7.3 vs. 8.9 m2, p < 0.001) and lower energy use (high vs. low adherence: 9689.5 vs. 10,265.9 kJ, p = 0.001). For GHG emission, we found a lower impact for those with lower adherence to MD (4042.8 g CO2-eq) and similar impact for the second and third tertile (4397.3 and 4370.0 g CO2-eq, p < 0.001, respectively).Table 2 Environmental footprint for different factors by tertiles of the Diet Score (DS) according to different adjustment models

	Low adherence to the MD	Medium adherence to the MD	High adherence to the MD	p-value	
Mean	95% CI	Mean	95% CI	Mean	95% CI	
Linear regression model adjusted for total energy intake	
 GHG (g CO2-eq)	4042.9	3951.4–4134.3	4397.3	4304.7–4490.0	4370.0	4271.9–4468.2	 < 0.001	
 Acidification (g SO2-eq)	65.5	63.9–67.2	62.4	60.8–64.1	54.5	52.7–56.3	 < 0.001	
 Eutrophication (g PO4-eq)	24.6	24.0–25.3	23.6	23.0–24.2	20.5	19.9–21.2	 < 0.001	
 Land (m2)	8.9	8.7–9.2	8.4	8.1–8.7	7.3	7.1–7.6	 < 0.001	
 Eenergy (kJ)	10,265.9	10,030.3–10,501.5	10,461.1	10,222.4–10,699.7	9689.5	9436.7–9942.3	 < 0.001	
Linear regression model adjusted for sex and parents' years of schooling	
 GHG (g CO2-eq)	3883.71	3779.2–3988.2	4366.9	4260.0–4473.8	4573.48	4461.6–4685.3	 < 0.001	
 Acidification (g SO2-eq)	62.86	61.1–64.7	61.7	59.9–63.5	58.14	56.2–60.1	 < 0.001	
 Eutrophication (g PO4-eq)	23.61	22.9–24.3	23.33	22.6–24.0	21.86	21.1–22.6	 < 0.001	
 Land (m2)	8.55	8.3–8.8	8.28	8.0–8.6	7.83	7.5–8.1	 < 0.001	
 Eenergy (kJ)	9905.92	9648.2–10,163.7	10,363.22	10,099.4–10,627.0	10,169.6	9893.6–10,445.6	 < 0.001	
The table shows the mean adjusted for the different environmental impact factors. The results of the linear regression models were adjusted for total calorie intake in the first case, and for sex and years of parental schooling in the second

MD Mediterranean Diet, GHG greenhouse gas emissions, CI Confidence Interval, g CO2-eq grams of Carbon Dioxide equivalents, g SO2-eq grams of Sulfur Dioxide equivalents, g PO4-eq grams of Phosphate equivalents, kJ kilojoules

The results highlighted in bold are those statistically significant (p < 0.05)

In the model adjusted for sex and parents’ years of schooling, we found that greater adherence to MD was significantly associated with lower acidification (high vs. low adherence: 58.1 vs. 62.9 g SO2-eq, p < 0.001), lower eutrophication (high vs. low adherence: 21.9 vs. 23.6 g PO4-eq, p = 0.001) and lower land use (high vs. low adherence: 7.8 vs. 8.6 m2, p < 0.001).

In addition, to try to understand the relationship we obtained between greater adherence to MD and a greater amount of GHG emissions, we carried out an analysis eliminating fish and seafood intakes from the diet. In this case, in the model adjusted for total energy intake, all the environmental factors analysed decreased with greater adherence to MD. Higher adherence to MD was associated with lower GHG emissions (high vs. low adherence: 3035.3 vs. 3281.2 g CO2-eq, p < 0.001), lower acidification (high vs. low adherence: 54.8 vs. 65.4 g SO2-eq, p < 0.001), lower eutrophication (high vs. low adherence: 20.6 vs. 24.4 g PO4-eq, p < 0.001), lower land use (high vs. low adherence: 7.3 vs. 8.9 m2, p < 0.001) and lower energy use (high vs. low adherence: 9701.5 vs. 10,202.1 kJ, p = 0.006) (Supplementary material).

The main contributor to GHG emissions was meat followed by fish and seafood (35.7% and 29.2% respectively); regarding energy use, the main contributor was meat followed by dairy (60.9% and 13.2% respectively); in the case of land use, the main contributor was meat followed by grains (72.8% and 11% respectively) and, finally, with respect to acidification and eutrophication, the main contributor was meat (70% and 61.8%) followed by dairy (21.8% and 25.9%) (Fig. 2).Fig. 2 Percentage contribution of food groups to the different environmental factors analysed

Discussion

The results of this work show that greater adherence to an MD pattern among participants in this cohort is associated with lower environmental impact in terms of acidification, eutrophication, and land use. In addition, the total energy intake-adjusted model also associated greater adherence to this dietary pattern with lower energy use. This is consistent with other published studies in which high adherence to MD was associated with lower energy and land use [30, 31]. In the study carried out by Fresán et al. [31] in which the actual diet consumed in a Mediterranean Spanish cohort was analysed, it was observed that greater adherence to the MD pattern was related to lower energy and land use in addition to improving other environmental factors.

In contrast to other studies [32, 33], our results indicate that greater adherence to MD is related to higher GHG emissions. This can be explained by the high consumption of fish (with high GHG values) of the participants, since Portugal is the third country in the world in which most fish is consumed behind Iceland and Japan [34]. In Portugal, the MD and the Atlantic Diet coexist and, although they have common characteristics, such as an abundant consumption of fruits and vegetables and the use of olive oil as the main fat, there is a greater consumption of fish, meat, legumes and potatoes in the Atlantic Diet [35].

Although the intake of fish is highly recommended from a nutritional point of view because of its wide-ranging health benefits, and consumption of at least two to three servings per week is recommended [36, 37], consuming more than this amount could be detrimental to the environment as it would increase the overexploitation to which fish stocks in more than 80% of the world are already subjected [38]. In addition, organisations such as the Council of Food Policy Advisors recommend a shift in consumption towards products sourced only from sustainable crops [39].

On the other hand, high fish consumption contributes to exposure and increased intake of heavy metals such as mercury [40]. Alternative with less environmental impact could be vegetable protein from legumes. As in the index proposed by Panagiotakos et al. [22], a higher consumption of fish is related to a greater adherence to the MD, we carried out a sensitivity analysis in which we eliminated these products from the calculations and obtained that, in this case, greater adherence to the MD also decreased GHG emissions.

In our work, we observed how meat products are responsible for a greater environmental impact in the five factors analysed. This is explained by the fact that most agricultural land is used by livestock, and this is the main cause of deforestation, loss of biodiversity and land degradation [41]. These data correspond to what is published in different articles relating to animal products, especially meat, with increases in GHG emissions and in land and energy use [4, 7, 42–44].

After meat, dairy is the food group with the second highest environmental impact in 4 of the 5 indicators used and is also the third product with the highest impact in the remaining indicator (GHG). This is in line with several published studies that establish that animal-based foods, especially meat and dairy, use far more resources and have a higher environmental impact than most plant-based products [45, 46].

Most of the papers that analyse the relationship between different dietary patterns and environmental impact agree that the shift towards diets with a lower animal product content and a higher consumption of plant products would be beneficial for the environment [2, 9, 47–49]. In the study published by Belgacem et al. [49], they show how the change of Western and European diets towards a MD pattern would mean less environmental impact in terms of GHG emissions, eutrophication, and land and water use. In addition, the revision published by Fresán et al. [45], they conclude that vegan and ovolactovegetarian diets generate lower GHG emissions and use fewer natural resources.

Other data obtained in the study were that participants with a greater adherence to the MD and therefore with a lower environmental impact on their diet were those with more years of schooling themselves and their parents, who performed physical exercise, non-smokers and who did not drink alcohol or did it less than once a week. Our results are partially consistent with those published by Sánchez-Villegas et al. [50], in which, in a Spanish cohort examining the relationship between sociodemographic factors and dietary patterns, non-smokers who were more physically active were in the highest quintile of adherence to MD. They are also consistent with various articles showing higher levels of education [51] or physical activity [52] are associated with greater adherence to the MD.

As the world's population is steadily increasing and is estimated to reach 10 billion by 2050 [53] and that food production is the main cause of global environmental change [4], it is essential that food guidelines and policies shift from a traditional health-only approach to a sustainability-sensitive approach [54], and, at this point, MD is presented as a possible solution to the health-diet-environment trilemma [55], as increasing adherence to this pattern, characterised by a low consumption of animal products, can help not only to improve our health, but also to reduce environmental impact as we have seen in our work.

Strengths and limitations

The results presented in this paper are not without limitations. Since there is no single method for assessing the environmental impact of diet, the results may not be comparable quantitatively, and it should also be borne in mind that, within the database used, there are products that could be produced locally and therefore present different environmental impacts from that used for our calculations. In addition, the environmental impact database chosen did not include some of the foods included in the FFQ, and that this questionnaire included recipes that had to be broken down into main ingredients following standard recipes. Finally, the collection of intake data through this type of questionnaire could present a recall bias.

However, it also has numerous strengths. To our knowledge, this is the first time that the environmental impact of diet in Portugal has been analysed in association with MD. In addition, it was conducted in a large population sample who were recruited in schools, with a high proportion of participation (about 78%). Another strength is that this study is population-based, and its information may contribute to the planning and implementation of healthy food promotion strategies.

Conclusions

Higher adherence to the MD is associated with lower environmental impact in terms of acidification, eutrophication, and land use, and even lower GHG emissions and lower energy use depending on the adjustment model used. Meat products have the most weight in terms of environmental impact in the five factors analysed, so it is expected that diets low in these products will be more environmentally sustainable.

Despite the impact of fish consumption on GHG emissions, our results support the recommendation of the Mediterranean Diet as a strategy to increase the health of the population and our planet.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 (XLSX 21 KB)

Supplementary file2 (DOCX 127 KB)

Acknowledgements

EPITeen cohort study was supported by national funding from the Portuguese Foundation for Science and Technology. This study was supported through FEDER from the Operational Programme Factors of Competitiveness—COMPETE and through national funding from the Portuguese Foundation for Science and Technology—FCT (Portuguese Ministry of Education and Science) within the project PTDC/DTP-EPI/6506/2014, and by the Epidemiology Research Unit—Institute of Public Health, University of Porto (UID/DTP/047507/2013).

Author contributions

LAA performed the statistical analysis and drafted the manuscript. MRG, FVS, VMS, CGF, CC and JA contributed to the data analysis and critically reviewed the manuscript. ER designed and supervised the study, coordinated data collection, and critically reviewed the manuscript. All authors approved the final version.

Funding

Open access funding provided by FCT|FCCN (b-on). The EPITeen cohort study was supported by national funding from the Portuguese Foundation for Science and Technology. This study was supported through FEDER from the Operational Programme Factors of Competitiveness—COMPETE and through national funding from the Portuguese Foundation for Science and Technology—FCT (Portuguese Ministry of Education and Science) within the project PTDC/DTP-EPI/6506/2014, and by the Epidemiology Research Unit—Institute of Public Health, University of Porto (UID/DTP/047507/2013).

Data availability

The data used and/or analyzed in the present study is available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The EPITeen cohort study was approved by the Ethic Committee of Hospital S. João and the Ethics Committee of the Institute of Public Health from the University of Porto. Written and oral information was given to both adolescents and their legal caregiver, explaining the purpose and design of the study. Written informed consent was obtained from both in the first and second evaluation. In the third evaluation, informed consent was obtained only from participants.
==== Refs
References

1. Bjørnarå HB Healthy and sustainable diet and physical activity: the rationale for and experiences from developing a combined summary score Scand J Public Health 2019 47 583 591 10.1177/1403494818785056 29963968
Bjørnarå HB, Torstveit MK, Bere E (2019) Healthy and sustainable diet and physical activity: the rationale for and experiences from developing a combined summary score. Scand J Public Health 47(5):583–591. 10.1177/140349481878505629963968 10.1177/1403494818785056
2. Aleksandrowicz L, Green R, Joy EJM et al (2016) The impacts of dietary change on greenhouse gas emissions, land use, water use, and health: a systematic review. PLoS One 11(11). 10.1371/journal.pone.0165797
3. Myers SS, Smith MR, Guth S, et al (2017) Climate change and global food systems: potential impacts on food security and undernutrition. Ann Rev Pub Health 38:259–277. 10.1146/ANNUREV-PUBLHEALTH-031816-044356
4. Tilman D Clark M Global diets link environmental sustainability and human health Nat 2014 515 518 522 10.1038/nature13959
Tilman D, Clark M (2014) Global diets link environmental sustainability and human health. Nat 515:518–522. 10.1038/nature1395910.1038/nature13959
5. Clark MA Domingo NGG Colgan K Global food system emissions could preclude achieving the 1.5° and 2°C climate change targets Science 2020 370 705 708 10.1126/SCIENCE.ABA7357 33154139
Clark MA, Domingo NGG, Colgan K et al (2020) Global food system emissions could preclude achieving the 1.5° and 2°C climate change targets. Science 370:705–708. 10.1126/SCIENCE.ABA735733154139 10.1126/SCIENCE.ABA7357
6. Röös E Sundberg C Hansson P-A Carbon footprint of food products Assessment of carbon footprint in different industrial sectors 2014 Singapore Springer 85 112
Röös E, Sundberg C, Hansson P-A (2014) Carbon footprint of food products. Assessment of carbon footprint in different industrial sectors. Springer, Singapore, pp 85–112
7. Hjorth T Huseinovic E Hallström E Changes in dietary carbon footprint over ten years relative to individual characteristics and food intake in the Västerbotten Intervention Programme Sci Rep 2020 10.1038/S41598-019-56924-8 31913331
Hjorth T, Huseinovic E, Hallström E et al (2020) Changes in dietary carbon footprint over ten years relative to individual characteristics and food intake in the Västerbotten Intervention Programme. Sci Rep. 10.1038/S41598-019-56924-831913331 10.1038/S41598-019-56924-8
8. World Health Organization Sustainable healthy diets: guiding principles—food and agriculture organization of the United Nations 2019 Rome Italy
World Health Organization (2019) Sustainable healthy diets: guiding principles—food and agriculture organization of the United Nations. Italy, Rome
9. Willett W Rockström J Loken B Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems Lancet 2019 393 447 492 10.1016/S0140-6736(18)31788-4 30660336
Willett W, Rockström J, Loken B et al (2019) Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet 393:447–49230660336 10.1016/S0140-6736(18)31788-4
10. Salas-Salvadó J Mena-Sánchez G El gran ensayo de campo nutricional Predimed Nutr Clin Med El 2017 10.7400/NCM.2017.11.1.5046
Salas-Salvadó J, Mena-Sánchez G (2017) El gran ensayo de campo nutricional Predimed. Nutr Clin Med El. 10.7400/NCM.2017.11.1.504610.7400/NCM.2017.11.1.5046
11. Martinez-Gonzalez MA Bes-Rastrollo M Dietary patterns, Mediterranean diet, and cardiovascular disease Curr Opin Lipidol 2014 25 20 26 10.1097/MOL.0000000000000044 24370845
Martinez-Gonzalez MA, Bes-Rastrollo M (2014) Dietary patterns, Mediterranean diet, and cardiovascular disease. Curr Opin Lipidol 25:20–26. 10.1097/MOL.000000000000004424370845 10.1097/MOL.0000000000000044
12. Álvarez-Álvarez I Martínez-González MÁ Sánchez-Tainta A Dieta mediterránea hipocalórica y factores de riesgo cardiovascular: análisis transversal de PREDIMED-Plus Rev Española Cardiol 2018 10.1016/J.RECESP.2018.08.007
Álvarez-Álvarez I, Martínez-González MÁ, Sánchez-Tainta A et al (2018) Dieta mediterránea hipocalórica y factores de riesgo cardiovascular: análisis transversal de PREDIMED-Plus. Rev Española Cardiol. 10.1016/J.RECESP.2018.08.00710.1016/J.RECESP.2018.08.007
13. Guasch-Ferré M Willett WC The Mediterranean diet and health: a comprehensive overview J Intern Med 2021 290 549 566 10.1111/JOIM.13333 34423871
Guasch-Ferré M, Willett WC (2021) The Mediterranean diet and health: a comprehensive overview. J Intern Med 290:549–566. 10.1111/JOIM.1333334423871 10.1111/JOIM.13333
14. Salas-Salvado J Bullo M Babio N Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial Diabetes Care 2011 34 14 19 10.2337/dc10-1288 20929998
Salas-Salvado J, Bullo M, Babio N et al (2011) Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care 34:14–19. 10.2337/dc10-128820929998 10.2337/dc10-1288
15. Serra-Majem L Ortiz-Andrellucchi A La dieta mediterránea como ejemplo de una alimentación y nutrición sostenibles: enfoque multidisciplinar Nutr Hosp 2018 10.20960/nh.2133 30070130
Serra-Majem L, Ortiz-Andrellucchi A (2018) La dieta mediterránea como ejemplo de una alimentación y nutrición sostenibles: enfoque multidisciplinar. Nutr Hosp 35. 10.20960/nh.213330070130 10.20960/nh.2133
16. Germani A Vitiello V Giusti AM Environmental and economic sustainability of the Mediterranean diet Int J Food Sci Nutr 2014 10.3109/09637486.2014.945152 25088933
Germani A, Vitiello V, Giusti AM et al (2014) Environmental and economic sustainability of the Mediterranean diet. Int J Food Sci Nutr. 10.3109/09637486.2014.94515225088933 10.3109/09637486.2014.945152
17. Ramos E Barros H Family and school determinants of overweight in 13-year-old Portuguese adolescents Acta Pædiatrica 2007 96 281 286 10.1111/J.1651-2227.2007.00107.X 17429921
Ramos E, Barros H (2007) Family and school determinants of overweight in 13-year-old Portuguese adolescents. Acta Pædiatrica 96:281–286. 10.1111/J.1651-2227.2007.00107.X17429921 10.1111/J.1651-2227.2007.00107.X
18. Willett WC Adjustment for total energy intake in epidemiologic studies Am J Clin Nutr 1997 65 1220S 1228S 10.1093/ajcn/65.4.1220S 9094926
Willett WC, Howe GR, Kushi LH (1997) Adjustment for total energy intake in epidemiologic studies. Am J Clin Nutr 65(4 Suppl):1220S–1228S. 10.1093/ajcn/65.4.1220S9094926 10.1093/ajcn/65.4.1220S
19. Lopes C Aro A Azevedo A Intake and adipose tissue composition of fatty acids and risk of myocardial infarction in a male Portuguese community sample{a figure is presented} J Am Diet Assoc 2007 107 276 286 10.1016/j.jada.2006.11.008 17258965
Lopes C, Aro A, Azevedo A et al (2007) Intake and adipose tissue composition of fatty acids and risk of myocardial infarction in a male Portuguese community sample{a figure is presented}. J Am Diet Assoc 107:276–286. 10.1016/j.jada.2006.11.00817258965 10.1016/j.jada.2006.11.008
20. Willett WC Sampson L Stampfer MJ Reproducibility and validity of a semiquantitative food frequency questionnaire Am J Epidemiol 1985 122 51 65 10.1093/OXFORDJOURNALS.AJE.A114086 4014201
Willett WC, Sampson L, Stampfer MJ et al (1985) Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol 122:51–65. 10.1093/OXFORDJOURNALS.AJE.A1140864014201 10.1093/OXFORDJOURNALS.AJE.A114086
21. Ferreira F, Graça M (1985) Composition table of Portuguese food, 2nd edn. National Institute of Health Dr Ricardo Jorge, Lisbon, Portugal
22. Panagiotakos DB Pitsavos C Arvaniti F Stefanadis C Adherence to the Mediterranean food pattern predicts the prevalence of hypertension, hypercholesterolemia, diabetes and obesity, among healthy adults; the accuracy of the MedDietScore Prev Med (Baltim) 2007 44 335 340 10.1016/j.ypmed.2006.12.009
Panagiotakos DB, Pitsavos C, Arvaniti F, Stefanadis C (2007) Adherence to the Mediterranean food pattern predicts the prevalence of hypertension, hypercholesterolemia, diabetes and obesity, among healthy adults; the accuracy of the MedDietScore. Prev Med (Baltim) 44:335–340. 10.1016/j.ypmed.2006.12.00910.1016/j.ypmed.2006.12.009
23. World Health Organization (2000) Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Heal Organ—Tech Rep Ser. 894:i–xii, 1–253
24. Sánchez-Tainta A, San Julián B, Martínez-González MA, Miguel A (2015) PREDIMED, date el gusto de comer sano, 1st ed. EUNSA, Barañáin. ISBN: 978-84-313-3076-7
25. Flo JM (1998) Postres del Mediterráneo. Ed. Planeta. ISBN: 978-84-08-02634-1
26. Lopes C, Torres D, Oliveira A et al (2017) Inquérito Alimentar Nacional e de Atividade Física, IAN-AF 2015-2016: Relatório de resultados Autores
27. Clark M Tilman D Comparative analysis of environmental impacts of agricultural production systems, agricultural input efficiency, and food choice Environ Res Lett 2017 12 064016 10.1088/1748-9326/AA6CD5
Clark M, Tilman D (2017) Comparative analysis of environmental impacts of agricultural production systems, agricultural input efficiency, and food choice. Environ Res Lett 12:064016. 10.1088/1748-9326/AA6CD510.1088/1748-9326/AA6CD5
28. R Core Team (2016). R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/
29. StataCorp (2023) Stata statistical software: release 15. StataCorp LLC, College Station, TX
30. Tepper S Kissinger M Avital K Shahar DR The environmental footprint associated with the Mediterranean diet, EAT-Lancet diet, and the sustainable healthy diet index: a population-based study Front Nutr 2022 9 951 10.3389/FNUT.2022.870883/BIBTEX
Tepper S, Kissinger M, Avital K, Shahar DR (2022) The environmental footprint associated with the Mediterranean diet, EAT-Lancet diet, and the sustainable healthy diet index: a population-based study. Front Nutr 9:951. 10.3389/FNUT.2022.870883/BIBTEX10.3389/FNUT.2022.870883/BIBTEX
31. Fresán U Martínez-Gonzalez MA Sabaté J Bes-Rastrollo M The Mediterranean diet, an environmentally friendly option: Evidence from the Seguimiento Universidad de Navarra (SUN) cohort Public Health Nutr 2018 10.1017/S1368980017003986 29380717
Fresán U, Martínez-Gonzalez MA, Sabaté J, Bes-Rastrollo M (2018) The Mediterranean diet, an environmentally friendly option: Evidence from the Seguimiento Universidad de Navarra (SUN) cohort. Public Health Nutr. 10.1017/S136898001700398629380717 10.1017/S1368980017003986
32. Naja F Itani L Hamade R Mediterranean diet and its environmental footprints amid nutrition transition: the case of Lebanon Sustain 2019 10.3390/su11236690
Naja F, Itani L, Hamade R et al (2019) Mediterranean diet and its environmental footprints amid nutrition transition: the case of Lebanon. Sustain. 10.3390/su1123669010.3390/su11236690
33. García S Bouzas C Mateos D Carbon dioxide (CO2) emissions and adherence to Mediterranean diet in an adult population: the Mediterranean diet index as a pollution level index Environ Health 2023 22 1 10.1186/s12940-022-00956-7 36600281
García S, Bouzas C, Mateos D et al (2023) Carbon dioxide (CO2) emissions and adherence to Mediterranean diet in an adult population: the Mediterranean diet index as a pollution level index. Environ Health 22:1. 10.1186/s12940-022-00956-736600281 10.1186/s12940-022-00956-7
34. Vaz-Velho ML Pinheiro R Rodrigues AS The Atlantic diet—origin and features Int J Food Stud 2016 5 106 119 10.7455/ijfs/5.1.2016.a10
Vaz-Velho ML, Pinheiro R, Rodrigues AS (2016) The Atlantic diet—origin and features. Int J Food Stud 5:106–119. 10.7455/ijfs/5.1.2016.a1010.7455/ijfs/5.1.2016.a10
35. Esteve-Llorens X Darriba C Moreira MT Towards an environmentally sustainable and healthy Atlantic dietary pattern: life cycle carbon footprint and nutritional quality Sci Total Environ 2019 646 704 715 10.1016/J.SCITOTENV.2018.07.264 30059930
Esteve-Llorens X, Darriba C, Moreira MT et al (2019) Towards an environmentally sustainable and healthy Atlantic dietary pattern: life cycle carbon footprint and nutritional quality. Sci Total Environ 646:704–715. 10.1016/J.SCITOTENV.2018.07.26430059930 10.1016/J.SCITOTENV.2018.07.264
36. Mohan D Mente A Dehghan M Associations of fish consumption with risk of cardiovascular disease and mortality among individuals with or without vascular disease from 58 countries JAMA Intern Med 2021 181 631 10.1001/JAMAINTERNMED.2021.0036 33683310
Mohan D, Mente A, Dehghan M et al (2021) Associations of fish consumption with risk of cardiovascular disease and mortality among individuals with or without vascular disease from 58 countries. JAMA Intern Med 181:631. 10.1001/JAMAINTERNMED.2021.003633683310 10.1001/JAMAINTERNMED.2021.0036
37. Jurek J Owczarek M Godos J Fish and human health: an umbrella review of observational studies Int J Food Sci Nutr 2022 73 851 860 10.1080/09637486.2022.2090520 35758202
Jurek J, Owczarek M, Godos J et al (2022) Fish and human health: an umbrella review of observational studies. Int J Food Sci Nutr 73:851–860. 10.1080/09637486.2022.209052035758202 10.1080/09637486.2022.2090520
38. Thurstan RH Brockington S Roberts CM The effects of 118 years of industrial fishing on UK bottom trawl fisheries Nat Commun 2010 11 1 1 6 10.1038/ncomms1013
Thurstan RH, Brockington S, Roberts CM (2010) The effects of 118 years of industrial fishing on UK bottom trawl fisheries. Nat Commun 11(1):1–6. 10.1038/ncomms101310.1038/ncomms1013
39. Clonan A Holdsworth M Swift JA The dilemma of healthy eating and environmental sustainability: the case of fish Public Health Nutr 2012 15 277 284 10.1017/S1368980011000930 21619717
Clonan A, Holdsworth M, Swift JA et al (2012) The dilemma of healthy eating and environmental sustainability: the case of fish. Public Health Nutr 15:277–284. 10.1017/S136898001100093021619717 10.1017/S1368980011000930
40. Castaño A Cutanda F Esteban M Fish consumption patterns and hair mercury levels in children and their mothers in 17 EU countries Environ Res 2015 141 58 68 10.1016/J.ENVRES.2014.10.029 25667172
Castaño A, Cutanda F, Esteban M et al (2015) Fish consumption patterns and hair mercury levels in children and their mothers in 17 EU countries. Environ Res 141:58–68. 10.1016/J.ENVRES.2014.10.02925667172 10.1016/J.ENVRES.2014.10.029
41. Friel S Dangour AD Garnett T Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture Lancet 2009 374 2016 2025 10.1016/S0140-6736(09)61753-0 19942280
Friel S, Dangour AD, Garnett T et al (2009) Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture. Lancet 374:2016–2025. 10.1016/S0140-6736(09)61753-019942280 10.1016/S0140-6736(09)61753-0
42. Sáez-Almendros S Obrador B Bach-Faig A Serra-Majem L Environmental footprints of Mediterranean versus Western dietary patterns: beyond the health benefits of the Mediterranean diet Environ Heal A Glob Access Sci Source 2013 10.1186/1476-069X-12-118
Sáez-Almendros S, Obrador B, Bach-Faig A, Serra-Majem L (2013) Environmental footprints of Mediterranean versus Western dietary patterns: beyond the health benefits of the Mediterranean diet. Environ Heal A Glob Access Sci Source. 10.1186/1476-069X-12-11810.1186/1476-069X-12-118
43. Hedenus F Wirsenius S Johansson DJA The importance of reduced meat and dairy consumption for meeting stringent climate change targets Clim Change 2014 124 79 91 10.1007/S10584-014-1104-5/FIGURES/3
Hedenus F, Wirsenius S, Johansson DJA (2014) The importance of reduced meat and dairy consumption for meeting stringent climate change targets. Clim Change 124:79–91. 10.1007/S10584-014-1104-5/FIGURES/310.1007/S10584-014-1104-5/FIGURES/3
44. Rose D Heller MC Willits-Smith AM Meyer RJ Carbon footprint of self-selected US diets: nutritional, demographic, and behavioral correlates Am J Clin Nutr 2019 109 526 10.1093/AJCN/NQY327 30698631
Rose D, Heller MC, Willits-Smith AM, Meyer RJ (2019) Carbon footprint of self-selected US diets: nutritional, demographic, and behavioral correlates. Am J Clin Nutr 109:526. 10.1093/AJCN/NQY32730698631 10.1093/AJCN/NQY327
45. Fresán U Sabaté J Vegetarian diets: planetary health and its alignment with human health Adv Nutr 2019 10 S380 S388 10.1093/advances/nmz019 31728487
Fresán U, Sabaté J (2019) Vegetarian diets: planetary health and its alignment with human health. Adv Nutr 10:S380–S38831728487 10.1093/advances/nmz019
46. Sabaté J Sranacharoenpong K Harwatt H The environmental cost of protein food choices Public Health Nutr 2015 18 2067 2073 10.1017/S1368980014002377 25374332
Sabaté J, Sranacharoenpong K, Harwatt H et al (2015) The environmental cost of protein food choices. Public Health Nutr 18:2067–2073. 10.1017/S136898001400237725374332 10.1017/S1368980014002377
47. Davis KF Gephart JA Emery KA Meeting future food demand with current agricultural resources Glob Environ Chang 2016 39 125 132 10.1016/J.GLOENVCHA.2016.05.004
Davis KF, Gephart JA, Emery KA et al (2016) Meeting future food demand with current agricultural resources. Glob Environ Chang 39:125–132. 10.1016/J.GLOENVCHA.2016.05.00410.1016/J.GLOENVCHA.2016.05.004
48. Berardy AJ Rubín-García M Sabaté J A scoping review of the environmental impacts and nutrient composition of plant-based milks Adv Nutr 2022 10.1093/advances/nmac098 36083996
Berardy AJ, Rubín-García M, Sabaté J (2022) A scoping review of the environmental impacts and nutrient composition of plant-based milks. Adv Nutr. 10.1093/advances/nmac09836083996 10.1093/advances/nmac098
49. Belgacem W Mattas K Arampatzis G Baourakis G Changing dietary behavior for better biodiversity preservation: a preliminary study Nutrients 2021 10.3390/nu13062076 34204478
Belgacem W, Mattas K, Arampatzis G, Baourakis G (2021) Changing dietary behavior for better biodiversity preservation: a preliminary study. Nutrients. 10.3390/nu1306207634204478 10.3390/nu13062076
50. Sánchez-Villegas A Delgado-Rodríguez M Martínez-González MÁ Gender, age, socio-demographic and lifestyle factors associated with major dietary patterns in the Spanish Project SUN (Seguimiento Universidad de Navarra Eur J Clin Nutr 2003 572 57 285 292 10.1038/sj.ejcn.1601528
Sánchez-Villegas A, Delgado-Rodríguez M, Martínez-González MÁ et al (2003) Gender, age, socio-demographic and lifestyle factors associated with major dietary patterns in the Spanish Project SUN (Seguimiento Universidad de Navarra. Eur J Clin Nutr 572(57):285–292. 10.1038/sj.ejcn.160152810.1038/sj.ejcn.1601528
51. Onetti W, Álvarez-Kurogi L, Castillo-Rodríguez A, et al (2019) Adherencia al patrón de dieta mediterránea y autoconcepto en adolescentes. Nutr Hosp 36:658–664. 10.20960/NH.02214
52. Tárraga Marcos A, Panisello Royo JM, Carbayo Herencia JA, et al (2021) Valoración de la adherencia a la dieta mediterránea en estudiantes universitarios de Ciencias de la Salud y su relación con el nivel de actividad física. Nutr Hosp 38:814–820. 10.20960/NH.03531
53. FAO (2018) Transformar la alimentación y la agricultura para alcanzar los ODS—20 acciones interconectadas para guiar a los encargados de adoptar decisiones. Organ las Nac Unidas para la Aliment y la Agric 76
54. Berry EM Dernini S Burlingame B Food security and sustainability: can one exist without the other? Public Health Nutr 2015 18 2293 2302 10.1017/S136898001500021X 25684016
Berry EM, Dernini S, Burlingame B et al (2015) Food security and sustainability: can one exist without the other? Public Health Nutr 18:2293–2302. 10.1017/S136898001500021X25684016 10.1017/S136898001500021X
55. Dernini S Berry EM Mediterranean diet: from a healthy diet to a sustainable dietary pattern Front Nutr 2015 10.3389/fnut.2015.00015 26284249
Dernini S, Berry EM (2015) Mediterranean diet: from a healthy diet to a sustainable dietary pattern. Front Nutr. 10.3389/fnut.2015.0001526284249 10.3389/fnut.2015.00015
