Abstract
Introduction
Healthful plant-based foods can improve youth nutrition and contribute to global targets such as Sustainable Development Goal (SDG) 2 on ending malnutrition, SDG3 improving health and SDG12 promoting sustainable diets, yet global intakes remain unquantified.
Methods
We analysed the Global Dietary Database, aggregating 1248 dietary surveys from 185 countries in a Bayesian hierarchical model adjusted for survey heterogeneity, temporal trends and data uncertainty. We assessed energy-adjusted consumption of fruits, non-starchy vegetables, starchy vegetables (excluding potatoes), beans/legumes and nuts/seeds among youth by age (0–19) globally in 2018; evaluated heterogeneity regionally, nationally and by sex, education and urbanicity; and assessed trends from 1990.
Results
Globally, plant-based food intake was low, from 1.19 servings/day (95% uncertainty interval (UI) 1.16 to 1.35) in <1-year-olds to 3.55 servings/day (3.35 to 3.79) in 15–19-year-olds. South Asia had the lowest intakes across all ages; East/Southeast Asia had the highest intakes for several ages, driven by non-starchy vegetables. Intake increased with age in all regions except high-income countries, where <1-year-olds consumed the most (3.77 servings/day (95% UI 3.30 to 4.35)), mainly from fruit (2.43 (2.14 to 2.77)). Across most regions, females consumed more fruit and non-starchy vegetables; urban youth consumed more fruit and nuts/seeds and those from higher educated households had higher intakes of all plant-based foods except beans/legumes. Among the 25 most populous countries, lowest intakes of total plant-based foods were in Spain (1.35 (1.10 to 1.75)), Pakistan (1.43 (1.21 to 1.76)), and the UK (1.71 (1.50 to 2.01)); and highest in Vietnam (4.28 (3.29 to 5.78)), Congo (4.38 (3.49 to 5.95)) and Mexico (5.18 (4.75 to 5.65)). Compared to 1990, youth globally in 2018 consumed more non-starchy vegetables and nuts/seeds, less starchy vegetables, and higher total plant-based foods.
Conclusion
Youth globally consume inadequate healthful plant-based foods, varying substantially by age, region and sociodemographic factors. These findings highlight gaps towards SDGs, underscoring the needs for targeted surveillance, policy interventions, and equity-focused strategies to improve youth dietary quality.
Keywords: Global Health, Child health, Nutrition, Public Health
WHAT IS ALREADY KNOWN ON THIS TOPIC
Prior global studies of children’s diets have assessed limited plant-based foods, animal-source foods, or overall dietary patterns. No prior global analysis has evaluated the intakes of multiple healthful plant-based foods across youth ages 0–19 years.
WHAT THIS STUDY ADDS
This study provides comprehensive estimates of global, regional and national consumption of healthful plant-based foods among youth, including first-ever estimates by sex, household education, and urbanicity. It reports intakes of fruits, non-starchy vegetables, starchy vegetables (excluding potatoes), beans/legumes, nuts/seeds, and their total. Temporal trends are also assessed from 1990 to 2018, highlighting dietary changes among youth over nearly three decades.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This first global analysis of healthful plant-based food consumption among youth offers critical insights for national and subnational surveillance, policy development, and public health interventions. The identified patterns and heterogeneity highlight opportunities for tailored approaches such as age-specific, context-specific or country-specific policies, culturally relevant dietary guidance and systems-level strategies targeting diets from early life to adolescence.
Introduction
Poor diets in childhood produce major health burdens worldwide.1 The double burden of malnutrition includes undernutrition, afflicting 150 million children <age 5 with stunted growth and 43 million with wasting, linked to micronutrient deficiencies, cognitive delays and weakened immunity,2 3 and obesity, present in 425 million children <age 18 and increasing the risk of type 2 diabetes, hypertension and cardiovascular disease across the life course.4,7
Healthful plant-based foods like fruits, vegetables, beans/legumes and nuts/seeds are critical to addressing youth undernutrition. These foods are minimally processed, rich in essential nutrients and support a healthy microbiome, physical and mental development, body weight and cardiometabolic risk profile.8 In addition, such foods can partly replace industrial livestock, helping to lower greenhouse gas emissions, conserve freshwater and prevent deforestation.9,12 However, while the United Nations Sustainable Development Goals (SDGs) aim to eliminate all forms of malnutrition by 2030,13 progress has been slow, especially for nutrition-related targets.14 Promoting healthful plant-based foods can support these goals and improve youth health.
Dietary behaviours and health outcomes in youth are also influenced by key social determinants, like parental education,15 urban or rural residence, other markers of socioeconomic status,16 race17,19 and food security.16 20 Dietary intakes likely also vary by child sex and age. However, global data on differences in healthful plant-based food consumption among youth by these factors remain limited.21 Understanding these patterns is important for designing interventions that are equity-focused and tailored to at-risk populations with lowest intakes.
Prior studies of plant-based foods among youth globally have included narrow age ranges, for example, focusing on 1–5-year-olds22 or limited numbers of foods among 12–17-year-olds.23 Prior reports from the Global Dietary Database (GDD) have published more comprehensive global estimates for certain dietary factors among youth, including for sugar-sweetened beverages,24 animal-source foods25 and overall dietary patterns.21 To our knowledge, no global analysis has evaluated intake of multiple healthful plant-based foods across the 0–19 age range. Such data are essential to understanding nutritional challenges and opportunities for youth and for supporting planetary health.
To address these gaps, we had three specific aims: (1) examine consumption of five healthful plant-based foods among youth aged 0–19 years at global, regional and national levels; (2) assess differences by age, sex, household education and urbanicity; and (3) evaluate temporal trends from 1990 to 2018. These data-driven insights help inform targeted interventions and policies to address the double burden of malnutrition, improve child diet and health and achieve the SDGs.
Methods
Data sources
We used data from the GDD, an international initiative that provides standardised estimates of dietary intake across 185 countries based on individual-level dietary surveys. Detailed methods for survey selection and standardisation have been described elsewhere.25,32 The GDD includes 54 dietary factors, food groups, beverages, macronutrients and micronutrients. This analysis focused on five healthful plant-based foods among youth 0–19 years: fruits, non-starchy vegetables, starchy vegetables (excluding potatoes), beans/legumes and nuts/seeds (definitions in online supplemental table S1). Potatoes were excluded due to more limited evidence of their benefit for undernutrition and chronic disease prevention.33
Dietary surveys
The GDD compiled individual-level dietary data organised from national representative samples that used validated dietary assessment methods, such as 24-hour dietary recalls or food frequency questionnaires.28 When national surveys were unavailable for any country, large subnational surveys, regional surveys or cohorts without evident selection or measurement bias were included. For any large countries lacking individual-level surveys, WHO STEPwise and household budget surveys were used. Surveys of special populations (eg, pregnant women or people with specific diseases) were excluded.
In total, GDD incorporated 1248 surveys across 185 countries and seven regions, covering an estimated 99% of the global population (online supplemental table S2).25 For this analysis, data were derived from 806 surveys for fruit (including a total of 5 209 894 participants), 792 for non-starchy vegetables (N=5 135 389), 380 for beans/legumes (N=3 189 559), 239 for starchy vegetables (N=1 677 068) and 267 for nuts/seeds (N=2 209 704) (online supplemental table S3).
Data extraction
For each included survey, the GDD team used standardised protocols to extract information on survey characteristics and dietary metrics, including units, mean intake and SD.25 29 Data were jointly stratified by age (22 total age groups, which for youth included <1, 1–2, 3–4, 5–9, 10–14 and 15–19 years), sex, urban or rural residence and education level (<6, 6–12, >12 years of education, for youth defined as the highest level attained within the household).29 All extracted data were systematically assessed for consistency and verified for accuracy prior to modelling. To ensure cross-survey comparability, all surveys were evaluated using harmonised GDD definitions, units and energy-adjusted metrics. Most individual-level dietary data were directly re-analysed by the original survey investigators, with results provided to the central GDD team; for a subset of surveys, the central GDD team directly analysed the individual-level data shared by the original survey investigators. All intakes were energy-adjusted using standardised age-specific reference values: 700 kcal/day (age 0–0.9 years), 1000 (1–1.9), 1300 (2–5), 1700 (6–10 and ≥75) and 2000 (11–74). For youngest ages (<2 years), intake estimates were for complementary foods, beyond breast milk or formula.
Data modelling and validation
To address missing data, heterogeneity across surveys and sampling uncertainty, the GDD applied a Bayesian nested hierarchical model, nesting countries within regions and regions within the globe. The model incorporated stratum-specific dietary intake data from each survey, jointly categorised by country, year, age, sex, education and urban/rural residence. The model incorporated country-level covariates and survey-level covariates, including survey type and food definition.
Country-year-specific covariates that were tested for inclusion into the model include data from the United Nations Food and Agricultural Organization (FAO) food balance sheets (1980–2018), Harvard Global Expanded Nutrient Supply (GENuS) (1980–2011), principal component analysis of FAO and GENuS data (2013), Euromonitor fat and oils sales data (1998–2018), World Bank Gross Domestic Product (1980–2018), World Bank unemployment rate (1980–2015), World Bank gini coefficient (1980–2015), World Bank poverty rate (1980–2015), Barro Lee years of schooling (1980–2010), World Bank precipitation (1982–2014), CIA Factbook latitude, CIA Factbook land area and CIA Factbook coastline ratio. Stepwise regression was used to identify three candidate models, each differing only in the set of country-level covariates included. These models were evaluated using fivefold cross-validation. We divide the data into five partitions, randomly binning each survey into a partition. Then, the models were trained on four partitions and tested on the fifth, rotating through all partitions. Model performance was assessed using expected log predictive density. Additional model validity was evaluated by comparing predicted versus observed intakes (excluding implausible estimates) and through visual inspection of global and national mean intakes using heat maps.25 Final covariates for each dietary factor are presented in the supplement. Overdispersion parameters in the Bayesian model adjusted for differences in survey quality, such as national representativeness or level of detailed stratification by age, sex or education. The final model estimated mean consumption in servings/day for 264 demographic strata, jointly defined by age (<1 to >95), sex, education (<6, 6–12, >12 years) and urban/rural residence, in each of 185 countries from 1990 to 2018. Stratum-specific intakes were pooled using population-weights for each stratum, calculated using data from the United Nations Population Division34 and additional stratification data on education and urbanicity from Barro and Lee35 and the United Nations.36
We fit each model in STAN37 38 using the RStan interface,39 employing the No-U-Turn Sampler,40 a variant of Hamiltonian Monte Carlo.41 Each model was run for 2000 iterations across four chains, with the first 1000 iterations of each chain discarded as burn-in. The remaining 4000 iterations (1000 per chain) were retained to characterise the posterior distributions of the model parameters.
Using these posterior samples, we generated posterior estimates of mean intake for each dietary factor by country-year and subgroup. For each iteration, we applied the sampled model parameters to calculate predicted values as a linear combination of covariates, including uncertainty propagation for countries or regions with no data by drawing from higher-level distributions (eg, region or global level). From these posterior predictive distributions, we calculated summary statistics, including the median and 95% uncertainty intervals (UIs), defined as the 2.5th and 97.5th percentiles. Further details on the methodology used to generate country-level estimates from the model parameters are provided in the supplemental text.
Statistical analysis
Estimates for each healthful plant-based food and their total were calculated at global, regional, national and within-country subgroup levels, stratified by age, sex, urban/rural residence and education level of the head of household. Findings were evaluated for the GDD age categories (<1, 1–2, 3–4, 5–9, 10–14 and 15–19 years) and for age<2 and 2–19 years.
Intakes were evaluated as mean servings/day with 95% UIs, overall and stratified by subgroups. Spearman correlations were used to assess between-nation relationships among the five food groups (online supplemental tables S4–S9). Absolute differences and percentage differences in mean intakes between subgroups and over time were calculated using all 4000 posterior draws. While formal hypothesis testing is not appropriate for Bayesian analysis, differences were considered meaningful when 95% UIs did not include zero.
Patient and public involvement
There was no patient or public involvement in the study; we used publicly available or privately stored data to conduct these analyses.
Results
Global consumption levels
In 2018, global total intake of healthful plant-based foods was 1.43 servings/day (95% UI 1.33 to 1.56) in children <2 years and 2.80 (2.65 to 2.99) in children aged 2–19 years (online supplemental tables S10 and S11). Non-starchy vegetables contributed the most in both age groups (0.64 servings/day (95% UI 0.61 to 0.68) and 1.38 (1.33 to 1.44), respectively). Adjusting for age-specific caloric needs, total intake increased nearly threefold from <1 year (1.19 (1.16 to 1.34)) to 15–19 years (3.55 (3.35 to 3.79)), with similar age-related gradients in each plant-based food category (figure 1, online supplemental table S12).
Figure 1. Global energy-adjusted mean intake of plant-based dietary foods by age in 2018. The filled bars represent the mean global consumption (servings/day) of fruits, non-starchy and other non-potato starchy vegetables, beans/legumes and nuts/seeds by age. One serving of fruit is equal to 49 g (6–11 months), 75 g (12–24 months) and 100 g (3–19 years). One serving of non-starchy vegetables is equal to 44 g (6–11 months), 50 g (12–24 months) and 100 g (3–19 years). One serving of other non-potato starchy vegetables is equal to 42 g (6–11 months), 47 g (12–24 months) and 160 g (3–19 years). One serving of beans/legumes is equal to 24 g (6–11 months), 32 g (12–24 months) and 100 g (3–19 years). One serving of nuts/seeds consumption is equal to 24 g (6–11 months), 32 g (12–24 months) and 28.35 g (3–19 years). All estimates are adjusted to age-specific daily energy intake levels as follows: 700 kcal/day for ages 0–0.9 years, 1000 kcal/day for ages 1–1.9 years, 1300 kcal/day for ages 2–5 years, 1700 kcal/day for ages 6–10 years, 2000 kcal/day for ages 11–74 years and 1700 kcal/day for ages >75 years.
Regional consumption levels
Age-related trends in energy-adjusted consumption of healthful plant-based foods were generally consistent across world regions, with the notable exception of high-income countries (figure 2, online supplemental table S13). In this region, intake was highest in children <2 years (3.11 servings/day (95% UI 2.80 to 3.52)) and lower in children aged 2–19 years (1.89 (1.79 to 1.98)), the lowest intake for this age group across regions (online supplemental tables S10–S13). In high-income countries, total plant-based food intake peaked in <1-year-olds (3.77 (3.30 to 4.35)), declined in mid-childhood (5–9 years: 1.71 (1.62 to 1.82)), then modestly increased by late adolescence (15–19 years: 2.14 (2.05 to 2.26)) (online supplemental table S13). These trends were driven primarily by declines in fruit and starchy vegetable intake from <1 to 15–19 years, whereas non-starchy vegetables and beans/legumes remained stable, and nuts/seeds increased.
Figure 2. Regional energy-adjusted mean intake of plant-based dietary foods by age in 2018. The filled bars represent the mean consumption (servings/day) of fruits, non-starchy and other non-potato starchy vegetables, beans/legumes and nuts/seeds by region and age. One serving of fruit is equal to 49 g (6–11 months), 75 g (12–24 months) and 100 g (3–19 years). One serving of non-starchy vegetables is equal to 44 g (6–11 months), 50 g (12–24 months) and 100 g (3–19 years). One serving of other non-potato starchy vegetables is equal to 42 g (6–11 months), 47 g (12–24 months) and 160 g (3–19 years). One serving of beans/legumes is equal to 24 g (6–11 months), 32 g (12–24 months) and 100 g (3–19 years). One serving of nuts/seeds consumption is equal to 24 g (6–11 months), 32 g (12–24 months) and 28.35 g (3–19 years). All estimates are adjusted to age-specific daily energy intake levels as follows: 700 kcal/day for ages 0–0.9 years, 1000 kcal/day for ages 1–1.9 years, 1300 kcal/day for ages 2–5 years, 1700 kcal/day for ages 6–10 years, 2000 kcal/day for ages 11–74 years and 1700 kcal/day for ages >75 years.
Across world regions, youth in South Asia had the lowest total plant-based food intake at age <2 years and (except for high-income countries) the second lowest intake at ages 2–19 years (online supplemental tables S10 and S11). Age-related trends in South Asia were primarily due to increased non-starchy vegetables and beans/legumes, while fruit and nuts/seeds remained low at all ages (online supplemental table S13). In comparison, youth in East/Southeast Asia had the highest total intake of healthful plant-based foods among world regions, driven by non-starchy vegetables which were high at the youngest age categories and increased across all ages, while fruit consumption was moderately high in early childhood but then declined.
Youth in Latin America/Caribbean had generally the highest starchy vegetable intake (0.66 (0.60 to 0.74) at 10–19 years), highest bean/legume intake after age 2 (0.65 (0.58 to 0.73) at 15–19 years) and highest fruit intake after age 5 (1.31 (1.24 to 1.39) at 15–19 years). Youth in the Former Soviet Union had the highest nuts/seeds intake across ages, peaking at age 10–14 (0.85 (0.65 to 1.08)). In contrast, intakes of fruit and non-starchy vegetables were more moderate, and beans/legumes low, relative to other regions. In the Middle East/North Africa, children <2 years had the second lowest intake of total plant-based foods, after South Asia, driven by the lowest intake of non-starchy vegetables of all regions (online supplemental table S10). By age 15–19, intakes of fruits and non-starchy vegetables increased and were more comparable to other regions (online supplemental table S13). Compared with other regions, youth in Sub-Saharan Africa had intermediate plant-based food consumption across ages (online supplemental tables S10 and S11), with the largest portion from non-starchy vegetables and, across ages, large age-related increases in fruit consumption (online supplemental table S13).
National consumption levels
Across the world’s 25 most populous countries, healthful plant-based food intake varied considerably (figures3 4, online supplemental tables S14 and S15; see onlinesupplemental figures S1S5 and online supplemental file 1 tables S6–S12 for all age categories across all 185 countries). At age <2, lowest total intakes were in Pakistan (0.41 servings/day (95% UI 0.34 to 0.55)), India (0.54 (0.49 to 0.61)) and Ethiopia (0.58 (0.51 to 0.66)), primarily due to low fruits and non-starchy vegetables. Intakes at age <2 years were highest in France (3.56 (3.1 to 4.08)), Germany (3.88 (3.39 to 4.44)) and Italy (4.38 (3.81 to 5.05)), with primary contributors being fruits and/or non-starchy vegetables.
Figure 3. Energy-adjusted mean intake of plant-based dietary foods for (A) infants and toddlers (0–23 months) and (B) children and adolescents (2–19 years) for the 25 most populous countries in 2018. The filled bars represent the mean consumption (servings/day) of fruits, non-starchy and other non-potato starchy vegetables, beans/legumes and nuts/seeds by nation and age. One serving of fruit is equal to 49 g (6–11 months), 75 g (12–24 months) and 100 g (3–19 years). One serving of non-starchy vegetables is equal to 44 g (6–11 months), 50 g (12–24 months) and 100 g (3–19 years). One serving of other non-potato starchy vegetables is equal to 42 g (6–11 months), 47 g (12–24 months) and 160 g (3–19 years). One serving of beans/legumes is equal to 24 g (6–11 months), 32 g (12–24 months) and 100 g (3–19 years). One serving of nuts/seeds consumption is equal to 24 g (6–11 months), 32 g (12–24 months) and 28.35 g (3–19 years). All estimates are adjusted to age-specific daily energy intake levels as follows: 700 kcal/day for ages 0–0.9 years, 1000 kcal/day for ages 1–1.9 years, 1300 kcal/day for ages 2–5 years, 1700 kcal/day for ages 6–10 years, 2000 kcal/day for ages 11–74 years and 1700 kcal/day for ages >75 years.
Figure 4. : Global energy adjusted decile ranked mean total intake of plant-based dietary foods in (A) infants and toddlers 0–23 months and (B) children and adolescents 2–19 years. The coloured countries are the decile ranked mean total consumption (servings/day) of fruits, non-starchy and other non-potato starchy vegetables, beans/legumes and nuts/seeds by country and by infants and toddlers (0–23 months) vs children and adolescents (2–19 years). Total consumption of plant-based foods is ranked into deciles, with light blue indicating the lowest decile of total consumption and dark blue indicating the highest decile of consumption. One serving of fruit is equal to 49 g (6–11 months), 75 g (12–24 months) and 100 g (3–19 years). One serving of non-starchy vegetables is equal to 44 g (6–11 months), 50 g (12–24 months) and 100 g (3–19 years). One serving of other non-potato starchy vegetables is equal to 42 g (6–11 months), 47 g (12–24 months) and 160 g (3–19 years). One serving of beans/legumes is equal to 24 g (6–11 months), 32 g (12–24 months) and 100 g (3–19 years). One serving of nuts/seeds consumption is equal to 24 g (6–11 months), 32 g (12–24 months) and 28.35 g (3–19 years). All estimates are adjusted to age-specific daily energy intake levels as follows: 700 kcal/day for ages 0–0.9 years, 1000 kcal/day for ages 1–1.9 years, 1300 kcal/day for ages 2–5 years, 1700 kcal/day for ages 6–10 years, 2000 kcal/day for ages 11–74 years and 1700 kcal/day for ages >75 years.
For youth aged 2–19 years, lowest intakes of total healthful plant-based foods were seen in Spain (1.35 (1.10 to 1.75)), Pakistan (1.43 (1.21 to 1.76)) and the UK (1.71 (1.50 to 2.01)); and highest in Vietnam (4.28 (3.29 to 5.78)), the Democratic Republic of the Congo (4.38 (3.49 to 5.95)) and Mexico (5.18 (4.75 to 5.65)). Higher intakes were primarily driven by fruits and non-starchy vegetables, as well as starchy vegetables in Mexico.
Consumption levels by demographic subgroups
Total intake of healthful plant-based foods was modestly lower in boys versus girls globally (−0.18 servings/day (95% UI −0.32 to −0.05)), in high-income countries (−0.19 (-0.29 to −0.10)) and in East/Southeast Asia (−0.41 (–0.79 to −0.07)) (online supplemental figure S6, online supplemental table S2). This was because boys generally consumed less fruits and non-starchy vegetables than girls. Differences by sex in other plant-based foods were minor and inconsistent across regions. Percentage differences by sex are shown in online supplemental table S23.
Globally, children in urban households consumed more healthful plant-based foods than those in rural households (+0.37 servings/day (95% UI 0.27 to 0.49)), a pattern consistent across most regions except high-income countries, where intake was lower in urban areas (−0.24 (–0.36 to −0.12)) (figure 5, online supplemental table S24). Fruit consumption was similarly higher in urban youth globally (+0.24 (0.22 to 0.26)) and regionally, except again in high-income countries, where it was lower (−0.21 (–0.27 to −0.16)). Urban youth also consumed more nuts/seeds globally (+0.10 (0.07 to 0.13)) and in most regions. In contrast, urban–rural differences in youth intake were smaller for non-starchy vegetables, starchy vegetables and beans/legumes, without consistent regional patterns. Percentage differences are in online supplemental table S25.
Figure 5. Mean absolute difference of (A) urban versus rural residence (2018), (B) high versus low education households (2018) and (C) 1990 versus 2018 in youth 0–19 years. The filled bars represent the absolute mean difference in servings/day in consumption of fruits, non-starchy and other non-potato starchy vegetables, beans/legumes and nuts/seeds, and the error bars the 95% uncertainty interval. Positive values indicate greater mean consumption in (A) urban versus rural households; (B) high (>12 years) versus low (<6 years) education households (middle education (>6–<12 years) excluded) and (C) 2018 versus 1990. One serving of fruit is equal to 49 g (6–11 months), 75 g (12–24 months) and 100 g (3–19 years). One serving of non-starchy vegetables is equal to 44 g (6–11 months), 50 g (12–24 months) and 100 g (3–19 years). One serving of other non-potato starchy vegetables is equal to 42 g (6–11 months), 47 g (12–24 months) and 160 g (3–19 years). One serving of beans/legumes is equal to 24 g (6–11 months), 32 g (12–24 months) and 100 g (3–19 years). One serving of nuts/seeds consumption is equal to 24 g (6–11 months), 32 g (12–24 months) and 28.35 g (3–19 years). All estimates are adjusted to age-specific daily energy intake levels as follows: 700 kcal/day for ages 0–0.9 years, 1000 kcal/day for ages 1–1.9 years, 1300 kcal/day for ages 2–5 years, 1700 kcal/day for ages 6–10 years, 2000 kcal/day for ages 11–74 years and 1700 kcal/day for ages >75 years.
Children in more educated households had higher healthful plant-based food consumption than in lower education households globally (+0.69 (0.52 to 0.84)) and in most regions (figure 5, online supplemental table S26). These differences reflect higher intakes of starchy vegetables (+0.04 (0.01 to 0.06)), non-starchy vegetables (+0.13 (0.09 to 0.17)), nuts/seeds (+0.13 (0.08 to 0.18)) and fruits (+0.41 (0.38 to 0.44)) in more educated households. These patterns were generally consistent across regions, except that more educated households had lower fruit intake in high-income countries (−0.16 (–0.23 to −0.10)) and lower non-starchy vegetable intake in the Former Soviet Union (−0.09 (–0.17 to −0.02)). Percentage differences are in online supplemental table S27.
Trends over time
Total intake of healthful plant-based foods among youth increased from 1990 to 2018 globally and in all regions except South Asia (figure 5, online supplemental table S28). Most of this was due to increases in non-starchy vegetables (+0.44 servings/day (95% UI 0.41 to 0.47)) and nuts/seeds (+0.15 (0.12 to 0.19)). In contrast, intake of beans/legumes and fruit remained relatively stable, while intake of starchy vegetables declined globally and in most regions. Percentage differences are in online supplemental table S29.
Discussion
This global, regional and national analysis of healthful plant-based food consumption among youth reveals important differences by food group, world region, age, sex, urbanicity and household education. To our knowledge, this is the first global report on these foods across youth, a critical yet understudied population. Healthful plant-based food consumption in youth is essential to achieving global nutrition and diet-related disease goals. The findings have implications for childhood nutrition and policy development, including for surveillance, nutrition assistance programmes42 and healthcare interventions.43 Our findings highlight major gaps, for example, in progress towards SDG targets on ending malnutrition (SDG2) and ensuring health (SDG3).
Consumption of total plant-based foods by youth remains low, averaging 2.80 servings/day overall and no more than 3.55 daily servings in any age group at a global level. Dietary shortfalls of these foods during childhood are linked to suboptimal growth, cognitive development and immune function2 3 as well as high blood pressure, dyslipidaemia, pre-diabetes,44 diabetes45 and obesity.46 Childhood dietary patterns also influence lifelong eating behaviours and chronic disease risk, reinforcing the need for interventions that support national and global objectives for child nutrition and health.47
We also identified substantial variation across regions and subgroups, underscoring the opportunities for context-specific interventions. In high-income countries, fruit and vegetable intake uniquely declined with age, consistent with prior reports from individual Western countries.48 49 This suggests that, despite higher purchasing power, other factors such as youth autonomy, food environments or cultural norms have a particular hold among older youth in this region. Many high-income nations have early-life nutrition programmes that include healthful plant-foods,50,54 which could explain higher intakes at youngest ages. In comparison, youth in East/Southeast Asia consumed more non-starchy vegetables, which may reflect cultural preferences and traditional market affordability55; yet, total healthful plant-food consumption remains below recommendations, indicating potential challenges around food system inefficiencies, production gaps, costs or educational and cultural barriers.56 57 We found that South Asia had very low intake of healthful plant-based foods, building on earlier findings evaluating fruits and vegetables in this region.56 These identified regional patterns inform future research and policy on the social, economic and cultural determinants of youth diets.
These regional findings highlight a few opportunities for policy priorities, including (1) strengthening and extending early childhood nutrition programmes in high-income countries to sustain healthy plant-based eating into adolescence; (2) improving access to diverse vegetables in South Asia through agricultural policy and market interventions; (3) leveraging existing cultural preferences for vegetables in East/Southeast Asia while addressing remaining gaps in fruit and vegetable consumption and (4) implementing equity-focused interventions targeting rural and lower-education households across most regions, while recognising reversed patterns in high-income settings.
Although many country-specific findings mirror their region, others diverge, such as high fruit and vegetable intake among youth in Mexico. These patterns underscore the need for both regionally and nationally targeted approaches to advance nutrition and health among youth.
Our subgroup analyses revealed that girls consumed slightly more fruits and non-starchy vegetables than boys, consistent with prior literature from individual countries.58 However, intakes of beans/legumes, nuts/seeds and other starchy vegetables were similar by sex, new findings not previously observed globally. In contrast, larger differences were seen by household education and urbanicity. Youth in higher-educated households generally consumed more healthful plant-based foods, suggesting a positive influence of education (and associated income and food access) on diet quality.21 An exception was beans/legumes, which were more common in lower-education households, suggesting a potential role for cultural tradition, affordability and nutrient-to-price advantages of this food group.59 Compared with rural youth, urban youth generally consumed more fruits and nuts/seeds, consistent with differences in income and market access. Interestingly, these education and urbanicity patterns were generally reversed in high-income countries, suggesting that other factors, like home production or more traditional diets, may promote healthful plant-based foods among children in rural or lower education households, an area ripe for research.
We found that over nearly three decades, youth consumption of non-starchy vegetables and nuts/seeds increased globally, which could relate to improved supply chains for access to more varied and non-seasonal produce.60 However, overall consumption of plant-based foods remained low in 2018, and absolute changes in intake were small in several regions and for several food groups (eg, fruits, beans/legumes), while consumption of starchy vegetables declined globally. These findings underscore the insufficient progress towards the SDGs and improving nutrition in youth, and the need for new and accelerated efforts to improve production, affordability, access, convenience and consumption.
In 2021, the Global Nutrition Report used GDD data to estimate that more than half the world’s children do not meet WHO–UNICEF dietary guidelines for fruits and vegetables, while two-thirds fall short on recommendations for beans/legumes and nuts/seeds.61 Our results expand on these findings by evaluating consumption across regions, nations and subgroups by age, sex, urbanicity and education. Other strengths of our investigation include the incorporation of 1248 mostly nationally representative, individual-level dietary surveys from countries representing 99% of the global population. This reduces misclassification, bias and ecologic fallacy from relying on national per capita food availability data, and further permits evaluation of intakes by age, sex, urbanicity and education. Model estimates were validated using fivefold cross-validation and model fit criteria; and heterogeneity and missingness were incorporated into uncertainty estimates.
Limitations include variability in the quality and completeness of input data, which were more limited for some countries, dietary exposures and time periods. Our findings should therefore be considered the best available, but still imperfect, estimates of these foods among youth; the reported uncertainty intervals should be considered in this regard. Standardisation and harmonisation of data inputs increased reliability and comparability but did not allow for more granular assessments of foods, such as subtypes of fruits or legumes. Given the time frame of GDD data collection, our results provide findings through 2018. Dietary patterns may have shifted since 2018 due to the COVID-19 pandemic, economic disruptions and climate events, highlighting the importance of continued surveillance and future GDD updates.
In conclusion, consumption of plant-based foods remains low among youth. The identified patterns and heterogeneity underscore opportunities for tailored interventions, such as age-specific, context-specific or country-specific policies, culturally relevant dietary guidance and systems-level strategies targeting diets in both early life and adolescence. These actions are critical to closing gaps in global nutrition, advancing child health and supporting food systems in line with the SDGs.
Supplementary material
Footnotes
Funding: Bill & Melinda Gates Foundation and National Institute of Health (T32TR004417).
Provenance and peer review: Not commissioned; externally peer reviewed.
Handling editor: Soumitra S Bhuyan
Patient consent for publication: Not applicable.
Ethics approval: This study did not require ethical review as it has previously been determined to be exempt (not-human subjects research) as we are using a publicly available, de-identified data source, the Global Dietary Database.
Data availability free text: Data is available through the Global Dietary Database website: https://globaldietarydatabase.org/.
Map disclaimer: The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Collaborators: Global Dietary Database - Antonia Trichopoulou⁹, Murat Bas¹⁰, Jemal Haidar Ali¹¹, Tatyana El-Kour¹², Anand Krishnan¹³, Puneet Misra¹³, Nahla Hwalla¹⁴, Chandrashekar Janakiram¹⁵, Nur Indrawaty Lipoeto¹⁶, Abdulrahman Musaiger¹⁷, Farhad Pourfarzi¹⁸, Iftikhar Alam¹⁹, Celine Termote²⁰, Anjum Memon²¹, Marieke Vossenaar²², Paramita Mazumdar²³, Ingrid Rached²⁴, Alicia Rovirosa²⁵, María Elisa Zapata²⁵, Roya Kelishadi²⁶, Tamene Taye Asayehu²⁷, Francis Oduor²⁸, Julia Boedecker²⁸, Lilian Aluso²⁸, Emanuele Marconi²⁹, Laura D'Addezio²⁹, Raffaela Piccinelli²⁹, Stefania Sette²⁹, Johana Ortiz-Ulloa³⁰, J.V. Meenakshi³¹, Giuseppe Grosso³², Anna Waskiewicz³³, Umber S. Khan³⁴, Kenneth Brown³⁵, Lene Frost Andersen³⁶, Anastasia Thanopoulou³⁷, Reza Malekzadeh³⁸, Neville Calleja³⁹, Anca Ioana Nicolau⁴⁰, Cornelia Tudorie⁴⁰, Marga Ocke⁴¹, Zohreh Etemad⁴¹, Mohannad Al Nsour⁴², Lydiah M. Waswa⁴³, Maryam Hashemian⁴⁴, Eha Nurk⁴⁵, Joanne Arsenault⁴⁶, Patricio Lopez-Jaramillo⁴⁷, Abla Mehio Sibai⁴⁸, Albertino Damasceno⁴⁹, Pulani Lanerolle⁵⁰, Carukshi Arambepola⁵¹, Carla Lopes⁵², Milton Severo⁵², Nuno Lunet⁵², Duarte Torres⁵³, Heli Tapanainen⁵⁴, Jaana Lindstrom⁵⁴, Suvi Virtanen⁵⁴, Cristina Palacios⁵⁵, Noel Barengo⁵⁵, Eva Roos⁵⁶, Irmgard Jordan⁵⁷, Charmaine Duante⁵⁸, Corazon Cerdena (retired)⁵⁸, Imelda Angeles-Agdeppa (retired)⁵⁸, Josie Desnacido⁵⁸, Mario Capanzana (retired)⁵⁹, Anoop Misra⁶⁰,¹²³, Ilse Khouw⁶¹, Swee Ai Ng⁶¹, Edna Gamboa Delgado⁶², Mauricio T. Caballero⁶³, Johanna Otero⁶⁴, Hae-Jeung Lee⁶⁵, Eda Koksal⁶⁶, Idris Guessous⁶⁷, Carl Lachat⁶⁸, Stefaan De Henauw⁶⁸, Ali Reza Rahbar⁶⁹, Alison Tedstone⁶⁹, Annie Ling⁶⁹, Beth Hopping⁶⁹, Catherine Leclercq⁶⁹, Christian Haerpfer⁶⁹, Christine Hotz⁶⁹, Christos Pitsavos⁶⁹, Coline van Oosterhout⁶⁹, Debbie Bradshaw⁶⁹, Dimitrios Trichopoulos⁶⁹, Dorothy Gauci⁶⁹, Dulitha Fernando⁶⁹, Elzbieta Sygnowska⁶⁹, Erkki Vartiainen⁶⁹, Farshad Farzadfar⁶⁹, Gabor Zajkas⁶⁹, Gillian Swan⁶⁹, Guansheng Ma⁶⁹, Hajah Masni Ibrahim⁶⁹, Harri Sinkko⁶⁹, Isabelle Sioen⁶⁹, Jean-Michel Gaspoz⁶⁹, Jillian Odenkirk⁶⁹, Kanitta Bundhamcharoen⁶⁹, Keiu Nelis⁶⁹, Khairul Zarina⁶⁹, Lajos Biro⁶⁹, Lars Johansson⁶⁹, Leanne Riley⁶⁹, Mabel Yap⁶⁹, Manami Inoue⁶⁹, Maria Szabo⁶⁹, Marja-Leena Ovaskainen⁶⁹, Meei-Shyuan Lee⁶⁹, Mei Fen Chan⁶⁹, Melanie Cowan⁶⁹, Mirnalini Kandiah⁶⁹, Ola Kally⁶⁹, Olof Jonsdottir⁶⁹, Pam Palmer⁶⁹, Philippos Orfanos⁶⁹, Renzo Asciak⁶⁹, Robert Templeton⁶⁹, Rokiah Don⁶⁹, Roseyati Yaakub⁶⁹, Rusidah Selamat⁶⁹, Safiah Yusof⁶⁹, Sameer Al-Zenki⁶⁹, Shu-Yi Hung⁶⁹, Sigrid Beer-Borst⁶⁹, Suh Wu⁶⁹, Widjaja Lukito⁶⁹, Wilbur Hadden⁶⁹, Xia Cao⁶⁹, Yi Ma⁶⁹, Yuen Lai⁶⁹, Zaiton Hjdaud⁶⁹, Jennifer Ali⁷⁰, Ron Gravel⁷⁰, Tina Tao⁷⁰, Jacob Lennert Veerman⁷¹, Mustafa Arici⁷², Demosthenes Panagiotakos⁷³, Yanping Li⁷⁴, Gülden Pekcan⁷⁵, Karim Anzid⁷⁶, Anuradha Khadilkar⁷⁷, Veena Ekbote⁷⁷, Irina Kovalskys⁷⁸, Arlappa Nimmathota⁷⁹, Avula Laxmaiah⁷⁹, Balakrishna Nagalla⁷⁹, Brahmam Ginnela⁷⁹, Hemalatha Rajkumar⁷⁹, Indrapal Meshram⁷⁹, Kalpagam Polasa⁷⁹, Licia Iacoviello⁸⁰,¹⁰⁶, Marialaura Bonaccio⁸⁰, Simona Costanzo⁸⁰, Yves Martin-Prevel⁸¹, Nattinee Jitnarin⁸², Wen-Harn Pan⁸³, Yao-Te Hsieh⁸³, Sonia Olivares⁸⁴, Gabriela Tejeda⁸⁵, Aida Hadziomeragic⁸⁶, Le Tran Ngoan⁸⁷,¹⁵², Amanda de Moura Souza⁸⁸, Daniel Illescas-Zarate⁸⁹,¹⁶¹, Inge Huybrechts⁹⁰, Alan de Brauw⁹¹, Mourad Moursi⁹¹, Augustin Nawidimbasba Zeba⁹², Maryam Maghroun⁹³, Nizal Sarrafzadegan⁹³, Noushin Mohammadifard⁹³, Lital Keinan-Boker⁹⁴, Rebecca Goldsmith⁹⁴, Tal Shimony⁹⁴, Gudrun B. Keding⁹⁵, Shivanand C. Mastiholi⁹⁶, Moses Mwangi⁹⁷, Yeri Kombe⁹⁷, Zipporah Bukania⁹⁷, Eman Alissa⁹⁸, Nasser Al-Daghri⁹⁹, Shaun Sabico⁹⁹, Rajesh Jeewon¹⁰⁰,¹⁹², Martin Gulliford¹⁰¹, Tshilenge S. Diba¹⁰², Kyungwon Oh¹⁰³, Sihyun Park¹⁰³, Sungha Yun¹⁰³, Yoonsu Cho¹⁰⁴, Suad Al-Hooti¹⁰⁵, Chanthaly Luangphaxay¹⁰⁷, Daovieng Douangvichit¹⁰⁷, Latsamy Siengsounthone¹⁰⁷, Pedro Marques-Vidal¹⁰⁸, Peter Vollenweider¹⁰⁸, Constance Rybak¹⁰⁹, Amy Luke¹¹⁰, Nipa Rojroongwasinkul¹¹¹, Noppawan Piaseu¹¹¹, Kalyana Sundram¹¹², Jeremy Koster¹¹³, Donka Baykova¹¹⁴, Parvin Abedi¹¹⁵, Sandjaja Sandjaja¹¹⁶, Fariza Fadzil¹¹⁷, Noriklil Bukhary Ismail Bukhary¹¹⁸, Pascal Bovet¹¹⁹,¹⁷⁷, Yu Chen¹²⁰, Norie Sawada¹²¹, Shoichiro Tsugane¹²¹, Lalka Rangelova¹²², Stefka Petrova¹²², Vesselka Duleva¹²², Ward Siamusantu¹²⁴, Lucjan Szponar¹²⁵, Hsing-Yi Chang¹²⁶, Makiko Sekiyama¹²⁷, Khanh Le Nguyen Bao¹²⁸, Sesikeran Boindala¹²⁹, Jalila El Ati¹³⁰, Ivonne Ramirez Silva¹³¹, Juan Rivera Dommarco¹³¹, Luz Maria Sanchez-Romero¹³¹, Simon Barquera¹³¹, Sonia Rodríguez-Ramírez¹³¹, Nayu Ikeda¹³², Sahar Zaghloul¹³³, Anahita Houshiar-rad¹³⁴, Fatemeh Mohammadi-Nasrabadi¹³⁴, Morteza Abdollahi¹³⁴, Khun-Aik Chuah¹³⁵, Zaleha Abdullah Mahdy¹³⁵, Alison Eldridge¹³⁶, Eric L. Ding¹³⁷, Herculina Kruger¹³⁸, Sigrun Henjum¹³⁹, Milton Fabian Suarez-Ortegon¹⁴⁰, Nawal Al-Hamad¹⁴¹, Veronika Janská¹⁴², Reema Tayyem¹⁴³, Bemnet Tedla¹⁴⁴, Parvin Mirmiran¹⁴⁵, Almut Richter¹⁴⁶, Gert Mensink¹⁴⁶, Lothar Wieler¹⁴⁶, Daniel Hoffman¹⁴⁷, Benoit Salanave¹⁴⁸, Shashi Chiplonkar¹⁴⁹, Anne Fernandez¹⁵⁰, Androniki Naska¹⁵¹, Karin De Ridder¹⁵³, Cho-il Kim¹⁵⁴, Rebecca Kuriyan¹⁵⁵, Sumathi Swaminathan¹⁵⁵, Didier Garriguet¹⁵⁶, Anna Karin Lindroos¹⁵⁷, Eva Warensjo Lemming¹⁵⁷, Jessica Petrelius Sipinen¹⁵⁷, Lotta Moraeus¹⁵⁷, Saeed Dastgiri¹⁵⁸, Sirje Vaask¹⁵⁹, Tilakavati Karupaiah¹⁶⁰, Fatemeh Vida Zohoori¹⁶², Alireza Esteghamati¹⁶³, Sina Noshad¹⁶³, Suhad Abumweis¹⁶⁴, Elizabeth Mwaniki¹⁶⁵, Simon G. Anderson¹⁶⁶, Justin Chileshe¹⁶⁷, Sydney Mwanza¹⁶⁷, Lydia Lera Marques¹⁶⁸, Samuel Duran Aguero¹⁶⁹, Mariana Oleas¹⁷⁰, Luz Posada¹⁷¹, Angelica Ochoa¹⁷², Alan Martin Preston¹⁷³, Khadijah Shamsuddin¹⁷⁴, Zalilah Mohd Shariff¹⁷⁵, Hamid Jan Bin Jan Mohamed¹⁷⁶, Wan Manan¹⁷⁶, Bee Koon Poh¹⁷⁸, Pamela Abbott¹⁷⁹, Mohammadreza Pakseresht¹⁸⁰, Sangita Sharma¹⁸⁰, Tor Strand¹⁸¹, Ute Alexy¹⁸², Ute Nöthlings¹⁸², Indu Waidyatilaka¹⁸³, Ranil Jayawardena¹⁸³, Julie M. Long¹⁸⁴, K. Michael Hambidge (†)¹⁸⁴, Nancy F. Krebs¹⁸⁴, Aminul Haque¹⁸⁵, Liisa Korkalo¹⁸⁶, Maijaliisa Erkkola¹⁸⁶, Riitta Freese¹⁸⁶, Laila Eleraky¹⁸⁷, Wolfgang Stuetz¹⁸⁷, Laufey Steingrimsdottir¹⁸⁸, Inga Thorsdottir¹⁸⁹, Ingibjorg Gunnarsdottir¹⁸⁹, Lluis Serra-Majem¹⁹⁰, Foong Ming Moy¹⁹¹, Corina Aurelia Zugravu¹⁹³, Elizabeth Yakes Jimenez¹⁹⁴, Linda Adair¹⁹⁵, Shu Wen Ng¹⁹⁵, Sheila Skeaff¹⁹⁶, Regina Fisberg¹⁹⁷, Carol Henry¹⁹⁸, Getahun Ersino¹⁹⁸, Gordon Zello¹⁹⁸, Alexa Meyer¹⁹⁹, Ibrahim Elmadfa¹⁹⁹, Claudette Mitchell²⁰⁰, David Balfour²⁰⁰, Johanna M. Geleijnse²⁰¹, Mark Manary²⁰², Laetitia Nikiema²⁰³, Masoud Mirzaei²⁰⁴, Rubina Hakeem²⁰⁵⁹Academy of Athens, Athens, Greece, ¹⁰Acibadem University, Istanbul, Turkey, ¹¹Addis Ababa University, Addis Ababa, Ethiopia, ¹²Aga Khan Foundation, Geneva, Switzerland, ¹³All India Institute of Medical Sciences, New Delhi, India, ¹⁴American University of Beirut, Beirut, Lebanon, ¹⁵Amrita School of Dentistry, Eranakulum, India, ¹⁶Andalas University, Padang, Indonesia, ¹⁷Arab Center for Nutrition, Manama, Bahrain, ¹⁸Ardabil University of Medical Sciences, Ardabil, Iran, ¹⁹Bacha Khan University, Charsadda, Pakistan, ²⁰Biodiversity International, Nairobi, Kenya, ²¹Brighton and Sussex Medical School, Brighton, United Kingdom, ²²Center for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM), Guatemala City, Guatemala, ²³Centre For Media Studies, New Delhi, India, ²⁴Centro de Atencion Nutricional Antimano (CANIA), Miami, United States, ²⁵Centro de Estudios sobre Nutrición Infantil (CESNI), Buenos Aires, Argentina, ²⁶Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, ²⁷College of Applied Sciences, Department of Food Science and Applied Nutrition, Addis Ababa Science and Technology University, Addis Ababa, Ethiopia, ²⁸Consultative Group on International Agricultural Research (CGIAR), Montpellier, France, ²⁹Council for Agricultural Research and Economics, Research Centre for Food and Nutrition, Rome, Italy, ³⁰Cuenca University, Cuenca, Ecuador, ³¹Delhi School of Economics, University of Delhi, Delhi, India, ³²Department of Biomedical and Biotechnological Sciences, University of Catnia, Catania, Italy, ³³Department of CVD Epidemiology, Prevention and Health Promotion, Institute of Cardiology, Warsaw, Poland, ³⁴Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan, ³⁵Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, United States, ³⁶Department of Nutrition at the University of Oslo, Oslo, Norway, ³⁷Diabetes Center, 2nd Department of internal Medicine, Athens University, Athens, Greece, ³⁸Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran, ³⁹Directorate for Health Information & Research, Pietà, Malta, ⁴⁰Dunarea de Jos University of Galati, Galati, Romania, ⁴¹Dutch National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands, ⁴²Eastern Mediterranean Public Health Network (EMPHNET), Amman, Jordan, ⁴³Egerton University, Njoro, Kenya, ⁴⁴Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesada, Maryland, USA, ⁴⁵Estonian National Institute for Health Development, Tallinn, Estonia, ⁴⁶FHI360, Washington, DC, United States, ⁴⁷FOSCAL and UDES, Bucaramanga, Colombia, ⁴⁸Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon, ⁴⁹Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique, ⁵⁰Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, ⁵¹Faculty of Medicine, University of Colombo, Sri Lanka, Colombo 5, Sri Lanka, ⁵²Faculty of Medicine/ Institute of Public Health, University of Porto, Porto, Portugal, ⁵³Faculty of Nutrition and Food Sciences of University of Porto, Porto, Portugal, ⁵⁴Finnish Institute for Health and Welfare, Helsinki, Finland, ⁵⁵Florida International University, Miami, United States, ⁵⁶Folkhälsan Research Center, Helsinki, Finland, ⁵⁷Food Envrionment Consumer Behaviour Lever of the Alliance Bioversity International and CIAT, Nairobi, Kenya, ⁵⁸Food and Nutrition Research Institute (DOST-FNRI), Manila, Philippines, ⁵⁹Food and Nutrition Research Institute (DOST-FNRI), Taguig City, Philippines, ⁶⁰Fortis CDOC Center for Excellence for Diabetes, New Delhi, India, ⁶¹FrieslandCampina, Amersfoort, The Netherlands, ⁶²Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, ⁶³Fundacion INFANT and Consejo Nacional De Investigaciones Cientificas y Tecnicas (CONICET), Ciudad Autonoma de Buenos Aires, Argentina, ⁶⁴Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca, Colombia, ⁶⁵Gachon University, Seongnam-si, South Korea, ⁶⁶Gazi University, Yenimahalle/Ankara, Turkey, ⁶⁷Geneva University Hospitals, Geneva, Switzerland, ⁶⁸Ghent University, Ghent, Belgium, ⁶⁹Global Dietary Database Consortium, Boston, United States, ⁷⁰Government of Canada, Statistics Canada, Ottawa, Canada, ⁷¹Griffith University, Gold Coast, Queensland, Australia, ⁷²Hacettepe University Faculty of Medicine, Ankara, Turkey, ⁷³Harokopio University, Athens (Kallithea), Greece, ⁷⁴Harvard School of Public Health, Cambridge, United States, ⁷⁵Hasan Kalyoncu University Dept. Nutrition and Dietetics, Gaziantep, Turkey, ⁷⁶Higher Institute of Nursing Professions and Health Techniques, Marrakesh, Morocco, ⁷⁷Hirabai Cowasji Jehangir Medical Research Institute, Pune, India, ⁷⁸ICCAS (Instituto para la Cooperacion Científica en Ambiente y Salud), Buenos Aires, Argentina, ⁷⁹ICMR-National Institute of Nutrition, Hyderabad, India, ⁸⁰IRCCS Neuromed, Pozzilli, Italy, ⁸¹Institut de Recherche pour le Developpement, Montpellier, France, ⁸²Institute for International Investigation, NDRI-USA, New York, United States, ⁸³Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, ⁸⁴Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile, ⁸⁵Institute of Nutrition in Central America and Panama (INCAP), Guatemala City, Guatemala, ⁸⁶Institute of Public Health of Federation of Bosnia and Herzegovina, Sarajevo, Bosnia And Herzegovina, ⁸⁷Institute of Research and Development, Duy Tan University, Da Nang City, Viet Nam, ⁸⁸Institute of Studies in Public Health, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil, ⁸⁹Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, ⁹⁰International Agency for Research on Cancer, Lyon, France, ⁹¹International Food Policy Research Institute (IFPRI), Washington, DC, United States, ⁹²Intitut de Recherche en Sciences de la Sante, Bobo Dioulasso, Burkina Faso, ⁹³Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran, Isfahan, Iran, ⁹⁴Israel Center for Disease Control, Tel-Hashomer, Israel, ⁹⁵Justus Liebig University of Giessen, Institute of Nutritional Sciences, Giessen, Germany, ⁹⁶KLE Academy of Higher Education and Research (Deemed-to-be-University) Jawaharlal Nehru Medical College, Belagavi, India, ⁹⁷Kenya Medical Research Institute, Nairobi, Kenya, ⁹⁸King Abdulaziz University, Jeddah, Saudi Arabia, ⁹⁹King Saud University, Riyadh, Saudi Arabia, ¹⁰⁰King Saud University, Riyadh, Saudi Arabi, ¹⁰¹King's College London, London, United Kingdom, ¹⁰²Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo, ¹⁰³Korea Disease Control and Prevention Agency (KDCA), Cheongju-si, Korea, ¹⁰⁴Korea University, Seoul, Korea, ¹⁰⁵Kuwait Institute for Scientific Research, Safat, Kuwait, ¹⁰⁶LUM University “Giuseppe Degennaro”, Casamassima, Italy, ¹⁰⁷Lao Tropical and Public Health Institute, Vientiane Capital, Lao PDR, ¹⁰⁸Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland, ¹⁰⁹Leibniz Centre for Agricultural Landscape Research, Muncheberg, Germany, ¹¹⁰Loyola University Chicago, Chicago, United States, ¹¹¹Mahidol University, Pathom, Thailand, ¹¹²Malaysian Palm Oil Council (MPOC), Kelana Jaya, Malaysia, ¹¹³Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany, ¹¹⁴Medical Center Markovs, Sofia, Bulgaria, ¹¹⁵Menopause Andropause Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, ¹¹⁶Ministry of Health, Jakarta, Indonesia, ¹¹⁷Ministry of Health, Kuala Lumpur, Malaysia, ¹¹⁸Ministry of Health, Sungai Besar, Sabak Bernam, Malaysia, ¹¹⁹Ministry of Health, Victoria, Seychelles, ¹²⁰NYU School of Medicine, New York, United States, ¹²¹National Cancer Center Institute for Cancer Control, Tokyo, Japan, ¹²²National Centre of Public Health and Analyses (NCPHA), Sofia, Bulgaria, ¹²³National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Chairman, Director, Diabetes Foundation (India), Fortis CDOC Hospital for Diabetes and Allied sciences., New Delhi, India, ¹²⁴National Food and Nutrition Commission, Lusaka, Zambia, ¹²⁵National Food and Nutrition Institute, Warsaw, Poland, ¹²⁶National Health Research Institutes, Zhunan township, Taiwan ROC, ¹²⁷National Institute for Environmental Studies, Health and Environmental Risk Division, Tsukuba, Japan, ¹²⁸National Institute of Nutrition, Hanoi, Viet Nam, ¹²⁹National Institute of Nutrition, Hyderabad, India, ¹³⁰National Institute of Nutrition and Food Technology & SURVEN RL, Tunis, Tunisia, ¹³¹National Institute of Public Health (INSP), Cuernavaca, Mexico, ¹³²National Institutes of Biomedical Innovation, Health and Nutrition, Osaka, Japan, ¹³³National Nutrition Institute, Cairo, Egypt, ¹³⁴National Nutrition and Food Technology Research Institute (NNFTRI): SBMU, Tehran, Iran, ¹³⁵National University of Malaysia (UKM), Kuala Lumpur, Malaysia, ¹³⁶Nestlé Research, Lausanne, Switzerland, ¹³⁷New England Complex Systems Institute, Cambridge, United States, ¹³⁸North-West University, Potchefstroom South Africa, Potchefstroom, South Africa, ¹³⁹Oslo Metropolitan University (OsloMet), Oslo, Norway, ¹⁴⁰Pontificia Universidad Javeriana Seccional Cali, Cali, Colombia, ¹⁴¹Public Authority For Food and Nutrition, Sabah Al Salem, Kuwait, ¹⁴²Public Health Authority of the Slovak Republic, Bratislava, Slovak Republic, ¹⁴³Qatar University and University of Jordan, Doha, Qatar, ¹⁴⁴Queensland University of Technology, Brisbane, Australia, ¹⁴⁵Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran, ¹⁴⁶Robert Koch Institute, Berlin, Germany, ¹⁴⁷Rutgers University, New Brunswick, United States, ¹⁴⁸Santé publique France, the French Public Health Agency, Saint Maurice, France, ¹⁴⁹Savitribai Phule Pune University (SPPU), Pune, India, ¹⁵⁰School of Medicine, Deakin University, Waurn Ponds, Australia, ¹⁵¹School of Medicine, National and Kapodistrian University of Athens, Athens, Greece, ¹⁵²School of Preventive Medicine and Public Health, Hanoi City, Viet Nam, ¹⁵³Sciensano (Belgian Public Health Institute), Brussels, Belgium, ¹⁵⁴Seoul National University, Seoul, Korea, ¹⁵⁵St John's Research Institute, Bangalore, India, ¹⁵⁶Statistics Canada, Ottawa, Canada, ¹⁵⁷Swedish Food Agency, Uppsala, Sweden, ¹⁵⁸Tabriz University of Medical Sciences, Tabriz, Iran, ¹⁵⁹Tallinn University, Tallinn, Estonia, ¹⁶⁰Taylor's University, Selangor, Malaysia, ¹⁶¹Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico, ¹⁶²Teesside University, Middlesbrough, United Kingdom, ¹⁶³Tehran University of Medical Sciences, Tehran, Iran, ¹⁶⁴The Hashemite University, Az Zarqa, Jordan, ¹⁶⁵The Technical University of Kenya, Nairobi, Kenya, ¹⁶⁶The University of the West Indies, Kingston, Jamaica, ¹⁶⁷Tropical Diseases Research Centre, Ndola, Zambia, ¹⁶⁸Unidad de Nutricion Publica, Macul, Chile, ¹⁶⁹Universidad San Sebastian, Providencia, Chile, ¹⁷⁰Universidad Tecnica del Norte, Ibarra, Ecuador, ¹⁷¹Universidad de Antioquia, Medellin, Colombia, ¹⁷²Universidad de Cuenca, Cuenca, Ecuador, ¹⁷³Universidad de Puerto Rico, Medical Sciences Department of Biochemistry, San Juan, Puerto Rico, ¹⁷⁴Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia, ¹⁷⁵Universiti Putra Malaysia, Serdang, Malaysia, ¹⁷⁶Universiti Sains Malaysia, Kubang Kerian, Malaysia, ¹⁷⁷University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland, ¹⁷⁸University Kebangsaan Malaysia, Selangor, Malaysia, ¹⁷⁹University of Aberdeen, Aberdeen, United Kingdom, ¹⁸⁰University of Alberta, Edmonton, Canada, ¹⁸¹University of Bergen, Bergen, Norway, ¹⁸²University of Bonn, Department of Nutrition and Food Sciences, Bonn, Germany, ¹⁸³University of Colombo, Colombo, Sri Lanka, ¹⁸⁴University of Colorado School of Medicine, Aurora, USA, ¹⁸⁵University of Dhaka, Dhaka, Bangladesh, ¹⁸⁶University of Helsinki, Department of Food and Nutrition, Helsinki, Finland, ¹⁸⁷University of Hohenheim, Stuttgart, Germany, ¹⁸⁸University of Iceland, Reykjavik, Iceland, ¹⁸⁹University of Iceland, Reykjavík, Iceland, ¹⁹⁰University of Las Palmas de Gran Canaria (ULPGC), Canary Islands, Las Palmas, Spain, ¹⁹¹University of Malaya, Kuala Lumpur, Malaysia, ¹⁹²University of Mauritius, Reduit, Mauritius, ¹⁹³University of Medicine and Pharmacy Carol Davila, Bucharest, Romania, ¹⁹⁴University of New Mexico Health Sciences Center, Albuquerque, United States, ¹⁹⁵University of North Carolina at Chapel Hill, Chapel Hill, United States, ¹⁹⁶University of Otago, Dunedin, New Zealand, ¹⁹⁷University of Sao Paulo, Sao Paulo, Brazil, ¹⁹⁸University of Saskatchewan, Saskatoon, Canada, Saskatoon, Canada, ¹⁹⁹University of Vienna, Vienna, Austria, ²⁰⁰University of the Southern Caribbean, Port-of-Spain, Trinidad And Tobago, ²⁰¹Wageningen University, Wageningen, Netherlands, ²⁰²Washington University in St. Louis, St. Louis, United States, ²⁰³World Health Organization (WHO), Geneva, Switzerland, ²⁰⁴Yazd Cardiovascular Research Centre, Shahid Sadoughi University of Medical Sciences, Yazd, Iran, ²⁰⁵Ziauddin University
Contributor Information
Global Dietary Database:
Antonia Trichopoulou, Murat Bas, Jemal Haidar Ali, Tatyana El-Kour, Anand Krishnan, Puneet Misra, Nahla Hwalla, Chandrashekar Janakiram, Nur Indrawaty Lipoeto, Abdulrahman Musaiger, Farhad Pourfarzi, Iftikhar Alam, Celine Termote, Anjum Memon, Marieke Vossenaar, Paramita Mazumdar, Ingrid Rached, Alicia Rovirosa, María Elisa Zapata, Roya Kelishadi, Tamene Taye Asayehu, Francis Oduor, Julia Boedecker, Lilian Aluso, Emanuele Marconi, Laura D'Addezio, Raffaela Piccinelli, Stefania Sette, Johana Ortiz-Ulloa, J.V. Meenakshi, Giuseppe Grosso, Anna Waskiewicz, Umber S. Khan, Kenneth Brown, Lene Frost Andersen, Anastasia Thanopoulou, Reza Malekzadeh, Neville Calleja, Anca Ioana Nicolau, Cornelia Tudorie, Marga Ocke, Zohreh Etemad, Mohannad Al Nsour, Lydiah M. Waswa, Maryam Hashemian, Eha Nurk, Joanne Arsenault, Patricio Lopez-Jaramillo, Abla Mehio Sibai, Albertino Damasceno, Pulani Lanerolle, Carukshi Arambepola, Carla Lopes, Milton Severo, Nuno Lunet, Duarte Torres, Heli Tapanainen, Jaana Lindstrom, Suvi Virtanen, Cristina Palacios, Noel Barengo, Eva Roos, Irmgard Jordan, Charmaine Duante, Corazon Cerdena, Imelda Angeles-Agdeppa, Josie Desnacido, Mario Capanzana, Anoop Misra, Ilse Khouw, Swee Ai Ng, Edna Gamboa Delgado, Mauricio T. Caballero, Johanna Otero, Hae-Jeung Lee, Eda Koksal, Idris Guessous, Carl Lachat, Stefaan De Henauw, Ali Reza Rahbar, Alison Tedstone, Annie Ling, Beth Hopping, Catherine Leclercq, Christian Haerpfer, Christine Hotz, Christos Pitsavos, Coline van Oosterhout, Debbie Bradshaw, Dimitrios Trichopoulos, Dorothy Gauci, Dulitha Fernando, Elzbieta Sygnowska, Erkki Vartiainen, Farshad Farzadfar, Gabor Zajkas, Gillian Swan, Guansheng Ma, Hajah Masni Ibrahim, Harri Sinkko, Isabelle Sioen, Jean-Michel Gaspoz, Jillian Odenkirk, Kanitta Bundhamcharoen, Keiu Nelis, Khairul Zarina, Lajos Biro, Lars Johansson, Leanne Riley, Mabel Yap, Manami Inoue, Maria Szabo, Marja-Leena Ovaskainen, Meei-Shyuan Lee, Mei Fen Chan, Melanie Cowan, Mirnalini Kandiah, Ola Kally, Olof Jonsdottir, Pam Palmer, Philippos Orfanos, Renzo Asciak, Robert Templeton, Rokiah Don, Roseyati Yaakub, Rusidah Selamat, Safiah Yusof, Sameer Al-Zenki, Shu-Yi Hung, Sigrid Beer-Borst, Suh Wu, Widjaja Lukito, Wilbur Hadden, Xia Cao, Yi Ma, Yuen Lai, Zaiton Hjdaud, Jennifer Ali, Ron Gravel, Tina Tao, Jacob Lennert Veerman, Mustafa Arici, Demosthenes Panagiotakos, Yanping Li, Gülden Pekcan, Karim Anzid, Anuradha Khadilkar, Veena Ekbote, Irina Kovalskys, Arlappa Nimmathota, Avula Laxmaiah, Balakrishna Nagalla, Brahmam Ginnela, Hemalatha Rajkumar, Indrapal Meshram, Kalpagam Polasa, Licia Iacoviello, Marialaura Bonaccio, Simona Costanzo, Yves Martin-Prevel, Nattinee Jitnarin, Wen-Harn Pan, Sonia Olivares Yao-Te Hsieh, Gabriela Tejeda, Aida Hadziomeragic, Le Tran Ngoan, Amanda de Moura Souza, Daniel Illescas-Zarate, Inge Huybrechts, Alan de Brauw, Mourad Moursi, Augustin Nawidimbasba Zeba, Maryam Maghroun, Nizal Sarrafzadegan, Noushin Mohammadifard, Lital Keinan-Boker, Rebecca Goldsmith, Tal Shimony, Gudrun B. Keding, Moses Mwangi, Yeri Kombe, Zipporah Bukania, Eman Alissa, Nasser Al-Daghri, Shaun Sabico, Rajesh Jeewon, Martin Gulliford, Tshilenge S. Diba, Kyungwon Oh, Sihyun Park, Sungha Yun, Yoonsu Cho, Suad Al-Hooti, Chanthaly Luangphaxay, Daovieng Douangvichit, Latsamy Siengsounthone, Pedro Marques-Vidal, Peter Vollenweider, Constance Rybak, Amy Luke, Nipa Rojroongwasinkul, Noppawan Piaseu, Kalyana Sundram, Jeremy Koster, Donka Baykova, Parvin Abedi, Sandjaja Sandjaja, Fariza Fadzil, Noriklil Bukhary Ismail Bukhary, Pascal Bovet, Yu Chen, Norie Sawada, Shoichiro Tsugane, Lalka Rangelova, Stefka Petrova, Vesselka Duleva, Ward Siamusantu, Lucjan Szponar, Hsing-Yi Chang, Makiko Sekiyama, Khanh Le Nguyen Bao, Sesikeran Boindala, Jalila El Ati, Ivonne Ramirez Silva, Juan Rivera Dommarco, Luz Maria Sanchez-Romero, Simon Barquera, Sonia Rodríguez-Ramírez, Nayu Ikeda, Sahar Zaghloul, Anahita Houshiar-rad, Fatemeh Mohammadi-Nasrabadi, Morteza Abdollahi, Khun-Aik Chuah, Zaleha Abdullah Mahdy, Alison Eldridge, Eric L. Ding, Herculina Kruger, Sigrun Henjum, Milton Fabian Suarez-Ortegon, Nawal Al-Hamad, Veronika Janská, Reema Tayyem, Bemnet Tedla, Parvin Mirmiran, Almut Richter, Gert Mensink, Lothar Wieler, Daniel Hoffman, Benoit Salanave, Shashi Chiplonkar, Anne Fernandez, Androniki Naska, Karin De Ridder, Cho-il Kim, Rebecca Kuriyan, Sumathi Swaminathan, Didier Garriguet, Anna Karin Lindroos, Eva Warensjo Lemming, Jessica Petrelius Sipinen, Lotta Moraeus, Saeed Dastgiri, Sirje Vaask, Tilakavati Karupaiah, Fatemeh Vida Zohoori, Alireza Esteghamati, Sina Noshad, Suhad Abumweis, Elizabeth Mwaniki, Simon G. Anderson, Justin Chileshe, Sydney Mwanza, Lydia Lera Marques, Samuel Duran Aguero, Mariana Oleas, Luz Posada, Angelica Ochoa, Alan Martin Preston, Khadijah Shamsuddin, and Zalilah Mohd Shariff
Data availability statement
Data are available in a public, open access repository. Data are available upon reasonable request.
References
- 1.Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity. Circulation . 2016;133:187–225. doi: 10.1161/CIRCULATIONAHA.115.018585. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Norris SA, Frongillo EA, Black MM, et al. Nutrition in adolescent growth and development. Lancet. 2022;399:172–84. doi: 10.1016/S0140-6736(21)01590-7. [DOI] [PubMed] [Google Scholar]
- 3.Lowe CJ, Morton JB, Reichelt AC. Adolescent obesity and dietary decision making-a brain-health perspective. Lancet Child Adolesc Health. 2020;4:388–96. doi: 10.1016/S2352-4642(19)30404-3. [DOI] [PubMed] [Google Scholar]
- 4.Lee EY, Yoon KH. Epidemic obesity in children and adolescents: risk factors and prevention. Front Med . 2018;12:658–66. doi: 10.1007/s11684-018-0640-1. [DOI] [PubMed] [Google Scholar]
- 5.Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet. 2020;395:75–88. doi: 10.1016/S0140-6736(19)32472-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.World Health Organization Joint child malnutrition estimates. 2025.. https://www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb Available.
- 7.World Health Organization Obesity and overweight. 2025.. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Available.
- 8.Dreher ML. Whole Fruits and Fruit Fiber Emerging Health Effects. Nutrients . 2018;10:1833. doi: 10.3390/nu10121833. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.James-Martin G, Baird DL, Hendrie GA, et al. Environmental sustainability in national food-based dietary guidelines: a global review. Lancet Planet Health. 2022;6:e977–86. doi: 10.1016/S2542-5196(22)00246-7. [DOI] [PubMed] [Google Scholar]
- 10.Fresán U, Sabaté J. Vegetarian Diets: Planetary Health and Its Alignment with Human Health. Adv Nutr . 2019;10:S380–8. doi: 10.1093/advances/nmz019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Springmann M, Spajic L, Clark MA, et al. The healthiness and sustainability of national and global food based dietary guidelines: modelling study. BMJ. 2020;370:m2322. doi: 10.1136/bmj.m2322. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chaudhary A, Gustafson D, Mathys A. Multi-indicator sustainability assessment of global food systems. Nat Commun . 2018;9:848. doi: 10.1038/s41467-018-03308-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ralston J, Cooper K, Powis J. Obesity, SDGs and ROOTS: a Framework for Impact. Curr Obes Rep . 2021;10:54–60. doi: 10.1007/s13679-020-00420-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Development Initiatives Global nutrition report 2017: nourishing the SDGs 2017. 2018. https://globalnutritionreport.org/reports/2017-global-nutrition-report/ Available.
- 15.Singh GK, Siahpush M, Kogan MD. Rising social inequalities in US childhood obesity, 2003-2007. Ann Epidemiol . 2010;20:40–52. doi: 10.1016/j.annepidem.2009.09.008. [DOI] [PubMed] [Google Scholar]
- 16.Ortiz-Marrón H, Ortiz-Pinto MA, Urtasun Lanza M, et al. Household food insecurity and its association with overweight and obesity in children aged 2 to 14 years. BMC Public Health . 2022;22:1930. doi: 10.1186/s12889-022-14308-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Isong IA, Rao SR, Bind M-A, et al. Racial and Ethnic Disparities in Early Childhood Obesity. Pediatrics. 2018;141:2017–0865. doi: 10.1542/peds.2017-0865. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Bacha F, Cheng P, Gal RL, et al. Racial and Ethnic Disparities in Comorbidities in Youth With Type 2 Diabetes in the Pediatric Diabetes Consortium (PDC) Diabetes Care. 2021 doi: 10.2337/figshare.15174003. [DOI] [PubMed] [Google Scholar]
- 19.Marzuillo P, Miraglia del Giudice E, Santoro N. Pediatric fatty liver disease: role of ethnicity and genetics. World J Gastroenterol . 2014;20:7347–55. doi: 10.3748/wjg.v20.i23.7347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lee AM, Scharf RJ, Filipp SL, et al. Food Insecurity Is Associated with Prediabetes Risk Among U.S. Adolescents, NHANES 2003–2014. Metab Syndr Relat Disord. 2019;17:347–54. doi: 10.1089/met.2019.0006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Miller V, Webb P, Cudhea F, et al. Global dietary quality in 185 countries from 1990 to 2018 show wide differences by nation, age, education, and urbanicity. Nat Food . 2022;3:694–702. doi: 10.1038/s43016-022-00594-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hamner HC, Dooyema CA, Blanck HM, et al. Fruit, Vegetable, and Sugar-Sweetened Beverage Intake Among Young Children, by State — United States, 2021. MMWR Morb Mortal Wkly Rep. 2021;72:165–70. doi: 10.15585/mmwr.mm7207a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Beal T, Morris SS, Tumilowicz A. Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-Food Consumption: A Meta-Analysis of Global School-Based Student Health Surveys. Food Nutr Bull . 2019;40:444–59. doi: 10.1177/0379572119848287. [DOI] [PubMed] [Google Scholar]
- 24.Lara-Castor L, Micha R, Cudhea F, et al. Intake of sugar sweetened beverages among children and adolescents in 185 countries between 1990 and 2018: population based study. BMJ . 2024;386:e079234. doi: 10.1136/bmj-2024-079234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Miller V, Reedy J, Cudhea F, et al. Global, regional, and national consumption of animal-source foods between 1990 and 2018: findings from the Global Dietary Database. Lancet Planet Health. 2022;6:e243–56. doi: 10.1016/S2542-5196(21)00352-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Micha R, Khatibzadeh S, Shi P, et al. Global, regional and national consumption of major food groups in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys worldwide. BMJ Open . 2015;5:e008705. doi: 10.1136/bmjopen-2015-008705. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Singh GM, Micha R, Khatibzadeh S, et al. Global, Regional, and National Consumption of Sugar-Sweetened Beverages, Fruit Juices, and Milk: A Systematic Assessment of Beverage Intake in 187 Countries. PLoS One. 2015;10:e0124845. doi: 10.1371/journal.pone.0124845. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Miller V, Singh GM, Onopa J, et al. Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide. BMJ Glob Health . 2021;6:e003585. doi: 10.1136/bmjgh-2020-003585. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Micha R, Kalantarian S, Wirojratana P, et al. Estimating the global and regional burden of suboptimal nutrition on chronic disease: methods and inputs to the analysis. Eur J Clin Nutr . 2012;66:119–29. doi: 10.1038/ejcn.2011.147. [DOI] [PubMed] [Google Scholar]
- 30.Khatibzadeh S, Saheb Kashaf M, Micha R, et al. A global database of food and nutrient consumption. Bull World Health Organ . 2016;94:931–4. doi: 10.2471/BLT.15.156323. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Micha R, Khatibzadeh S, Shi P, et al. Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ . 2014;348:g2272. doi: 10.1136/bmj.g2272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open . 2013;3:e003733. doi: 10.1136/bmjopen-2013-003733. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Miller V, Mente A, Dehghan M, et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet. 2017;390:2037–49. doi: 10.1016/S0140-6736(17)32253-5. [DOI] [PubMed] [Google Scholar]
- 34.United Nations Population Division Total population by sex (thousands) 2024.. https://population.un.org/wpp/DataQuery/2019 Available.
- 35.Barro RJ, Lee JW. A new data set of educational attainment in the world, 1950–2010. J Dev Econ. 2013;104:184–98. doi: 10.1016/j.jdeveco.2012.10.001. [DOI] [Google Scholar]
- 36.United Nations Population Division United Nations Population Division. 2024.. https://data.worldbank.org/indicator/SP.URB Available.
- 37.Carpenter B, Gelman A, Hoffman MD, et al. Stan: A Probabilistic Programming Language. J Stat Softw. 2017;76:1. doi: 10.18637/jss.v076.i01. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Stan Development Team Stan modeling language users guide and reference manual, version 2.27. 2021
- 39.Stan Development Team RStan: the R interface to stan. 2019
- 40.Homan MD AG. The No-U-turn sampler: adaptively setting path lengths in Hamiltonian Monte Carlo. J Mach Learn Res. 2014;15:1593–623. [Google Scholar]
- 41.Radford N. Handbook of Markov Chain Monte Carlo. 2011. [Google Scholar]
- 42.Mozaffarian D, Blanck HM, Garfield KM, et al. A Food is Medicine approach to achieve nutrition security and improve health. Nat Med . 2022;28:2238–40. doi: 10.1038/s41591-022-02027-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Hager K, Du M, Li Z, et al. Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States. Circ Cardiovasc Qual Outcomes. 2023;16:e009520. doi: 10.1161/CIRCOUTCOMES.122.009520. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Han C, Song Q, Ren Y, et al. Global prevalence of prediabetes in children and adolescents: A systematic review and meta-analysis. J Diabetes . 2022;14:434–41. doi: 10.1111/1753-0407.13291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Wu H, Patterson CC, Zhang X, et al. Worldwide estimates of incidence of type 2 diabetes in children and adolescents in 2021. Diabetes Res Clin Pract. 2022;185:109785. doi: 10.1016/j.diabres.2022.109785. [DOI] [PubMed] [Google Scholar]
- 46.Di Cesare M, Sorić M, Bovet P, et al. The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. BMC Med . 2019;17:212. doi: 10.1186/s12916-019-1449-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Hruby A, Hu FB. The Epidemiology of Obesity: A Big Picture. Pharmacoeconomics . 2015;33:673–89. doi: 10.1007/s40273-014-0243-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Queral J, Wargers A, Tarro L, et al. Changes over time of fruit, vegetable and sweets consumption among European adolescents and associations with sociodemographic characteristics: an HBSC study. J Public Health (Oxf) 2024;46:392–402. doi: 10.1093/pubmed/fdae033. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Wambogo EA, Ansai N, Ahulwalia N, et al. Fruit and Vegetable Consumption Among Children and Adolescents in the United States, 2015-2018. NCHS Data Brief . 2020:1–8. [PubMed] [Google Scholar]
- 50.Venkataramani M, Ogunwole SM, Caulfield LE, et al. Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children : A Systematic Review. Ann Intern Med. 2022;175:1411–22. doi: 10.7326/M22-0604. [DOI] [PubMed] [Google Scholar]
- 51.Barrett M, Spires M, Vogel C. The Healthy Start scheme in England “is a lifeline for families but many are missing out”: a rapid qualitative analysis. BMC Med . 2024;22:177. doi: 10.1186/s12916-024-03380-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Muhajarine N, Ng J, Bowen A, et al. Understanding the Impact of the Canada Prenatal Nutrition Program: A Quantitative Evaluation. Can J Public Health . 2012;103:S26–31. doi: 10.1007/BF03404456. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.KidsHealth Well Child Tamariki Ora Programme. 2025.. https://www.kidshealth.org.nz/well-child-tamariki-ora-programme Available.
- 54.Center for Public Impact Free antenatal and postnatal care: seventy years of the protection maternelle et infantile. 2016.. https://www.centreforpublicimpact.org/case-study/public-care-of-young-children-france Available.
- 55.Gaupholm J, Papadopoulos A, Asif A, et al. The influence of food environments on dietary behaviour and nutrition in Southeast Asia: A systematic scoping review. Nutr Health . 2023;29:231–53. doi: 10.1177/02601060221112810. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Jayawardena R, Jeyakumar DT, Gamage M, et al. Fruit and vegetable consumption among South Asians: A systematic review and meta-analysis. Diabetes Metab Syndr. 2020;14:1791–800. doi: 10.1016/j.dsx.2020.09.004. [DOI] [PubMed] [Google Scholar]
- 57.Peltzer K, Pengpid S. Fruits and vegetables consumption and associated factors among in-school adolescents in five Southeast Asian countries. Int J Environ Res Public Health. 2012;9:3575–87. doi: 10.3390/ijerph9103575. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Rasmussen M, Krølner R, Klepp K-I, et al. Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part I: Quantitative studies. Int J Behav Nutr Phys Act . 2006;3:22. doi: 10.1186/1479-5868-3-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Drewnowski A. The Nutrient Rich Foods Index helps to identify healthy, affordable foods. Am J Clin Nutr . 2010;91:1095S–1101S. doi: 10.3945/ajcn.2010.28450D. [DOI] [PubMed] [Google Scholar]
- 60.Huang S. Global Trade Patterns in Fruits and Vegetables. SSRN Journal. 2004 doi: 10.2139/ssrn.753525. [DOI] [Google Scholar]
- 61.Saavedra JM. The Changing Landscape of Children’s Diet and Nutrition: New Threats, New Opportunities. Ann Nutr Metab. 2022;78 Suppl 2:40–50. doi: 10.1159/000524328. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available in a public, open access repository. Data are available upon reasonable request.