https://orcid.org/0000-0003-3830-8329
Figures
Abstract
Addressing overconsumption of protein-rich foods from high ecological footprint sources can have positive impacts on health such as reduction of non-communicable disease risk and protecting the natural environment. With the increased attention towards development of ecologically sustainable diets, this systematic review aimed to critically review literature on effectiveness of those interventions aiming to promote protein-rich foods from lower ecological footprint sources. Five electronic databases (Medline, Web of Science, Scopus, Embase and Global Health) were searched for articles published up to January 2021. Quantitative studies were eligible for inclusion if they reported on actual or intended consumption of protein-rich animal-derived and/or plant-based foods; purchase, or selection of meat/plant-based diet in real or virtual environments. We assessed 140 full-text articles for eligibility of which 51 were included in this review. The results were narratively synthesised. Included studies were categorised into individual level behaviour change interventions (n = 33) which included education, counselling and self-monitoring, and micro-environmental/structural behaviour change interventions (n = 18) which included menu manipulation, choice architecture and multicomponent approaches. Half of individual level interventions (52%) aimed to reduce red/processed meat intake among people with current/past chronic conditions which reduced meat intake in the short term. The majority of micro-environmental studies focused on increasing plant-based diet in dining facilities, leading to positive dietary changes. These findings point to a clear gap in the current evidence base for interventions that promote plant-based diet in the general population.
Citation: Ronto R, Saberi G, Leila Robbers GM, Godrich S, Lawrence M, Somerset S, et al. (2022) Identifying effective interventions to promote consumption of protein-rich foods from lower ecological footprint sources: A systematic literature review. PLOS Glob Public Health 2(3): e0000209. https://doi.org/10.1371/journal.pgph.0000209
Editor: Changwoo Han, Chungnam National University, REPUBLIC OF KOREA
Received: November 19, 2021; Accepted: January 23, 2022; Published: March 16, 2022
Copyright: © 2022 Ronto et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: RR funded by Macquarie University New Staff Grant No. 109740183 (https://www.mq.edu.au/). The Funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Current global food systems are not environmentally sustainable [1,2]. Food systems account for 21–37% of anthropogenic greenhouse gas (GHG) emissions and agriculture production for 70% of global freshwater withdrawals [3–5]. Dietary behaviours are both the result and driver of food systems [1]. Unhealthy dietary behaviours have significant impacts on human health, environmental sustainability and contribute to climate change [4]. In order to achieve positive outcomes for human health and the environment, diets that are both healthy and environmentally sustainable are needed.
In 2019, the Food and Agriculture Organization (FAO) of the United Nations and World Health Organization defined sustainable diets as “healthy dietary patterns that aim to promote optimal health and wellbeing and have minimal environmental pressure and impact. Sustainable healthy diets are equitable, affordable, accessible and culturally acceptable” [6]. The EAT-Lancet Commission stated that a “planetary healthy diet” consists largely of plant-based foods, low amounts of animal-derived foods (red and processed meat in particular) and little to no added sugars, refined grains, and ultra-processed foods [7]. Addressing overconsumption of animal-derived foods such as red and processed meat can have positive impact on health and environment. Cultivation of animal-derived foods, in aggregate, has a larger environmental impact compared with plant-based food alternatives [8]. Animal-derived foods require more water, more fossil fuels and generate substantially more greenhouse gasses than plant-based food equivalents [9]. Additionally, overconsumption of red meat has been linked to negative health outcomes such as cardiovascular diseases and colorectal cancer [10,11] whereas adequate consumption of fruit and vegetables have protective effects [12]. Processed animal-derived foods have been linked to growing rates of obesity [13] and place burden on natural resources [8].
Growing evidence demonstrates that population level dietary changes can improve health and environmental sustainability and also help in achieving the United Nation’s Sustainable Development Goals (SDGs) [14–19]. Changing dietary preferences and behaviours and food systems from animal-derived foods to plant-based diets will require a ‘Great Food Transformation’ [7]. There has been an increase in advocacy for and feasibility of harnessing the increasing interest in plant-based diets to influence large population-based public health nutrition interventions, for example Meatless Monday campaigns [20]. However, there is limited evidence on the effectiveness of plant-based dietary behaviour interventions in changing people’s behaviour. Therefore, this study aimed to critically review literature on interventions aiming to promote protein rich food intake from low ecological footprint sources to inform the design of larger population-based dietary interventions to achieve major shifts away from a reliance on animal-based foods.
Materials and methods
The systematic literature review was planned and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting (PRISMA) statement [21] and the protocol was registered on PROSPERO (Registration Number CRD42020178683). Details of each eligibility criteria are presented in Table 1. This systematic review included quantitative studies only published in peer review academic literature in English language, but it had no restrictions on the study design or year of publication (up until January 2021).
Search strategy
We searched the following databases: Medline, Web of Science, Scopus, Embase and Global Health. Initially, five primary concepts (meat, plant, food, intake and intervention) were adopted, in order to identify search terms (listed in Table 2). Subsequently, search strings were developed by the research team and with the help of research librarian. Two researchers (GS and GR) conducted the search independently through all databases. Then, potential articles were imported into Covidence (covidence.org) where duplicates were removed. The screening of search results was conducted and recorded using the PRISMA checklist, by two researchers (GS and GR) independently and in consultation with a third researcher (RR). First, two researchers (GS and GR) independently performed the title and abstract screening of all imported studies against inclusion and exclusion criteria. Where a consensus regarding the inclusion of a study between the first and a second researcher was not reached, it was resolved with two other researchers (RR and SG). Then, full-text versions were obtained for all studies identified to be suitable in the first stage of data screening and reviewed by two researchers (GS and GR) independently. The reference lists of all included studies were hand searched for relevant studies not identified in the first search strategy. Authors of identified studies and experts of the field were consulted, where further details were required. The PRISMA flow diagram was used to document the number of articles at each screening stage (see Fig 1).
Data extraction and analysis
The following information was extracted from included articles: author(s), year of publication, country of study, title, location, study type (structural/individual), intervention year, intervention length, target audience, sample characteristics, aims, intervention design, behaviour change theory/framework used, eligibility, recruitment, demographic characteristics, measure/tool(s) used, outcomes measured, results, follow up period, follow up results. Three researchers (GS, GR and RR) tested the data extraction sheet by extracting data from 10% of articles; minor disagreements were identified and discussed. Then, two researchers (GS and GR) extracted data from all included studies independently and then cross-checked all extracted data. Any disagreements were resolved in consultation with the third researcher (RR).
The risk and sources of potential bias of each included study were assessed by two researchers (GS and GR) independently by using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP) [22]. This tool was developed to assess the quality of a diverse group of empirical studies. Each included study was assessed on study design, selection bias, confounders, blinding, data collection method, withdrawals and dropouts and assigned to either ‘strong’, ‘moderate’ or ‘weak’ category. Finally, the overall rating was determined based on these ratings as indicated in the assessment tool dictionary. Any disagreements were resolved with a third researcher (RR). Finally, all quantitative data were summarised.
Results
Search results and characteristics of included studies
The initial search strategy yielded 5043 studies from five databases. Of these studies, 141 were assessed for eligibility for full-text reviewing of which 90 were excluded due to not meeting the inclusion criteria. The remaining 51 studies formed the final sample for this review (see Fig 1). These studies were divided into two categories: individual level [23–55] and micro-environmental/structural level [56–73] studies. The summary of each study is provided in Tables 3 and 4.
Of the 33 individual level studies, there were 24 Randomised Controlled Trials (RCT) [23–46], two Non-randomised Controlled Trials (CT) [47,48] and seven used a pre-post study design [49–54]. The number of participants ranged from 7 to 48,835 and the participants’ age ranged from 6 months (infants) to 75 and older. Nine studies had close to 100% female participants [24,25,38,42,43,46–48,52], and three studies had 100% male participants [23,29,53]. In six studies, gender distribution was either even or the difference between them was less than 10% [26,28,34,36,44,49]. In total, 30 studies aimed to reduce animal-derived foods (mainly red and processed meat intake) due to health concerns (cancer, overweight/obesity, high risk of developing Type 2 diabetes, ischemic heart disease), and only three studies considered both health and the environmental concerns in reducing animal-derived foods [23,26,27]. Half of the studies (n = 17) used behavioural change theories to guide their interventions. The Social Cognitive Theory (SCT) was the most frequently used theory [31,34,39,47,49,50,55], following by the Theory of Planned Behaviour (TPB) [26,27] and the Transtheoretical Model (TTM) [32,38].
Of the 51 included studies, 18 studies were categorised as micro-environmental/structural level studies which were conducted in high income countries. Micro-environmental/structural level studies refer to those studies which aimed to change immediate food environments in which people make food choices. They included nine RCTs [56–64], two CTs [65,66], three field experimental design studies [67,68,73], one quasi-experimental design study [69], and three pre-post design studies [70–72]. The number of participants ranged from 24 to 3,066 participants, and the participants’ age ranged from 12 to 75 years and older. In eight studies, there were no significant differences in gender ratio of the sample (less than 10%) [56–58,62,63,66,69,70] and six studies did not provide the sex differences between the participants [59,60,65,67,71,72]. Nearly all studies took place in dining facilities, for example restaurants, cafés or worksite canteens; one study selected a farm and a small community as their participants [70]. In total, eight studies focused on health concerns only when designing the interventions to reduce unsustainable protein intake [60–62,64,66,68,71,72], two studies were developed to address the environmental considerations [65,73], and nine studies considered both health and environmental concerns for reducing unsustainable protein intake [56–59,63–65,69,70]. Twelve studies reported using one or more behavioural change theories in their intervention design [56–59,61,62,65,68–71,73]. Nudge theory either on its own or in combination with other theories (e.g. choice architecture, TPB) was used most commonly [56,58,59,65,68,69,73].
Study quality
The overall methodological quality for all included studies was ‘strong’ for 12 studies, ‘moderate’ for 28 studies and ‘weak’ for 11 studies. The quality assessment for each individual study on each individual criterion is provided in Table 5.
Individual level studies
Educational interventions.
Twelve studies (RCT = 8, Pre/post = 4) used educational approach to reduce red/processed meat intake and purchase behaviour which included tailored education, educational classes, workshops and courses. Among RCT studies, six found positive impacts on the reduction in red meat intake in IG in comparison to CG [25,29,36,43,45,46], follow up varied between 3 months to 6 years. Two RCTs found that daily consumption of red meat was reduced in the IG, but it was not significant in comparison to CG [38,39]. Among pre-post studies: one study found a significant decrease in processed meat intake from baseline to 6 weeks [49]; one study found decrease in meat servings per week by 86% over 3 weeks period and significant increase in legume intake (pre-intervention 4.43 servings to 12.13 servings post-intervention) [52]; one study showed that intakes of red meat and poultry decreased significantly post intervention from baseline to 6 weeks [53]. Finally, one study found a decrease in purchases of meat (average dollars/week spent on meat) at baseline to 6 weeks [51].
Counselling interventions.
Eleven studies (RCT = 9, CT = 1, Pre/post = 1) used counselling approach to reduce red/processed meat intake (n = 10) and increase in soya intake (n = 1). These interventions included telephone and in person counselling sessions providing dietary advice. Among RCT studies, nine studies found positive impact on reduction in red/processed meat intake in IG in comparison to CG [24,28,30,33–35,40,42,44] and increase intake in soyabean products [24], follow up period varied between 4 weeks to 24 months. One CT study showed that the IG improved their adherence of red/processed meat intake to the guidelines over 12-month program [48]. Pre-post study found that processed meat intake decreased pre- to post- intervention (6 weeks) but no changes for red meat intake were observed [50].
Self-monitoring interventions.
Two studies used self-monitoring approach to reduce red meat intake. They were both RCTs and used daily text-messaging (SMS) approach to reduce red and processed meat intake. These studies urged participants to self-monitor meat intake and measured attitudes, intentions and anticipated regret [26,27]. It found positive impact on reduction in processed meat intake in IG in comparison to CG after one week [26], and red meat intake in IG in comparison to CG after two weeks [27].
Multicomponent interventions.
Eight studies (RCT = 5, CT = 1, Pre/post = 2) used multicomponent approach to reduce red/processed meat intake such as education and self-monitoring [23], education and counselling approaches [31,32,37,41,47,54,55]. Among RCTs, three studies found no significant intervention effect on red meat/processed meat [31,32,41] and two studies showed significant reductions in red meat intake at 4 weeks [23] and over 9 years [37]. Also, a CT study showed significant reductions in red/processed meat intake among women with breast cancer after 12 months [47]. Two pre-post studies showed significant changes in decreasing red/processed meat intake among students and cancer survivors [54,55].
Micro-environment level studies
Menu manipulation interventions.
Of 18 micro-environmental level studies, seven studies (RCT = 4, CT = 1, Exp = 3) used menu manipulation approach in order to reduce meat options or increase choice/sale of plant-based meal options [56–59,65,67,69,73]. Menu manipulation included different approaches such as adding attractive meat free choices on the menu, adding specific symbols specifying that less meat intake can save the environment, increasing the visibility of plant-based options, and describing the plant-based option as a ‘Dish of the day’. Of four RCTs, two did not show a difference on the choice of plant-based options in IG compared to CG [56,57], and two showed a positive impact on meat reduction behaviour by choosing more plant-based options in restaurants in IG compared to CG [58,59]. Also, a CT study showed increase in sales of plant-based lunches [65]. One experimental study revealed a significant changes on plant-based dish sales by changing the language to explain plant-based options on café/restaurant menus (e.g. replacing Meat-Free Breakfast with Garden Breakfast) [67]. However, the other experimental study found that the nudging strategy a ‘Dish of the day’ did not show a difference on the choice of the plant-based option among adolescents [69].
Choice architecture interventions.
Three studies used choice architecture approach (RCT = 2, Exp = 1) which included dining environment manipulation such as altering the serving sequence of plant-based and meat-based dishes [61], altering portion sizes of plant and meat-based foods [63] and using priming (environmental changes- adding green plants, herbs and green colour bowls), default (pre-portioned salad bowls) and perceived variety options (pre-mixed salad to increase the visual variety of vegetables) [68]. The manipulation of altering the serving sequence and default approach found no significant difference in selection of meat dishes between IG and CG [61,68]. However, the manipulation of altering portion sizes resulted in significant higher vegetable intake and lower meat intake in IG than CG [63] as well as using the priming and perceived variety conditions showed decrease in choosing meat-based options [68].
Multicomponent interventions.
Seven studies (RCT = 3, CT = 1, Pre/post = 3) used multicomponent approach to reduce red meat intake which included combination of education, labelling, policy, counselling and choice architecture. Of three RCTs, two studies found significant decrease in ground and processed meat intake [60] and high-fat meat intake [62]. One RCT showed that percentage of participants eating ≤3 servings per week of red meat did not differ between IG and CG over 18-months [64]. One CT study and three pre-/post- studies showed significant reduction in processed meat intake [66] and red meat intake [70–72].
Discussion
This systematic literature review explored the effectiveness of interventions which aimed to promote protein consumption from low ecological footprint sources (reduction in animal-derived proteins and increase in plant-based proteins). Most of individual level studies demonstrated reduction of animal-derived protein intake, mainly measured by reduction in red and/or processed meat intake with only a few studies measured increase intake in plant-based proteins such as legumes and soyabeans. Furthermore, 52% of these studies (n = 17) targeted people with current or past chronic conditions such as cancer, diabetes and cardiovascular diseases. The majority of micro-environmental/structural level studies found positive dietary changes in reducing animal-derived protein intake mainly red meat and increase in plant-based protein (e.g. plant-based vegetarian dishes). The majority of these studies were conducted in dining facilities such as cafes, restaurants and canteens. Similar findings have been observed in a several systematic literature reviews which evaluated the effectiveness of interventions targeting to reduce demand for meat [74,75].
Educational, counselling and self-monitoring interventions are promising approaches to dietary behaviour change such as increase in environmentally sustainable protein intake which have been observed in other systematic literature reviews [76,77]. However, these approaches have been often used among at risk or highly motivated populations such as people with obesity or other chronic condition, cancer survivors, and may have limited success in changing behaviour among general population. In addition, research indicates that educational interventions on its own may not be sufficient to behaviour change in long term [77,78]. There is a need for further longitudinal studies to confirm that the reduction in animal-derived protein intake from high ecological footprint sources among healthy general population sustain over prolonged period of time.
The majority of our included interventions focused on reduction of red/processed meat intake mainly from a health perspective with only three studies emphasising the reduction of animal-derived foods due to negative impact on the environment. This is not a surprising finding as recent studies reported general population having low food literacy and limited understanding of food impact on the environment and often focus on changing their dietary behaviours such as reducing red/processed meat intake due to health reasons [79–82]. Therefore, there is a need to develop interventions aiming to educate general public on sustainable and healthy diets and evaluate how feasible these interventions are in reducing overconsumption of protein from high ecological footprint sources in order to reduce the negative impact it has on health and environment.
The findings from included micro-environmental behaviour change interventions showed that altering food environments using nudges or choice architecture can lead to positive dietary behaviour changes such as reduction in unsustainable protein intake/purchase and increase in plant-based meals which aligns with findings from previous studies [75,83]. Most promising approaches included altering portion sizes, menu manipulation by adding plant-based meal options and policy implementation; similar environmental approaches have been identified as successful in changing dietary behaviours among young adults [84]. In order to reduce the human behaviour towards more environmentally sustainable protein intake, it is important not only to change the supply but also the demand of unsustainable foods [78]. Interestingly, the most recent qualitative study indicated that young Australians were open to or interested in affordable meat alternatives such as plant-based meals and reported that often these options were not available or very limited when dining out (unpublished work). This indicates that people may be interested in changing their dietary behaviours to more sustainable and healthy but food environments need to be supportive in helping them to make informed food choices. Choice architecture, nudging strategies and policy implementation can be promising approaches to create enabling food environments and for changing dietary behaviour towards more sustainable diets. However, there is still a need to develop and test different strategies among more general population and settings to determine what motivates them in choosing more environmentally sustainable food options and if it leads to sustained behaviour change. In addition, there is a need to explore what would motivate food retailers to offer plant-based meal options and what the impact it may have on the food purchasing behaviour.
The main strength of this review is that a systematic approach was used and reported following the PRISMA guidelines to synthesise the evidence on the interventions aiming to promote protein intake from low ecological footprint sources. We included individual and micro-environmental level behaviour change interventions, which provides a more comprehensive picture on the effectiveness of interventions in changing people behaviour towards increase in environmentally sustainable protein intake. One limitation of this review is that most of the included studies have been conducted in high income countries and only a few studies were conducted in low- and middle-income countries (LMIC). This might be due to the fact that plant-based diet concept in high income countries has received increased attention in the last five years and LMICs have not prioritised it as a significant nutrition and environmental issue due to dealing with other diet related issues such as undernutrition and nutrient deficiencies. Research indicates that meat intake in LMIC has been associated with wealth as the rise in income has resulted in significant animal-derived food consumption in these countries [85]. Furthermore, most studies used self-reported measures to measure dietary behaviours which may increase biases [86]. Also, this review was limited to the literature published in English language and did not included articles published in grey literature, therefore it may be we missed some important research written in other languages. Finally, the majority of individual level behaviour change interventions included people who may be highly motivated to change their dietary behaviour such as cancer survivors, people at risk of developing chronic conditions, limiting the generalizability of the data to general population.
Conclusions
The present review identified effective individual and micro-environmental behaviour change interventions which showed promising results in reducing protein intake from high ecological footprint sources. The findings suggest that individual behaviour change interventions such as education, counselling and self-monitoring interventions might be useful strategies to educate people to change their dietary behaviours to more sustainable ones. However, there is a need to test these strategies among the general population longitudinally. In addition, our findings showed that altering food environments using nudging and choice architecture approaches can achieve positive dietary changes but there is a need for development and evaluation of interventions in general settings (macro-environments) and explore motivations in sustainable food purchasing behaviours. Our findings inform future research for development and evaluation of interventions and strategies to encourage greater adoption of sustainable and healthy diets.
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