**1. Introduction**

Ethnicity-based health disparities have been central to the public health discourse in the past decades [1–3] and have remained so, particularly amid the current COVID-19 pandemic [4–7]. Major risk factors for hospitalization, severity and mortality of COVID-19 include diet-related conditions, such as obesity, hypertension and type 2 diabetes, which have been shown to disproportionally affect the most vulnerable [8–10].

Mounting evidence has consistently shown a strong link between ethnic and socioeconomic disparities with dietary and nutrient patterns [11–13]. Such inequities exist in

**Citation:** Llanaj, E.; Vincze, F.; Kósa, Z.; Bárdos, H.; Diószegi, J.; Sándor, J.; Ádány, R. Deteriorated Dietary Patterns with Regards to Health and Environmental Sustainability among Hungarian Roma Are Not Differentiated from Those of the General Population. *Nutrients* **2021**, *13*, 721. https://doi.org/10.3390/ nu13030721

Academic Editor: Lourdes Varela

Received: 14 January 2021 Accepted: 20 February 2021 Published: 24 February 2021

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many forms, including in diet composition, nutritional behaviors, intake patterns, etc. often resulting in substandard dietary quality, poorer health outcomes and disproportionate burden of disease [14,15]. Along with the growing burden of diet-related noncommunicable diseases (NCDs), there is also a growing interest in characterizing their association with dietary and nutrient patterns in specific, particularly among disadvantaged minority population groups.

In Europe, the Roma population constitutes the largest ethnic minority (estimated to be between 10–12 million) [16] and has been a target of ethnicity-based studies over the past decade [17,18]. Results from different European countries, characterizing dietary aspects of Roma, have revealed inadequate presence of fruits, vegetables [19–32] and dairy products [23,25–27,33] in their diet, frequent fast-foods consumption [34–37], as well as high intake of animal fats [28,31,35,38], sugar-sweetened beverages [22,23,28,37] and sweets [28]. In our previous work, we reported a suboptimal dietary profile and nutritional status of Hungarian Roma (HR) living in segregated colonies in northeastern Hungary, with inadequate nutrient composition and anthropometric status estimates, not strongly different than Hungarian general (HG) population, but occasionally worse among HR. Our findings indicated small differences in meeting nutrient-based dietary recommendations between the two populations, with Roma being less likely to comply with health-promoting nutrient targets [39]. Such information is very useful in informing public health nutrition preventive interventions among Roma, i.e., identifying effective ways of intervening to reduce health inequalities. However, further information on dietary patterns is necessary, in order to gain a higher-resolution and deeper understanding on the current dietary situation and its relation, not only with health, but sustainability considerations as well. What we are eating and how we are producing food is also exerting huge environmental pressures, besides health and nutritional concerns [40]. Diet has emerged as one of the most promising levers to improve health and environmental sustainability, particularly on the demand side of the challenge [41]. It has been demonstrated how health-promoting dietary patterns often have lower environmental impacts, suggesting that dietary shifts that might reduce the risk of NCDs, have the potential to also support attainment of environmental sustainability targets [42,43]. To address the needs emerging from a growing global population, a healthy diet from sustainable food systems was defined by the EAT-Lancet report, a universal reference diet which aims to promote both human health and environmental sustainability [43].

It is reasonable to suppose that diversity and inclusion is key to unlocking sustainability and in creating the kind of development which meets the needs of current generations without compromising the ability of future generations to meet their own needs. Therefore, it is timely and highly relevant to address malnutrition in all its forms and its implications not only with regards to health, but environmental sustainability considerations as well, among underserved groups. With that in mind, we attempt to elucidate the association of Roma ethnicity with regards to dietary patterns shown to strongly influence health (i.e., Healthy Diet Indicator (HDI) and Dietary Inflammatory Index (DII)) and environmental sustainability (i.e., Dietary Approaches to Stop Hypertension (DASH), EAT-Lancet), while considering HG population as reference. To the best of our knowledge, this is the first study among Roma, to date, addressing the relevance of diet for human and planetary health.

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

#### *2.1. Study Design*

For this report, we analyzed data obtained from a three-pillar (questionnaire-based, physical examination and laboratory examination) complex (health behavior and examination) survey. Details of sampling and data collection and management are thoroughly described elsewhere [44]. In brief, individuals aged 20 to 64 years, were selected randomly, to be representative of the adult HR population living in segregated colonies of northeast Hungary (Hajdú-Bihar and Szabolcs-Szatmár-Bereg counties), where a great proportion of the HR population resides, as well as that of the HG population living in the same counties. In addition to the demographic, anthropometric, health behavior, physical and laboratory data collection, two 24 h recalls were also obtained to quantify dietary intake. The intended sample size was 500 participants for both study groups, but the final study sample, with full recall data, included 797 participants, of whom 410 subjects were of the HG and 387 individuals of the HR population. The current analysis included 703 participants (359 HG and 344 HR). Detailed information on design, sampling, piloting and validation of the dietary instrument are described elsewhere [39]. In brief, dietary intake data were collected in the case of each participant through a double (one non-consecutive weekday and a weekend day), interviewer-assisted, multiple-pass 24 h dietary recall protocol developed and validated in our previous study [45].
