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BMJ Open. 2019 Feb 21;9(2):e021541. doi: 10.1136/bmjopen-2018-021541.

Global sustainability (health, environment and monetary costs) of three dietary patterns: results from a Spanish cohort (the SUN project).

Author information

Center for Nutrition, Healthy Lifestyles and Disease Prevention, Loma Linda University, Loma Linda, California, USA.
Department of Preventive Medicine and Public Health, Universidad de Navarra, Pamplona, Spain.
CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain.
Center for Nutrition, Healthy Lifestyles, and Disease Prevention, Adventist Health Sciences Center, Loma Linda University, Loma Linda, California, USA.



To evaluate the sustainability of the dietary patterns, according to their effects on health and environment and their affordability.


Prospective, ongoing cohort study of university graduates.


The Spanish SUN project (Seguimiento Universidad de Navarra, University of Navarra Follow-up), starting from 1999.


A total of 18 429 participants.


Information from participants is collected every 2 years by validated questionnaires. We assessed three dietary patterns (the Mediterranean, the Western and the Provegetarian dietary patterns). The rate advancement period (RAP) was used to assess the healthiness of each pattern (considering the composite endpoint of all-cause mortality, cardiovascular disease, breast cancer or type 2 diabetes). We also assessed environmental footprints and monetary costs of each dietary pattern.


After a median follow-up of 10.1 years, we identified 469 incident cases of the composite endpoint. The Mediterranean dietary pattern exhibited the best RAP (3.10 years gained [95% CI 4.35 to 1.85] for the highest vs the lowest quartile), while the Western pattern was the unhealthiest pattern (1.33 years lost when comparing extreme quartiles). In a scale between 4 and 16 of harmful environmental effects (the lower, the more environmentally friendly), the Provegetarian pattern scored best (8.82 [95% CI 8.75 to 8.88] when comparing extreme quartiles), whereas the Western pattern was the most detrimental pattern (10.80 [95% CI 10.72 to 10.87]). Regarding monetary costs, the Western pattern was the most affordable pattern (€5.87/day [95% CI 5.82 to 5.93], for the upper quartile), while the Mediterranean pattern was the most expensive pattern (€7.52/day [95% CI 7.47 to 7.56]). The Mediterranean dietary pattern was the most overall sustainable option, closely followed by the Provegetarian pattern. The least overall sustainable pattern was the Western dietary pattern.


Following plant-based diets, like the Mediterranean or Provegetarian dietary patterns, could be a good option in order to achieve an overall sustainable diet.


NCT02669602; Results.


epidemiology; public health

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