*Article* **Most Frequently Consumed Red/Processed Meat Dishes and Plant-Based Foods and Their Contribution to the Intake of Energy, Protein, and Nutrients-to-Limit among Canadians**

**Mojtaba Shafiee 1, Naorin Islam 1, D. Dan Ramdath 2,\* and Hassan Vatanparast 1,3,\***


**Abstract:** Using cross-sectional data from the 2015 Canadian Community Health Survey–Nutrition, we aimed to identify and characterize the top 10 most frequently consumed plant-based foods and red/processed meat dishes in the Canadian population. Plant-based foods and red/processed meat dishes categories included 659 and 265 unique food codes, respectively, from the Canadian Nutrient File. A total of 20,176 Canadian individuals aged ≥1 year were included in our analysis. The most frequently consumed plant-based food was "Cooked regular long-grain white rice", which made a significant contribution to energy (12.1 ± 0.3%) and protein (6.1 ± 0.2%) intake among consumers. The most frequently consumed red/processed meat dish in Canada was "Cooked regular, lean or extra lean ground beef or patty". Among red/processed meat dishes, "ham and cheese sandwich with lettuce and spread" made the most significant contribution to the intake of energy (21.8 ± 0.7%), saturated fat (31.0 ± 1.0%), sodium (41.8 ± 1.3%), and sugars (8.2 ± 0.5%) among the consumers. Ground beef is the most frequently consumed red/processed meat dish and white rice is the most frequently consumed plant-based food among Canadians. Red/processed meat dishes are major drivers of the excessive intake of nutrients-to-limit.

**Keywords:** red/processed meat dishes; plant-based foods; long-grain white rice; nutrients to limit; Canadian population

#### **1. Introduction**

In 2017, dietary risk factors were responsible for 255 million disability-adjusted lifeyears (DALYs) and 11 million deaths across 195 countries [1]. Globally, the three major dietary risk factors for mortality and DALYs were high intake of sodium, low intake of whole grains, and low intake of fruits [1]. Health Canada recommends the regular intake of nutritious foods (e.g., whole grains, fruit, vegetables) that are commonly found in dietary patterns such as Dietary Approaches to Stop Hypertension (DASH) and Mediterraneanstyle diets, which are known to be associated with beneficial effects on human health [2–4]. According to Canada's new food guide (2019), consumption of nutritious foods often leads to low intakes of saturated fat (<10% of total energy intake), free sugars (<10% of total energy intake), or sodium (<2300 mg/day) [5]. While many animal-based foods are nutritious, Canada's new food guide (2019) emphasizes the consumption of more plant-based foods because of the positive health effects associated with higher intakes of vegetables and fruit, nuts, soy protein, and dietary fiber [5]. Moreover, dietary shifts toward fewer animal-based foods and more plant-based foods could encourage lower intakes of processed meat (such as sausages, ham, and hot dogs), and foods high in saturated fat [5].

**Citation:** Shafiee, M.; Islam, N.; Ramdath, D.D.; Vatanparast, H. Most Frequently Consumed Red/Processed Meat Dishes and Plant-Based Foods and Their Contribution to the Intake of Energy, Protein, and Nutrients-to-Limit among Canadians. *Nutrients* **2022**, *14*, 1257. https://doi.org/10.3390/ nu14061257

Academic Editors: Colin Bell and Penny Love

Received: 16 February 2022 Accepted: 14 March 2022 Published: 16 March 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

In this regard, Kirkpatrick et al. reported that red meat (beef, pork, lamb, and goat) mixed dishes are the largest contributors to saturated fat and sodium intake in the diet of Canadians [6]. Further, it has been found that rice (84%) is the most commonly consumed plant-based food, and beef (48.7%) is the most commonly consumed animal-based food among the Brazilian population aged 10 years or over [7]. A growing body of evidence suggests that consumption of red and processed meat is not only associated with poorer health outcomes but also with negative environmental impacts [8–10]. According to the EAT-Lancet Commission report, a diet with fewer animal source foods and rich in plantbased foods confers environmental benefits [11]. In this regard, a study conducted in the European Union (EU) showed that replacing 25–50% of animal-derived foods (i.e., eggs, dairy products and meat) in the EU with plant-based foods on a dietary energy basis would lead to less per capita use of cropland for food production (23%), a reduction in greenhouse gas emissions (25–40%), and a reduction in nitrogen emissions (40%) [12]. Examining the most frequently consumed plant-based foods and red/processed meat dishes and their contribution to dietary components gives us an overview of the current dietary habits of Canadians and provides insights into targets for interventions to support healthy eating patterns.

The primary objective of the present study was to identify the top 10 most frequently consumed plant-based foods and red/processed meat dishes in the Canadian population aged ≥1 year in 2015. We also aimed to (1) rank the top 10 plant-based foods and red/processed meat dishes based on their contribution to nutrients-to-limit, energy, and protein, and (2) determine the mean and percentage contribution of the top five plant-based foods and red/processed meat dishes to nutrients-to-limit, energy, and protein intake of consumers.

#### **2. Materials and Methods**

#### *2.1. Study Population and Dietary Data Collection*

Cross-sectional data from the Canadian Community Health Survey (CCHS)–Nutrition 2015 was used in this study. These survey data were collected from 20,487 individuals across ten provinces of Canada, excluding individuals living in Indigenous settlements and reserves, Canadian forces employees, and the institutionalized population [13,14]. The survey respondents provided 24 h dietary recall information as well as sociodemographic and supplement use information. For this study, we used day 1 of the 24 h recall. The dietary recall data included all foods and beverages consumed by participants within a 24 h period as well as frequency, time, location, and amount of food consumed. These also included information on food groups, nutrients, and eating patterns. The Automated Multiple Pass Method (AMPM) was used to derive dietary information [14]. This method is based on the United States Department of Agriculture (USDA) and it is an automated questionnaire that maximizes the survey respondent's response to report and recall dietary intake in the last 24 h. A proxy interview was used to collect information from children aged 1–6 years under the supervision of parents or guardians. Children aged 6–11 years participated with their parental guidance, and respondents aged ≥12 years provided information using a non-proxy method. Detailed information on the survey design and methodology of the CCHS 2015–Nutrition can be found on the Statistics Canada website [13,14]. We accessed data at the Research Data Centre (RDC) of Statistics Canada. This study was exempt from ethics approval, since we used secondary data from a national survey conducted by Statistics Canada.

#### *2.2. Analytical Sample*

This study included all individuals aged ≥1 year, excluding pregnant and lactating women and individuals with no dietary data, resulting in a final sample size of 20,176. Individuals more than 1 year of age were added to the analyses because, from this age, children are introduced to solid food and breastfeeding is often discontinued.

#### *2.3. Plant-Based Food and Red/Processed Meat Dishes Categories*

The red/processed meat dishes that we included in this study were any beef/pork/lamb/goat dishes. This category included a range of 265 unique food codes from the Canadian Nutrient File (CNF). Any red/processed meats that are not part of any dishes were not included. Plant-based food categories included nuts, seeds and nuts, seed mixes, trail mixes, plant-based beverages, nut butters, legume dishes with meat, legume dishes without meat, Mexican dishes, rice and rice mixed dishes, soups, canned/jarred vegetables and legumes, legumes, grains, tofu and meat substitutes and plant-based non-dairy desserts. Fruits and vegetables were excluded from this study given their low consumption and minor contribution to protein intakes. This category included a range of 659 unique food codes from the CNF.

#### *2.4. Statistical Analyses*

We identified the top 10 most frequently consumed plant-based foods and red/processed meat dishes among the Canadian population. If an individual reported any amount of a particular food item (i.e., if serving size > 0 of the specific food code), then it was considered as one eating occasion of that specific food code. If any individual has the same food more than once a day, that person contributed to more than one eating occasion. Among the top 10 most frequently consumed plant-based foods and red/processed meat dishes, we ranked the highest contributors of energy, protein, saturated fat, sodium, and sugars to the daily intake of Canadians. We reported the percentage of individuals consuming the top five plant-based foods and red/processed meat dishes. Further, the mean amount and the mean proportion of energy, protein, saturated fat, sodium, and sugars derived from the top five plant-based foods and red/processed meat dishes were reported per consumer. For the mean percent contribution, individual percentages were calculated first and then the average was taken of that individual's percentages. All analyses were performed using SAS (version 9.3). We used appropriate bootstrapping weights to obtain population-level estimates using Statistics Canada guidelines [15]. The values were reported as mean ± SE or % ±SE for continuous or categorical variables, respectively.

#### **3. Results**

Table 1 represents the top 10 most frequently reported plant-based foods and red/processed meat dishes among Canadians aged ≥1 year along with the percentages of individuals reporting the food. The most frequently consumed red/processed meat dish was "Cooked regular, lean or extra lean ground beef or patty". "Ham and cheese sandwich with lettuce and spread" and "ham sandwich with lettuce and spread" were the second and third most frequently consumed red/processed meat dishes. "Frankfurter (wiener/hot dog) on bun", "homemade-style spaghetti sauce", "barbecued pork", and "shepherd's pie" were also among the top 10 most frequently reported red/processed meat dishes. The most frequently consumed plant-based food in the Canadian population was "Cooked regular long-grain white rice", followed by "canned red ripe tomatoes". "Canned tomato puree, no salt added", and "smooth type peanut butter, fat, sugar and salt added" were the third and fourth most frequently consumed plant-based foods. "Canned cream of asparagus soup, ready-to-serve beef or chicken broth soup", "canned tomato sauce", "sweetened enriched almond milk", and "dried almonds" were also among the top 10 most frequently reported plant-based foods.

Ranking of the top 10 most frequently reported red/processed meat dishes based on their contribution to nutrients-to-limit, energy, and protein intake is presented in Table 2. Among the top 10 most frequently reported red/processed meat dishes, "ham and cheese sandwich with lettuce and spread" was the largest contributor to energy, protein, and saturated fat intake, and the second-largest contributor to sugars and sodium intake within the red/processed meat dishes category. Moreover, among red/processed meat dishes, "ham sandwich with lettuce and spread" was the top contributor to sodium intake, and "frankfurter (wiener/hot dog), with ketchup and/or mustard, on bun" was the top contributor to sugars intake in the Canadian diet within the red/processed meat dishes category.

**Table 1.** Top 10 most frequently reported plant-based foods and red/processed meat dishes among individuals ≥ 1 year in Canada (*n* = 20,176), 2015 Canadian Community Health Survey.


NS: Not specified.

Table 3 reports the ranking of the top 10 most frequently reported plant-based foods based on their contribution to energy, protein, saturated fat, sodium, and sugars intake. Among plant-based foods, "cooked regular long-grain white rice" was the largest contributor to energy and protein intake within the plant-based food category. In addition, "smooth type peanut butter with added fat, sugar and salt" was the top contributor to saturated fat intake, "ready-to-serve beef broth soup" was the top contributor to sodium intake, and "vanilla flavored sweetened enriched almond milk" was the top contributor to sugars intake among the top 10 most frequently reported plant-based foods within the plant-based food category.


**Table 2.** Ranking of the top 10 most frequently reported red/processed meat dishes based on their contribution to nutrients-to-limit, energy, and protein intake (*n* = 20,176), 2015 Canadian Community Health Survey.

NS: Not specified; SFA: Saturated fatty acids.

**Table 3.** Ranking of the top 10 most frequently reported plant-based foods based on their contribution to nutrients-to-limit, energy, and protein intake (*n* = 20,176), 2015 Canadian Community Health Survey.


SFA: Saturated fatty acids.

Table 4 presents the proportion of individuals consuming the top five most frequently reported red/processed meat dishes as well as the mean and percentage contribution of each food item to energy, protein, saturated fat, sugars, and sodium intake of consumers on any given day. Since these results are based on 24 h recall, the proportion of individuals consuming the top five food sources are based on any given day. The proportion of Canadians consuming "cooked regular, lean or extra lean ground beef or patty" was 4.6%, followed by 2.9% for "ham sandwich with lettuce and spread". Among red/processed meat dishes, "ham and cheese sandwich with lettuce and spread" made the largest contribution to energy (21.8%), protein (31.4%), saturated fat (31.0%), and sodium (41.8%) intake among its consumers. In addition, "frankfurter (wiener/hot dog), with ketchup and/or mustard, on bun" accounted for 10.9% of the sugars intake of the consumers of this food item.

As reported in Table 5, the proportion of Canadians consuming "cooked regular longgrain white rice" was 15.5%, followed by 13.4% for "canned red ripe tomato". Among plant-based foods, "cooked regular long-grain white rice" made the largest contribution to energy intake (12.1%), followed by "smooth type peanut butter with added fat, sugar and salt" (8.4%). In addition, "smooth type peanut butter with added fat, sugar and salt" made the largest contribution to protein (8.1%), saturated fat (13.3%), sodium (4.8%), and sugars (3.8%) intake among its consumers.

**Table 4.** The mean and percentage contribution of the top five reported red/processed meat dishes to nutrients-to-limit, energy, and protein intake of Canadians aged ≥1 year in Canada, 2015 Canadian Community Health Survey.


NS: Not specified; SFA: Saturated fatty acids. <sup>1</sup> Units: Energy in kcal, Protein in grams, SFA in grams, Sugars in grams, and Sodium in mg.

**Table 5.** The mean and percentage contribution of the top five reported plant-based foods to nutrientsto-limit, energy, and protein intake of Canadians aged ≥1 year in Canada, 2015 Canadian Community Health Survey.


SFA: Saturated fatty acids. <sup>1</sup> Units: Energy in kcal, Protein in grams, SFA in grams, Sugars in grams, and Sodium in mg.

#### **4. Discussion**

This is the first study to identify the top 10 most frequently consumed plant-based foods and red/processed meat dishes in the Canadian population, using a nationally representative sample. Overall, the most frequently consumed plant-based food in Canada was "cooked regular long-grain white rice". The mean contribution of this food item to the energy intake of its consumers was just under 200 kcal/day. The most frequently consumed red/processed meat dish was "cooked regular, lean or extra lean ground beef or patty". Among all red/processed meat dishes, "ham and cheese sandwich with lettuce and spread" made the largest contribution to energy, protein, saturated fat, and sodium intake.

Rice is the most widely consumed food staple for almost 50% of the world's population [16]. On a global basis, rice provides 21% of energy and 15% of protein per capita [17], and long-grain white rice is known to be the most commonly eaten form of rice [18]. Similarly, our results revealed that the most frequently consumed plant-based food in Canada in 2015 was "cooked regular long-grain white rice". More than 15% of Canadians reported consuming this food item, and it contributed to 12.1% of energy intake and 6.1% of protein intake among consumers. Using data from the CCHS 2015, Kirkpatrick et al. reported that rice and rice mixed dishes were among the top 10 contributors to energy intake in the general Canadian population (≥1 year), and among the top five contributors to energy intake in the low-income group [6]. In a study investigating the dietary sources of energy and nutrient intakes among five ethnic groups (i.e., Caucasian; Latino; Native Hawaiian; Japanese-American; African American) in the U.S., it was found that rice made a significant contribution to dietary energy intake, ranging from 5.3% (Caucasian women) to 22.9% (Japanese-American men). In addition, rice was found to be the top dietary source of protein for Japanese-American men and women, respectively, contributing 12.7% and 10.4% to protein intake [19]. Sharma et al. also reported that white rice was the most commonly consumed grain food among Japanese-American, Native Hawaiian, and Caucasian men (12.0–44.1%), and the most commonly consumed refined grain among all ethnic groups (10.3–54.1%), except for Latinos [20]. In another study aiming to describe the most commonly consumed foods in the Brazilian diet, Souza et al. found that rice (84%) was the most frequently recorded food by Brazilian individuals (≥10 years), followed by coffee (79%) and beans (72.8%) [7]. Using data from the 2009–2013 Korea National Health and Nutrition Examination Surveys (KNHANES), it was revealed that white rice was the major source of energy (31%) among Korean preschoolers aged 1–5 years, followed by milk (10.2%) and bread (3.5%) [21]. Although white rice (milled and/or polished rice) is the most commonly consumed form of rice, it is a poor source of vitamins and minerals due to removing the bran and germ layers of the seed during the milling process [22]. In their review of the literature, Saleh et al. reported that brown rice is nutritionally superior to white rice because of higher levels of nutrients such as protein, vitamins, and minerals [22]. In accordance with this, the new Canada's Food Guide has placed a major emphasis on whole grain foods and recommended regular consumption of whole grains and decreasing consumption of refined grains [5].

Our results showed that the most frequently consumed red/processed meat dish in Canada in 2015 was "cooked regular, lean or extra lean ground beef or patty". This food item was consumed by 4.6% of the Canadian population and accounted for 4% of energy intake, 9.5% of saturated fat intake, and 10.5% of protein intake among its consumers. Ground beef is the most commonly consumed form of beef in the U.S., accounting for more than 40% of all beef consumed [23]. Results from a multiethnic cohort study of 215,000 individuals aged 45–75 years showed that lean beef (steak/roast) was the most commonly consumed red meat for all ethnic groups in the U.S. (9.3–14.3%), except for Japanese-Americans and Native Hawaiians [24]. Using data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES), O'Neil et al. reported that beef was the top source of protein (14.0%), the third-highest ranked source of saturated fat (7.9%), and the fourthhighest ranked source of energy (5.0%) among American adults aged ≥19 years [25]. Using the same survey data, Huth et al. found that the top three food sources of saturated fat in the diet of Americans aged ≥2 years were cheese (16.5%), beef (8.5%), and milk (8.3%) [26]. In addition, results from the 2007–2010 NHANES showed that ground beet contributed to 5.6% of animal protein intake and 2.6% of total protein intake among U.S. adults aged 19 years and older [27]. Souza et al. reported that beef was the fifth most commonly reported food item, and the most frequently reported animal-based food on the first day's food record of Brazilian individuals (≥10 years) [7]. A more recent study also showed that beef was the most commonly consumed meat among Brazilian individuals aged 10 years and older (49%), and the mean beef intake for the entire country was 63 g/day [28]. In a survey conducted in Spanish adults aged 25 to 75 years, beef was found to be the most frequently consumed red meat (63.6%), with pork in second place (52.6%) [29]. Using data from the 2011–2012 National Nutrition and Physical Activity Survey (NNPAS), Sui et al. reported that red meat was consumed by 48.6% of Australian men and women, with beef as the most frequently reported type (41.8% and 34.7%, respectively) [30]. Some observational studies have found an association between consumption of beef and increased risk of a number of cancers [31–34]. Therefore, reducing beef intake and replacing it with plantbased proteins could be an effective strategy in the prevention of such conditions. In line with this, the new Canada's Food Guide has recommended regular consumption of protein foods, with particular emphasis on plant-based proteins [5]. Further, according to the new food guide, ruminant animal-based foods such as beef and lamb are natural sources of trans fat, a type of unsaturated fat known to have adverse health effects [5].

Processed meats, such as ham, bacon, frankfurters, and sausages that have been modified through salting, curing, fermentation, or smoking, account for a large proportion of the world's meat consumption [35]. Our results revealed that "ham and cheese sandwich with lettuce and spread" was the second most frequently consumed red/processed meat dish in Canada in 2015. This food item accounted for 41.8% of sodium intake, 31.4% of protein intake, 31.0% of saturated fat intake, and 21.8% of energy intake among its consumers. Among red/processed meat dishes, "ham sandwich with lettuce and spread" and "frankfurter (wiener/hot dog) with ketchup and/or mustard on bun" were in the next rankings. Using data from the 2009–2010 NHANES, Sebastian et al. reported that nearly half of American adults (49%) reported eating a sandwich on any given day, and the mean contribution of sandwiches to energy intakes of all adults was 200 kcal for women and 350 kcal for men [36]. In addition, the mean contribution of sandwiches to sodium intake of American men and women was 902 mg and 489 mg, respectively [36]. In the U.S., processed meat intake constitutes 22% of the total meat consumed from either poultry or red meat categories [37]. Using data of Australians aged ≥2 years from the 2011–2012 NNPAS, Sui et al. found that 37.8% of participants reported consuming processed meat, and ham was the most frequently reported type of processed meat (females 16.8%, males 19.4%), followed by bacon (females 12.4%, males 15.3%), and sausage (females 5.8%, males 8.5%) [30]. Kirkpatrick et al. reported that processed meats are among the top 10 Contributors to sodium and saturated fat intake of Canadians aged 1 year and older [6]. In a study aiming to identify the major food sources of dietary sodium using 3-day food records, it was found that processed meat was the largest contributor to daily sodium intake among Mexican adults, representing 8% of total sodium intake per capita [38]. The results also showed that total sodium contributed by processed meat in the entire sample population was 223 mg/day [38]. Using data obtained from 21,108 British households, Ni Mhurchu et al. observed that processed meat (18%) was the second largest contributor to sodium purchases after table salt (23%) [39]. In a nationwide survey conducted in Brazil, it was found that processed meat was among the top five contributors to saturated fat intake among Brazilian individuals aged ≥10 years [40]. Moreover, increased morbidity and mortality related to high consumption of processed meat has been linked to their high content of sodium and saturated fat [41–44]. We have recently shown that reducing red and processed meat by half and increasing plant-based meat alternatives by 100% may assist in reducing the intake of sodium and saturated fat, and increase the overall nutritional value of the diet [45].

#### *Strengths and Limitations*

This study used nutrition data from CCHS–Nutrition 2015, a nationally representative survey of the Canadian population aged one year and older. A major strength of this study was the opportunity to identify the top 10 most frequently consumed plant-based foods and red/processed meat dishes, shortly after the introduction of the new Canada's Food Guide, which places a major emphasis on the consumption of plant-based foods. We also acknowledge some limitations. First, since we combined age and sex groups in this study, some results may vary for different age/sex groups. Second, detailed dietary data were obtained using a 24 h dietary recall and, therefore, may not reflect the usual intake of the participants. In addition, the 24 h dietary recall is a self-report method subject to recall bias and misreporting (i.e., overestimating or underestimating dietary intake). Third, CCHS–Nutrition 2015 does not include added sugar intake information of Canadians. That is why we were only able to report the total sugar intake for the analyses. Fourth, the descriptive, cross-sectional design of the study does not allow us to determine the causal relationship between patterns of food consumption and health outcomes. Fifth, we included the consumption data of only two main food categories, namely plant-based foods and red/processed meat dishes. It is notable that the plant-based foods make up a broader category compared to the red/processed meat dishes category, and include vegetables and fruit, grain products, and protein-based foods.

#### **5. Conclusions**

The results of this study revealed that the most frequently consumed plant-based food among the Canadian population aged ≥1 year was "cooked regular long-grain white rice", followed by "canned red ripe tomatoes". Cooked regular long-grain white rice made a significant contribution to energy and protein intake among the consumers of this food item. Among the top five most frequently consumed plant-based foods, "smooth type peanut butter, fat, sugar, and salt added" made the most significant contribution to saturated fat, protein, sugars, and sodium intake. The most frequently consumed red/processed meat dish in Canada was "Cooked regular, lean or extra lean ground beef or patty". Further, the top five red/processed meat dishes, especially "ham and cheese sandwich with lettuce and spread", made a significant contribution to the intake of saturated fat, sugars, and sodium in the diet of Canadians. According to the new Canada's Food Guide, patterns of eating that place a major emphasis on plant-based foods typically result in higher intakes of dietary fiber, nuts, vegetables and fruit, and soy protein, and also encourage lower intakes of processed meat and saturated fat [5]. Thus, minimizing the consumption of red/processed meat dishes and shifting intakes towards more plant-based foods may improve the health of Canadians and confer environmental benefits [5,11]. Putting this into practice, in the most recent Canada's Food Guide, Health Canada has merged the two food groups (Meat & Alternatives and Milk & Alternatives) of the 2007 Food Guide into a single group called "Protein Foods" [5]. Among protein foods, health Canada also recommended consuming plant-based more often. The new guidelines along with relevant health promotion initiatives may have an impact on shifting toward consumption of more plant-based foods among Canadians. Further research is required to determine and compare the most frequently consumed red/processed meat dishes and plant-based foods among different age/sex groups of Canadians and how they can contribute to the intake of energy, protein, and nutrients-to-limit.

**Author Contributions:** Conceptualization, H.V. and D.D.R.; Formal analysis, H.V. and N.I.; Funding acquisition, H.V. and D.D.R.; Investigation, H.V.; Methodology, H.V., N.I. and M.S.; Project administration, H.V.; Resources, H.V.; Supervision, H.V.; Writing—original draft, H.V., N.I. and M.S.; Writing—review and editing, H.V., N.I., M.S. and D.D.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by a grant provided by Saskatchewan Pulse Growers Association (funding number: 350778).

**Institutional Review Board Statement:** Ethical review and approval were waived for this study due to using secondary data.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data will be available at the Research Data Centre (RDC) of Statistics Canada.

**Acknowledgments:** The analysis presented in this paper was conducted at the Saskatchewan RDC, which is part of the Canadian Research Data Centre Network (CRDCN). We thank Ruben Mercado, Analyst, and Saskatchewan RDC for all his cooperation in the data access and vetting process. We also thank Anne Kennedy and Sheryl Conrad of Agriculture and Agri-Food Canada for assisting in conceptualization of the study.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


### *Review* **Plant-Based Dietary Patterns for Human and Planetary Health**

**Joshua Gibbs 1,\* and Francesco P. Cappuccio 1,2,\***


**Abstract:** The coronavirus pandemic has acted as a reset on global economies, providing us with the opportunity to build back greener and ensure global warming does not surpass 1.5 ◦C. It is time for developed nations to commit to red meat reduction targets and shift to plant-based dietary patterns. Transitioning to plant-based diets (PBDs) has the potential to reduce diet-related land use by 76%, diet-related greenhouse gas emissions by 49%, eutrophication by 49%, and green and blue water use by 21% and 14%, respectively, whilst garnering substantial health co-benefits. An extensive body of data from prospective cohort studies and controlled trials supports the implementation of PBDs for obesity and chronic disease prevention. The consumption of diets high in fruits, vegetables, legumes, whole grains, nuts, fish, and unsaturated vegetable oils, and low in animal products, refined grains, and added sugars are associated with a lower risk of all-cause mortality. Meat appreciation, health concerns, convenience, and expense are prominent barriers to PBDs. Strategic policy action is required to overcome these barriers and promote the implementation of healthy and sustainable PBDs.

**Keywords:** plant-based diet; planetary health; human health; sustainability; chronic disease prevention

#### **1. Introduction**

There is scientific consensus that anthropogenic greenhouse gas (GHG) emissions influence global warming and climate change [1]. To limit the negative consequences of climate change, 196 parties have committed to keep the increase in global average temperature below 2 ◦C above pre-industrial levels and try to limit warming to 1.5 ◦C [2]. The coronavirus pandemic has acted as a reset on global economies providing us with the opportunity to build back greener and maximize our chances of meeting the 1.5 ◦C target [3]. For example, the government of the United Kingdom (UK) has laid out a ten-point plan for a green industrial revolution in which they commit to transforming the energy sector, ending the sale of petrol and diesel cars, decarbonising public transport, developing greener buildings, investing in carbon capture and storage, and protecting the natural environment [4]. Worryingly, they failed to address agriculture in their plans. Revolutionizing agricultural systems should arguably be a top priority considering food production is the single largest cause of global environmental change [5]. Current agricultural practices constitute up to 30% of global anthropogenic GHG emissions [6] and 70% of freshwater use [7], whilst occupying approximately 40% of Earth's land [8]. Therefore, innovation within the agricultural sector has the potential to generate substantial sustainability gains.

A possible line of action, that is receiving ever-increasing interest, is to transition towards a plant-based food system. Plant-based foods have a significantly smaller footprint on the environment than animal-based foods. Even the least sustainable vegetables and cereals cause less environmental harm than the lowest impact meat and dairy products [9]. On top of the low environmental impact of plant-based diets (PBDs), they may provide additional benefits to human health. Unhealthy diets now represent the largest burden of disease globally, presenting a greater risk to morbidity, disability, and mortality than unsafe

**Citation:** Gibbs, J.; Cappuccio, F.P. Plant-Based Dietary Patterns for Human and Planetary Health. *Nutrients* **2022**, *14*, 1614. https:// doi.org/10.3390/nu14081614

Academic Editors: Colin Bell and Penny Love

Received: 9 March 2022 Accepted: 11 April 2022 Published: 13 April 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

sex, alcohol, drug, and tobacco use combined [5]. Adopting plant-based food systems may allow countries to reduce their environmental footprints and tackle their obesity and diet-related non-communicable disease burdens simultaneously. A few reviews have covered the planetary and human health benefits associated with PBDs; however, since their publication, additional data of relevance have become available [10–12]. The aim of this review is to provide a concise summary of the planetary and human health benefits associated with PBDs using evidence from the latest advances in the field. This review will also summarise the main barriers to PBDs and offer potential solutions.

PBD is an umbrella term that describes any dietary pattern that emphasises the consumption of foods derived from plants and excludes or limits the consumption of most or all animal products. PBDs can be healthy or unhealthy depending on their composition. Healthy PBDs focus on unprocessed plant foods, including fruits, vegetables, whole grains, legumes, nuts, and seeds, whereas unhealthy PBDs contain high quantities of processed and ultra-processed plant foods such as sugar-sweetened beverages, refined grains, sweets, and desserts. Descriptions of the various PBDs mentioned in this review are shown in Table 1.

**Table 1.** Descriptions of various plant-based dietary patterns.


#### **2. Planetary Health**

#### *2.1. Greenhouse Gas (GHG) Emission*

Food systems are responsible for 21–37% of all GHG emissions globally [13]. Innovation and transformation within the food and agricultural sectors are imperative to limiting global warming to 1.5 ◦C. Between 2017 and 2018, agricultural emissions rose by 1.5% reaching a total of 5.6 GtCO2, even with modest improvements in efficiency [14]. Of this total, 52% was caused by cattle products, primarily meat and dairy. Per-capita emissions from food consumption are 39% and 41% higher in very high human development index (HDI) countries than in high HDI countries and low HDI countries, respectively [14]. These differences in emissions are despite the use of high emission-intensity beef farming in low HDI countries. In very high HDI countries, cattle products are responsible for 68% of total consumption-based agricultural GHG emissions [14]. Reducing red meat consumption is a major key to meeting emission targets for very high HDI countries and it would deliver substantial health co-benefits. The rate of red meat-related mortality is nearly nine times greater in very high HDI countries than in low HDI countries [14]. Life cycle assessment studies have shown that pork, chicken, and seafood produce less GHG emissions than beef; however, even the lowest impact animal products exceed the average GHG emissions of

substitute plant proteins [9,15]. Moving to diets that exclude animal products could reduce global GHG emissions by 49% (Figure 1) [9].

**Figure 1.** Summary of the planetary and human health benefits associated with the adoption of plant-based dietary patterns. Abbreviations: CVD, cardiovascular disease; GHG, greenhouse gas; LDL, low-density lipoprotein; T2D, type 2 diabetes.

#### *2.2. Agricultural Land Use*

Around 43% of the planet's ice-free terrestrial landmass is occupied by farmland (including croplands and pasturelands). Approximately 83% of this farmland is used to produce meat, eggs, farmed fish, and dairy, yet they only provide 18% and 37% of our calories and protein, respectively [9]. Per kilogram, animal products require more lifecycle energy inputs than plant foods [16]. The adoption of PBDs would substantially reduce agricultural land use. Eshel et al. [17] estimated that Americans could save approximately 34% and 24% of dietary and total land use, respectively, if they replaced all meat with plant-based alternatives. Considering the amount of land required to produce animal products, it is unsurprising that they are accountable for 67% of the deforestation caused by agriculture [9]. The destruction of ecosystems for croplands and pasturelands is the single largest factor causing species to be threatened with extinction [18]. Biodiversity is essential for the productivity and resilience of our food systems [19]. Shifting to PBDs would slow biodiversity loss substantially, thus having a protective effect on global food security [5]. It is estimated that animal product-free diets have the potential to reduce diet-related land use by 3.1 billion hectares (76% reduction), including a 19% reduction in arable land (Figure 1) [9].

#### *2.3. Water Use*

In total, 70% of all global freshwater withdrawals are used for the irrigation of crops, of which 24% are fed to livestock [5,20]. Approximately 43,000 L of water are required to produce 1 kg of beef, whereas it only takes 1000 L to produce 1 kg of grain [21]. A modelling study found that reducing animal product consumption would reduce global green and blue water use by 21% and 14%, respectively (Figure 1) [22]. PBDs may therefore play a role in water conservation. Animal product-free diets may also improve water quality by reducing eutrophication caused by nitrogenous fertilizer and manure runoff by 49% (Figure 1) [9].

#### *2.4. Healthy Reference Dietary Pattern*

The EAT-Lancet Commission has developed a healthy reference dietary pattern that would allow humanity to stay within a safe operating space, in terms of climate change, land use, biodiversity loss, freshwater use, and nitrogen and phosphorus pollution, even with a 10 billion global population [5]. The dietary pattern largely consists of fruits and vegetables, whole grains, legumes, nuts, and unsaturated oils; low to moderate consumption of seafood and poultry; zero to low consumption of red meat, processed meat, added sugar, refined grains, and starchy vegetables. Using data from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort involving 443,991 participants, Laine et al. [23] estimated that up to 19–63% of deaths and up to 10–39% of cancers could be prevented in a 20-year risk period by adopting different levels of adherence to the EAT-Lancet reference diet. They also estimated that switching from low adherence to higher adherence could reduce food-associated greenhouse gas emissions by up to 50% and land use up to 62%.

#### **3. Human Health**

Globally we are experiencing an unprecedented level of diet-related disease. Worldwide, 2.1 billion adults are overweight or obese [5]. Overweight and obesity are associated with a range of chronic diseases including type 2 diabetes (T2D) [24], hypertension [25], cardiovascular disease (CVD) [26], and some types of cancer [27]. Together, these diseases have a massive cost on society in terms of lives lost and healthcare spending. The Global Burden of Disease study estimated that increased consumption of whole grains, vegetables, nuts and seeds, and fruit could prevent 1.7 million, 1.8 million, 2.5 million, and 4.9 million premature deaths per year, respectively, via the beneficial effects on chronic disease risk factors [28].

#### *3.1. Obesity*

An extensive body of population studies and clinical trials supports the implementation of PBDs for the prevention of obesity and obesity-related diseases. Observational data from the Adventist Health Study-2 (AHS-2) involving 41,387 participants, showed that body mass index (BMI) was positively correlated with the amount of animal-based foods consumed, such that non-vegetarians had the highest BMI, followed by semi-vegetarians, pescatarians, vegetarians, and vegans [29]. In addition, findings from the EPIC-Oxford cohort, containing 21,966 men and women, have shown that vegans and pescatarian women gain significantly less weight annually compared with meat-eaters [30]. The lowest mean annual weight gain was observed in individuals who converted, during follow-up, to diets containing fewer animal-derived foods. In accordance with these findings, the European Prospective Investigation into Cancer, Physical Activity, Nutrition, Alcohol, Cessation of smoking, Eating out of home and obesity (EPIC-PANACEA) study found total meat consumption was positively associated with weight gain in 103,455 men and 270,348 women [31]. After adjusting for estimated energy intake, an additional 250 g/d of meat led to a 2 kg higher weight gain after 5 years (95% CI: 1.5, 2.7 kg). In a 5-year longitudinal study of 787 non-obese participants, dietary patterns were evaluated with overall plant-based diet index (PDI) scores, in which plant foods received positive scores and animal-derived foods received reverse scores [32]. A healthy PDI (hPDI) and an unhealthy PDI (uPDI) were also created. For the hPDI, healthy plant foods (fruits, vegetables, legumes, whole grains, nuts, and unsaturated vegetable oils) received positive scores, and animal foods and unhealthy plant foods (fruit juices, refined grains, and added sugars) received reverse scores. For the uPDI, unhealthy plant foods were allocated positive scores and animal foods and healthy plant foods were allocated reverse scores. At follow-up, both the hPDI (Risk Ratio (RR) = 0.31; 95% CI: 0.12–0.77) and overall PDI (RR = 0.56; 95% CI: 0.23–1.33) were inversely associated with obesity risk. However, only the hPDI association achieved statistical significance. Conversely, the uPDI was positively associated with obesity risk (RR = 1.94; 95% CI: 0.81–4.66); however, this finding was not statistically significant.

Robust evidence from clinical trials supports the use of PBDs for weight loss. In 2015, Barnard et al. [33] performed a meta-analysis of 15 clinical trials with vegan and vegetarian interventions lasting four weeks or more with no energy restrictions. Consumption of PBDs was associated with a mean weight change of −3.4 kg (95% CI: −4.4, −2.4 kg) in an intention-to-treat analysis and −4.6 kg (−5.4, −3.8 kg) in a completer analysis (Figure 1). Similarly, a 2021 meta-analysis of seven clinical trials found that PBDs significantly lowered bodyweight in Type 2 diabetics (−2.35 kg (95% CI: −3.51, −1.19)) [34]. A few new clinical trials assessing the effect of PBDs on bodyweight have been published since 2015 [35–40]. The BROAD study, which prescribed a whole food PBD, had noteworthy results [38]. It showed greater weight loss at 6 and 12 months than any other comparable interventional trial (no energy restrictions or regular exercise orders) to date.

#### *3.2. Type 2 Diabetes*

The global prevalence of T2D has nearly doubled in the past 30 years [41]. In 2021, diabetes was responsible for 6.7 million deaths and \$966 billion USD in health expenditure [42]. Large cohort studies show that the prevalence and incidence of T2D are significantly lower among those following PBDs. T2D prevalence in the AHS-2 cohort followed a similar trend as BMI with the lowest prevalence occurring in vegans (2.9%) and the highest in non-vegetarians (7.6%) [43]. Pescatarians (4.8%), semi-vegetarians (6.1%), and vegetarians (3.2%) had intermediate T2D prevalence. After adjusting for BMI and other confounding variables, vegans had half the risk of T2D than non-vegetarians (Odds Ratio (OR)) 0.51 (95% CI: 0.40, 0.66)) and semi-vegetarians had an intermediate risk (0.76 (0.65, 0.90)). In a 2-year prospective study of the AHS-2 cohort, vegans had less than half the risk of T2D than non-vegetarians (OR 0.38 (0.24, 0.62)) even when adjustments were made for BMI and other confounders [29]. In a 17-year prospective study with 8401 participants, long-term weekly dietary inclusion of meat was associated with 74% increased (OR 1.74 (1.36, 2.22)) odds of T2D compared with long-term adherence to a vegetarian dietary pattern [44]. Weekly meat intake remained an important risk factor (1.38 (1.06,1.68)) after adjusting for weight and weight change.

In a prospective study of three US cohorts (Nurses' Health Study (NHS), NHS II, Health Professionals Follow-up Study) totalling 192,657 participants, Chen et al. [45] evaluated the associations between changes in PBDs and subsequent T2D risk. During the 2,955,350 person-years of follow-up, 12,627 cases of T2D developed. Participant dietary patterns were evaluated with overall PDI, hPDI, and uPDI scores. Compared with participants whose indices remained stable over the 4-year follow-up, participants with the largest decrease (>10%) in PDI and hPDI had a 12–23% higher T2D risk in the subsequent 4 years. Each 10% increment in PDI and hPDI over 4 years was associated with a 7–9% lower T2D risk. It is worth noting that changes in the PDI scores were primarily due to changes in healthy plant-food intake, not changes in animal-derived food intake. No associations were observed between changes in uPDI and subsequent T2D risk. This may be due to the benefits of low animal food intake cancelling out the harmful effects associated with low intake of healthy plant foods [45].

A 2019 meta-analysis of nine prospective studies totalling 307,099 participants, found a significant inverse association between higher adherence to PBDs and T2D risk (RR 0.77 (95% CI: 0.71, 0.84)) in comparison with poorer adherence (Figure 1) [46]. As well as preventing T2D, there is evidence that PBDs may be an effective tool in the treatment of the disease. A meta-analysis of six controlled clinical trials found that consumption of PBDs was associated with a significant reduction in haemoglobin A1c (−0.39 points) compared with the consumption of omnivorous control diets [47]. This hypoglycaemic effect is approximately half of that observed with the prescription of the first-line medication, metformin [48].

#### *3.3. CVD Risk*

CVDs are the leading cause of mortality globally. In 2019, CVDs were responsible for 18.6 million deaths worldwide [49]. There is a range of evidence that supports the use of PBDs for the prevention of CVDs. A 2021 meta-analysis of prospective cohort studies totalling 698,707 participants, found that PBDs were associated with a 16% lower risk of CVD and an 11% lower risk of coronary heart disease (CHD) [50]. However, there were no associations between PBDs and risk of stroke. Another 2021 meta-analysis of prospective cohort studies totalling 410,085 participants found that PBDs were associated with a 10% lower risk of CVD incidence and 8% lower risk of cardiovascular mortality [51]. In a randomised secondary prevention trial (The Lyon Diet Heart Study) with 275 events recorded during a mean follow-up of 46 months, adherence to a plant-based Mediterranean-type dietary pattern was associated with a 72% reduction in cardiovascular events compared with adherence to a western-type dietary pattern [52]. In a randomised controlled trial with a 5-year follow-up, intensive lifestyle changes including the adoption of a healthful plantbased dietary pattern were shown to cause regression of atherosclerosis [53]. The control group in this trial had more than twice the risk of a cardiovascular event than the intensive lifestyle changes group (Figure 1). The reduced risk of CVD incidence and cardiovascular mortality observed in those following PBDs is likely due to the beneficial effects on CVD risk factors including overweight or obesity, T2D, hypertension, and hypercholesterolemia.

#### *3.4. Hypertension and Hypercholesterolemia*

In the AHS-2 cohort, vegans had approximately half the odds of hypertension than omnivores, even after controlling for BMI [54]. A 2021 meta-analysis including 41 controlled trials and 8416 participants found that PBDs significantly lower both systolic and diastolic blood pressure even with the inclusion of some animal products (Figure 1) [55]. A 2017 meta-analysis of 19 clinical trials including 1484 participants, found that compared with the consumption of omnivorous diets, vegetarian diets were significantly associated with decreased total cholesterol (−12.5 mg/dL) and low-density lipoprotein cholesterol (−12.2 mg/dL) (Figure 1) [56].

#### *3.5. CVD Prevention*

Taken together, the beneficial effects of PBDs on chronic disease risk factors found in controlled trials, and their associations with lower chronic disease risk found in prospective cohort studies provide strong support for the implementation of PBDs for chronic disease prevention. In a prospective cohort of 315,919 participants, high hPDI scores were associated with a 36% lower risk of mortality and each 10-point increase was associated with a 19% lower risk [57]. On the other hand, high uPDI scores were associated with a 41% increase in mortality risk and each 10-point increase was associated with a 15% increase in risk. This is supported by the most comprehensive systematic review on dietary patterns and all-cause mortality (ACM) to date [58]. It found that dietary patterns characterised by higher intake of vegetables, legumes, fruits, nuts, unrefined grains, fish, and unsaturated vegetable oils, and lower or no consumption of animal products (red and processed meat, meat and meat products, and high-fat dairy), refined grains, and added sugar, were associated with lower ACM risk.

#### **4. Barriers and Potential Solutions**

In 2020, a comprehensive review of the literature outlined the most prominent perceived and objective barriers preventing people from switching to PBDs [59]. The most prominent barrier to PBDs is meat appreciation and the difficulty perceived in abstaining from consumption (Figure 2). The development of plant-based meat alternatives provides an opportunity to overcome this barrier. Plant-based products have been developed to visually resemble meat and match the taste, structure, and nutritional value preferences of meat eaters. These products make the transition to PBDs less difficult and more appealing. Environmental life cycle assessments for two popular plant-based substitutes, Beyond

Meat's Beyond Burger and Impossible Food's Impossible Burger, showed that switching from beef to either of the products reduces GHG emissions, land use, and water footprint by approximately 90% [60,61]. Although plant-based meat alternatives are classified as ultra-processed, they may still exert some of the beneficial effects on CVD risk factors as healthy PBDs [62]. A randomized cross-over trial investigating the effect of Beyond Meat products versus animal-derived meat on CVD risk factors found that consumption of plantbased meat alternatives was associated with significantly lower trimethylamine-N-oxide (TMAO) concentrations, LDL-cholesterol concentrations, and body weight compared with the consumption of animal meat [63]. Moreover, there were no adverse effects on other risk factors during the plant-based phase. More controlled trials are needed to characterize the effect of ultra-processed meat analogues on health markers.

**Figure 2.** The main barriers to widespread adoption of plant-based dietary patterns.

The second most prominent barrier to PBDs is health concerns, specifically nutrient deficiencies, for example, protein and calcium (Figure 2) [59]. International and national commitments to PBDs demonstrated by investment in public health and sustainability education could break down these barriers. The public needs to be educated on specific plant-based food sources of essential nutrients such as iron, calcium, and zinc and be reassured that their protein needs can be sufficiently met. A potential strategy for relieving the perceived health concerns attached to PBDs is to provide proper nutrition education to medical students and health professionals. A survey of medical schools found that on average fewer than 20 h over four years are spent on nutrition education [64]. Accordingly, physicians often lack important nutrition knowledge and the counselling skills required to successfully guide their patients [65–75]. In a survey of resident physicians, only 14% of participants felt physicians were adequately trained to provide nutritional counselling [76]. Ironically, in a survey of the public, 61% of participants considered physicians to be "very credible" sources of nutrition information [77]. Educating doctors on how to prevent and treat chronic diseases with healthful PBDs may have positive effects beyond individual patient care, by influencing the wider public's negative perceptions of PBDs. However, a lack of nutrition training is not the only way that physicians act as barriers. Firstly, they may have conflicts of interest and personal prejudices that bias their views on PBDs, preventing them from promoting the implementation of PBDs. Secondly, there is a lack of financial incentive for physicians to implement the use of PBDs [78,79]. Preventing chronic diseases with healthful PBDs reduces the demand for expensive medical treatments and procedures, which results in reduced income for physicians.

The third most common barrier relates to convenience and tastes factors (Figure 2) [59]. The availability of plant-based options out of home are limited and people believe that the preparation of plant-based meals is complicated. PBDs are also perceived as tasteless [80]. New policies mandating that canteens at schools, hospitals, universities, and other stateowned services must provide healthful plant-based options could be implemented to reduce the convenience barrier. Incentives for businesses to offer more healthful plantbased options would also help to overcome this barrier. Online educational resources and community cooking classes could be utilized to facilitate the teaching of plant-based food preparation to the public, potentially tacking both convenience and taste factors [79]. Taste barriers could also be overcome with the previously mentioned meat analogues.

The final prominent barrier to PBDs is the expense of plant-based foods (Figure 2) [59]. This barrier could be broken down by allocating subsidies to the production of sustainable, healthful foods (e.g., fruits and vegetables) financed by a tax on unhealthful, environmentally damaging foods (e.g., red and processed meat) or an incremental increase in income tax [81]. It is estimated that a subsidy of 25% of the cost of fruits and vegetables could close the gap between the recommended intake and the actual average intake by a third [81].

**Author Contributions:** J.G. and F.P.C. conceptualized the article, J.G. wrote the manuscript, F.P.C. contributed to the revision. All authors have read and agreed to the published version of the manuscript.

**Funding:** J.G. is supported by an Economic & Social Research Council PhD Scholarship. This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Acknowledgments:** The views expressed herein are not necessarily the views or the stated policy of the World Health Organization (WHO) and the presentation of the material does not imply the expression of any opinion on the part of WHO.

**Conflicts of Interest:** F.P.C.: Past president, the British and Irish Hypertension Society (2017-9) (unpaid); Member, Action on Salt and World Action on Salt, Sugar and Health (unpaid); Head, World Health Organization (WHO) Collaborating Centre for Nutrition (unpaid); Senior Advisor, WHO (received travel, accommodation, per-diem, refund of expenses); OMRON Academy (received speaker fees, travel, accommodation, expenses); annual royalties from Oxford University Press (OUP) for two books on topics unrelated to salt. J.G. declares no conflict of interest.

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