지속가능한 식이의 개념과 측정방법 및 한국형 식이 지수 개발을 위한 방안 모색: 주제범위 문헌고찰과 기술 연구

Sukyoung Jung

doi:10.5720/kjcn.2024.29.1.34

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Research Article 지속가능한 식이의 개념과 측정방법 및 한국형 식이 지수 개발을 위한 방안 모색: 주제범위 문헌고찰과 기술 연구: 정수경^1),†
Sustainable diets: a scoping review and descriptive study of concept, measurement, and suggested methods for the development of Korean version: Sukyoung Jung^1),†; Korean Journal of Community Nutrition 2024;29(1):34-50.
DOI: https://doi.org/10.5720/kjcn.2024.29.1.34
Published online: February 29, 2024

¹⁾충남대학교병원 의생명연구원, 연구교수

¹⁾Research Professor, Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea

†Corresponding author: Sukyoung Jung Biomedical Research Institute, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea. Tel: +82-42-280-6705 Fax: +82-42-280-6751 Email: sukyoung_jung@gwu.edu

• Received: December 26, 2023 • Revised: February 2, 2024 • Accepted: February 2, 2024

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSIONS
NOTES
SUPPLEMENTARY MATERIALS
REFERENCES

Abstract

Objectives
Transformation through a sustainable food system to provide healthy diets is essential for enhancing both human and planetary health. This study aimed to explain about sustainable diets and illustrate appropriate measurement of adherence to sustainable diets using a pre-existing index.
Methods
For literature review, we used PubMed and Google Scholar databases by combining the search terms “development,” “validation,” “sustainable diet,” “sustainable diet index,” “planetary healthy diet,” “EAT-Lancet diet,” and “EAT-Lancet reference diet.” For data presentation, we used data from National Health and Nutrition Examination Survey, 2017–2018, among adults aged 20 years and older (n = 3,920). Sustainable Diet Index-US (SDI-US), comprising four sub-indices corresponding to four dimensions of sustainable diets (nutritional quality, environmental impacts, affordability, and sociocultural practices), was calculated using data from 24-hour dietary recall interview, food expenditures, and food choices. A higher SDI-US score indicated greater adherence to sustainable diets (range: 4–20). This study also presented SDI-US scores according to the sociodemographic status. All analyses accounted for a complex survey design.
Results
Of 148 papers, 16 were reviewed. Adherence to sustainable diets fell into 3 categories: EAT-Lancet reference diet-based (n = 8), Food and Agriculture Organization (FAO) definition-based (n = 4), and no specific guidelines but including the sustainability concept (n = 4). Importantly, FAO definition emphasizes on equal importance of four dimensions of diet (nutrition and health, economic, social and cultural, and environmental). The mean SDI-US score was 13 out of 20 points, and was higher in older, female, and highly educated adults than in their counterparts.
Conclusions
This study highlighted that sustainable diets should be assessed using a multidimensional approach because of their complex nature. Currently, SDI can be a good option for operationalizing multidimensional sustainable diets. It is necessary to develop a Korean version of SDI through additional data collection, including environmental impact of food, food price, food budget, and use of ready-made products.
Keywords: sustainable diet; sustainable dietary pattern; sustainable diet index; Korea

INTRODUCTION

지속가능한 식이(sustainable diets)는 급격한 기후 변화와 다양한 질환의 증가라는 인류가 직면한 위기에 대해 대응할 수 있는 방안으로 최근 관심이 집중되고 있다. 1980년대 초반 처음 식이 지침에의 ‘지속가능성’ 개념 적용의 필요성이 제기되었으나[1], 세계 기근 해결의 시급성으로 2000년 전까지 지속가능한 식이 연구는 활발히 진행되지 못하다가 2005년 “Giessen” 선언을 통해 생물학적, 사회적, 그리고 환경적 측면을 포괄하는 새로운 영양 과학의 필요성이 제기된 것을 계기로 다시금 그 필요성을 인정받게 되었다[2]. 2010년 이탈리아에서 열린 생물학적 다양성과 지속가능한 식이를 위한 국제 심포지엄에서 유엔식량농업기구(Food and Agriculture Organization of the United Nations, FAO)와 각 관련 분야의 전문가들이 지속가능한 식이를 다음과 같이 정의하기로 합의하였다: “Sustainable Diets are those diets with low environmental impacts which contribute to food and nutrition security and to healthy life for present and future generations. Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimizing natural and human resources” [3].

지속가능한 식이 정의와 더불어 학계와 정부기관 간 국제적 협력을 통한 노력도 계속되어 오고 있다. 2019년 저명학술지 란셋(The Lancet)과 비영리단체 EAT이 의기투합하여 건강하고 지속가능한 식품과 식이, 건강, 환경 지속가능성을 도모하기 위해 잇 란셋 위원회(EAT-Lancet Commission)를 출범하였다. EAT-Lancet Commission은 보고서에서 현재 식이는 건강하지도 환경 친화적이지도 않으며, 유엔의 지속가능개발목표(sustainable development goals, SDGs) 달성과 파리 기후 협약을 위해서는 전세계적으로 식이를 변화시킬 필요가 있다고 지적하고, 지구와 인간 모두를 위한 식이 지침과 식이 관련 환경 지표 목표량을 제시한 잇 란셋 식이(EAT-Lancet reference diet)를 발표하였다[4]. EAT-Lancet reference diet은 전곡류, 채소류(감자류 제외), 과일류, 견과류, 종실류의 섭취를 권장하고 첨가당, 정제곡류, 전분 및 감자류, 육류의 섭취를 제한하고 있으며, 국제적으로 적용 가능한 권장 섭취 범위를 제안하고 있다[4].

유엔식량농업기구의 정의에서 알 수 있듯이 지속가능한 식이는 어느 한 측면만을 만족하는 것으로 충족될 수 없다[3]. 영양학적으로 우수하면서, 환경 영향도 적어야 하고, 문화적으로 수용 가능하며, 경제적으로 감당할 만한 수준이어야 가능한 것임을 고려할 때, 지속가능한 식이는 다차원적이고 포괄적인 개념임을 알 수 있다. 기존 연구들은 지속가능한 식이와 관련된 개별 지표들에 국한되어 있어 유엔식량농업기구에서 정의한 지속가능한 식이의 다차원성을 구현하기에는 제한이 있다[5-8]. 따라서, 이를 효율적으로 평가하기 위해서는 다양한 지표들을 아우르는 복합적인 접근이 필요하다. 국외의 여러 국가에서 지속가능한 식이를 정의하고 측정하기 위한 복합 지수(composite index) 개발 연구를 활발히 진행해 온 것에 비해[9-24], 국내에서의 관심과 연구는 미흡한 실정이다.

이 연구는 국외에서 개발된 지속가능한 식이 패턴 평가 지수들을 소개하고, 우리 국민의 지속가능한 식이 패턴 평가를 위해서 필요한 데이터를 제안하고자 한다. 또한, 미국 국민건강영양조사를 이용한 지속가능한 식이 패턴 지수를 예로 제시하고 추후 한국형 지속가능한 식이 패턴 지수 개발의 필요성을 알리고자 하였다.

METHODS

Ethics statement

The study protocols of National Health and Nutrition Examination Survey were approved by the National Center for Health Statistics Ethics Review Board (https://www.cdc.gov/nchs/nhanes/irba98.htm). This study was deemed exempt by the Chungnam National University Hospital Institutional Review Board because we only used publicly available data without identifiable information (CNUH-2023-10-057).

국외에서 개발된 지속가능한 식이 패턴 평가 지수 소개를 위해, PubMed를 이용하여 2023년 11월 27일부터 2023년 12월 18일까지 검색을 실시하였다. 검색은 저자 외 1인의 국외 전문가가 수행하였고, 논문의 포함 여부 및 요약에 공동으로 참여하였다. 개별적으로 검색 방법 합의 후 동일한 방식으로 검색을 수행하여 각자의 검색 결과를 비교 평가하고, 충돌이 있는 경우 회의를 통해 논문의 본문까지 함께 검토 후 재 합의하였다. 검색 시 지속가능한 식이 지수는 상대적으로 새로운 연구분야로 기존 논문의 게재연도에는 별도의 제한을 두지 않았고 2023년 12월 17일까지 발표된 논문을 대상으로 한다. 세부적으로 “development,” “validation,” “sustainable diet,” “sustainable diet index,” “planetary healthy diet,” “EAT-Lancet diet,” “EAT-Lancet reference diet”의 검색어를 조합하여 사용하였고, 원저(original article)만을 대상으로 하였다. 검색된 논문 148개 중 제목과 초록을 우선적으로 검토하여 연구 목적 및 내용이 지속가능한 지수 개발 연구에 해당하지 않으면 제외하였고(118편), 원문 확인을 통해 실제 지수 개발에 대한 내용이 없는 경우 제외하였다(20편). 간혹 PubMed에 나타나지 않는 문헌들이 있어Google Scholar를 활용하여 검색을 다시 실시 후 PubMed에서 선택된 문헌과의 교차비교를 통해 누락된 문헌 6개를 추가적으로 포함시켜 최종적으로 16개의 논문을 요약 및 정리하였다(Supplementary Figure 1).

다양한 지속가능한 식이 패턴 평가 지수 중, 유엔식량농업기구의 정의에서 제시한 다차원적 개념을 포함한 지수를 어떻게 구현하는지 설명하기 위해 미국 국민건강영양조사(National Health and Nutrition Examination Survey, NHANES) 2017–2018 자료를 이용하여 Sustainable Diet Index-US (SDI-US)를 계산하여 제시하였다. 2017-2018 미국 국민건강영양조사에 참여한 20세 이상 미국 성인 5,569명 중 임신 및 수유 중이거나(95명), 24시간 회상조사에 한 번도 참여하지 않았거나(818명), SDI-US 계산에 필요한 자료에 결측이 있는 경우(733명), 인구사회학적 변수에 결측이 있는 경우(3명)를 제외한 3,920명이 최종 분석에 포함되었다. 전체 SDI-US 점수 및 하위 지수 점수는 평균값과 95% 신뢰구간으로 제시하였고, 인구사회학적 특성에 따라 점수에 차이가 있는지는 일반적 선형 모형(general linear model)을 통해 검정하였다. 모든 통계 분석은 복합 표본 디자인의 특성을 고려하기 위해 영양조사 가중치(dietary sample weights)를 적용하였고, SAS 9.4 프로그램(version 9.4; SAS Institute, Cary, NC, USA)의 PROC SURVEY procedure를 사용하였다.

RESULTS

1. 지속가능한 식이 개념의 구성

앞서 언급된 유엔식량농업기구의 정의를 번역하면, 지속가능한 식이란 ‘환경 영향이 적으며 식품과 영양 보장과 현재 그리고 미래 세대의 건강한 삶에 기여하는 식이’ 그리고 ‘생물 다양성과 생태계를 보호하며, 문화적으로 수용 및 접근 가능하고, 경제적으로 공평하고 감당할만하며, 영양학적으로 충분하고, 안전하고, 건강하며; 동시에 자연과 인적 자원을 최적화하는 식이’이다. 따라서, 지속가능한 식이를 잘 평가하기 위해서는 영양적, 환경적, 경제적, 사회문화적 측면을 모두 포괄할 수 있는 복합적이고 다차원적(multi-dimensional)인 방법이 필요함을 알 수 있다(Supplementary Figure 2).

2. 지속가능한 식이 패턴 평가 지수

현재까지 다양한 형태의 지속가능한 식이 패턴을 평가하기 위한 지수가 개발되어 왔지만, 모두 국외의 사례로 국내에서는 개발 사례가 없다. 국외의 개발 사례를 Table 1에 요약 정리하였다[9-24]. 기존 지수들은 크게 EAT-Lancet reference diet에 기반한 경우, FAO의 지속가능한 식이 정의에 기반한 경우, 그 외 환경 또는 지속가능성을 염두에 둔 경우로 분류해 볼 수 있다.

1) EAT-Lancet reference diet 기반 지수

2019년 발표된 EAT-Lancet Commission의 보고서에서 인간의 건강과 환경의 지속가능성을 모두 지킬 수 있는 푸드시스템을 위한 각 식품군별 권장 섭취 범위를 제시하였다[4]. EAT-Lancet reference diet은 전곡류, 채소류(감자류 제외), 과일류, 견과류, 종실류의 섭취를 권장하고 첨가당, 정제곡류, 전분 및 감자류, 육류의 섭취를 제한하고 있으며, 하루 열량 2,500 kcal를 기준으로 했을 때 권장 섭취 범위는 Table 2에 정리하였다.

Table 2에 제시된 것처럼 EAT-Lancet reference diet은 식품군별 섭취량을 바탕으로 한 것으로, 24시간 회상조사 또는 식품섭취빈도조사를 통해 수집된 식이 자료가 있으면 산출해 볼 수 있다. EAT-Lancet reference diet을 바탕으로 한 지수들은 여러 나라에서 개발되었고, 국가의 특성과 연구자 판단에 따라 점수 계산 방식이 다양하다(Table 3). 크게 이분법적으로 점수를 부여하는 방식(binary scoring) [9,10], 섭취 범위를 세 군 이상의 카테고리로 나누어 각각 점수를 부여하는 방식(categorical scoring) [11,12], 그리고 비례식으로 점수를 부여하는 방식(proportional scoring) [13-16]이 있다. 이분법적 점수 부여 방식으로 EAT-Lancet score는 영국에서 개발된 지수로 가장 먼저 발표되어 다양한 연구에서 사용되어져 왔다[9]. 총 14개의 식품군 섭취량을 바탕으로 하며 EAT-Lancet reference diet 기준을 충족하면 1점, 그렇지 못하면 0점을 주는 방식으로 총 0–14점으로 계산된다[9]. 독일에서 개발된 Dietary Index은 총 18개의 식품군 섭취량을 바탕으로 하며 EAT-Lancet reference diet 기준을 충족하면 1점, 그렇지 못하면 0점을 부여하는 방식으로 총 0–18점으로 계산된다[10]. 섭취 범위를 세 군 이상의 카테고리로 나누어 보다 상세히 점수를 부여하는 방식으로 스웨덴에서 개발된 EAT-Lancet index [11]와 감비아에서 개발된 Sustainable and Healthy Diet Index (SHDI) [12]가 있고, 두 가지 모두 0–3점을 범위에 따라 부여하는 방식이다. 예를 들면, 채소 섭취량은 권장하는 식품군으로 권장섭취량은 하루 300 g (200–600 g)이다. 이 경우, 300 g초과는 3점, 200–300 g은 2점, 100–200 g은 1점, 100 g 미만은 0점을 부여한다. 섭취를 제한하는 경우 많이 섭취하는 경우에 점수를 적게 주는 방식이다. 이런 제한점을 보완하기 위한 다른 접근 방법으로 비례식을 이용하여 점수를 부여한 지수들이 있으며, 대표적으로 브라질에서 개발된 Planetary Healthy Diet Index (PHDI)가 있다[14]. 브라질 개발 방법과 동일하게 미국인을 대상으로 한 PHDI-US도 개발된 바 있다[15]. 비례식을 이용하기 때문에 PHDI는 모든 권장 섭취 범위뿐만 아니라 범위를 벗어나는 경우까지도 점수 계산에 고려할 수 있다. 예를 들면, 충분히 섭취해야 하는 식품군(견과류, 종실류, 과일류, 채소류, 전곡류)에는 0–10점을 부여하는데 많이 섭취할수록 큰 점수를 받게 된다. 그러나 적정 섭취를 유지해야 하는 경우(유제품, 전분류 등) 적정 범위만 가장 높은 점수를 주고, 너무 적거나 너무 많은 섭취는 낮은 점수를 주는 방식이다. 총 16개의 식품군 섭취량을 바탕으로 하며 각 요소 당 5–10점을 최대점으로 하기 때문에 최종 점수는 0–150점으로 계산된다. 이외에 베트남에서 개발된 World Index for Sustainability and Health (WISH)는 14개 식품군을 바탕으로 0–10 사이의 점수를 비례식을 이용하여 부여하며, 총 0–130점으로 계산된다 [13]. 네덜란드에서 개발한 Healthy Reference Diet (HRD) score 역시 비례식을 이용하여 EAT-Lancet reference diet을 바탕으로 개발된 바 있다 [16].

2) FAO의 지속가능한 식이 정의 기반 지수

FAO에서 발표한 지속가능한 식이의 합의된 정의를 평가하는 지수가 프랑스[17], 스페인[18], 미국[20], 멕시코[19]에서 개발된 사례를 Table 4에 정리하였다. 지속가능한 식이는 상당히 복잡하고 다차원적 개념이지만, 국가나 사회 단위가 아닌 개인에 초점을 맞추었을 때 크게 4개의 차원으로 축소해 볼 수 있다. 2019년 프랑스에서 FAO의 정의를 바탕으로 영양학적, 환경적, 경제적, 사회문화적 차원의 4개의 하위 지수로 구성된 Sustainable Diet Index (SDI)가 처음 소개되었다. 프랑스 SDI는 총 4개의 하위 지수 당 1-5점을 부여하여, 총 4-20점으로 계산된다. 영양학적으로 적정한가(nutritional sub-index)에 대한 평가를 위해 에너지 필요량과 섭취량의 절대값 차이와 프랑스 식이 섭취 권장량 대비 24개의 영양소 섭취량의 적정성 평가를 위한 PANDiet index 점수를 사용하였다. 환경에 얼마나 영향을 주는가(environmental sub-index)에 대한 평가를 위해 ReCipe score라는 네덜란드에서 만든 전과정평가를 이용하여 개발된 식품별 온실가스 배출량, 화석 연료 사용량, 땅 사용량의 단일값과 전체 식품 섭취량 중 유기농 식품이 차지하는 비중을 사용하였다. 경제적으로 감당할 만한지(economic sub-index)를 평가하기 위해 전체 가구 수입 중 식품 지출의 비중인 엥겔 지수를 사용하였고, 사회문화적으로 수용 가능한지(sociocultural sub-index)를 평가하기 위해 식품을 주로 어디서 구입하는지와 간편식(냉동식품, 통조림, 간편조리식품 등)을 얼마나 자주 이용하는지를 사용하였다. 각 하위 지수 내 지표의 점수는 오분위수로 나누어 1-5점을 부여하는데, 영양학 하위 지수만 숫자가 클수록 높은 점수를 부여하고, 나머지 하위 지수들은 숫자가 클수록 지속가능한 개념과는 거리가 멀어지므로 낮은 점수를 부여하게 된다 [17]. 프랑스 SDI와 동일한 방법으로 SDI-US [20]가 개발된 바 있고, 이들과 유사하지만 영양, 환경, 경제 차원만으로 구성된 SDI가 스페인 [18]과 멕시코 [19]에서 개발되었다.

3) 그 외 환경 또는 지속가능성을 고려한 지수

직접적으로 EAT-Lancet reference diet이나 FAO의 지속가능한 식이 정의에 기반하지는 않았지만 “지속가능성”의 개념을 포함시킨 지수들도 있다(Table 5). 이스라엘에서 30개의 항목으로 구성된 설문지를 개발하여 환경 지표로 음료 섭취 습관을 포함하거나 쓰레기 배출 관련된 질문도 포함시키는 등 다양한 항목의 설문을 통해 Sustainable HEalthy Diet (SHED) index를 계산하기도 했고[21], 호주에서 개발된 Healthy and Sustainable Diet Index (HSDI)처럼 기존 식품군에 아닌 계절 과일, 초가공식품 섭취, 잔반량 등을 추가로 고려한 지수도 개발된 바 있다[22]. EAT-Lancet reference diet과 유사하지만 식품군 분류에 다소 차이가 있는 Sustainable Dietary Score (SDS)도 멕시코에서 개발되었다[23]. 최근 이스라엘 SHED index 개발과 같은 방식으로 포르투갈 버전이 발표되기도 했다[24].

3. 미국 SDI 개발 사례 소개 및 한국형 지속가능한 식이 지수 개발의 필요성

미국형 SDI의 계산 방법은 프랑스 SDI와 매우 유사하다(Table 6) [17,25-28]. FAO의 정의를 바탕으로 영양학적, 환경적, 경제적, 사회문화적 차원의 4개의 하위 지수로 구성되어 있고, 하위 지수 당 1–5점을 부여하여, 총 4–20점으로 계산된다. 영양학적으로 적정한가(nutritional sub-index)에 대한 평가를 위해 식이 다양성 지수인 Nutrient-Rich Foods9.3 Index와 비타민 및 무기질 결핍 정도 파악을 위해 평균 영양소 적정 섭취비를 사용하였다. 환경에 얼마나 영향을 주는가(environmental sub-index)에 대한 평가를 위해 Poore and Nemecek의 식품별 환경 영향 데이터베이스[29]를 이용하여 24시간 회상조사에서 조사된 각 식품별 식품 생산 시 물 사용량(L), 산성 물질 배출량(gSO₂eq), 부영양화 물질 배출량(gPO₄³⁻), 온실가스 배출량(kgCO₂eq), 땅 사용면적(m²)을 식품코드를 활용하여 환경 영향 데이터베이스와 연계 후 계산하였다[28]. 경제적으로 감당할 만한지(economic sub-index)를 평가하기 위해 전체 가구 수입 중 식품 지출의 비중을 사용하였고, 사회문화적으로 수용 가능한지(sociocultural sub-index)를 평가하기 위해 간편식품을 얼마나 자주 이용하는지에 대해 세 가지 문항으로 조사한 내용을 사용하였다(패스트푸드점 또는 피자 식당에서 식사한 빈도, 간편식 사용 빈도, 냉동식품 사용 빈도). 각 하위 지수 내 지표의 점수는 오분위수로 나누어 1–5점을 부여하는데, 영양학 하위 지수만 숫자가 클수록 높은 점수를 부여하고, 나머지 하위 지수들은 숫자가 클수록 지속가능한 개념과는 거리가 멀어지므로 낮은 점수를 부여하였다. 미국형 SDI의 타당도 연구는 현재 국외 저널에서 심사 중으로 해당 지수와 EAT-Lancet diet 기반의 식이 지수와의 비교 평가 및 다양한 지표들의 추가 또는 삭제와의 비교 분석을 통해 검증되었고, 타당도 연구를 요약한 내용이 포함된 연구가 출판된 바 있다[20,30].

계산 결과는 Table 7에 제시하였다. 2017–2018 자료를 분석하였을 때, 총 SDI-US 점수는 13.2점으로 나타났다. 인구사회학적 특성별로 나누어 살펴보면, 지속가능한 식이 점수는 20–30대의 젊은 층보다 60세 이상에서 (12.9 vs. 13.9, P-value < 0.0001), 남자보다 여자에서 (13.0 vs. 13.5, P-value = 0.0002), 교육 수준이 낮은 층보다 높은 층에서 (12.7 vs. 13.6, P-value < 0.0001) 더 높게 나타났다(Table 8).

DISCUSSION

이 연구에서는 지구와 인간의 공존을 위한 지속가능한 식이의 필요성과 정의를 살펴보고, 기존 논문을 분석하여 현재까지 개발된 다양한 형태의 지속가능한 식이 패턴 평가 지수를 요약 및 정리하였다. 현재까지 가장 빈번하게 사용되어오고 있는 EAT-Lancet reference diet의 권장 섭취 범위는 환경에 미치는 영향까지 고려한 것이긴 하지만 이를 바탕으로 한 지수의 경우 식품군별 섭취량만이 계산에 이용되기 때문에 FAO의 지속가능한 식이의 정의를 종합적으로 구현하기에는 제한이 있다고 볼 수 있다[20]. 또한 점수를 이분법적으로 부여할 경우, 단일화된 기준 적용으로 기준 범위를 벗어나는 경우나 특정 인구 집단이 가지는 특성 및 변이를 충분히 반영하지 못할 수 있다. 이를 보완하기 위해 보다 많은 카테고리로 분류하여 점수를 부여한 지수들이 소개되었다. 이처럼 보다 다양한 카테고리로 나누어 이분화했을 때 누락될 수 있는 부분을 보완했다고는 하지만 여전히 변이를 충분히 반영하지 못할 수 있고, 어느 한 군에 섭취량이 쏠리는 경우에는 제한이 있을 수 있다. 이런 제한점을 보완하기 위한 다른 접근 방법으로 비례식을 이용하여 점수를 부여한 지수들을 개발한 사례도 있다.

위에 기술된 지수들은 모두 EAT-Lancet reference diet을 토대로 한다는 공통점이 있지만, 국가별 식품 섭취, 식이 자료의 가용성, 연구자의 판단 등에 따라 지수를 구성하는 요소, 범위, 점수 부여 방식에 상당한 차이가 있었다. 아직 한국인을 대상으로 한 EAT-Lancet reference diet 점수 계산 사례가 없기 때문에 후속 연구가 이루어질 필요가 있다. 이와 같은 연구를 위해서는 한국인의 특성을 가장 잘 반영할 수 있는 방식이 어떤 것일지, 데이터베이스의 부재로 계산에 포함시킬 수 없는 요소(첨가당)는 어떻게 고려할 것인지, 그리고 무엇보다 EAT-Lancet reference diet에서 제시하고 있는 섭취 범위가 한국인에도 적용할 수 있을지에 대한 충분한 고민이 필요하다.

EAT-Lancet reference diet을 이용한 식이 지수가 연구자들의 많은 관심을 받고 있고, 여러 국가에서 개발되어 왔으나, 식이의 환경 영향을 직접적으로 계산에 포함시킨 것은 아니고, 경제적 그리고 사회문화적 차원은 전혀 고려하지 않아 FAO 정의의 지속가능한 식이의 다차원적 개념을 복합적으로 평가하기에는 제한이 있다. SDI [17]는 프랑스에서 처음 개발되어 미국[20,30], 스페인[18], 멕시코[19]에서 각 나라에 맞게 수정 및 개발되었고, 같은 점수 체계를 사용하기 때문에 국가 간 비교도 가능하며, 무엇보다 다차원적 개념을 아우르는 평가 방법이라는 장점을 가진다. 현재까지는 SDI가 FAO의 지속가능한 식이의 개념을 가장 근접하게 구현하는 식이 지수일 수 있으나, 관련된 제한점도 고려하지 않을 수 없다. 첫째, 각 하위 지수를 구성하는 세부 지표들의 선택이 다소 주관적일 수 있다. 특히, SDI-US와 프랑스 SDI의 사회문화적 하위 지수를 구성하는 지표는 간편식 사용 빈도인데 이 지표 하나만으로 사회문화적으로 수용 가능한가를 평가하기에는 무리가 있다[17,20]. 사회문화적 차원에 대한 명확한 정의가 먼저 이루어져야 하는데 그 또한 연구자의 주관이 포함될 수 있는 부분이라는 제한점이 있다. 또 경제적 하위 지수를 구성하는 엥겔 지수 역시 명확한 평가 방법이라고 단정짓기 어렵다. 엥겔 지수와 더불어 식품 불안정성이나 식품 가격 자체를 조사하여 함께 사용하는 방법도 고려해 볼 수 있다. 둘째, 환경 지표값 계산과 관련된 제한점이 있다. SDI-US에서는 6개의 환경 영향 지표들을 포함하였지만, 현재 기술로는 모든 섭취 식품의 생산 시 환경 영향 지표값을 완벽하게 계산할 수도 없으며, 각 지표들끼리의 이해상충에 대한 문제도 있다[20]. 예를 들면, 견과류는 식물성으로 섭취가 권장되는 식품군으로 생산 시 온실가스 배출량은 적은 편이지만 물 사용량은 육류보다 훨씬 많다[29]. 이러한 특성은 분명히 고려되어야 하는 요소로 환경 영향 계산 시 여러 환경 지표의 통합 방식에 대한 충분한 고민이 필요하다. 보다 정확한 여러 지표들을 추가로 조사하여 사용할 수도 있지만, 사용 및 재현의 편리성과 실용성을 고려한다면 지표의 개수를 무한히 늘리는 것도 좋은 방법은 아닐 수 있다. 따라서, 현재 개발된 식이 지수를 바탕으로 보다 지속가능한 식이의 정의에 가까운 지표들은 무엇일지 고민하고 관련 자료를 수집하여 다듬어 나가는 작업이 필요할 것이다.

미국 국민건강영양조사를 이용한 지속가능한 식이의 구현 결과, 미국 성인의 지속가능한 식이 점수는13점(20점 만점)으로, 어느 정도의 점수가 지속가능한지에 대한 기준점이 제시되지는 않았지만, 99번째 백분위수의 점수가 18.5점에 불과해 대부분의 미국 성인은 지속가능한 식이를 위해서는 현재 패턴에 변화를 줄 필요가 있음을 시사한다. 그러나 프랑스 SDI의 평균 점수(약 12점)[17]와 비교했을 때는 미국 성인이 보다 지속가능한 식이 패턴을 보이고 있음을 간접적으로 알 수 있다. 한국인의 경우 육류 섭취가 상대적으로 낮아 환경 측면의 점수는 높을 것으로 예측되나, 사회문화 측면의 점수는 간편식 사용의 증가 및 이용 편리성으로 인해 상당히 낮게 산출될 것으로 예측된다. 국가의 개별 특성을 잘 반영한 지표 선정을 통해 지속가능한 식이 지수를 산출하여 평가해 볼 필요가 있다.

SDI-US는 무엇보다 미국인을 대표할 수 있는 데이터인 미국 국민건강영양조사 자료를 활용했다는 것에 장점이 있다 [20]. 우리나라에도 한국 국민건강영양조사가 있어 유사한 접근 방식으로 한국형 지속가능한 식이 패턴 지수를 개발할 수 있다. Table 9에 제시된 것처럼[17,25-28] 현재 한국 국민건강영양조사 자료로 계산 가능한 지표들은 한국인 식생활 평가 지수(Korean Healthy Eating Index), 평균 영양소 적정 섭취비, 식품 불안정 수준, 초가공식품 섭취량, 끼니별 동반 식사 여부 정도이다. 식품별 환경 영향 부분은 현재로서는 온실가스 배출량 정도를 산출해 볼 수 있다. 최근 도시기반 코호트(Health Examinee study) 자료를 토대로 식품섭취빈도조사를 이용해 조사된 106개의 식품별 생산 시 온실가스 배출량 데이터베이스[31]가 공개되어 이를 국민건강영양조사 자료에서 조사된 식이 자료로 연계하여 사용할 수 있을 것이다. 온실가스 배출량이 주요 환경 문제로 언급되고 있지만 비단 온실가스만이 문제는 아니기 때문에, 다른 주요한 환경 영향(물 사용량, 토지 사용 면적 등)도 함께 고려해야 한다. 또한 기 발표된 한국형 식이의 온실가스 배출량 데이터베이스[31]도 식품섭취빈도조사를 바탕으로 개발된 것으로 24시간 회상 조사를 통해 조사된 식이 자료로부터 환경 영향을 산출하려면 그에 맞는 데이터베이스가 별도로 필요할 것이다. 현재 국내에는 체계적으로 정리된 환경 영향 데이터베이스가 없어 환경부 및 한국농업기술진흥원 등에서 정리한 내용[32-34]과 이를 기반으로 기 발표된 식이의 온실가스 배출량 산출 데이터베이스[31], 그리고 국외의 개발 사례[29,35-38] 들을 체계적으로 고찰하여 한국형 식이-환경 데이터베이스 개발을 고려해야 한다. 경제적 하위 지수 계산을 위한 엥겔 지수는 현재 국민건강영양조사 자료로는 산출할 수 없어 해당 내용을 추후 설문을 통한 데이터 확보 방안을 고려할 필요가 있다. 엥겔 지수 단독으로 경제적 지속가능성을 제대로 측정하기 어려울 수 있으므로 식품 불안정성과 식이의 가격을 추가로 포함시킬 수 있다. 현재 국민건강영양조사 2012, 2013–2015, 2019–2021에서 18문항의 식품안정성 조사가 이루어졌으므로 해당 연도에는 식품안정성을 지수 계산에 사용할 수 있다. 식품의 시장 가격을 식이 섭취 데이터와 연계하는 방법을 통해 1인당 섭취하는 식이의 시장 가격을 추산할 수 있다면 이 역시 경제적 지속가능성 고려에 유용한 지표가 될 수 있을 것으로 보인다. 사회문화적 지속가능성은 기존 연구들에서 ready-made products의 사용빈도로 조사를 했지만, 한국형 NOVA 체계[39]를 이용하여 국민건강영양조사 자료로 보다 정확하게 초가공식품 섭취량을 산출하여 대신할 수 있을 것이고, 추가적으로 집에서 직접 요리하는 문화에서 현재 포장 및 배달을 이용하거나 밀키트(meal-kit)를 빈번하게 이용하는 문화로 변화한 것을 반영하기 위해 배달 음식 섭취 빈도, 밀키트 특히 건강한 재료로 만들어졌지만 바로 조리만 하는 되는 경우 등을 잘 반영할 수 있는 문항을 조사하는 방안도 고려해 볼 수 있다.

CONCLUSIONS

유엔식량농업기구의 지속가능한 식이의 다차원적 정의를 평가하기 위해 개발된 SDI의 사례를 미국 국민건강영양조사 자료를 이용하여 소개하였고, 평균 13점으로 만점이 20점임을 고려할 때 현재 미국 성인의 식이도 지속가능한 식이를 위해 변화가 필요함을 알 수 있었다. 기후변화에 대한 전 세계적인 관심과 중요성이 증가하고 있어 지속가능한 식이 패턴 평가를 위해 한국형 SDI 개발이 필요한 시점이고, 일부는 현재 국민건강영양조사에서 이용 가능하지만 식이-환경 데이터베이스나 식품에 사용하는 비용 등의 자료가 추가 및 보완된다면 한국형 지수 개발이 가능할 것이다. 한국형 SDI가 국민건강영양조사 자료를 이용하여 개발된다면 한국 식이의 지속가능성을 국제적 합의된 정의 안에서 평가하고 지속적 모니터링을 통해 부족한 부분을 파악하는 데에도 사용할 수 있을 것이다. 또한 환경과 건강을 지키기 위해서는 어떤 식이를 해야 하는지에 대한 지침이나 관련 정책 수립의 실질적인 근거자료를 제공할 수 있다. 환경오염으로 인한 기후변화는 이미 우리 사회의 큰 위기이며, 이를 늦추기 위해서는 많은 노력이 필요하다. 국내에서도 지속가능한 식이를 평가하고 나아가 건강과의 연관성을 밝히는 등의 연구가 활발히 진행된다면 식이 변화를 통해 비용 효과적 해결 방안을 제시할 수 있을 것이다.

NOTES

Conflict of Interest

There are no financial or other issues that might lead to conflict of interest.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (Ministry of Science and ICT) (RS-2023-00274240).

Data Availability

All data are publicly available at https://wwwn.cdc.gov/nchs/nhanes/Default.aspx.

ACKNOWLEDGMENTS

I thank Dr. Cynthia L. Ogden (Adjunct Professor, The George Washington University Milken Institute School of Public Health and Branch Chief, National Center for Health Statistics, Centers for Disease Control and Prevention) for her in-depth guidance of the methodological accuracy of this paper.

SUPPLEMENTARY MATERIALS

Supplementary Fig. 1.

Article review process.

kjcn-2024-29-1-34-Supplementary-Fig-1.pdf

Supplementary Fig. 2.

The concept of sustainable diets.

kjcn-2024-29-1-34-Supplementary-Fig-2.pdf

Table 1.

Summary of composite indices for measuring adherence to sustainable diets

Categories	Composite indices for sustainable diets
EAT-Lancet reference diet based	EAT-Lancet score by Knuppel et al. [9], Dietary Index by Montejano Vallejo et al [10], EAT-Lancet index by Stubbendorff et al. [11], Sustainable and Healthy Diet Index (SHDI) by Ali et al. [12], World Index for Sustainability and Health (WISH) by Trijsburg et al. [13], Planetary Healthy Diet Index (PHDI) by Cacau et al. [14], PHDI-US by Parker et al [15], Healthy Reference Diet (HRD) score by Colizzi et al. [16]
FAO definition based	Sustainable Diet Index (SDI)-France by Seconda et al. [17], SDI-Spain by Fresán et al. [18], Index by Curi-Quinto et al. [19], SDI-US by Jung et al. [20]
No specific guideline but including the sustainability concept	Sustainable HEalthy Diet (SHED) index by Tepper et al. [21], Healthy and Sustainable Diet Index (HSDI) by Harray et al. [22], Sustainable Dietary Score by Campirano et al. [23], SHED index-Portugal by Liz Martins et al. [24]

FAO, Food and Agriculture Organization.

Table 2.

The proposed EAT-Lancet diet by Willett et al., “Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems” [4]

Food groups	Macronutrient intake (possible range) (g/day)	Caloric intake (kcal/day)
Whole grains¹⁾
Rice, wheat, corn, and other²⁾	232 (total grains 0–60% of energy)	811
Tubers or starchy vegetables
Potatoes and cassava	50 (0–100)	39
Vegetables
All vegetables	300 (200–600)
Dark green vegetables	100	23
Red and orange vegetables	100	30
Other vegetables	100	25
Fruits
All fruit	200 (100–300)	126
Dairy foods
Whole milk or derivative equivalents (for example, cheese)	250 (0–500)	153
Protein sources³⁾
Beef and lamb	7 (0–14)	15
Pork	7 (0–14)	15
Chicken and other poultry	29 (0–58)	62
Eggs	13 (0–25)	19
Fish⁴⁾	28 (0–100)	40
Legumes
Dry beans, lentils, and peas¹⁾	50 (0–100)	172
Soy foods	25 (0–50)	112
Peanuts	25 (0–75)	142
Tree nuts	25	149
Added fats
Palm oil	6.8 (0–6.8)	60
Unsaturated oils⁵⁾	40 (20–80)	354
Dairy fats (included in milk)	0	0
Lard or tallow⁶⁾	5 (0–5)	36
Added sugars
All sweeteners	31 (0–31)	120

Healthy reference diet, with possible ranges, for an energy intake of 2,500 kcal/day. For an individual, an optimal energy intake to maintain a healthy weight will depend on body size and level of physical activity. Processing of foods such as partial hydrogenation of oils, refining of grains, and addition of salt and preservatives can substantially affect health but is not addressed in this table.

¹⁾Wheat, rice, dry beans, and lentils are dry and raw.

²⁾Mix and amount of grains can vary to maintain isocaloric intake.

³⁾Beef and lamb are exchangeable with pork and vice versa. Chicken and other poultry are exchangeable with eggs, fish, or plant protein sources. Legumes, peanuts, tree nuts, seeds, and soy foods are interchangeable.

⁴⁾Seafood consist of fish and shellfish (for example, mussels and shrimps) and originate from both capture and farming. Although seafood is a highly diverse group that contains both animals and plants, the focus of this report is solely on animals.

⁵⁾Unsaturated oils are 20% each of olive, soybean, rapeseed, sunflower, and peanut oil.

⁶⁾Some lard or tallow are optional in instances when pigs or cattle are consumed.

Table 3.

Composite indices for measuring adherence to sustainable diets based on the EAT-Lancet reference diet

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Binary scoring
Knuppel et al. [9], 2019	40,069 UK participants of the European Prospective Investigation into Cancer and Nutrition (EPIC) Oxford study	EAT-Lancet score	14 components (rice, wheat, corn, and other; tubers and starchy vegetables; all vegetables; all fruits; dairy products; beef, lamb, pork; chicken, other poultry; eggs; fish; beans, lentils, peas; soy foods; peanuts or tree nuts; added fats (ratio of 0.8 for unsaturated to saturated fat intake); added sugars)	Binary: 1 point if a criterion met; 0 point otherwise (0–14 in total)	EAT-Lancet score had inverse associations with ischemic heart disease and diabetes; no association with stroke; no clear association with mortality.
Montejano Vallejo et al. [10], 2022	298 participants of the Dortmund Nutritional and Anthropometric Longitudinal Designed (DONALD) Study in Germany	Dietary Index (DI)	18 components (whole grains and all grains; tubers or starchy vegetables; all vegetables; all fruits; dairy products; beef and lamb; pork; chicken and other poultry; eggs; fish; dry beans, lentils, peas; soy foods; nuts; palm oil; unsaturated oils; lard and tallow; butter; all sweeteners)	Binary: 1 point if a criterion met; 0 point otherwise (0–18 in total)	A higher DI score in adolescence was also beneficial with respect to anthropometric markers in early adulthood, although not for further cardiometabolic risk markers.
Categorical scoring
Stubbendorff et al. [11], 2022	22,421 participants of the Malmö Diet and Cancer Study (MDCS) in Sweden	EAT-Lancet index	14 components (whole grains; potatoes; all vegetables; all fruits; dairy products; beef and lamb; pork; poultry; eggs; fish; legumes; nuts; unsaturated oils; added sugars)	0–3 points per component using the EAT-Lancet recommendation ranges (0–42 points in total)	The highest EAT-Lancet index score was associated lower risks of all-cause, cardiovascular, and cancer mortality compared to the lowest score.
Ali et al. [12], 2022	12,713 households from the Integrated Household Survey (IHS2015/16) in Gambia	Sustainable and Healthy Diet Index (SHDI)	16 components (all vegetables; all fruits; unsaturated oils; beans, lentils, and peas; peanuts and tree nuts; whole grains; potatoes and cassava; fish; palm oil; added sugar; refined grains; beef and lamb; pork; poultry; dairy; eggs)	0–3 points per component using the EAT-Lancet recommendation ranges (0–48 points in total)	The average Gambian diet had very low adherence to EAT-Lancet recommendations. The diet was dominated by refined grains and added sugars, the amount of which exceeded the recommendations.
Proportional scoring
Trijsburg et al. [13], 2021	396 participants of urban residents in Vietnam	World Index for Sustainability and Health (WISH)	14 components (whole grains; vegetables; fruits; dairy foods; red meat; fish; eggs; chicken and other poultry; legumes; nuts; unsaturated oils; saturated oils; added sugars)	Considering health benefits (protective, neutral, limit) and impact on environment (high, medium, low), 0–10 points could be assigned (0–130 in total)	The WISH seeks to measure two complex multidimensional concepts of diet quality and environmental sustainability in one scoring system. Out of a maximum score of 130, the mean total WISH score was 46 ± 11. Our initial analysis shows that the WISH can differentiate between the health benefits and environmental sustainability of a Vietnamese diet.
Cacau et al. [14], 2021	14,779 participants of the Longitudinal Study on Adult Health (ELSA)-Brazil	Planetary Healthy Diet Index (PHDI)	16 components (nuts and peanuts; legumes; fruits; vegetables; whole cereals; eggs; fish and seafood; tubers and potatoes; dairy; vegetable oils; ratio of dark green vegetable to total; ratio of red vegetable to total; red meat; chicken and substitutes; animal fats; added sugars)	For each of 16 components, a maximum of 5 or 10 points could be assigned (0–150 in total)	The PHDI (mean 60.4) had six dimensions, was associated in an expected direction with the selected nutrients and was significantly lower in smokers than in non-smokers. Cronbach’s alpha value was 0.51. There were low correlations between the components and between components and PHDI with total energy intake. After adjustment for age and sex, the PHDI score remained associated with higher overall dietary quality and lower carbon footprint.
Parker et al. [15], 2023	4,741 participants of the National Health and Nutrition Examination Survey (NHANES) 2017–2018	Planetary Healthy Diet Index-US (PHDI-US)	16 components (nuts and peanuts; legumes; fruits; non-starchy vegetables; whole grains; eggs; seafood and substitutes; tubers and starchy vegetables; dairy; unsaturated oils; ratio of dark green vegetable to total; ratio of red vegetable to total; red and processed meat; poultry; saturated fats; added sugars)	For each of 16 components, a maximum of 5 or 10 points could be assigned (0–150 in total)	The PHDI-US has 16 components with scores ranging between 0 and 150, and higher scores indicate better adherence to the Planetary Health Diet. The PHDI-US is a new tool that can assess adherence to the Planetary Health Diet and identify key aspects of United States adults’ diets that could be altered to potentially improve dietary sustainability and quality.
Colizzi et al. [16], 2023	37,349 Dutch participants of the EPIC-Nutrition (EPIC-NL)	Healthy Reference Diet (HRD) score	14 components (whole grains; potatoes; all vegetables; all fruits; dairy products; beef and lamb; pork; chicken; eggs; fish; legumes; nuts; ratio of 0.6 for unsaturated to saturated fat intake; added sugars)	Proportional scores from 0–10 points for each of 14 components (0–140 points in total)	A higher HRD score was associated with lower risk of coronary heart disease and all-cause mortality than that of a lower HRD score.

FAO, Food and Agriculture Organization; SD, standard deviation.

Table 4.

Composite indices for measuring adherence to sustainable diets based on the FAO definition

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Seconda et al. [17], 2019	29,388 participants of the NutriNet-Santé cohort study in France	Sustainable Diet Index (SDI)	7 indicators with 4 sub-indices (nutritional: absolute difference value between energy needed and intake, PANDiet score; environmental: pReCiPe; economic: contribution of organic food to diet; proportion of income spent on food; sociocultural: place of food purchase; ready-made products use)	1–5 points per indicator using quintiles and 5 points per sub-index (4–20 in total)	The SDI (mean 12.1) is based on a multicriteria approach and could be used to easily assess the sustainability of diets; there were high correlations between SDI and all sub-indices; a higher SDI was positively associated with the already published sustainable diets.
Fresán et al. [18], 2020	15,492 participants of the Seguimiento Universidad de Navarra(SUN) project in Spain	Sustainable Diet Index (SDI)	6 indicators with 3 sub-indices (nutritional: 2015–2020 Dietary Guidelines for Americans index; environmental: land, water, energy, GHG emissions; economic: cost of the diet in market)	0–3 points per sub-index using quartiles (0–9 in total)	The highest SDI quartile was associated with lower risk of all-cause and cardiovascular mortality. There were positive correlations between SDI and beans and potato consumption and negative correlations between SDI and red meat intake. Red and processed meats, fatty dairy products, and fish consumption accounted for the major variability in the SDI.
Curi-Quinto et al. [19], 2022	2,438 participants of the National Health and Nutrition Survey (ENSANUT-2012) in Mexico	NA	6 indicators (nutritional: Healthy Eating index-2015, cost of the diet; environmental: land use, biodiversity loss, carbon footprint, blue water footprint; economic: cost of the diet)	Binary: 1 point if a criterion met based on the median value; 0 point otherwise	MSD were consumed by 10.2% of adults, who had lower intake of animal-source foods, unhealthy foods (refined grains, added sugar and fats, mixed processed dishes, and sweetened beverages), fruits, and vegetables, and higher intake of whole grains than non-MSD subjects. The MSD is a realistic diet pattern mainly found in disadvantaged populations, but diet quality is still sub-optimal.
Curi-Quinto et al. [19], 2022		NA		More sustainable diets (MSD) as those with HEI-2015 above the overall median, and cost of the diet and environmental indicators below the median.
Jung et al. [20], 2023	25,262 participants of National Health and Nutrition Examination Survey (NHANES) 2007–2018	Sustainable Diet Index-US (SDI-US)	12 indicators with 4 sub-indices (nutritional: nutrient-rich foods 9.3 index, mean nutrient adequacy ratio; environmental: water footprint, acidifying emissions, eutrophying emission, greenhouse gas emissions, land use; economic: proportion of income spent on food; sociocultural: frequency of meals at fast-food or pizza place, ready-to-eat products, frozen meals/pizza)	1–5 points per indicator using quintiles and 5 points per sub-index (4–20 in total).	Mean SDI-US score was 13.2 (range: 4.3–20.0). More sustainable dietary patterns were inversely associated with obesity among US adults, supporting the potential of sustainable diets in preventing obesity.

FAO, Food and Agriculture Organization; NA, not applicable.

Table 5.

Composite indices for measuring adherence to sustainable diets with no specific guideline but including the sustainability concept

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Tepper et al. [21], 2021	348 participants recruited by social media and phone in Israel	Sustainable HEalthy Diet (SHED) index	30-item questionnaire (health: healthy eating items; environment and socioeconomic: sustainable eating items; sociocultural: organic food relevant; sociocultural and socioeconomic: fruits and vegetables; sociocultural and health: ready-made meals; environmental: drinking habits; environmental and health: drinking habits (soda); environmental: waste streams)	Mixed methods of 1–4 points scale, multiple choice, binary choice, or percent (%)	A linear correlation was found between the SHED index score and food groups of the EAT-Lancet reference diet and the Mediterranean diet score. The SHED index score revealed high reliability in test–retest, high validity in training and verification sets, and internal consistency.
Harray et al. [22], 2022	247 participants of the Connecting Health and Technology study in Australia	Healthy and Sustainable Diet Index (HSDI)	12 components (fruit; vegetables; seasonality of fruits and vegetables; ruminant animal meat and pigs; poultry, fish, and eggs; milk, yogurt, and cheese; non-animal protein foods (legumes, tofu, nuts, seeds); ultra-processed energy-dense nutrient-poor (EDNP) foods; unhealthy beverages (sugar-sweetened beverages and alcohol); individually packaged EDNP foods and beverages; individually packaged healthy foods and beverages; edible plate waste)	For each of 12 components, a maximum of 5 or 10 points could be assigned (6–90 in total)	The HSDI uses 12 components within five categories related to environmental sustainability. The mean HSDI score was 42.7 (SD 9.3). Participants who consumed meat were less likely to consume vegetables (P < 0.001) and those who consume non-animal protein foods were more likely to consume fruits (P < 0.001), vegetables (P < 0.05), and milk, yogurt, and cheese (P < 0.05). HSDI provides a new reference standard to assess adherence to a healthy and sustainable diet.
Campirano et al. [23], 2023	1,908 participants of the Health Workers Cohort Study in Mexico	Sustainable Dietary Score (SDS)	14 components (high-fiber cereals; tubers; vegetables; fruits; dairy; red meat; poultry; eggs; fish; legumes; nuts; unsaturated fats; saturated fats; added sugar)	A maximum of 10 points according to below range, within range, or upper range (0–140 in total)	The median of the SDS was 80.5 (p25, p75 = 72.7, 88.0) out of a total of 140. We propose a practical methodology to estimate SDS incorporating a gradual score for a better distinction between the degrees of adherence to the reference diet proposed by the EAT-Lancet Commission.
Liz Martins et al. [24], 2023	347 volunteers recruited from academic institutions, schools, and private institutions in Portugal	Sustainable HEalthy Diet (SHED) index	Same as SHED index in Israel	Same as SHED index in Israel	A higher SHED Index score was associated with moderate to high adherence to the Mediterranean diet, while it was inversely related to the proportion of animal-sourced foods in the overall food intake (r = −0.281, P < 0.001). Good reliability and agreement were found for the SHED index score. Our findings suggest that the SHED index is a valid and reliable tool for assessing sustainable and healthy diets in the Portuguese adult population.

FAO, Food and Agriculture Organization.

Table 6.

Description of selected indicators and calculation of the total Sustainable Diet Index-US and sub-index scores by Jung et al. [20]

Sub-index	Measure [17]	Relationship with sustainable diets [17]	Indicators in the sub-index	SDI-US	Assessment
Sub-index	Measure [17]	Relationship with sustainable diets [17]	Indicators in the sub-index	Points allocating	Assessment
Nutritional (/5)	Dietary diversity index	Diet diversity with nutrient adequacy is essential to avoid malnutrition and negative health outcomes.	1-1) Nutrient-rich foods index 9.3 [25,26]	Q1 = 1-point, Q2 = 2-point, Q3 = 3-point, Q4 = 4-point, Q5 = 5-point	Nutrition sub-index = the average scores of indicators 1-1 and 1-2
Nutritional (/5)	Micronutrient deficiencies of vitamins and minerals		1-2) Mean nutrient adequacy ratio [27]	Q1 = 1-point, Q2 = 2-point, Q3 = 3-point, Q4 = 4-point, Q5 = 5-point
Environmental (/5)	Water footprint	Clean water resource is becoming scarce in zones.	2-1) Freshwater withdrawals (L) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point	Environment sub-index = the average scores of indicators 2-1 to 2-6
	Water footprint	Clean water resource is becoming scarce in zones.	2-2) Stress-weighted water use (L) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Nitrogen footprint	Nitrogen balance is essential to avoid eutrophication and harmful algal bloom.	2-3) Acidifying emissions (g SO₂eq, CML2 baseline) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Nitrogen footprint		2-4) Eutrophying emissions (g PO₄^3-eq, CML2 Baseline) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Carbon footprint	Anthropogenic greenhouse gas emissions contribute to climate change.	2-5) Greenhouse gas emissions (kg CO₂ eq, IPCC 2013 includes feedbacks) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Land use	The availability of arable land is limited; moreover, land use change impacts the biodiversity preservation.	2-6) Land use (m²) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
Economic (/5)	Affordability	Healthy diet should be available at affordable prices to all, specifically to low-income consumers.	3) Proportion of income spent on food	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point	Economic sub-index = the score of the economic indicator
Sociocultural (/5)	Ready-made products	The use of ready-made products minimizes cooking activities and thus limit the opportunity for social exchange, culinary heritage promotion, and cultural diversity preservation.	4-1) Frequency of meals not prepared at home and purchased from a fast-food or pizza place	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point	Sociocultural sub-index = the average scores of indicators 4-1 to 4-3
			4-2) Frequency of ready-to-eat products	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point
			4-3) Frequency of frozen meals/pizza	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point

SDI-US, Sustainable Diet Index-US; Q, quintile.

Table 7.

Mean scores of total SDI-US, sub-indices, and individual indicators (n = 3,920)

Scores	NHANES 2017–2018
Total SDI-US score	13.2 (13.1–13.4)
Nutritional sub-index	3.0 (2.9–3.1)
NRF9.3 Index	17.4 (16.0–18.9)
MAR	70.4 (69.6–71.3)
Environmental sub-index	3.2 (3.2–3.3)
Freshwater use (L)	327 (308–346)
Stress-weighted water use (L)	11,044 (10,329–11,758)
Acidifying emissions (gSO₂eq)	18.8 (18.0–19.6)
Eutrophying emissions (gPO₄^3-)	14.9 (14.0–15.8)
Greenhouse gas emissions (kgCO₂eq)	3.7 (3.4–3.9)
Land use (m²)	8.8 (7.9–9.7)
Economic sub-index	3.1 (3.1–3.2)
Share of budget spent on food (%)	25.9 (23.8–28.1)
Sociocultural sub-index	3.9 (3.8–4.0)
Frequency of meals from a fast-food or pizza place	1.8 (1.6–2.0)
Frequency of ready-to-eat products	2.2 (1.9–2.6)
Frequency of frozen meals and pizza	2.2 (1.9–2.5)

Mean score (range).

SDI-US, Sustainable Diet Index-US; NHANES, National Health and Nutrition Examination Survey; NRF9.3 Index, Nutrient-Rich Foods 9.3 Index; MAR, mean nutrient adequacy ratio.

Table 8.

Mean scores of total SDI-US by sociodemographic characteristics

Characteristic	Mean score (95% CI)	P-value¹⁾
Total SDI-US score	13.2 (13.1–13.4)
Age group (years)		< 0.0001
20–39	12.9 (12.7–13.2)
40–59	13.1 (12.8–13.4)
≥ 60	13.9 (13.6–14.2)
Sex		0.0002
Male	13.0 (12.8–13.3)
Female	13.5 (13.3–13.7)
Race/ethnicity		0.2090
Hispanic	13.1 (12.9–13.3)
Non-Hispanic white	13.3 (13.0–13.6)
Non-Hispanic black	13.2 (12.9–13.4)
Other²⁾	13.5 (13.1–13.9)
Education level		< 0.0001
Less than high school graduate	12.7 (12.3–13.1)
High school graduate or GED	12.8 (12.4–13.1)
Some college or above	13.6 (13.4–13.8)
Household size		0.2061
Single	13.5 (13.1–13.8)
Multiple	13.2 (13.0–13.5)

SDI-US, Sustainable Diet Index-US; CI, confidence interval; GED, general equivalency diploma.

¹⁾P-value was obtained using the general linear model to present the difference between groups.

²⁾“Other” includes race/Hispanic origin other than non-Hispanic white, non-Hispanic black, and Hispanic, including multiracial.

Table 9.

Suggested data for the development of SDI-Korea using KNHANES

Sub-index	Measure [17]	SDI-US	SDI-Korea
Sub-index	Measure [17]	Indicator	Data availability (Y/N)	Possible indicator	Suggested data in KNHANES
Nutritional	Dietary diversity index	Nutrient-Rich Foods 9.3 Index [25,26]	Y	Korean Healthy Eating Index	KNHANES provides KHEI in selected years
Nutritional	Micronutrient deficiencies	Mean Nutrient Adequacy Ratio [27]	Y	Mean Nutrient Adequacy Ratio	Nutrient intake estimated from 24-h dietary recall data or other dietary assessment methods
Environmental	Water footprint	Freshwater withdrawal (L) per serving food [28]	N	Freshwater withdrawals (L) per serving food	Database needed
	Water footprint	Stress-weighted water use (L) per serving food [28]	N	Stress-weighted water use (L) per serving food	Database needed
	Nitrogen footprint	Acidifying emissions (g SO₂eq) per serving food [28]	N	Acidifying emissions (g SO₂eq) per serving food	Database needed
	Nitrogen footprint	Eutrophying emissions (g PO₄^3-eq) per serving food [28]	N	Eutrophying emissions (g PO₄^3-eq) per serving food	Database needed
	Carbon footprint	Greenhouse gas emissions (kg CO₂eq) per serving food [28]	Y	Greenhouse gas emissions (kg CO₂eq) per serving food	Can use predeveloped database [28]
	Land use	Land use (m²) per serving food [28]	N	Land use (m²) per serving food	Database needed
Economic	Affordability	Proportion of income spent on diet (%)	N	Proportion of income spent on diet (%)	Data needed
		-	Y	Food insecurity	KNHANES provides food security data in selected years
		-	N	Food price	Database needed
Sociocultural	Ready-made products	Frequency of meals not prepared at home and from a fast-food or pizza place	N	Daily energy contribution of ultra-processed foods	Dietary data from 24-hour dietary recall and classified using the Korean NOVA system [36]
		Frequency of ready-to-eat products	N
		Frequency of frozen meals/pizza	N
		-	Y	Use of food delivery	Data needed
		-	Y	Eating together with family or others	Data of eating together with someone at each eating occasion is available since 2013
		-	N	Frequency of meal kit delivery (particularly healthy ingredients)	Data needed

KNHANES, Korea National Health and Nutrition Examination Survey; SDI, Sustainable Diet Index.

REFERENCES

1. Gussow JD, Clancy KL. Dietary guidelines for sustainability. J Nutr Educ 1986; 18(1): 1-5.Article
2. The Giessen declaration. Public Health Nutr 2005; 8(6A): 783-786.Article PubMed
3. In: Burlingame B, Dernini S, editors. Sustainable diets and biodiversity: directions and solutions for policy, research and action. Proceedings of the International Scientific Symposium on Biodiversity and Sustainable Diets: United Against Hunger; 2010 Nov 3-5; Rome, Italy. Rome: Food and Agriculture Organization; 2012.
4. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 2019; 393(10170): 447-492.PubMed
5. Johnston JL, Fanzo JC, Cogill B. Understanding sustainable diets: a descriptive analysis of the determinants and processes that influence diets and their impact on health, food security, and environmental sustainability. Adv Nutr 2014; 5(4): 418-429.Article PubMed PMC
6. Auestad N, Fulgoni VL 3rd. What current literature tells us about sustainable diets: emerging research linking dietary patterns, environmental sustainability, and economics. Adv Nutr 2015; 6(1): 19-36.Article PubMed PMC
7. EAT; Sustainable Development Solutions Network; CGIAR. Integrated indicators for sustainable food systems and healthy diets in the post-2015 development agenda. Final Statement September 17th 2015 [Internet]; 2015 [cited 2023 Dec 16]. Available from: https://hdl.handle.net/10947/4011
8. Eme PE, Douwes J, Kim N, Foliaki S, Burlingame B. Review of methodologies for assessing sustainable diets and potential for development of harmonised indicators. Int J Environ Res Public Health 2019; 16(7): 1184.Article PubMed PMC
9. Knuppel A, Papier K, Key TJ, Travis RC. EAT-Lancet score and major health outcomes: the EPIC-Oxford study. Lancet 2019; 394(10194): 213-214.Article PubMed
10. Montejano Vallejo R, Schulz CA, van de Locht K, Oluwagbemigun K, Alexy U, Nöthlings U. Associations of adherence to a dietary index based on the EAT-Lancet reference diet with nutritional, anthropometric, and ecological sustainability parameters: results from the German DONALD cohort study. J Nutr 2022; 152(7): 1763-1772.Article PubMed PMC PDF
11. Stubbendorff A, Sonestedt E, Ramne S, Drake I, Hallström E, Ericson U. Development of an EAT-Lancet index and its relation to mortality in a Swedish population. Am J Clin Nutr 2022; 115(3): 705-716.Article PubMed PMC PDF
12. Ali Z, Scheelbeek PF, Felix J, Jallow B, Palazzo A, Segnon AC, et al. Adherence to EAT-Lancet dietary recommendations for health and sustainability in the Gambia. Environ Res Lett 2022; 17(10): 104043.Article PubMed PMC PDF
13. Trijsburg L, Talsma EF, Crispim SP, Garrett J, Kennedy G, de Vries JH, et al. Method for the development of WISH, a globally applicable index for healthy diets from sustainable food systems. Nutrients 2020; 13(1): 93.Article PubMed PMC
14. Cacau LT, De Carli E, de Carvalho AM, Lotufo PA, Moreno LA, Bensenor IM, et al. Development and validation of an index based on EAT-Lancet recommendations: the Planetary Health Diet Index. Nutrients 2021; 13(5): 1698.Article PubMed PMC
15. Parker MK, Misyak SA, Gohlke JM, Hedrick VE. Cross-sectional measurement of adherence to a proposed sustainable and healthy dietary pattern among United States adults using the newly developed Planetary Health Diet Index for the United States. Am J Clin Nutr 2023; 118(6): 1113-1122.Article PubMed
16. Colizzi C, Harbers MC, Vellinga RE, Verschuren WM, Boer JM, Biesbroek S, et al. Adherence to the EAT-Lancet healthy reference diet in relation to risk of cardiovascular events and environmental impact: results from the EPIC-NL cohort. J Am Heart Assoc 2023; 12(8): e026318.Article PubMed PMC
17. Seconda L, Baudry J, Pointereau P, Lacour C, Langevin B, Hercberg S, et al. Development and validation of an individual sustainable diet index in the NutriNet-Santé study cohort. Br J Nutr 2019; 121(10): 1166-1177.Article PubMed
18. Fresán U, Martínez-González MA, Segovia-Siapco G, Sabaté J, Bes-Rastrollo M. A three-dimensional dietary index (nutritional quality, environment and price) and reduced mortality: the “Seguimiento Universidad de Navarra” cohort. Prev Med 2020; 137: 106124.Article PubMed
19. Curi-Quinto K, Unar-Munguía M, Rodríguez-Ramírez S, Rivera JA, Fanzo J, Willett W, et al. Sustainability of diets in Mexico: diet quality, environmental footprint, diet cost, and sociodemographic factors. Front Nutr 2022; 9: 855793.Article PubMed PMC
20. Jung S, Young HA, Simmens SJ, Braffett BH, Ogden CL. The cross-sectional association between a sustainable diet index and obesity among US adults. Obesity (Silver Spring) 2023; 31(7): 1962-1971.PubMed
21. Tepper S, Geva D, Shahar DR, Shepon A, Mendelsohn O, Golan M, et al. The SHED Index: a tool for assessing a Sustainable HEalthy Diet. Eur J Nutr 2021; 60(7): 3897-3909.Article PubMed PDF
22. Harray AJ, Boushey CJ, Pollard CM, Dhaliwal SS, Mukhtar SA, Delp EJ, et al. Healthy and Sustainable Diet Index: development, application and evaluation using image-based food records. Nutrients 2022; 14(18): 3838.Article PubMed PMC
23. Campirano F, López-Olmedo N, Ramírez-Palacios P, Salmerón J. Sustainable dietary score: methodology for its assessment in Mexico based on EAT-Lancet recommendations. Nutrients 2023; 15(4): 1017.Article PubMed PMC
24. Liz Martins M, Tepper S, Marques B, Abreu S. The SHED Index: a validation study to assess Sustainable HEalthy Diets in Portugal. Nutrients 2023; 15(24): 5071.Article PubMed PMC
25. Fulgoni VL 3rd, Keast DR, Drewnowski A. Development and validation of the nutrient-rich foods index: a tool to measure nutritional quality of foods. J Nutr 2009; 139(8): 1549-1554.Article PubMed
26. Drewnowski A. Defining nutrient density: development and validation of the nutrient rich foods index. J Am Coll Nutr 2009; 28(4): 421S-426S.Article PubMed
27. Guthrie HA, Scheer JC. Nutritional adequacy of self-selected diets that satisfy the four food groups guide. J Nutr Educ 1981; 13(2): 46-49.Article
28. Bryan T, Hicks A, Barrett B, Middlecamp C. An environmental impact calculator for 24-h diet recalls. Sustainability (Basel) 2019; 11(23): 6866.Article
29. Poore J, Nemecek T. Reducing food’s environmental impacts through producers and consumers. Science 2018; 360(6392): 987-992.Article PubMed
30. Jung S, Young HA, Simmens SJ, Braffett BH, Ogden CL. Sustainable dietary patterns and all-cause mortality among US adults. Int J Epidemiol 2024; 53(1): dyad176.Article PubMed PMC PDF
31. Tan LJ, Shin S. Low greenhouse gas emission self-selective diets and risk of metabolic syndrome in adults 40 and older: a prospective cohort study in South Korea. Environ Health Perspect 2023; 131(11): 117010.Article PubMed PMC
32. The Foundation of Agriculture Technology Commercialization and Transfer. Smart green food [Internet]; 2020 [cited 16 Dec 2023]. Available from: http://www.smartgreenfood.org/jsp/front/story/game1_canvas.html
33. Ministry of Environment. Research of energy consumption and calculation of GHG emissions from food [Internet]; 2010 [cited 16 Dec 2023]. Available from: https://eng.me.go.kr/eng/web/main.do
34. Korea Environmental Industry & Technology Institute. Carbon footprint of products [Internet]; 2020 cited 16 Dec 2023]. Available from: http://www.epd.or.kr/eng/main.do
35. Heller MC, Willits-Smith A, Meyer R, Keoleian GA, Rose D. Greenhouse gas emissions and energy use associated with production of individual self-selected US diets. Environ Res Lett 2018; 13(4): 044004.Article PubMed PMC PDF
36. Mertens E, Kaptijn G, Kuijsten A, van Zanten H, Geleijnse JM, van ’t Veer P. SHARP-Indicators Database towards a public database for environmental sustainability. Data Brief 2019; 27: 104617.Article PubMed PMC
37. Sugimoto M, Murakami K, Asakura K, Masayasu S, Sasaki S. Diet-related greenhouse gas emissions and major food contributors among Japanese adults: comparison of different calculation methods. Public Health Nutr 2021; 24(5): 973-983.Article PubMed PMC
38. Cai H, Biesbroek S, Wen X, Fan S, van ’t Veer P, Talsma EF. Environmental footprints of Chinese foods and beverages: literature-based construction of a LCA database. Data Brief 2022; 42: 108244.Article PubMed PMC
39. Park HJ, Park S, Kim JY. Development of Korean NOVA Food Classification and estimation of ultra-processed food intake among adults: using 2018 Korea National Health and Nutrition Examination Survey. Korean J Community Nutr 2022; 27(6): 455-467.Article PDF

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Sustainable diets: a scoping review and descriptive study of concept, measurement, and suggested methods for the development of Korean version

Korean J Community Nutr. 2024;29(1):34-50. Published online February 29, 2024

DOI: https://doi.org/10.5720/kjcn.2024.29.1.34

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Sustainable diets: a scoping review and descriptive study of concept, measurement, and suggested methods for the development of Korean version

Categories	Composite indices for sustainable diets
EAT-Lancet reference diet based	EAT-Lancet score by Knuppel et al. [9], Dietary Index by Montejano Vallejo et al [10], EAT-Lancet index by Stubbendorff et al. [11], Sustainable and Healthy Diet Index (SHDI) by Ali et al. [12], World Index for Sustainability and Health (WISH) by Trijsburg et al. [13], Planetary Healthy Diet Index (PHDI) by Cacau et al. [14], PHDI-US by Parker et al [15], Healthy Reference Diet (HRD) score by Colizzi et al. [16]
FAO definition based	Sustainable Diet Index (SDI)-France by Seconda et al. [17], SDI-Spain by Fresán et al. [18], Index by Curi-Quinto et al. [19], SDI-US by Jung et al. [20]
No specific guideline but including the sustainability concept	Sustainable HEalthy Diet (SHED) index by Tepper et al. [21], Healthy and Sustainable Diet Index (HSDI) by Harray et al. [22], Sustainable Dietary Score by Campirano et al. [23], SHED index-Portugal by Liz Martins et al. [24]

Food groups	Macronutrient intake (possible range) (g/day)	Caloric intake (kcal/day)
Whole grains¹⁾
Rice, wheat, corn, and other²⁾	232 (total grains 0–60% of energy)	811
Tubers or starchy vegetables
Potatoes and cassava	50 (0–100)	39
Vegetables
All vegetables	300 (200–600)
Dark green vegetables	100	23
Red and orange vegetables	100	30
Other vegetables	100	25
Fruits
All fruit	200 (100–300)	126
Dairy foods
Whole milk or derivative equivalents (for example, cheese)	250 (0–500)	153
Protein sources³⁾
Beef and lamb	7 (0–14)	15
Pork	7 (0–14)	15
Chicken and other poultry	29 (0–58)	62
Eggs	13 (0–25)	19
Fish⁴⁾	28 (0–100)	40
Legumes
Dry beans, lentils, and peas¹⁾	50 (0–100)	172
Soy foods	25 (0–50)	112
Peanuts	25 (0–75)	142
Tree nuts	25	149
Added fats
Palm oil	6.8 (0–6.8)	60
Unsaturated oils⁵⁾	40 (20–80)	354
Dairy fats (included in milk)	0	0
Lard or tallow⁶⁾	5 (0–5)	36
Added sugars
All sweeteners	31 (0–31)	120

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Binary scoring
Knuppel et al. [9], 2019	40,069 UK participants of the European Prospective Investigation into Cancer and Nutrition (EPIC) Oxford study	EAT-Lancet score	14 components (rice, wheat, corn, and other; tubers and starchy vegetables; all vegetables; all fruits; dairy products; beef, lamb, pork; chicken, other poultry; eggs; fish; beans, lentils, peas; soy foods; peanuts or tree nuts; added fats (ratio of 0.8 for unsaturated to saturated fat intake); added sugars)	Binary: 1 point if a criterion met; 0 point otherwise (0–14 in total)	EAT-Lancet score had inverse associations with ischemic heart disease and diabetes; no association with stroke; no clear association with mortality.
Montejano Vallejo et al. [10], 2022	298 participants of the Dortmund Nutritional and Anthropometric Longitudinal Designed (DONALD) Study in Germany	Dietary Index (DI)	18 components (whole grains and all grains; tubers or starchy vegetables; all vegetables; all fruits; dairy products; beef and lamb; pork; chicken and other poultry; eggs; fish; dry beans, lentils, peas; soy foods; nuts; palm oil; unsaturated oils; lard and tallow; butter; all sweeteners)	Binary: 1 point if a criterion met; 0 point otherwise (0–18 in total)	A higher DI score in adolescence was also beneficial with respect to anthropometric markers in early adulthood, although not for further cardiometabolic risk markers.
Categorical scoring
Stubbendorff et al. [11], 2022	22,421 participants of the Malmö Diet and Cancer Study (MDCS) in Sweden	EAT-Lancet index	14 components (whole grains; potatoes; all vegetables; all fruits; dairy products; beef and lamb; pork; poultry; eggs; fish; legumes; nuts; unsaturated oils; added sugars)	0–3 points per component using the EAT-Lancet recommendation ranges (0–42 points in total)	The highest EAT-Lancet index score was associated lower risks of all-cause, cardiovascular, and cancer mortality compared to the lowest score.
Ali et al. [12], 2022	12,713 households from the Integrated Household Survey (IHS2015/16) in Gambia	Sustainable and Healthy Diet Index (SHDI)	16 components (all vegetables; all fruits; unsaturated oils; beans, lentils, and peas; peanuts and tree nuts; whole grains; potatoes and cassava; fish; palm oil; added sugar; refined grains; beef and lamb; pork; poultry; dairy; eggs)	0–3 points per component using the EAT-Lancet recommendation ranges (0–48 points in total)	The average Gambian diet had very low adherence to EAT-Lancet recommendations. The diet was dominated by refined grains and added sugars, the amount of which exceeded the recommendations.
Proportional scoring
Trijsburg et al. [13], 2021	396 participants of urban residents in Vietnam	World Index for Sustainability and Health (WISH)	14 components (whole grains; vegetables; fruits; dairy foods; red meat; fish; eggs; chicken and other poultry; legumes; nuts; unsaturated oils; saturated oils; added sugars)	Considering health benefits (protective, neutral, limit) and impact on environment (high, medium, low), 0–10 points could be assigned (0–130 in total)	The WISH seeks to measure two complex multidimensional concepts of diet quality and environmental sustainability in one scoring system. Out of a maximum score of 130, the mean total WISH score was 46 ± 11. Our initial analysis shows that the WISH can differentiate between the health benefits and environmental sustainability of a Vietnamese diet.
Cacau et al. [14], 2021	14,779 participants of the Longitudinal Study on Adult Health (ELSA)-Brazil	Planetary Healthy Diet Index (PHDI)	16 components (nuts and peanuts; legumes; fruits; vegetables; whole cereals; eggs; fish and seafood; tubers and potatoes; dairy; vegetable oils; ratio of dark green vegetable to total; ratio of red vegetable to total; red meat; chicken and substitutes; animal fats; added sugars)	For each of 16 components, a maximum of 5 or 10 points could be assigned (0–150 in total)	The PHDI (mean 60.4) had six dimensions, was associated in an expected direction with the selected nutrients and was significantly lower in smokers than in non-smokers. Cronbach’s alpha value was 0.51. There were low correlations between the components and between components and PHDI with total energy intake. After adjustment for age and sex, the PHDI score remained associated with higher overall dietary quality and lower carbon footprint.
Parker et al. [15], 2023	4,741 participants of the National Health and Nutrition Examination Survey (NHANES) 2017–2018	Planetary Healthy Diet Index-US (PHDI-US)	16 components (nuts and peanuts; legumes; fruits; non-starchy vegetables; whole grains; eggs; seafood and substitutes; tubers and starchy vegetables; dairy; unsaturated oils; ratio of dark green vegetable to total; ratio of red vegetable to total; red and processed meat; poultry; saturated fats; added sugars)	For each of 16 components, a maximum of 5 or 10 points could be assigned (0–150 in total)	The PHDI-US has 16 components with scores ranging between 0 and 150, and higher scores indicate better adherence to the Planetary Health Diet. The PHDI-US is a new tool that can assess adherence to the Planetary Health Diet and identify key aspects of United States adults’ diets that could be altered to potentially improve dietary sustainability and quality.
Colizzi et al. [16], 2023	37,349 Dutch participants of the EPIC-Nutrition (EPIC-NL)	Healthy Reference Diet (HRD) score	14 components (whole grains; potatoes; all vegetables; all fruits; dairy products; beef and lamb; pork; chicken; eggs; fish; legumes; nuts; ratio of 0.6 for unsaturated to saturated fat intake; added sugars)	Proportional scores from 0–10 points for each of 14 components (0–140 points in total)	A higher HRD score was associated with lower risk of coronary heart disease and all-cause mortality than that of a lower HRD score.

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Seconda et al. [17], 2019	29,388 participants of the NutriNet-Santé cohort study in France	Sustainable Diet Index (SDI)	7 indicators with 4 sub-indices (nutritional: absolute difference value between energy needed and intake, PANDiet score; environmental: pReCiPe; economic: contribution of organic food to diet; proportion of income spent on food; sociocultural: place of food purchase; ready-made products use)	1–5 points per indicator using quintiles and 5 points per sub-index (4–20 in total)	The SDI (mean 12.1) is based on a multicriteria approach and could be used to easily assess the sustainability of diets; there were high correlations between SDI and all sub-indices; a higher SDI was positively associated with the already published sustainable diets.
Fresán et al. [18], 2020	15,492 participants of the Seguimiento Universidad de Navarra(SUN) project in Spain	Sustainable Diet Index (SDI)	6 indicators with 3 sub-indices (nutritional: 2015–2020 Dietary Guidelines for Americans index; environmental: land, water, energy, GHG emissions; economic: cost of the diet in market)	0–3 points per sub-index using quartiles (0–9 in total)	The highest SDI quartile was associated with lower risk of all-cause and cardiovascular mortality. There were positive correlations between SDI and beans and potato consumption and negative correlations between SDI and red meat intake. Red and processed meats, fatty dairy products, and fish consumption accounted for the major variability in the SDI.
Curi-Quinto et al. [19], 2022	2,438 participants of the National Health and Nutrition Survey (ENSANUT-2012) in Mexico	NA	6 indicators (nutritional: Healthy Eating index-2015, cost of the diet; environmental: land use, biodiversity loss, carbon footprint, blue water footprint; economic: cost of the diet)	Binary: 1 point if a criterion met based on the median value; 0 point otherwise	MSD were consumed by 10.2% of adults, who had lower intake of animal-source foods, unhealthy foods (refined grains, added sugar and fats, mixed processed dishes, and sweetened beverages), fruits, and vegetables, and higher intake of whole grains than non-MSD subjects. The MSD is a realistic diet pattern mainly found in disadvantaged populations, but diet quality is still sub-optimal.
Curi-Quinto et al. [19], 2022		NA		More sustainable diets (MSD) as those with HEI-2015 above the overall median, and cost of the diet and environmental indicators below the median.
Jung et al. [20], 2023	25,262 participants of National Health and Nutrition Examination Survey (NHANES) 2007–2018	Sustainable Diet Index-US (SDI-US)	12 indicators with 4 sub-indices (nutritional: nutrient-rich foods 9.3 index, mean nutrient adequacy ratio; environmental: water footprint, acidifying emissions, eutrophying emission, greenhouse gas emissions, land use; economic: proportion of income spent on food; sociocultural: frequency of meals at fast-food or pizza place, ready-to-eat products, frozen meals/pizza)	1–5 points per indicator using quintiles and 5 points per sub-index (4–20 in total).	Mean SDI-US score was 13.2 (range: 4.3–20.0). More sustainable dietary patterns were inversely associated with obesity among US adults, supporting the potential of sustainable diets in preventing obesity.

Reference	Data source	Index name	Dietary components	Scoring method	Main results (excerpt from abstract)
Tepper et al. [21], 2021	348 participants recruited by social media and phone in Israel	Sustainable HEalthy Diet (SHED) index	30-item questionnaire (health: healthy eating items; environment and socioeconomic: sustainable eating items; sociocultural: organic food relevant; sociocultural and socioeconomic: fruits and vegetables; sociocultural and health: ready-made meals; environmental: drinking habits; environmental and health: drinking habits (soda); environmental: waste streams)	Mixed methods of 1–4 points scale, multiple choice, binary choice, or percent (%)	A linear correlation was found between the SHED index score and food groups of the EAT-Lancet reference diet and the Mediterranean diet score. The SHED index score revealed high reliability in test–retest, high validity in training and verification sets, and internal consistency.
Harray et al. [22], 2022	247 participants of the Connecting Health and Technology study in Australia	Healthy and Sustainable Diet Index (HSDI)	12 components (fruit; vegetables; seasonality of fruits and vegetables; ruminant animal meat and pigs; poultry, fish, and eggs; milk, yogurt, and cheese; non-animal protein foods (legumes, tofu, nuts, seeds); ultra-processed energy-dense nutrient-poor (EDNP) foods; unhealthy beverages (sugar-sweetened beverages and alcohol); individually packaged EDNP foods and beverages; individually packaged healthy foods and beverages; edible plate waste)	For each of 12 components, a maximum of 5 or 10 points could be assigned (6–90 in total)	The HSDI uses 12 components within five categories related to environmental sustainability. The mean HSDI score was 42.7 (SD 9.3). Participants who consumed meat were less likely to consume vegetables (P < 0.001) and those who consume non-animal protein foods were more likely to consume fruits (P < 0.001), vegetables (P < 0.05), and milk, yogurt, and cheese (P < 0.05). HSDI provides a new reference standard to assess adherence to a healthy and sustainable diet.
Campirano et al. [23], 2023	1,908 participants of the Health Workers Cohort Study in Mexico	Sustainable Dietary Score (SDS)	14 components (high-fiber cereals; tubers; vegetables; fruits; dairy; red meat; poultry; eggs; fish; legumes; nuts; unsaturated fats; saturated fats; added sugar)	A maximum of 10 points according to below range, within range, or upper range (0–140 in total)	The median of the SDS was 80.5 (p25, p75 = 72.7, 88.0) out of a total of 140. We propose a practical methodology to estimate SDS incorporating a gradual score for a better distinction between the degrees of adherence to the reference diet proposed by the EAT-Lancet Commission.
Liz Martins et al. [24], 2023	347 volunteers recruited from academic institutions, schools, and private institutions in Portugal	Sustainable HEalthy Diet (SHED) index	Same as SHED index in Israel	Same as SHED index in Israel	A higher SHED Index score was associated with moderate to high adherence to the Mediterranean diet, while it was inversely related to the proportion of animal-sourced foods in the overall food intake (r = −0.281, P < 0.001). Good reliability and agreement were found for the SHED index score. Our findings suggest that the SHED index is a valid and reliable tool for assessing sustainable and healthy diets in the Portuguese adult population.

Sub-index	Measure [17]	Relationship with sustainable diets [17]	Indicators in the sub-index	SDI-US	Assessment
Sub-index	Measure [17]	Relationship with sustainable diets [17]	Indicators in the sub-index	Points allocating	Assessment
Nutritional (/5)	Dietary diversity index	Diet diversity with nutrient adequacy is essential to avoid malnutrition and negative health outcomes.	1-1) Nutrient-rich foods index 9.3 [25,26]	Q1 = 1-point, Q2 = 2-point, Q3 = 3-point, Q4 = 4-point, Q5 = 5-point	Nutrition sub-index = the average scores of indicators 1-1 and 1-2
Nutritional (/5)	Micronutrient deficiencies of vitamins and minerals		1-2) Mean nutrient adequacy ratio [27]	Q1 = 1-point, Q2 = 2-point, Q3 = 3-point, Q4 = 4-point, Q5 = 5-point
Environmental (/5)	Water footprint	Clean water resource is becoming scarce in zones.	2-1) Freshwater withdrawals (L) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point	Environment sub-index = the average scores of indicators 2-1 to 2-6
	Water footprint	Clean water resource is becoming scarce in zones.	2-2) Stress-weighted water use (L) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Nitrogen footprint	Nitrogen balance is essential to avoid eutrophication and harmful algal bloom.	2-3) Acidifying emissions (g SO₂eq, CML2 baseline) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Nitrogen footprint		2-4) Eutrophying emissions (g PO₄^3-eq, CML2 Baseline) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Carbon footprint	Anthropogenic greenhouse gas emissions contribute to climate change.	2-5) Greenhouse gas emissions (kg CO₂ eq, IPCC 2013 includes feedbacks) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
	Land use	The availability of arable land is limited; moreover, land use change impacts the biodiversity preservation.	2-6) Land use (m²) per serving food [28]	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point
Economic (/5)	Affordability	Healthy diet should be available at affordable prices to all, specifically to low-income consumers.	3) Proportion of income spent on food	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 = 5-point	Economic sub-index = the score of the economic indicator
Sociocultural (/5)	Ready-made products	The use of ready-made products minimizes cooking activities and thus limit the opportunity for social exchange, culinary heritage promotion, and cultural diversity preservation.	4-1) Frequency of meals not prepared at home and purchased from a fast-food or pizza place	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point	Sociocultural sub-index = the average scores of indicators 4-1 to 4-3
			4-2) Frequency of ready-to-eat products	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point
			4-3) Frequency of frozen meals/pizza	Q5 = 1-point, Q4 = 2-point, Q3 = 3-point, Q2 = 4-point, Q1 (“never”) = 5-point

Scores	NHANES 2017–2018
Total SDI-US score	13.2 (13.1–13.4)
Nutritional sub-index	3.0 (2.9–3.1)
NRF9.3 Index	17.4 (16.0–18.9)
MAR	70.4 (69.6–71.3)
Environmental sub-index	3.2 (3.2–3.3)
Freshwater use (L)	327 (308–346)
Stress-weighted water use (L)	11,044 (10,329–11,758)
Acidifying emissions (gSO₂eq)	18.8 (18.0–19.6)
Eutrophying emissions (gPO₄^3-)	14.9 (14.0–15.8)
Greenhouse gas emissions (kgCO₂eq)	3.7 (3.4–3.9)
Land use (m²)	8.8 (7.9–9.7)
Economic sub-index	3.1 (3.1–3.2)
Share of budget spent on food (%)	25.9 (23.8–28.1)
Sociocultural sub-index	3.9 (3.8–4.0)
Frequency of meals from a fast-food or pizza place	1.8 (1.6–2.0)
Frequency of ready-to-eat products	2.2 (1.9–2.6)
Frequency of frozen meals and pizza	2.2 (1.9–2.5)

Characteristic	Mean score (95% CI)	P-value¹⁾
Total SDI-US score	13.2 (13.1–13.4)
Age group (years)		< 0.0001
20–39	12.9 (12.7–13.2)
40–59	13.1 (12.8–13.4)
≥ 60	13.9 (13.6–14.2)
Sex		0.0002
Male	13.0 (12.8–13.3)
Female	13.5 (13.3–13.7)
Race/ethnicity		0.2090
Hispanic	13.1 (12.9–13.3)
Non-Hispanic white	13.3 (13.0–13.6)
Non-Hispanic black	13.2 (12.9–13.4)
Other²⁾	13.5 (13.1–13.9)
Education level		< 0.0001
Less than high school graduate	12.7 (12.3–13.1)
High school graduate or GED	12.8 (12.4–13.1)
Some college or above	13.6 (13.4–13.8)
Household size		0.2061
Single	13.5 (13.1–13.8)
Multiple	13.2 (13.0–13.5)

Sub-index	Measure [17]	SDI-US	SDI-Korea
Sub-index	Measure [17]	Indicator	Data availability (Y/N)	Possible indicator	Suggested data in KNHANES
Nutritional	Dietary diversity index	Nutrient-Rich Foods 9.3 Index [25,26]	Y	Korean Healthy Eating Index	KNHANES provides KHEI in selected years
Nutritional	Micronutrient deficiencies	Mean Nutrient Adequacy Ratio [27]	Y	Mean Nutrient Adequacy Ratio	Nutrient intake estimated from 24-h dietary recall data or other dietary assessment methods
Environmental	Water footprint	Freshwater withdrawal (L) per serving food [28]	N	Freshwater withdrawals (L) per serving food	Database needed
	Water footprint	Stress-weighted water use (L) per serving food [28]	N	Stress-weighted water use (L) per serving food	Database needed
	Nitrogen footprint	Acidifying emissions (g SO₂eq) per serving food [28]	N	Acidifying emissions (g SO₂eq) per serving food	Database needed
	Nitrogen footprint	Eutrophying emissions (g PO₄^3-eq) per serving food [28]	N	Eutrophying emissions (g PO₄^3-eq) per serving food	Database needed
	Carbon footprint	Greenhouse gas emissions (kg CO₂eq) per serving food [28]	Y	Greenhouse gas emissions (kg CO₂eq) per serving food	Can use predeveloped database [28]
	Land use	Land use (m²) per serving food [28]	N	Land use (m²) per serving food	Database needed
Economic	Affordability	Proportion of income spent on diet (%)	N	Proportion of income spent on diet (%)	Data needed
		-	Y	Food insecurity	KNHANES provides food security data in selected years
		-	N	Food price	Database needed
Sociocultural	Ready-made products	Frequency of meals not prepared at home and from a fast-food or pizza place	N	Daily energy contribution of ultra-processed foods	Dietary data from 24-hour dietary recall and classified using the Korean NOVA system [36]
		Frequency of ready-to-eat products	N
		Frequency of frozen meals/pizza	N
		-	Y	Use of food delivery	Data needed
		-	Y	Eating together with family or others	Data of eating together with someone at each eating occasion is available since 2013
		-	N	Frequency of meal kit delivery (particularly healthy ingredients)	Data needed

Table 1. Summary of composite indices for measuring adherence to sustainable diets

FAO, Food and Agriculture Organization.

Table 2. The proposed EAT-Lancet diet by Willett et al., “Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems” [4]

Wheat, rice, dry beans, and lentils are dry and raw.

Mix and amount of grains can vary to maintain isocaloric intake.

Beef and lamb are exchangeable with pork and vice versa. Chicken and other poultry are exchangeable with eggs, fish, or plant protein sources. Legumes, peanuts, tree nuts, seeds, and soy foods are interchangeable.

Seafood consist of fish and shellfish (for example, mussels and shrimps) and originate from both capture and farming. Although seafood is a highly diverse group that contains both animals and plants, the focus of this report is solely on animals.

Unsaturated oils are 20% each of olive, soybean, rapeseed, sunflower, and peanut oil.

Some lard or tallow are optional in instances when pigs or cattle are consumed.

Table 3. Composite indices for measuring adherence to sustainable diets based on the EAT-Lancet reference diet

FAO, Food and Agriculture Organization; SD, standard deviation.

Table 4. Composite indices for measuring adherence to sustainable diets based on the FAO definition

FAO, Food and Agriculture Organization; NA, not applicable.

Table 5. Composite indices for measuring adherence to sustainable diets with no specific guideline but including the sustainability concept

FAO, Food and Agriculture Organization.

Table 6. Description of selected indicators and calculation of the total Sustainable Diet Index-US and sub-index scores by Jung et al. [20]

SDI-US, Sustainable Diet Index-US; Q, quintile.

Table 7. Mean scores of total SDI-US, sub-indices, and individual indicators (n = 3,920)

Mean score (range).

SDI-US, Sustainable Diet Index-US; NHANES, National Health and Nutrition Examination Survey; NRF9.3 Index, Nutrient-Rich Foods 9.3 Index; MAR, mean nutrient adequacy ratio.

Table 8. Mean scores of total SDI-US by sociodemographic characteristics

SDI-US, Sustainable Diet Index-US; CI, confidence interval; GED, general equivalency diploma.

P-value was obtained using the general linear model to present the difference between groups.

“Other” includes race/Hispanic origin other than non-Hispanic white, non-Hispanic black, and Hispanic, including multiracial.

Table 9. Suggested data for the development of SDI-Korea using KNHANES

KNHANES, Korea National Health and Nutrition Examination Survey; SDI, Sustainable Diet Index.