Achieving dietary micronutrient adequacy in a finite world
2021; Elsevier BV; Volume: 4; Issue: 9 Linguagem: Inglês
10.1016/j.oneear.2021.08.019
ISSN2590-3330
Autores Tópico(s)Consumer Attitudes and Food Labeling
ResumoModern food systems have contributed to extensive environmental degradation, resulting in calls for a planetary health diet that dramatically reduces the consumption of animal-source foods. However, animal-source foods provide key micronutrients vital to healthy diets. Planetary boundaries and local contexts must be considered to facilitate regenerative and sustainable livestock production. Modern food systems have contributed to extensive environmental degradation, resulting in calls for a planetary health diet that dramatically reduces the consumption of animal-source foods. However, animal-source foods provide key micronutrients vital to healthy diets. Planetary boundaries and local contexts must be considered to facilitate regenerative and sustainable livestock production. Main textNo species has transformed the planet like humans. Much of this transformation has come from the processes involved in producing food for human consumption. Modern food systems—which include the people, places, and practices involved in food production, capture, harvest, processing, transport, retail, consumption, and disposal—are responsible for extensive loss of natural resources and the destruction of ecosystems and biodiversity. But food systems are also essential for human survival. Much of the destructive nature of our food systems has been attributed to our domestication of livestock and the resources this requires. The animal-source foods (ASFs) derived from these livestock also happen to provide us with many of the nutrients we need (Figure 1), access to which varies dramatically around the world. How we provide a growing global population with these essential nutrients while staying within environmental limits is one of our greatest and most pressing challenges.In particular, micronutrients such as iron, zinc, folate, calcium, and vitamins A, B12, and D are commonly lacking globally, to the greatest degree in South Asia and Africa.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar And ASFs contain the highest amounts of these micronutrients (Figure 1). But there is a growing consensus that ASFs are generally more resource intensive to produce and have greater negative environmental impacts than plant-source foods (PSFs), at least based on average existing production practices and per quantity of kilograms, calories, or protein.4Poore J. Nemecek T. Reducing food’s environmental impacts through producers and consumers.Science. 2018; 360: 987-992Crossref PubMed Scopus (1472) Google Scholar For example, a recent modeling analysis suggested that replacing just 10% of calories from beef and processed meat with PSFs and select seafoods could reduce an individual’s dietary carbon footprint by 33%.5Stylianou K.S. Fulgoni V.L. Jolliet O. Small targeted dietary changes can yield substantial gains for human and environmental health.Nat. Food. 2021; 2: 616-627Crossref Scopus (19) Google Scholar Most recently, the EAT-Lancet Commission developed a “planetary health diet” (PHD) that considerably reduces (where intake is high) and limits the increase of (where intake is low) the global production and consumption of ASFs (i.e., meat, fish, eggs, and dairy), especially meat and eggs.6Willett W. Rockström J. Loken B. Springmann M. Lang T. Vermeulen S. Garnett T. Tilman D. DeClerck F. Wood A. et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Abstract Full Text Full Text PDF PubMed Scopus (3059) Google Scholar Compared with the current diet in the United States, of which ASFs make up 30% of calories,7Rehkamp S. A Look at Calorie Sources in the American Diet.https://www.ers.usda.gov/amber-waves/2016/december/a-look-at-calorie-sources-in-the-american-diet/Date: 2016Google Scholar the PHD recommends only 14% of dietary energy come from ASFs or even as little as 0%.6Willett W. Rockström J. Loken B. Springmann M. Lang T. Vermeulen S. Garnett T. Tilman D. DeClerck F. Wood A. et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Abstract Full Text Full Text PDF PubMed Scopus (3059) Google Scholar Given the widespread global burden of micronutrient deficiencies and the higher density and bioavailability of several of these micronutrients in ASFs, there is concern about the extent to which a PHD can practically satisfy micronutrient requirements.Burden of micronutrient deficienciesMicronutrient deficiencies, particularly deficiencies in iron, zinc, folate, calcium, and vitamins A, B12, and D, can have severe and long-term consequences.8Beal T. White J.M. Arsenault J.E. Okronipa H. Hinnouho G.-M. Morris S.S. Comprehensive Nutrient Gap Assessment (CONGA): A method for identifying the public health significance of nutrient gaps.Nutr. Rev. 2021; 79: 4-15Crossref PubMed Scopus (7) Google Scholar These include increased morbidity and mortality, delayed cognitive and motor development, and impaired academic and work capacity, reproductive outcomes, and overall health.8Beal T. White J.M. Arsenault J.E. Okronipa H. Hinnouho G.-M. Morris S.S. Comprehensive Nutrient Gap Assessment (CONGA): A method for identifying the public health significance of nutrient gaps.Nutr. Rev. 2021; 79: 4-15Crossref PubMed Scopus (7) Google Scholar The global prevalence and number of people with micronutrient deficiencies are unknown. However, existing evidence reveals a large burden globally, especially in women and children.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar For example, more than four in five adolescents in India have a deficiency in at least one micronutrient.9Sethi V. Lahiri A. Bhanot A. Kumar A. Chopra M. Mishra R. Adolescents, Diets and Nutrition: Growing well in a Changing World.https://www.unicef.org/india/reports/adolescents-diets-and-nutritionDate: 2019Google Scholar In general, deficiencies are highest in South Asia and sub-Saharan Africa.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar However, prevalence of micronutrient deficiencies among women is high even in high-income countries, including the United Kingdom and United States,3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar where a large majority of the population has access to diverse diets and large-scale food fortification is widespread. This might be due to dietary preferences for palatable but nutrient-poor foods—for example, more than half of calories consumed in both countries come from ultra-processed foods.10Lane M.M. Davis J.A. Beattie S. Gómez-Donoso C. Loughman A. O’Neil A. Jacka F. Berk M. Page R. Marx W. Rocks T. Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies.Obes. Rev. 2021; 22: e13146Crossref PubMed Scopus (113) Google Scholar Access to diverse diets, including ASFs, and to fortified foods has certainly helped to reduce the prevalence of micronutrient deficiencies globally, but has not been enough to end micronutrient malnutrition.Potential micronutrient gaps on a PHDProponents of a PHD have argued that diets exclusively consisting of PSFs (with vitamin B12 supplements) or those that are very low in ASFs can adhere to dietary guidelines and easily meet nutrient requirements.6Willett W. Rockström J. Loken B. Springmann M. Lang T. Vermeulen S. Garnett T. Tilman D. DeClerck F. Wood A. et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Abstract Full Text Full Text PDF PubMed Scopus (3059) Google Scholar While this is theoretically possible based on a limited number of essential nutrients, data on micronutrient adequacy of the food supply11Beal T. Massiot E. Arsenault J.E. Smith M.R. Hijmans R.J. Global trends in dietary micronutrient supplies and estimated prevalence of inadequate intakes.PLoS ONE. 2017; 12: e0175554Crossref PubMed Scopus (168) Google Scholar,12Smith N.W. Fletcher A.J. Dave L.A. Hill J.P. McNabb W.C. Use of the DELTA Model to Understand the Food System and Global Nutrition.J. Nutr. 2021; : nxab199Crossref PubMed Scopus (11) Google Scholar and prevalence of micronutrient deficiencies3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar suggest that practically meeting micronutrient requirements and preventing deficiency is remarkably challenging for a large proportion of the population in countries of all income levels and dietary patterns. Limiting or eliminating nutrient-dense ASFs from the diet reduces dietary robustness and the likelihood of meeting requirements for several micronutrients. For example, ASFs provide the only dietary source of vitamin D and B12 and contain higher densities and more bioavailable forms of iron, zinc, and vitamin A than found in PSFs, as shown to some extent in Figure 1 (although the units for iron and zinc do not reflect the higher bioavailability in ASFs). Thus, attempts to adopt a PHD might exacerbate or hinder progress toward achieving micronutrient adequacy, particularly in sub-Saharan Africa and South Asia where diets lack diversity and are already low in ASFs, especially among lower-income consumers.A potential strategy to fill the gapsThe top food sources of micronutrients commonly lacking globally are organ meats (including liver, spleen, kidney, and heart), dark green leafy vegetables, shellfish (including bivalves and crustaceans), fish (with bones), ruminant meat, eggs, and dairy.2U.S. Department of Agriculture, Agricultural Research ServiceFoodData Central.https://fdc.nal.usda.gov/Date: 2019Google Scholar Any changes in dietary patterns to reduce ASF consumption will require substantial efforts to increase intake of the most nutrient-dense PSFs, particularly dark green leafy vegetables and, to a lesser extent, pulses, traditional whole grains, and seeds. Nevertheless, because several key micronutrients (such as iron, vitamin D, and B12) are challenging to obtain adequate quantities of with diets containing limited ASFs, a shift to a PHD will also require complementary approaches such as fortification, biofortification, and/or supplementation, especially for population groups with increased needs, including women of reproductive age, pregnant and lactating women, adolescents, and young children during the complementary feeding period.However, the continued high prevalence of micronutrient deficiencies in wealthy countries3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar with widespread availability of fortified foods and supplements suggests that these approaches alone may be insufficient means to fill the micronutrient gaps. Rather, a more robust strategy from a nutritional perspective would be to simultaneously improve overall diet quality, increasing the diversity of foods inherently dense in micronutrients, including a moderate amount of the most nutrient-dense ASFs, while at the same time improving fortification coverage of nutrient-poor staple foods and making better use of appropriate supplementation when needed. This approach, which depending on the context might include more ASFs than recommended in the EAT-Lancet Commission PHD, could still support planetary health, with attention to diversifying crop and livestock production and regeneratively and sustainably producing foods in alignment with local ecosystems.Importantly, such a strategy should however recognize the increasing concern around ultra-processed foods globally, which are associated with obesity and numerous non-communicable diseases, including diabetes, heart disease, and some cancers.10Lane M.M. Davis J.A. Beattie S. Gómez-Donoso C. Loughman A. O’Neil A. Jacka F. Berk M. Page R. Marx W. Rocks T. Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies.Obes. Rev. 2021; 22: e13146Crossref PubMed Scopus (113) Google Scholar Moreover, foods contain tens of thousands of compounds that are bound together in a food matrix—many of which are exclusive to ASFs, including creatine, anserine, carnosine, and taurine.13van Vliet S. Kronberg S.L. Provenza F.D. Plant-Based Meats, Human Health, and Climate Change.Front. Sustain. Food Syst. 2020; https://doi.org/10.3389/fsufs.2020.00128Crossref Scopus (39) Google Scholar While most of these compounds have not been identified as essential, they may play important roles in health and disease.13van Vliet S. Kronberg S.L. Provenza F.D. Plant-Based Meats, Human Health, and Climate Change.Front. Sustain. Food Syst. 2020; https://doi.org/10.3389/fsufs.2020.00128Crossref Scopus (39) Google Scholar Shifts to a PHD would limit intake of numerous compounds exclusive to ASFs. It could also have the unintended consequence of increasing the consumption of ultra-processed foods, since plant-based foods are often universally framed as healthy, regardless of whether or not they are ultra-processed. Whereas, even if fortified, ultra-processed foods may not provide the same nutritional value as minimally processed whole foods inherently rich in diverse and synergistic nutrients13van Vliet S. Kronberg S.L. Provenza F.D. Plant-Based Meats, Human Health, and Climate Change.Front. Sustain. Food Syst. 2020; https://doi.org/10.3389/fsufs.2020.00128Crossref Scopus (39) Google Scholar and may exacerbate obesity and non-communicable diseases.10Lane M.M. Davis J.A. Beattie S. Gómez-Donoso C. Loughman A. O’Neil A. Jacka F. Berk M. Page R. Marx W. Rocks T. Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies.Obes. Rev. 2021; 22: e13146Crossref PubMed Scopus (113) Google ScholarMeeting micronutrient needs within planetary boundariesAs suggested above and supported by a recent analysis of the global food system and nutrient adequacy,12Smith N.W. Fletcher A.J. Dave L.A. Hill J.P. McNabb W.C. Use of the DELTA Model to Understand the Food System and Global Nutrition.J. Nutr. 2021; : nxab199Crossref PubMed Scopus (11) Google Scholar nutritionally adequate diets at the population level should include moderate amounts of ASFs. The remaining questions to tackle are how much, which foods, and where? The answers to these questions will vary depending on the context. That is the problem with overly prescriptive diets that include global per capita recommended amounts of ASFs. In Australia, where the large majority of land is natural rangeland with limited suitability for producing crops and where there are cultural preferences for ruminant meat, a fair amount could arguably be produced sustainably with appropriate grazing practices. In contrast, it would be ecologically unsustainable to produce large amounts of ruminant meat in Indonesia, where the natural ecosystems consist largely of biodiverse rainforests that also serve as important carbon sinks—instead it would make more sense to sustainably produce greater quantities of seafood. Determining the exact amounts of particular foods that can sustainably be produced in any context will require careful analysis of the carrying capacity of the agricultural land, consideration of a range of feasible and sustainable production practices, and an equitable decision-making process that fairly involves all stakeholders when considering population level dietary changes based on such evidence.The discussion becomes more complicated when considering planetary boundaries, such that about half of global food production at present has transgressed several boundaries including biosphere integrity, land-system change, freshwater use, and nitrogen flows.14Gerten D. Heck V. Jägermeyr J. Bodirsky B.L. Fetzer I. Jalava M. Kummu M. Lucht W. Rockström J. Schaphoff S. et al.Feeding ten billion people is possible within four terrestrial planetary boundaries.Nat Sustain. 2020; 3: 200-208Crossref Scopus (156) Google Scholar An expected future global population of nearly 10 billion by 2050, with rapid increase in sub-Saharan Africa in particular, will add additional challenges to feeding a growing population within the boundaries of a finite world. Current production methods of ASFs on the whole are unsustainable, as they are to some extent for many PSFs, which are often produced on croplands with marginal yields yet high costs to wildlife.15Lark T.J. Spawn S.A. Bougie M. Gibbs H.K. Cropland expansion in the United States produces marginal yields at high costs to wildlife.Nat. Commun. 2020; 11: 4295Crossref PubMed Scopus (69) Google Scholar Part of the negative impact of current livestock production methods is that one-third of global arable land is used to grow crops for animal feed. Further, much of the crops for human consumption and animal feed are produced through intensive monocultures that are reliant on fossil-fuel derived fertilizers (e.g., nitrogen fertilizer) and pollute waterways, deplete topsoil, and reduce biodiversity.16Kremen C. Miles A. Ecosystem Services in Biologically Diversified versus Conventional Farming Systems: Benefits, Externalities, and Trade-Offs.Ecol. Soc. 2012; 17: 40Crossref Scopus (565) Google ScholarBut there are many alternative options for producing livestock sustainably and even regenerating degraded land, and the potential for these methods to improve upon the status quo can only increase with greater investment in related research and development. Available evidence suggests diverse agricultural production that incorporates well-managed livestock has potential to regenerate degraded soil, increase biodiversity and water retention, and reduce greenhouse gas emissions and the use of external inputs, thereby increasing the profitability, resilience, and sustainability of food production and the livelihoods depending on it.16Kremen C. Miles A. Ecosystem Services in Biologically Diversified versus Conventional Farming Systems: Benefits, Externalities, and Trade-Offs.Ecol. Soc. 2012; 17: 40Crossref Scopus (565) Google Scholar,17LaCanne C.E. Lundgren J.G. Regenerative agriculture: merging farming and natural resource conservation profitably.PeerJ. 2018; 6: e4428Crossref PubMed Scopus (105) Google Scholar For example, Figure 2 shows a diverse, regenerative permaculture farm in Nepal that produces over 100 crops and livestock products, while providing a natural habitat for insects and wildlife. Indeed, natural ecosystems contain plants, animals, and microorganisms. We must move away from the notion that agriculture and nature are somehow separate entities that are unable to coexist. Agroecological systems are capable of modeling, to some extent, locally appropriate natural ecosystems and still producing high overall yields sustainably.Figure 2Regenerative permaculture farm in NepalShow full captionThis is an example of a regenerative farming approach that can co-produce over 100 different crops and livestock products. Photo by Almost Heaven Farms (https://permaculturenepal.com).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Finally, the nutritional and environmental metrics that are used influence the conclusions made regarding impacts. For example, if environmental impacts were assessed in terms of each food’s density in bioavailable nutrients, many ASFs might fare better than PSFs. Moreover, environmental metrics like biodiversity, soil health, and water retention may favor regenerative ruminant production over crop production in contexts with marginal rangeland or degraded soil.16Kremen C. Miles A. Ecosystem Services in Biologically Diversified versus Conventional Farming Systems: Benefits, Externalities, and Trade-Offs.Ecol. Soc. 2012; 17: 40Crossref Scopus (565) Google Scholar,17LaCanne C.E. Lundgren J.G. Regenerative agriculture: merging farming and natural resource conservation profitably.PeerJ. 2018; 6: e4428Crossref PubMed Scopus (105) Google Scholar Ruminant livestock can also uniquely convert non-human edible resources such as crop residues and forage (which make up >95% of their diet), even on marginal or non-arable land, into nutrient-dense meat and milk for human consumption (among other non-food products that further contribute to livelihoods and society).18Mottet A. Teillard F. Boettcher P. Besi G.D. Besbes B. Review: Domestic herbivores and food security: current contribution, trends and challenges for a sustainable development.Animal. 2018; 12: s188-s198Crossref PubMed Scopus (39) Google Scholar Future global environmental impact studies could incentivize best practices for regenerative and sustainable animal agriculture by modeling the scaling up of the most sustainable livestock practices available. Such efforts could also support approaches to sustainably increase consumption of ASFs in sub-Saharan Africa and South Asia, where populations would largely benefit from increased intake of nutrient dense ASFs.ConclusionThere is robust evidence that the global food system is failing to provide adequate nutrients to prevent micronutrient deficiencies and at the same time is transgressing planetary boundaries. Achieving nutrient adequate diets within planetary boundaries will require unified societal and political will, innovative research, and adaptation to local context. Initial approaches to quantitatively design a PHD have provided the first step toward addressing the urgent need for food systems transformation. Future research toward a PHD 2.0 should be more inclusive of diverse stakeholders, give more credence to the potential of regenerative and sustainable animal agriculture, be less prescriptive and allow for more flexibility in proportions of dietary components such as ASFs depending on the context, and better acknowledge trade-offs across a range of food system outputs, such as environmental impact and risk of micronutrient malnutrition. All foods, be they animal-sourced or plant-based, must be produced sustainably according to the local context and within planetary boundaries and produced in proportions that facilitate healthy diets for all. The health of humanity and our planet depend on it. Main textNo species has transformed the planet like humans. Much of this transformation has come from the processes involved in producing food for human consumption. Modern food systems—which include the people, places, and practices involved in food production, capture, harvest, processing, transport, retail, consumption, and disposal—are responsible for extensive loss of natural resources and the destruction of ecosystems and biodiversity. But food systems are also essential for human survival. Much of the destructive nature of our food systems has been attributed to our domestication of livestock and the resources this requires. The animal-source foods (ASFs) derived from these livestock also happen to provide us with many of the nutrients we need (Figure 1), access to which varies dramatically around the world. How we provide a growing global population with these essential nutrients while staying within environmental limits is one of our greatest and most pressing challenges.In particular, micronutrients such as iron, zinc, folate, calcium, and vitamins A, B12, and D are commonly lacking globally, to the greatest degree in South Asia and Africa.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar And ASFs contain the highest amounts of these micronutrients (Figure 1). But there is a growing consensus that ASFs are generally more resource intensive to produce and have greater negative environmental impacts than plant-source foods (PSFs), at least based on average existing production practices and per quantity of kilograms, calories, or protein.4Poore J. Nemecek T. Reducing food’s environmental impacts through producers and consumers.Science. 2018; 360: 987-992Crossref PubMed Scopus (1472) Google Scholar For example, a recent modeling analysis suggested that replacing just 10% of calories from beef and processed meat with PSFs and select seafoods could reduce an individual’s dietary carbon footprint by 33%.5Stylianou K.S. Fulgoni V.L. Jolliet O. Small targeted dietary changes can yield substantial gains for human and environmental health.Nat. Food. 2021; 2: 616-627Crossref Scopus (19) Google Scholar Most recently, the EAT-Lancet Commission developed a “planetary health diet” (PHD) that considerably reduces (where intake is high) and limits the increase of (where intake is low) the global production and consumption of ASFs (i.e., meat, fish, eggs, and dairy), especially meat and eggs.6Willett W. Rockström J. Loken B. Springmann M. Lang T. Vermeulen S. Garnett T. Tilman D. DeClerck F. Wood A. et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Abstract Full Text Full Text PDF PubMed Scopus (3059) Google Scholar Compared with the current diet in the United States, of which ASFs make up 30% of calories,7Rehkamp S. A Look at Calorie Sources in the American Diet.https://www.ers.usda.gov/amber-waves/2016/december/a-look-at-calorie-sources-in-the-american-diet/Date: 2016Google Scholar the PHD recommends only 14% of dietary energy come from ASFs or even as little as 0%.6Willett W. Rockström J. Loken B. Springmann M. Lang T. Vermeulen S. Garnett T. Tilman D. DeClerck F. Wood A. et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Abstract Full Text Full Text PDF PubMed Scopus (3059) Google Scholar Given the widespread global burden of micronutrient deficiencies and the higher density and bioavailability of several of these micronutrients in ASFs, there is concern about the extent to which a PHD can practically satisfy micronutrient requirements.Burden of micronutrient deficienciesMicronutrient deficiencies, particularly deficiencies in iron, zinc, folate, calcium, and vitamins A, B12, and D, can have severe and long-term consequences.8Beal T. White J.M. Arsenault J.E. Okronipa H. Hinnouho G.-M. Morris S.S. Comprehensive Nutrient Gap Assessment (CONGA): A method for identifying the public health significance of nutrient gaps.Nutr. Rev. 2021; 79: 4-15Crossref PubMed Scopus (7) Google Scholar These include increased morbidity and mortality, delayed cognitive and motor development, and impaired academic and work capacity, reproductive outcomes, and overall health.8Beal T. White J.M. Arsenault J.E. Okronipa H. Hinnouho G.-M. Morris S.S. Comprehensive Nutrient Gap Assessment (CONGA): A method for identifying the public health significance of nutrient gaps.Nutr. Rev. 2021; 79: 4-15Crossref PubMed Scopus (7) Google Scholar The global prevalence and number of people with micronutrient deficiencies are unknown. However, existing evidence reveals a large burden globally, especially in women and children.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar For example, more than four in five adolescents in India have a deficiency in at least one micronutrient.9Sethi V. Lahiri A. Bhanot A. Kumar A. Chopra M. Mishra R. Adolescents, Diets and Nutrition: Growing well in a Changing World.https://www.unicef.org/india/reports/adolescents-diets-and-nutritionDate: 2019Google Scholar In general, deficiencies are highest in South Asia and sub-Saharan Africa.3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar However, prevalence of micronutrient deficiencies among women is high even in high-income countries, including the United Kingdom and United States,3WHOVitamin and Mineral Nutrition Information System (VMNIS).https://www.who.int/teams/nutrition-and-food-safety/databases/vitamin-and-mineral-nutrition-information-systemDate: 2021Google Scholar where a large majority of the population has access to diverse diets and large-scale food fortification is widespread. This might be due to dietary preferences for palatable but nutrient-poor foods—for example, more than half of calories consumed in both countries come from ultra-processed foods.10Lane M.M. Davis J.A. Beattie S. Gómez-Donoso C. Loughman A. O’Neil A. Jacka F. Berk M. Page R. Marx W. Rocks T. Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies.Obes. Rev. 2021; 22: e13146Crossref PubMed Scopus (113) Google Scholar Access to diverse diets, including ASFs, and to fortified foods has certainly helped to reduce the prevalence of micronutrient deficiencies globally, but has not been enough to end micronutrient malnutrition.Potential micronutrient gaps on a PHDProponents of a PHD have argued that diets exclusively consisting of PSFs (with vitamin B12 supp
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