Three reads of the EAT-Lancet Commission Report

Geneva, 21 February 2019 - 

This is a long blog, on a game-changing report!

Every so often good science makes us think very differently about how we are answering big questions. For everyone whose big questions include how we can make a world in which everyone is fed, healthy and we also stop destroying the planet, the EAT-Lancet Commission Report is one such science report.

It establishes that there is a direct causal link between health, the environment and climate change, and it makes the bold claim that diets are central to it all.

For a nutrition organisation this has big consequences, and not all comfortable. First, a welcome recognition that nutrition is no niche subject – what we eat and how we produce it is relevant to planetary health as it is to every person’s wellbeing. Second, discomfort: it is already complex enough working out how to optimise diets, and change behaviour to achieve that, now we have to layer in a whole new set of objectives around the economy, and land and energy use, and GAIN is relatively new to these areas! 

We know that unhealthy diets – those that do not provide enough essential nutrients and/or provide too much salt, fat, sugar, and other substances – are a leading cause of death and disability. Overweight and obesity and associated non-communicable diseases including cancer, heart disease, diabetes in many parts of the world now coexist with stunting, wasting, micronutrient deficiency.  At the same time, we know that many environmental systems are stressed and the current food system – from production to processing and distribution – is a major contributor to this – think about the worry over "food miles", the destruction of forests for palm oil, or to expand beef production, or the huge percentage of food that is lost or goes to waste.

[The Report] establishes that there is a direct causal link between health, the environment and climate change, and it makes the bold claim that diets are central to it all.

Well, now we have a scientific assessment of how these are all interconnected. The EAT-Lancet Commission is the first robust, extensive review of the evidence combining criteria for healthy dietary changes with environmental analyses of food system’s impacts, to find common ground that results in recommendations for food systems transformation. The Great Food Transformation, somewhat grandly described in the report, is designed to favour both human health and a sustainable environment, taking into consideration environmental constraints, healthy diet, and population growth trends.

GAIN’s purpose is to make nutritious and safe foods more affordable, accessible and desirable, for us all and especially for the poorest. So, we welcome the Commission Report. It is an impressive piece of work; a daunting task to include all the key components and supporting analyses into a single journal article. 

Like any quantum shift in approach, it creates as many questions as answers, so we have tried in this blog to offer three reads of the Report, each with a different slant. First, as an organisation seeking to change the food system. Second, as a group of nutrition experts committed to addressing the ongoing burden of malnutrition in all its forms. Third, at least some of us, as cooks and lovers of good food!  

The Food Systems read

As an organisation whose strategy is centered on changing the food system for nutrition, The Great Food System Transformation (OK, from here on we will just use the term transformation) is a welcome, innovative call to action. The Report is the first major work that holds food production and consumption to two sets of constraints – health and the environment – and considers several dimensions of environmental impact. It provides a robust discussion of what is known about the effects of production of different types of food, and different steps in the food supply chain on the environment. The Report stresses that transformation requires changes to the structure and function of the food system and recognises that this will not happen without coordinated actions across multiple sectors. The authors stress that this change must be driven by demand (i.e. shifts in dietary intake to the "reference diet" – we’ll come back to this below), combined with improved production practices, and reduced food loss and waste. While a daunting task, the report lays out several policy options (table 6) and highlights examples where similar challenges have been addressed globally (table 5).

There are two areas that we would have liked to see further developed (perhaps they will come in subsequent publications). There is no meaningful discussion of the current affordability of health diets or the extent to which the proposed transformation can be implemented in a manner to ease huge inequities in access to nutritious foods. For example, a recent analysis of data from Bangladesh, Brazil, Malawi, and Zimbabwe found that it would cost approximately 52% of per capita household income to purchase enough fruits and vegetables for all household members to consume 5 servings a day (a typical recommendation, similar to the amount that would be required for the reference diet). Improved production and less waste should certainly contribute to affordability of nutritious foods but driving change through demand – the shift that is central to the Report – cannot happen if people can’t afford it. On a similar note, change in the food production system will inevitably shift employment – across the supply chain from farmers to manufacturers and distributers. The potential impact of the changes on livelihoods of actors across the food system is not touched in the Report. Economic interests are, naturally, fundamental shapers of the food system.

Reading as nutrition experts

We have some concerns here – about the degree of universality and the weak recognition of inequity of current consumption. For reference diet, you can basically read "a balanced healthy diet", but this is not always the same for everyone at every stage of their lives.

There certainly would be important health benefits of a switch to the EAT-Lancet reference diet (table 1 in the report) for adults currently consuming a "western diet" (i.e. high in red meat, refined sugar, highly processed foods). The authors provide a fairly thorough review of the relevant evidence for diet and health associations in this context. The specific quantities for some food groups that they propose however, is not always well justified from a science point of view. This may be due at least in part to:

  1. Important gaps in the literature to define specific dietary patterns that optimise health outcomes.
  2. Variability in results for some outcomes and across some contexts, possibly related to diversity in need by context and life course, and lifestyle and other factors that make it difficult to attribute health outcomes directly to diet in some studies.

Particularly for animal source foods (meat, dairy, fish, eggs) however, amounts on the lower end were consistently chosen, even if the evidence did not support that choice. This begs the question whether such decisions were driven by the environmental constraints rather than health constraints, or whether considerations other than the health-related evidence was brought to bear for those serving sizes. The environmental constraints may be valid, but we need to be explicit about that.

Vegetables in a market

Vegetables in a market in Asia. © GAIN/Nathalie Perroud

This might be particularly important in understanding whether there would be health benefits from the reference diet among those not currently consuming the "western diet" mentioned above. The authors recognise this in Panel 3 – addressing the potentially greater need for animal source foods in sub-Saharan Africa. They also briefly mention the special needs of pregnant and lactating women and infants and young children. But do not address potential variability in the nutrient needs of other sub-groups of the population including older children, adolescents, women of reproductive age, the elderly, etc. A recent blog highlighted important nutrient gaps that the reference diet would have for such groups. Similarly, in many countries in most regions around the world, sub-groups of the population have nutritional issues and dietary patterns not unlike those described in Panel 3 for Sub-Saharan Africa. We worry about this for 2 reasons. First, with an equity lens – because policy messages should be clear and there is a risk that the nutritional needs of many groups vulnerable to malnutrition will drop from the policy agenda. The authors refer to the reference diet as universally healthy – inconsistent with the recognition of such sub-groups and a message that may be misconstrued. Second, if the needs of these special cases are taken into consideration, then the reference does not represent a "global average", because it may underestimate the nutrient needs, particularly for those nutrients that are primarily found in animal source foods (e.g. zinc, iron, vitamin B12), and are exactly those that may be required in higher proportion by some of these special sub-groups. It is unclear whether the assumptions of the analysis would hold true if these were factored in. There are echoes here of the climate debate, where the importance of richer and higher emitters of CO2 over developing countries had to be addressed for global consensus – who pays the costs of adjustment?

Reading as cooks and lovers of good food

Translating a healthy reference diet into actions that are acceptable and implemented by individuals is beyond the scope of the EAT Lancet Commission Report. But inevitably, a transformation of the food system will have implications for individual choices – and that is already resulting in some media stir. Some of you have probably read other blogs and posts, including some outrage verging on "…stay out of my kitchen!".

For those of us at GAIN, as with many people around the world, food is not only about health and nutrition. Depending on the day and the context, food may also be about culture, tradition, pleasure, status, convenience, and a myriad of other considerations that often trump healthy choices even those we know we should make. Addressing these and finding ways that nutritious food can meet these other food considerations will be part of what organisations like GAIN and others seeking to stimulate greater demand for nutritious food will need to double our efforts on. We urgently need to engage more with the economic actors who put food on our tables – farmers and businesses, big and small.

The EAT-Lancet Commission report changes the boundaries of the problem, and we need to change the boundaries of who we work with in response.

Profound change in food systems will require all of us to reconcile the reality that what we eat does affect what others have an option to eat, and the production systems of our food affect the environment in ways that are currently unsustainable. This is not the first time that these messages have been emphasised to the non-expert. While not necessarily informed by science, there have been several books and cookbooks published with the aim to help individuals decrease their "footprint" on the world’s food supply. The suggestions and recipes in these books will not necessarily align with the reference diet proposed by the EAT-Lancet Commission Report, but they remind us that we have a role to play as individuals – everyday. But it won’t be easy – read a great blog which explains why translating these recommendations into something doable is going to take a lot of work.  

So what next?

If there is one obvious gap in the Report, it is the lack of much of a roadmap on what next. Millions of jobs and livelihoods are dependent on what we eat now, and change will require a complex recipe of policy, political leadership, research and technology, and dialogue. We don’t have any more time to waste in building bridges with environmental and climate campaigns, and designing the economic tools needed to support transformation so that we can show that planet-friendly and nutritious-food friendly is no only necessary, but possible. The EAT-Lancet Commission report changes the boundaries of the problem, and we need to change the boundaries of who we work with in response. We urgently need to engage more with the economic actors who put food on our tables – farmers and businesses, big and small.