Simple, cost-effective and convenient instruments like food group-based scores are proposed to assess micronutrient adequacy of children in developing countries. We assessed the predictive ability and seasonal stability of a dietary diversity score (DDS) to indicate dietary quality of infants.

A 24 h dietary recall assessment was carried out on a sample of 320 and 312 breast-fed infants aged 6–12 months during harvest (HS) and pre-harvest (PHS) seasons, respectively, in Ethiopia. DDS was calculated based on seven food groups, while mean micronutrient density adequacy (MMDA) was calculated for eight micronutrients. Multiple linear regression models were used to assess the relationship between DDS and MMDA, and differences in nutrient intake between the two seasons. A receiver-operating characteristic curve analysis was performed to derive DDS cut-offs that maximized sensitivity and specificity of assessing dietary quality.

The study was conducted in the catchment of the Gilgel Gibe Field Research Centre of Jimma University, south-west Ethiopia.

The mean (sd) DDS for HS and PHS was 2·1 (0·94) and 2·3 (1·1), respectively. The DDS was associated with MMDA (β=0·045, P<0·0001 in HS; β=0·044, P<0001 in PHS). A DDS of ≤2 food groups best predicted ‘low’ MMDA (<50 %) with 84 % and 92 % sensitivity, 36 % and 43 % specificity, and 47 % and 51 % correct classification for the HS and PHS, respectively.

DDS is predictive of dietary quality of breast-fed infants. The study supports the use of DDS to indicate inadequate intakes of micronutrients by breast-fed infants in different seasons.

To develop and validate a photographic food atlas of common foods for dietary assessment in southern Nepal.

We created a life-sized photographic atlas of forty locally prepared foods. Between March and June 2014, data collectors weighed portion sizes that respondents consumed during one mealtime and then a different data collector revisited the household the next day to record respondents’ estimations of their previous day’s intakes using the atlas. Validity was assessed by percentage error, Cohen’s weighted kappa (κw) and Bland–Altman limits of agreement.

Dhanusha and Mahottari districts in southern Nepal.

A random sample of ninety-five adults in forty-eight rural households with a pregnant woman.

Overall, respondents underestimated their intakes (mean error =−4·5 %). Rice and dal (spiced lentil soup) intakes were underestimated (−14·1 % and −34·5 %, respectively), but vegetable curry intake was overestimated (+20·8 %). Rice and vegetable curry portion size images were significantly reliably selected (Cohen’s κw (se): rice=0·391 (0·105); vegetable curry=0·430 (0·139)), whereas dal images were not. Energy intake over one mealtime was under-reported by an average of 569 kJ (136 kcal; 4·5 % error) using recall compared with the weighing method.

The photographic atlas is a useful tool for field estimation of dietary intake. Average errors were low, and there was ‘modest’ agreement between weighed and recalled portion size image selection of rice and vegetable curry food items. Error in energy estimation was low but with wide limits of agreement, suggesting that there is scope for future work to reduce error further.

Estimates of fruit and vegetable (FV) consumption vary depending on intake definition, which may be determined by research purpose. Researchers have used two methods to evaluate intake: epidemiological and behavioural. The present study describes FV intake by adults using epidemiological v. behavioural approaches.

One-day dietary intake data from What We Eat In America, National Health and Nutrition Examination Survey 2009–2012 were used. Sample weights were used to produce nationally representative estimates. FV intake (in cup-equivalents (CE)) was estimated using the Food Patterns Equivalents Database. The epidemiological method considered all FV after disaggregating foods and beverages. The behavioural method included foods that provided at least 0·2 CE FV per 100 g, and excluded sources high in fat, added sugar and Na.

Nationally representative survey of the US population.

Adults (n 10 563) aged ≥20 years.

For epidemiological v. behavioural, fruit intake was 1·1 v. 1·0 CE for males and 1·0 v. 0·9 CE for females. Vegetable intake was 1·8 v. 1·1 CE for males and 1·5 v. 1·0 CE for females.

The definition of FV intake affects estimates of consumption by the population and is an important consideration when planning and comparing research studies. The method used should align with research goals to assure accurate interpretation and validity of results.

To compare the performance of mid-upper arm circumference (MUAC) against weight-for-height Z-score (WHZ) for predicting inpatient deaths in children under 5 years of age.

Diagnostic test accuracy study.

Paediatric emergency department of a tertiary care hospital catering to semi-urban and rural population in Delhi, India.

Hospitalized children (n 1663) aged 6 months to 5 years, for whom discharge outcome was available, were consecutively recruited over 14 months. MUAC (cm), weight (kg) height (cm), clinical details and the outcome were recorded. MUAC (index test) was compared with WHZ based on the WHO growth standards (reference test) for predicting the outcome.

One hundred and twenty-four (7 %) children died during hospital stay. Both MUAC < 11·5 cm (adjusted OR (95 % CI): 3·7 (2·43, 5·60), P<0·001) and WHZ<−3 (2·0 (1·37, 2·99), P<0·001) served as independent predictors of inpatient mortality. However, MUAC was a significantly better predictor of mortality compared with WHZ in terms of area under the receiver-operating characteristic curve (MUAC=0·698, WHZ=0·541, P<0·001). MUAC<11·5 cm had the best trade-off of sensitivity and specificity for predicting inpatient mortality. A combination of WHZ<−3 and/or MUAC<11·5 cm did not significantly improve the predictive value over that of MUAC/WHZ, assessed individually.

MUAC<11·5 cm is a better predictor of mortality in hospitalized under-5 children, as compared with WHZ<−3. It should be measured in all emergency settings to identify the children at higher risk of death.

The present analysis aimed to observe nutritional impacts among children <5 years of age by mother’s engagement in paid employment.

Between 1996 and 2012, 21 443 children <5 years of age with diarrhoea attended the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka Hospital. They were enrolled in the hospital-based Diarrhoeal Disease Surveillance System and their relevant information was extracted from the electronic database.

The icddr,b, Bangladesh.

The analytic sample was 19 597 children aged <5 years who had a mother aged ≤35 years with or without engagement in paid employment.

Eleven per cent of the mothers (n 2051) were currently engaged in paid employment on behalf of the family. Univariate analysis showed that children with mothers engaged in paid employment had a 1·14 times higher risk of being undernourished, a 1·20 times of higher risk of being stunted, a 1·21 times higher risk of being wasted and a 1·31 times higher risk of being underweight (risk ratios) than were children with mothers not likewise engaged. Multivariate analysis showed that such associations remained significant for stunting (1·08; 95 % CI 1·00, 1·16), wasting (1·15; 95 % CI 1·06, 1·25) and underweight (1·09; 95 % CI 1·02, 1·17) after controlling for covariates.

Mothers’ engagement in income-generating employment was associated with undernutrition in children <5 years of age in urban Bangladesh.

The mechanism by which the home food environment (HFE) influences childhood obesity is unclear. The present study aimed to investigate the relationship between HFE and childhood obesity as mediated by diet in primary-school children.

Cross-sectional data collected from parents and primary-school children participating in the Obesity Prevention and Lifestyle Evaluation Project. Only children aged 9–11 years participated in the study. Matched parent/child data (n 3323) were analysed. Exploratory factor analysis underlined components of twenty-one HFE items; these were linked to child diet (meeting guidelines for fruit, vegetable and non-core food intakes) and measured child BMI, in structural equation modelling, adjusting for confounders.

Twenty geographically bounded metropolitan and regional South Australian communities.

School children and their parents from primary schools in selected communities.

In the initial exploratory factor analysis, nineteen items remaining extracted eight factors with eigenvalues >1·0 (72·4 % of total variance). A five-factor structure incorporating ten items described HFE. After adjusting for age, gender, socio-economic status and physical activity all associations in the model were significant (P<0·05), explaining 9·3 % and 4·5 % of the variance in child diet and BMI, respectively. A more positive HFE was directly and indirectly associated with a lower BMI in children through child diet.

The robust statistical methodology used in the present study provides support for a model of direct and indirect dynamics between the HFE and childhood obesity. The model can be tested in future longitudinal and intervention studies to identify the most effective components of the HFE to target in childhood obesity prevention efforts.

We explored how Americans aged ≥2 years who consumed the recommended amount of fruits and vegetables on a given day incorporated fruits and vegetables into their diet compared with those who did not consume recommended amounts.

We used 1 d of dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 2007–2010 to examine cross-sectional differences in mean intakes of fruits and vegetables in cup-equivalents by meal, source and form between the two groups.

USA.

NHANES 2007–2010 participants aged ≥2 years (n 17 571) with 1 d of reliable 24 h recall data.

On a given day, the proportions of fruits and vegetables consumed at different meals were similar between those who consumed recommended amounts and those who did not. Among adults, 59–64 % of their intake of fruits was consumed at breakfast or as a snack and almost 90 % came from retail outlets regardless of whether they consumed the recommended amount or not. Adults who consumed the recommended amount of fruits ate more fruits in raw form and with no additions than those who did not. Among children and adults, 52–57 % of vegetables were consumed at dinner by both groups. Retail outlets were the main source of vegetables consumed (60–68 %).

Our findings indicate that habits of when, where and how consumers eat fruits and vegetables might not need to change but increasing the amount consumed would help those not currently meeting the recommendation.

The marketing of infant/child milk-based formulas (MF) contributes to suboptimal breast-feeding and adversely affects child and maternal health outcomes globally. However, little is known about recent changes in MF markets. The present study describes contemporary trends and patterns of MF sales at the global, regional and country levels.

Descriptive statistics of trends and patterns in MF sales volume per infant/child for the years 2008–2013 and projections to 2018, using industry-sourced data.

Eighty countries categorized by country income bracket, for developing countries by region, and in countries with the largest infant/child populations.

MF categories included total (for ages 0–36 months), infant (0–6 months), follow-up (7–12 months), toddler (13–36 months) and special (0–6 months).

In 2008–2013 world total MF sales grew by 40·8 % from 5·5 to 7·8 kg per infant/child/year, a figure predicted to increase to 10·8 kg by 2018. Growth was most rapid in East Asia particularly in China, Indonesia, Thailand and Vietnam and was led by the infant and follow-up formula categories. Sales volume per infant/child was positively associated with country income level although with wide variability between countries.

A global infant and young child feeding (IYCF) transition towards diets higher in MF is underway and is expected to continue apace. The observed increase in MF sales raises serious concern for global child and maternal health, particularly in East Asia, and calls into question the efficacy of current regulatory regimes designed to protect and promote optimal IYCF. The observed changes have not been captured by existing IYCF monitoring systems.

Breast-feeding is associated with positive maternal and infant health and development outcomes. To assist identifying women less likely to meet infant nutritional guidelines, we investigated the role of socio-economic position and parity on initiation of and sustaining breast-feeding for at least 6 months.

Prospective cohort study.

Australia.

Parous women from the Australian Longitudinal Study on Women’s Health (born 1973–78), with self-reported reproductive and breast-feeding history (N 4777).

While 89 % of women (83 % of infants) had ever breast-fed, only 60 % of infants were breast-fed for at least 6 months. Multiparous women were more likely to breast-feed their first child (~90 % v. ~71 % of primiparous women), and women who breast-fed their first child were more likely to breast-feed subsequent children. Women with a low education (adjusted OR (95 % CI): 2·09 (1·67, 2·62)) or a very low-educated parent (1·47 (1·16, 1·88)) had increased odds of not initiating breast-feeding with their first or subsequent children. While fewer women initiated breast-feeding with their youngest child, this was most pronounced among high-educated women. While ~60 % of women breast-fed their first, second and third child for at least 6 months, low-educated women (first child, adjusted OR (95 % CI): 2·19 (1·79, 2·68)) and women with a very low (1·82 (1·49, 2·22)) or low-educated parent (1·69 (1·33, 2·14)) had increased odds of not breast-feeding for at least 6 months.

A greater understanding of barriers to initiating and sustaining breast-feeding, some of which are socio-economic-specific, may assist in reducing inequalities in infant breast-feeding.

Polycyclic aromatic hydrocarbons (PAH) are common dietary exposures that cross the human placenta and are classified as a probable human carcinogen. The aim of the present study was to investigate the potential impact of exposure to PAH-containing meat consumed during pregnancy on birth outcomes.

Prospective birth cohort study. Only non-smoking women with singleton pregnancies, who were free from chronic disease such as diabetes and hypertension, were included in the study. Maternal consumption of PAH-rich meat was estimated through FFQ. Multiple linear regression was used to assess factors related to higher intake and the association between dietary PAH and birth outcomes.

Republic of Korea, 2006–2011.

Pregnant women (n 778) at 12–28 weeks of gestation enrolled in the Mothers and Children’s Environmental Health (MOCEH) study.

The multivariable regression model showed a significant reduction in birth weight associated with higher consumption level of foods rich in PAH, such as grilled or roasted meat, during pregnancy (β=−17·48 g, P<0·05 for every 1 point higher in meat score). Further adjusting for biomarkers of airborne PAH did not alter this association. There was no evidence that higher consumption level of PAH-rich meat shortens the duration of gestation (P=0·561). Regression models performed for birth length and head circumference produced negative effects that were not statistically significant.

Consumption of higher levels of barbecued, fried, roasted and smoked meats during pregnancy was associated with reduced birth weight. Dietary risk of PAH exposure in Korean women is of concern.

To examine the association between BMI and folate concentrations in serum and red blood cells (RBC) in pregnant women.

A cross-sectional comparison of folate concentrations in serum and RBC sampled simultaneously from the same individual.

The Ottawa Hospital and Kingston General Hospital, Ontario, Canada.

Pregnant women recruited between 12 and 20 weeks of gestation.

A total of 869 pregnant women recruited from April 2008 to April 2009 were included in the final analysis. Serum folate was inversely associated and RBC folate positively associated with BMI, after adjusting for folic acid supplementation, age, gestational age at blood sample collection, race, maternal education, annual income, smoking and MTHFR 677C→T genotype. In stratified analyses, this differential association was significant in women with the MTHFR CC variant. In women with the CT and TT variants, the differential associations were in the same direction but not significant. Folic acid supplementation during pregnancy did not alter the differential association of BMI with serum and RBC folate concentration. This indicates that the current RBC folate cut-off approach for assessing risk of neural tube defects in obese women may be limited.

BMI is inversely associated with serum folate and positively associated with RBC folate in pregnant women, especially for those with the MTHFR CC variant.

To identify dietary patterns in the current Japanese diet and evaluate the associations between these patterns and Na and K intakes.

Dietary patterns were extracted by factor analysis from the intakes of food groups assessed with a validated self-administrated diet history questionnaire. Na and K intakes and urinary Na:K were assessed by repeated 24 h urine collection.

Healthy Japanese adults aged 20–69 years (353 men and 349 women).

Twenty study areas in twenty-three prefectures in Japan.

Four dietary patterns were identified in each sex. After adjustment for several confounding factors, the ‘Fish and vegetable’ pattern was associated with higher urinary Na excretion, but the association was not significant (P=0·37 in men and P=0·06 in women). This pattern was also associated with higher K excretion in both sexes. The ‘Noodle’ pattern tended to be associated with higher urinary Na excretion (P=0·17 in men and P=0·04 in women) and higher Na:K (P=0·02 in men). The ‘Meat, vegetable and oil’ (in men)/‘Meat and oil’ (in women) and ‘Bread and confectioneries’ patterns were not associated with urinary Na excretion (in men) or were negatively associated (in women).

Contrary to the case in Western countries, the ‘Fish and vegetable’ and ‘Noodle’ patterns contributed to higher Na intake in Japan. Target foods for salt reduction should be set based on careful consideration of the relationships between dietary patterns and Na and K intakes in the target population.

To assess alcoholic beverage intake among Australian adults and its contribution to dietary energy intake.

Secondary analysis of a national dietary survey using 24 h dietary recall.

Australian National Nutrition and Physical Activity Survey (NNPAS) conducted from May 2011 to June 2012.

Adults (n 9341) aged 19 years and over.

On the day preceding the survey, 32·8% of Australian adults consumed one or more alcoholic drinks. The median contribution to total energy intake for consumers did not differ significantly between males and females (13·7% and 12·9%, respectively; P=0·10). The prevalence of consumption of alcoholic drinks on Friday, Saturday and Sunday was 38·8 (95% CI 37·1, 40·5)%, higher than the other days (28·6 (95% CI 27·5, 29·8)%). Consumers had a median daily intake of 4·0 standard drinks on the weekend compared with 3·0 standard drinks during the week (P<0·001). Beer was the most commonly consumed alcoholic beverage for men and white wine for women. The highest prevalence of alcoholic beverage intake occurred in the highest quintile of adjusted household income (42·7 (95% CI 40·4, 45·0)%) and the ‘overweight’ BMI category (40·3 (95% CI 38·5, 42·0)%). Alcoholic beverage intake among consumers was significantly different by household income quintile (median 3·84 (highest) v. 3·05 standard drinks (lowest); P<0·05) and by waist circumference category (median 4·09 standard drinks (highest)).

Alcoholic drinks contribute substantially to the dietary energy intake of Australian adults. The type and pattern of consumption of alcoholic beverage intake should be considered in the development of strategies to improve dietary intake.

Conflicting results on the association between fruit consumption and cancer risk have been reported. Little is known about the cancer preventive effects of different fruit types. The present meta-analysis investigates whether an association exists between apple intake and cancer risk.

Relevant observational studies were identified by literature search (PubMed, Web of Science and Embase). A random-effect model was used to estimate the cancer risk in different anatomical sites. Between-study heterogeneity and publication bias were assessed using adequate statistical tests.

Twenty case–control (three on lung, five on colorectal, five on breast, two on oesophageal, three on oral cavity, two on prostate and one each on pancreas, bladder, larynx, ovary, kidney and brain cancer) and twenty-one cohort (seven on lung, two on colorectal, three on breast and one each on oesophageal, pancreas, bladder, kidney, endometrial, head–neck, urothelial and stomach cancer) studies met the inclusion criteria. Comparing the highest v. lowest level of apple consumption, the reduction of lung cancer risk was statistically highly significant in both case–control (OR=0·75; 95% CI 0·63, 0·88; P=0·001, I2=0 %) and cohort studies (relative risk=0·89; 95% CI 0·84, 0·94; P<0·001, I2=53 %). Instead, in the case of colorectal (OR=0·66; 95% CI 0·54, 0·81; P<0·001, I2=55%), breast (OR=0·79; 95% CI 0·73, 0·87; P<0·001, I2=1 %) and overall digestive tract (OR=0·50; 95% CI 0·36, 0·69; P<0·001, I2=90 %) cancers a significant preventive effect of apples was found only in case–control studies while prospective studies indicated no effect. No evidence of publication bias could be detected for colorectal, oral cavity, oesophageal and breast cancer. However, some confounding effects may be present and related to the consumption of other fruit which have not been considered as adjusting factors.

The present meta-analysis indicates that consumption of apples is associated with a reduced risk of cancer in different anatomical sites.

To investigate the use of community-supported agriculture (CSA) as an employer-based health promotion intervention.

Quasi-experimental study using a convenience sample of employees at three employers.

Participants and controls from three Minnesota employers completed baseline and follow-up health assessments and surveys about their experiences with CSA.

A total of 324 participants purchased a CSA share and were eligible for study inclusion. Study participants were matched by age, sex, employer and occupation to a non-randomized control group of individuals who did not purchase a CSA share but completed health assessments during the same time frame as the study participants.

The majority of participants were female, white, middle-aged and highly educated. The most common reason for purchasing a CSA share was a desire for fresh food, and the majority of participants were satisfied with their experience. Participants reported a significant increase in the number of vegetables present in the household and the frequency of family meals. The frequency of eating out decreased significantly, especially at fast-food restaurants. Participants also reported an increase in the amount and variety of produce consumed. However, health assessment data did not show significant changes in dietary intake, health status or BMI.

CSA participation was associated with improvement in some aspects of the household environment and dietary behaviours. Further research is needed to determine whether employer-based CSA interventions may also lead to improvements in dietary intake and health.

Conditional cash transfer (CCT) programmes provide income to low-income families in return for fulfilling specific behavioural conditions. CCT have been shown to improve child health, but there are few systematic studies of their impact on multiple determinants of child health. We examined the impact of a CCT programme in Colombia on: (i) use of preventive health services; (ii) food consumption and dietary diversity; (iii) mother’s knowledge, attitudes and practices about caregiving practices; (iv) maternal employment; and (v) women’s empowerment.

Secondary analysis of the quasi-experimental evaluation of the Familias en Accion programme. Children and families were assessed in 2002, 2003 and 2005–06. We applied a difference-in-differences approach using logistic or linear regression, separately examining effects for urban and rural areas.

Colombia.

Children (n 1450) and their families in thirty-one treatment municipalities were compared with children (n 1851) from sixty-five matched control municipalities.

Familias en Accion was associated with a significant increase in the probability of using preventive care services (OR=1·85, 95 % CI 1·03, 3·30) and growth and development check-ups (β=1·36, 95 % CI 0·76, 1·95). It had also a positive impact on dietary diversity and food consumption. No effect was observed on maternal employment, women’s empowerment, and knowledge, attitudes and practices about caregiving practices. Overall, Familias en Accion’s impact was more marked in rural areas.

CCT in Colombia increase contact with preventive care services and improve dietary diversity, but they are less effective in influencing mother’s employment decisions, empowerment and knowledge of caregiving practices.

To progress nutrition policy change and develop more effective advocates, it is useful to consider real-world factors and practical experiences of past advocacy efforts to determine the key barriers to and enablers of nutrition policy change. The present review aimed to identify and synthesize the enablers of and barriers to public policy change within the field of nutrition.

Electronic databases were searched systematically for studies examining policy making in public health nutrition. An interpretive synthesis was undertaken.

International, national, state and local government jurisdictions within high-income, democratic countries.

Sixty-three studies were selected for inclusion. Numerous themes were identified explaining the barriers to and enablers of policy change, all of which fell under the overarching category of ‘political will’, underpinned by a second major category, ‘public will’. Sub-themes, including pressure from industry, neoliberal ideology, use of emotions and values, and being visible, were prevalent in describing links between public will, political will and policy change.

The frustration around lack of public policy change in nutrition frequently stems from a belief that policy making is a rational process in which evidence is used to assess the relative costs and benefits of options. The findings from the present review confirm that evidence is only one component of influencing policy change. For policy change to occur there needs to be the political will, and often the public will, for the proposed policy problem and solution. The review presents a suite of enablers which can assist health professionals to influence political and public will in future advocacy efforts.

To evaluate what is known about the relative health impacts, in terms of nutrient intake and health outcomes, of diets with reduced greenhouse gas emissions (GHGE).

We systematically reviewed the results of published studies that link GHGE of dietary patterns to nutritional content or associated consequences for health.

We included studies published in English in peer-reviewed journals that included data on actual and modelled diets and enabled a matched comparison of GHGE with nutrient composition and/or health outcomes.

Studies included used data from subjects from the general population, who had taken part in dietary surveys or prospective cohort studies.

We identified sixteen eligible studies, with data on 100 dietary patterns. We present the results as dietary links between GHGE reduction and impact on nutrients to limit (n 151), micronutrient content (n 158) and health outcomes (n 25). The results were highly heterogeneous. Across all measures of ‘healthiness’, 64 % (n 214) of dietary links show that reduced GHGE from diets were associated with worse health indicators. However, some trends emerged. In particular, reduced saturated fat and salt are often associated with reduced GHGE in diets that are low in animal products (57/84). Yet these diets are also often high in sugar (38/55) and low in essential micronutrients (129/158).

Dietary scenarios that have lower GHGE compared with average consumption patterns may not result in improvements in nutritional quality or health outcomes. Dietary recommendations for reduced GHGE must also address sugar consumption and micronutrient intake.

To assess the compatibility between reduction of diet-related greenhouse gas emissions (GHGE) and nutritional adequacy, acceptability and affordability dimensions of diet sustainability.

Dietary intake, nutritional composition, GHGE and prices were combined for 402 foods selected among those most consumed by participants of the Individual National Study on Food Consumption. Linear programming was used to model diets with stepwise GHGE reductions, minimized departure from observed diet and three scenarios of nutritional constraints: none (FREE), on macronutrients (MACRO) and for all nutrient recommendations (ADEQ). Nutritional quality was assessed using the mean adequacy ratio (MAR) and solid energy density (SED).

France.

Adults (n 1899).

In FREE and MACRO scenarios, imposing up to 30 % GHGE reduction did not affect the MAR, SED and food group pattern of the observed diet, but required substitutions within food groups; higher GHGE reductions decreased diet cost, but also nutritional quality, even with constraints on macronutrients. Imposing all nutritional recommendations (ADEQ) increased the fruits and vegetables quantity, reduced SED and slightly increased diet cost without additional modifications induced by the GHGE constraint up to 30 % reduction; higher GHGE reductions decreased diet cost but required non-trivial dietary shifts from the observed diet. Not all the nutritional recommendations could be met for GHGE reductions ≥70 %.

Moderate GHGE reductions (≤30 %) were compatible with nutritional adequacy and affordability without adding major food group shifts to those induced by nutritional recommendations. Higher GHGE reductions either impaired nutritional quality, even when macronutrient recommendations were imposed, or required non-trivial dietary shifts compromising acceptability to reach nutritional adequacy.