I think this was covered in the presentation. The EAT Lancet recommendations are not meant to be applied directly to individual countries. The EAT Lancet has made it clear that these are just guidelines and each country has to adapt the recommendations according to their country needs including culture, affordability, accessibility, food safety, consumer acceptability, nutritional needs etc. In fact, EAT Lancet recommends increase in red meat intake in deprived countries who do not consume any appreciable amounts of meat and whose iron, vit B12 and protein levels are low. The aim of the EAT Lancet recommendations is to highlight how diets globally have to change to be more plant-based but how exactly this occurs will differ from country to country.

The EAT Lancet actively promotes soya within the protein foods section. It has not specified plant-based drinks within the dairy section as their key argument is that a ‘dairy food group’ is not essential as calcium intakes can be met through plant foods. From a practical perspective, to remove the dairy group altogether from their recommendations would not be practical, especially in the western world. Anecdotally, when I have asked a member of the EAT Lancet group about plant-based drinks, they are neutral about them and of course emphasise that they must be calcium fortified. In the UK, advice is either dairy or sugar free calcium fortified plant-based drinks. It is a personal choice.

Yes, the recommendations for an average adult of a healthy body weight who is moderately active is 0.75-0.8g protein/kg body weight/day. This is accepted by the majority of the scientific world. Requirements based on kg body weight would in fact be lower if we consider that the majority of the western population is overweight and obese! Clearly, there are population groups that will fall outside this ‘average adult’ requirements. One group is athletes who will require more protein. Depending on frequency, type and intensity of the activity, a professional athlete’s requirements can vary from 1-2g/kg body weight/day. Unfortunately, few of the general population undertake enough physical activity to warrant higher protein recommendations. As mentioned in the presentation, the evidence is growing that the elderly (65 years and older) should be encouraged to consume 1-1.2g protein/kg body weight/day in addition to regular weight bearing exercise to maintain muscle mass and reduce risk of sarcopenia. Leucine is a key amino acid for muscle protein synthesis and plant foods provide adequate amounts. The latest advice for optimum muscle protein synthesis on a purely plant-based diet is the consumption of 20-30g plant proteins at each meal. Exceeding this amount at one sitting will not add any further benefit.

Evidence was presented of actual protein intakes across different dietary patterns. All exceeded this recommendation even vegans reached 1g/kg body weight/day. There are numerous studies showing vegans consuming this level of protein.
Mariotti & Gardner. Dietary Protein and Amino Acids in Vegetarian Diets-A Review. Nutrients. 2019;11(11). pii: E2661.

Each plant does contain all 20 amino acids including the 9 indispensable/essential amino acids. Apart from a few individual plant foods (e.g. soya and QuornTM) most individual plant foods will be low (not devoid) in one or two amino acids including essential amino acids. Nitrogen balance occurs over a 24-hour period, thus, if you consume toast at breakfast (wheat low level of lysine) and then beans at lunchtime (good lysine levels) your body will complement the amino acids. The evidence is clear that as long as an individual meets energy requirement, all essential amino acid needs will be met.
Mariotti & Gardner. Dietary Protein and Amino Acids in Vegetarian Diets-A Review. Nutrients. 2019;11(11). pii: E2661.
Ahnen et al. Role of plant protein in nutrition, wellness, and health. Nutr Rev. 2019;pii: nuz028.

Low oxalate green leafy vegetables e.g. Pak choi, Broccoli, Kale have a higher calcium bioavailability than dairy. Calcium found in fortified soya drinks and calcium set tofu is marginally lower than dairy, but this is not clinically significant.
Zhao et al. Calcium bioavailability of calcium carbonate fortified soymilk is equivalent to cow’s milk in young women J Nutr. 2005;135(10):2379-82.
Heaney et al. Bioavailability of the calcium in fortified soy imitation milk, with some observations on method. Am J Clin Nutr. 2000;71(5):1166 9.
Weaver C et al. Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr. 1999;70(3):543S-8S

If a healthy individual is following a varied and balanced vegan diet which includes plant-based calcium rich foods, there is absolutely no reason to supplement with calcium. Calcium is ubiquitous in the diet. The only instance would be when requirement are increased such as if at risk of osteoporosis/low mineral density but the advice on supplementation would be the same as for omnivores.

The issue is more with teenage girls who unfortunately have low intakes of the majority of essential micronutrients. This reflects more their poor overall dietary intake. Interestingly, 12% teenage boys are also low on calcium intakes.

Teenage girls and women of child-bearing age in the UK have poor iron intakes (as well as calcium and other key nutrients) which does reflect their overall poor dietary habits. Their actual intakes of iron as grammes per day are not significantly lower than men’s: intakes for 11-18 year old males is 10.4g iron/day and for females is 8.3g iron/day whilst intakes for 19-64 year olds is 11.6g iron/day for men and 9.3g for women. However, the requirements for women 11-50 years are significantly higher compared to men, 14.8g per day for women compared to 11.3g (11-18yrs) and 8.7g (19-64yrs) for men. This means that a significantly greater proportion of women consume iron well below the lower recommended nutrient intake (LRNI): 54% 11-18 year old girls and 27% of 19-64 year old women do not meet the minimum requirements (LRNI) vs 12% and 2% of men respectively.

Men tend to do much better with regard to iron intakes and status across all dietary groups. It is well established that men consume much greater volumes of food and are the biggest red meat eaters. Additionally, men’s iron requirements are much lower than pre-menopausal women, 8.7g and 14.8g respectively for adults. As iron is particularly important in foetal brain and neurological development, the focus on women’s iron intake becomes even more important. Teenage boys have the worst intakes with 12% not meeting their minimum requirements (LRNI). When it comes to iron stores, 9% of girls and boys aged 4-10 years have low ferritin stores, however in older age, especially teenage hood, 24% of girls fall outside the normal threshold for ferritin stores compared to 2% of boys. Despite these differences it is paramount that all sexes are provided with healthy balanced nutrition advice that optimises all micronutrient intakes.

This is true, and I am kicking myself for not including. The content varies depending on the water content. Thus, firm tofu that is steamed would provide approx. 1.2-1.5mg iron per 100g, whilst fried tofu (lower water content) would provide up to 3.5mg per 100g.

Vitamin B12
Vitamin B12 sources are indeed animal foods however, a number of foods are now fortified. Someone following a plant-based sustainable diet containing moderate amounts of meat and dairy will be fine. However, if someone chooses to follow a vegan diet, then their options are:
2-3 servings of fortified foods daily: majority of plant-based drinks (non-organic) and yogurt alternatives are fortified and most breakfast cereals. Yeast extract is also fortified but due to the high salt content may not be appropriate.
Supplements: daily 10mcg supplements would be most effective or an alternative is one 2,000mcg weekly dose.

Vitamin D
Vitamin D food sources are scarce and the richest sources – oil-rich fish and cod liver oil – are rarely consumed. All individuals consume insufficient vitamin D. The major source is sunlight during the months of April through to September and during the hours of 10am and 2pm. Outside these months, we rely on our stores and food sources. The government recommends 10mcg daily supplements throughout the year for all at risk groups including children under 5 years and those with dark skin, and for winter months, all should consider a supplement.

Vitamin D and dairy
Some countries such as Finland, Canada and the United States fortify their milk with vitamin D. The majority of European countries, including the UK and Ireland, do not standardly fortify milk thus it is not a source of vitamin D. In contrast, non-organic plant-based drinks and alternatives to yogurt are in the main fortified. It is important to bear this in mind when reading research papers on this topic as many come from the US.

Phytates naturally found in plant foods will bind to non-haem iron and zinc in the gut to form insoluble complexes that cannot be digested or absorbed.
Interestingly, some small studies have demonstrated that the body can adapt to high phytate intakes with regard to iron bioavailability. Studies undertaken over 8 and 12-week periods have shown increased efficiency of iron utilisation in the body and reduced excretion.
Polyphenols including tannins which are found in vegetables but especially in tea and coffee will also bind with non-haem iron to form insoluble complexes which cannot be digested or absorbed. Tannins do not seem to affect zinc.
Oxalates are found in beans and dark green vegetables as well as coffee, and chocolate. Like phytates and polyphenols, will form insoluble complexes in the gut which reduces calcium bioavailability.

Although we cannot remove phytates from plant foods, many food processes and cooking methods can help lower levels.
Fermentation can breakdown of phytic acids e.g. fermented soya products such as tempeh and miso and yeast leavened bread (microbial fermentation) will enhance the bioavailability of iron.
Soaking of legumes and beans will diffuse water soluble phytic acid into the water. Thus, rinse canned beans well!
Sprouting of beans and legumes – although not common practice nowadays – enhances the activity of naturally occurring phytase enzymes in plants which breaks down phytates.
High temperature food preparation e.g. canning can reduce phytic acid content of legumes and beans, however, the effect is highly variable.
Milling and refined cereal. For the majority of cereals e.g. wheat, rice, and rye, phytates are present on the outer layers, therefore extraction of the outer layer.
Plant-based drinks: as the base ingredient e.g. rice, oats, soya, nuts are soaked and ground and then heavily diluted – the level of phytates and other inhibitors is negligible and will impact little on calcium bioavailability.

As well as cooking and food preparations (see above).
Vitamin C foods or drinks e.g. salad, fruit juice, served with the non-haem plant foods is the single biggest enhancer of iron absorption.
Small quantities of meat, fish or poultry served with non-haem foods. Meat flesh components including soluble lignans help to improve both zinc and iron bioavailability.
Consuming tea and coffee away from mealtimes.
Low zinc and iron status or if demands are increased, the body will increase absorption of the minerals.
High dose zinc supplement intakes will reduce zinc absorption from foods.

A very timely questions and this has been tackled by a number of studies.
The Eatwell guide undertook cost assessments comparing current eating habits with the Eatwell guide recommendations and found the cost to be a little lower for the Eatwell guide. However, they only looked at food costs and not preparation.
A more recent study by Reynolds from the Rowett Institute, Aberdeen, investigated the feasibility of shifting towards a more sustainable eating pattern by income quintiles in the UK. The study highlighted that all income groups can eat more sustainable within their budget constraints and the key message of increasing plant foods and reducing meat and dairy was applicable to all incomes. The study also found that more tailored advice is needed as different income groups will need to adapt their diets differently e.g. higher income groups can more easily afford to make sustainable changes, the types of meat consumed differed by income groups and the type and variety of fruit and veg also differed. In a follow up interview with the lead author by MyNutriWeb, the Reynolds provided more detail around their study. They also investigated cooking methods and consumers attitudes to sustainable eating. Interestingly, the most sustainable form of cooking was using the hob or the microwave which are also the least expensive ways of cooking.
Eatwell guide: Scarborough et al. Eatwell Guide: modelling the dietary and cost implications of incorporating new sugar and fibre guidelines. BMJ Open 2016;6:e013182.
Publication: Reynolds et al. Healthy and sustainable diets that meet greenhouse gas emission reduction targets and are affordable for different income groups in the UK. Public Health Nutrition 2019;22(8):1503-1517
Listen to the Expert Interview with Reynolds: https://mynutriweb.com/is-a-sustainable-diet-more-expensive/

This will depend on which nutrient is under discussion. Please see earlier question on calcium.

Goitre and thyroid dysfunction still arise in the Western world however, incidences are low and now rarely caused by dietary iodine deficiency whereas up to the 1950’s goitre was rife in the UK due to lack of dietary iodine. Goitre in the UK is often a result of a medical condition such as over or underactive thyroid gland. I cannot comment on global incidence of Goitre.

Unfortunately, natural sources of iodine foods will all have highly variable levels including white fish. Iodine content will vary depending on where it is sourced, the season, cooking and preparation methods as well as the specie and type of seaweed and fish. Kelp is the most variable and one that provides the highest values. Kelp can provide up to 6,500 mcg per g. Nori is more modest with values ranging from 16mcg to 185mcg per gram.