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An Iraqi man has reportedly gunned down seven Islamic State (ISIS) terrorists in a revenge attack for the death of his son.

A string of reports claim Basil Ramadan, said to be in his 60s, opened fire with an AK-47 assault rifle on a group of ISIS militants at a checkpoint in the city of Tikrit.

He killed seven before he was shot dead on Sunday morning.

Local media say ISIS terrorists executed Ahmed Ramadan, an 18-year-old college student, earlier this year.

He was killed alongside seven other young men who were accused of collaborating with the Iraqi security forces, reports say.

It was also reported in January that the group were undercover Iraqi police officers.

Photographs and video were released last month by ISIS terrorists showing the men blindfolded and handcuffed being frogmarched along the edge of a river.

Forced to kneel down, each prisoner was executed with a single bullet to the head.

In early 2007, another son of Ramadan was killed by the al-Qaida terrorist group in Tikrit.

The news comes just days after Japanese journalist Rinko Goto was killed by Islamic State terrorists.

The militants released a gruesome video claiming to show the beheading of Mr Goto, who was kidnapped in October last year.


Experian ‘Boost’ Improves FICO Scores Via Data

Experian has announced the launch of Experian Boost, a free online platform that allows consumers to potentially boost their credit scores in an instant.

Through the platform, consumers can allow Experian Boost to connect to their online bank accounts to access utility and telecommunications payments. After the date is verified and a consumer confirms it should be added to their Experian credit file, an updated FICO Score is delivered in real time.

“Globally, we are constantly innovating and leveraging technology to find new ways to help consumers gain access to quality credit, while promoting fair and responsible lending,” said Experian Global CEO Brian Cassin in a press release. “We are committed to financial inclusion, and Experian Boost is the latest example of our efforts to increase consumer awareness of credit’s impact and value, while giving them greater control.”

The company noted that consumers with thin credit files (less than five trade lines), and scores between 580 and 669, will see the most benefit from Experian Boost. Consumers with low or subprime credit scores often face higher interest rates, with data showing that a subprime credit score costs the average consumer approximately $200,000 more over the course of their life.

“Limited credit activity and history are key barriers for consumers to achieve their financial goals,” said Dara Duguay, executive director of Credit Builders Alliance. “We fully support initiatives that promote financial inclusion, and think Experian Boost could play an important role in overcoming that barrier. We look forward to seeing how Experian’s new platform impacts consumers.”

Only positive payment histories will be aggregated through the platform, and consumers can remove the new data at any time. In addition, a person can contribute new data to the Experian Boost platform as many times as they want. The platform will be open to all credit-active adults in early 2019.


Q:

How to align subplot with specified size?

I have a lot of different plots, wich sizes must be strongly specified. One plot per one file. The problem is that when size too large I have some free spaces in subplot from the left, which I want to crop. I can't use subplots_adjust because plots with small sizes will be croped too. Also I can't use tight option when I call savefig. So, how can I align all my plots to the left side with fixed indent in all my files?
import sys, os
import matplotlib.pyplot as plt

path = sys.path[0]
sizes = [(12,3,), (4,3,)]
x =  range(20)

for i, size in enumerate(sizes):
    fig = plt.figure(figsize = size, dpi = 80, facecolor='white', edgecolor=None, linewidth=0.0, frameon=True, subplotpars=None)
    ax = fig.add_subplot(111)
    ax.plot(x)
    plt.ylabel ('Some label')

    fig.savefig(os.path.join(path, 'size_'+str(i)+'.png'), dpi=80, facecolor=fig.get_facecolor(), edgecolor=None, papertype=None, format='png' ,transparent=False)

A:

I think you can just use tight_layout():
import sys, os
import matplotlib.pyplot as plt

path = sys.path[0]
sizes = [(12,3,), (4,3,)]
x =  range(20)

for i, size in enumerate(sizes):
    fig = plt.figure(figsize = size, dpi = 80, facecolor='white', edgecolor=None,linewidth=0.0, frameon=True, subplotpars=None)
    ax = fig.add_subplot(111)
    ax.plot(x)
    plt.ylabel ('Some label')

    plt.tight_layout()

    fig.savefig(os.path.join(path, 'size_'+str(i)+'.png'), dpi=80,facecolor=fig.get_facecolor(), edgecolor=None, papertype=None, format='png',transparent=False)

Also you can use something like
fig.subplots_adjust(right=0.9, left=0.1, top=0.9, bottom=0.1, wspace=0.2)

instead of plt.tight_layout(). If you want.

Please, tell me if that's not what you need.


Introduction {#S0005}
============

Typhoid fever is the commonest cause of ileal perforation in India. After initial resuscitation with intravenous fluids and correction of electrolyte imbalance, emergency laparotomy is performed to either repair the perforation or exteriorization of the bowel segment bearing the perforation.

The risk of postoperative morbidity and mortality can be predicted using several scoring systems. These scoring systems can also be used for surgical audits and qualitative assessments of different surgeons, hospitals and countries. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) score, developed by Copeland et al in 1991, is one of the most widely used scoring system \[[@CIT0001]\]. It uses 12 preoperative physiological and 6 operative variables on a four grade scoring system and the results are analysed using linear or exponential method of analysis; exponential method is better but more difficult. Since its advent, several modifications have come in existence to more accurately predict morbidity and mortality and also to include other subspecialties. It can also be used for risk adjustment in similar subgroups of patients in different settings so that outcome can be compared. Several studies have suggested it to be accurate. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) is the only scoring system which is meant for exclusive use in surgical cases. Of late, "Portsmouth" modification of POSSUM (P-POSSUM) scoring system has been introduced which predicts mortality more accurately than the former \[[@CIT0002]\]. P-POSSUM (Portsmouth POSSUM) uses same variables but results are derived using simpler linear analysis method. A comparison of POSSUM and P-POSSUM scoring systems has never been done in patients with enteric perforation peritonitis.

The objective of this study was to validate the POSSUM score in predicting mortality and morbidity in enteric perforation peritonitis and to use risk adjustment with POSSUM to compare treatment groups in our set up.

Methods {#S0006}
=======

This prospective, non-randomized observational clinical study was conducted in single surgical unit at our institute from January 2005 to December 2009. 887 patients aged between 05 years to 75 years were treated for peritonitis during this period and were included in the study. Their demographic profile, detailed history and examination were recorded in predesigned proforma. Investigations for POSSUM scoring like haemoglobin, WBC count, blood urea, serum electrolytes, arterial blood gases, chest X-ray and ECG were done at admission. Investigations conducted to further confirm the diagnosis of typhoid, besides Widal test, included typhidot test, blood culture, urine culture, and stool culture wherever possible.

After blood sampling, intravenous antibiotics (Injection Ceftriaxone and metronidazole) were administered in all patients. All patients underwent correction of fluid and electrolyte imbalance through intravenous route, guided by urine output. Patients underwent laparotomy as soon as possible; operative findings were noted and tailored surgical procedure was carried out. All patients with ileal perforation underwent either ileostomy at the perforation site or repair of the perforation and proximal diverting ileostomy. Antibiotics were continued for 7 to 10 days. Intravenous fluids were continued for 3-4 days postoperatively. Oral fluids and feeds were started and tolerated, generally, on 3^rd^ or 4^th^ postoperative days. Patients were discharged on or around 10th postoperative days and then followed up in outpatient for a period of 6 months. Morbidity and mortality was recorded. Morbidity was treated as appropriate. Ileal perforations were considered to be of typhoid origin when patient was Widal positive (titre\>1/80) with one or all of the following present: 1) Acute abdomen preceded by a variable period of high non-swinging fever, abdominal pain and toxaemia; 2) Typhidot positive according to manufacturer\'s instructions; 3) *S. typhi* isolated from blood, stool or urine cultures.

Data analysis {#S0007}
-------------

Continuous data was presented as mean+SD. For calculation of significance between continuous variables between two separate groups, unpaired t- test was used. For calculation of significance between two proportions and percentages, Chi-square and Fischer\'s test were used.

Methods of calculating POSSUM predicted morbidity or mortality \[[@CIT0003]\] {#S0008}
-----------------------------------------------------------------------------

POSSUM equation for morbidity:

Log~n~ R/(1-R) = -5.91 + (0.16 × physiological score) + (.19 × operative severity score)

POSSUM equation for mortality:

Log~n~ R/(1-R) = -7.04 + (.13 × physiological score) + (.16 × operative severity score)

Methods of calculating number of patients to undergo morbidity or mortality {#S0009}
---------------------------------------------------------------------------

1\) Linear analysis: the mean predicted risk (R) is multiplied with the total number of patients in group, to give the predicted number of patients; 2) Exponential analysis: it calculates the predicted number of individuals within each probability group by subtracting those with a risk more than the upper group limit from those with a risk more than lower group limit.

Using predicted and observed morbidity and mortality, O:E ratios were calculated. O:E ratio less than 1 meant over-prediction. O:E ratio more than one meant under-prediction. Observed/Expected (O:E) ratio were calculated and the difference between observed and expected mortality and morbidity was detected by chi-square test. P

Patients with ileal perforation underwent either ileostomy (subgroup A) or primary repair (subgroup B).These two subgroups were compared for POSSUM risk-adjusted morbidity and mortality to find the true status of morbidity and mortality in these two subgroups of patients. For this purpose, odds ratio for morbidity and mortality in patients in subgroup A was calculated against patients in subgroup B as reference. Then POSSUM morbidity and mortality scores were used for risk adjusting.

Results {#S0010}
=======

General results (n=380) {#S0011}
-----------------------

The age of these patients ranged from 05 years to 75 years with mean of 32.07±14.24 years. There were 348 (91.8%) males. Physiological component of POSSUM score ranged from 12 to 34 with mean of 19.61 ±4.57 and operative score ranged from 11 to 19with mean of 17.82±1.89. Duodenum was the commonest site of perforation ([Table 1](#T0001){ref-type="table"}). Surgical site infection (SSI) was the most common complication, found in 231(60.8%) patients. Other common complications were burst abdomen in 76 (20%), renal failure in 25(7.8%) and chest infection in 19 (5%). Hospital stay ranged from 5 days to 35 days, with mean of 13.73±6.7 days. Twelve patients received postoperative treatment in ICU at one or the other time during their hospital stay; mean±SD stay in ICU was 4.33±5.32 days. Eight patients expired (mortality-8.2%).

######

Causes of peritonitis (n=887)

  Causes of peritonitis                       Number (%)
  ------------------------------------------- ------------
  Peptic ulcer (duodenal+pyloric)             431 (48.5)
  Ileal                                       380 (42.8)
  Appendiceal                                 32(3.6)
  Gastric[\*](#TF0001){ref-type="table-fn"}   18 (2.0)
  Jejunal                                     8 (0.9)
  Large intestinal                            8 (0.9)
  Pyoperitoneum (no perforation)              7 (0.7)
  Gall bladder                                3 (0.3)

Five were malignant ulcers

Relation between "at admission-complications" and duration of peritonitis (n=380) {#S0012}
---------------------------------------------------------------------------------

Close observation led us to recognize two distinct groups of patients at admission: one category of patients having one or more organ failure at admission, the other category of patients with apparently normal physiology (or no organ failure). The mean duration of peritonitis (in hours) in these two categories of patients was calculated and a graph was drawn ([Figure 1](#F0001){ref-type="fig"}). Mean duration of peritonitis in patients with no complications at the time of presentation was in the narrow band of 50-60 hrs. On the other hand, in patients who presented with complications duration of peritonitis ranged from 44 hrs to 96 hrs. This suggests that with increasing duration of peritonitis chances of patient presenting with complications like dyselectrolytemia, adult respiratory distress syndrome (ARDS), acute renal failure (ARF) and multi organ dysfunction syndrome (MODS) increases. However, shock at presentation showed an inverse relationship with duration of peritonitis i.e. shorter the duration of peritonitis, greater the chances of patient presenting with shock. The duration of peritonitis in patient presenting with or without systemic inflammatory response syndrome (SIRS) was comparable.

![Relation between "at admission-complications" and duration of peritonitis](PAMJ-09-22-g001){#F0001}

Small bowel perforation: enteric versus Non-specific (n=53) {#S0013}
-----------------------------------------------------------

Ileum was the seat of perforation in 380 patients. Based on diagnostic criteria specified in the material and methods section, perforation of enteric origin (EP) was suspected in 327 (86.05%); remaining 24 (24.7%) patients were considered to have non-specific ileal perforation (NSIP). These two groups of patients were compared on several parameters in order to find if one could really differentiate. EP group of patients differed only in terms of higher BMI, tendency to present with higher (\>2) systemic inflammatory response score (SIRS) and longer hospital stay than NSIP patients.

Timing of perforation in EP patients (n=327) {#S0014}
--------------------------------------------

Perforation occurred in first week of illness in most (n=17) EP patients. Ten patients presented with perforation in the second week of their illness. Remaining two had perforation in the third week of the illness.

Value of culture, histopathology and typhidot in diagnosing EP (n=327) {#S0015}
----------------------------------------------------------------------

Isolation of the bacteria is considered the gold standard against which sensitivity and specificity of another diagnostic test is measured. However, culture was negative in all of our patients (possibly due to indiscriminate use of antibiotics at family physician level. Histopathology (for erythrophagocytosis) and typhidot were positive in 19 and 20 cases, respectively.

Value of POSSUM predicted morbidity for all patients (n=380) {#S0016}
------------------------------------------------------------

POSSUM tended to over-predict morbidity, except in the lower risk bands. Overall O:E ratio was 0.85. The difference between observed and expected morbidity was statistically significant in exponential analysis (p=0.0219) ([Table 2](#T0002){ref-type="table"}). P=0.0219 (significant)

######

Exponential analysis for calculation of morbidity (n=380)

  Risk %      Predicted morbidity   Observed morbidity   O/E
  ----------- --------------------- -------------------- ----------
  0-20        0                     0                    NA
  20-40       16                    12                   0.75
  40-60       92                    68                   0.74
  60-80       124                   112                  0.90
  80-100      52                    48                   0.92
  **Total**   **284**               **240**              **0.85**

O/E: Observed/Expected

Value of POSSUM predicted mortality for all patients (n=380) {#S0017}
------------------------------------------------------------

Except in the middle risk bands (20-40), POSSUM tended to over predict mortality. Overall O:E ratio was 0.47. The difference between observed and expected mortality was statistically significant (p=0.0162) ([Table 3](#T0003){ref-type="table"}).

######

Exponential analysis for mortality using POSSUM (n=380)

  Risk %      Predicted mortality   Observed mortality   O/E
  ----------- --------------------- -------------------- ----------
  0 -- 10     4                     0                    0
  10 -- 20    32                    8                    0.25
  20 -- 30    20                    16                   0.8
  30 -- 40    8                     8                    1
  40 -- 50    4                     0                    0
  \>50        0                     0                    NA
  **Total**   **68**                **32**               **0.47**

Value of POSSUM predicted morbidity in EP patients (n=327) {#S0018}
----------------------------------------------------------

POSSUM under predicted morbidity in EP patients especially in the low risk band. Overall O:E ratio was 1.27 and the difference between observed and predicted morbidity was not statistically significant (p value=0.0557).

Value of POSSUM predicted mortality in EP patients (n=327) {#S0019}
----------------------------------------------------------

POSSUM over predicted mortality in EP patients with O:E ratio of 0.4, but there was no statistical difference between predicted and observed mortality (p value=0.1403)

Risk adjusted morbidity and mortality in patients undergoing ileostomy (subgroup A) versus patients undergoing primary repair (subgroup B) {#S0020}
------------------------------------------------------------------------------------------------------------------------------------------

Crude mortality rates were higher (10%) in subgroup A. Odds of morbidity and mortality were calculated in subgroup A against that in subgroup B as reference before and after risk adjustment. Odds of morbidity for subgroup A before risk adjustment was 0.625, with p value=0.704. When this odds ratio was adjusted with POSSUM morbidity scores, the odds of morbidity reduced to 0.068 and the p value was 0.115. This drop in odds ratio for morbidity was not significant. Odds of mortality for subgroup A before risk adjustment was 1.33, with p value=0.805. When this odds ratio was adjusted with POSSUM mortality scores, the odds of mortality reduced to 0.620 and the p value was 0.711. This drop in odds ratio for mortality was not significant. There was significant association of POSSUM morbidity and mortality scores on moving from subgroup B to subgroup A. Thus, there were 10 times more chances for getting higher morbidity score in subgroup A patients as compared to subgroup B.

Discussion {#S0021}
==========

Laparotomy for perforation peritonitis is a commonly performed emergency surgery in tropical countries \[[@CIT0004]\]. The aetiology of intestinal perforation varies from region to region because of differences in socioeconomic factors and prevalent diseases. Thus, enteric fever and ileal perforation as its complication is common in our country \[[@CIT0005]--[@CIT0007]\]. Our study supports that duodenal perforation is the commonest cause of peritonitis and enteric fever accounts for more than 80% of all ileal perforations. It further emerged that EP is the disease of young males in our set up, the reason for which is unclear.

Enteric fever is reported to be associated with bowel complications in later stages (3^rd^ or 4^th^ week); however, we found that EP patients presented with fever of short duration (\<1week). This may be due to greater virulence of the causative organism. Other studies have also reported shorter duration of symptoms with perforation. Once again, classically, patients of enteric fever are reported to present with step-ladder pattern of fever. We did not find so. There may be various factors responsible for this, the most important being pre-hospitalization treatment with antibiotics and antipyretics. The clinician therefore, should not entirely depend upon the classical history to diagnose enteric fever and perforation.

Traditionally, the diagnosis of enteric fever can only be confirmed by isolation of the Salmonella bacteria from blood, or some other body fluid, such as urine, stool or bone-marrow aspirate. But isolation rate is very low from various cultures \[[@CIT0008]--[@CIT0010]\]. In the present study salmonella could not be isolated by standard culture technique in any of the patients with Ileal perforation, most probably due to rampant use of antibiotics during pre-hospital treatment. In our study, we therefore relied on the histopathological (HP) confirmation of enteric aetiology of the ileal perforation. We calculated sensitivity and specificity of two widely used serological tests -- Widal and Typhidot against HP positive cases with clinical suspicion \[[@CIT0011]--[@CIT0013]\]. Sensitivity and specificity of Widal was comparable with other studies in this region. Sensitivity and specificity of Typhidot was lower as compared to other studies. These authors had done their study in patients of typhoid fever without having any complication \[[@CIT0014]--[@CIT0016]\].

Relationship between duration of peritonitis and organ failure at admission has not been studied earlier. We felt that this was an important aspect of peritonitis, and found direct relationship between mean duration of peritonitis with different complications at presentation. With increasing duration of peritonitis chances of complications like dyselectrolytemia, ARDS, ARF and MODS increased in the order listed. However, shock showed inverse or no relation to duration of peritonitis. It is difficult to explain the significance and reason for this observation; it may be due to adverse effect of duration of peritonitis on outcome.

We could broadly categorize ileal perforation patients in to two: those with EP and those with NSIP. It was of interest to see if we could differentiate these on clinical grounds. Therefore, several factors were studied; it emerged that BMI, SIRS and hospital stay could differentiate the two. We found no study that has attempted this differentiation. A lower BMI in NSIP may be due to tuberculosis as the underlying cause in most of these cases. A higher SIRS in EP patients is possibly due to systemic nature of enteric infection. For similar reason, EP patients experienced complications more often than NSIP patients. Finally, mean hospital stay was significantly longer in EP patients. This is, possibly, due to comparatively higher morbidity in these patients.

POSSUM has proved to be accurate tools for audit of results of emergency surgery in our country \[[@CIT0017], [@CIT0018]\]. However, its usefulness as audit tool exclusively in EP patients has not been examined earlier although it occurs in almost epidemic proportions in our country. We found that POSSUM accurately predicted morbidity but not the mortality. Ileal perforations can be dealt with a number of operative procedures \[[@CIT0019]--[@CIT0021]\]. Commonly performed operative procedures include exteriorization of the bowel at the site of perforation, repair of the perforation and proximal ileostomy, primary repair of the perforated site and resection-anastomosis of the perforated segment. In this series, ileostomy was the most common operative procedure done in all ileal perforation patients. It was carried out in 40 (75.47%) patients. Other operative procedures performed were primary repair of perforation (12/22.64%) and resection/anastomosis (1/1.9%). Using crude mortality rates we found that there was no mortality in EP patients undergoing primary repair while mortality was 10% in ileostomy patients. This difference was also seen in all Ileal perforations (EP+NSIP) patients, with mortality of 10% in ileostomy group as compared to 7.5% in primary repair group. These observations suggest that patients undergoing ileostomy for either EP or NSIP origin tend to have poorer outcome \[[@CIT0022]--[@CIT0024]\]. Similar finding have been noted by Altamanap et al. This gives us an impression that ileostomy is a bad surgical choice. Mortality in ileostomy patients may be high from several factors, the most important of which is (perhaps) the fact that ileostomy is preferred in patients with poor general condition. This is supported by the higher POSSUM and P-POSSUM scores in these patients in our series. Therefore, when the risk is adjusted by applying the POSSUM/P-POSSUM scores the odds of mortality from ileostomy reduce considerably \[[@CIT0025]--[@CIT0027]\]. This has been previously demonstrated by Mohil et al. \[[@CIT0028]\]. These observations suggest that to draw any conclusions regarding mortality and morbidity crude rates should not be relied upon. Further, ileostomy as the operative procedure should not be criticized to have higher mortality \[[@CIT0029]--[@CIT0032]\]. EP patients are generally very sick patients. Their postoperative hospital course is punctuated by significant morbidity. This is proved by our observations (morbidity rate- 79%) as well as by a recent study from Safdarjang hospital (morbidity rate- 79.3%). However, morbidity in our study as well as in Safdarjang hospital study was substantially higher compared to the observations made by Edino et al (morbidity rate- 49.1%).

Surgical site infection (SSI) was the most common complication, occurring in 60.8% of EP patients. The SSI rate observed by us was slightly higher than most other studies, viz Atamanalp et al \[[@CIT0033]\]: 55%; Mohil et al: 42%; Eldino et al \[[@CIT0034]\]: 53.8%). Incidence of burst abdomen in our EP patients was similar (20%) to that found by other authors (Atamanalp et al: 33.3%; Mohil et al: 20%; Eldino et al: 25.1%). Overall, morbidity rate was comparable in both, EP and NSIP categories of patients \[[@CIT0035]\]. Further, rate of various complications was also comparable in EP and NSIP patients.

Conclusion {#S0022}
==========

POSSUM is an accurate tool for predicting morbidity in EP patients. P-POSSUM is an accurate tool for predicting mortality in EP patients. Ileostomy is a good surgical option in patients presenting with EP. It is not associated with higher mortality and morbidity as is commonly believed. Risk adjustment with POSSUM and or P-POSSUM corrects the anomaly.

Authors' contribution {#S0023}
=====================

SK: Under his guidance the work was carried out. He did the final editing and corrections; AG and NA collected the data, operated the cases and reviewed the literature to write the article. SC has given her inputs to compile the article in a systematic manner. All the authors have read and approved the final version of the manuscript.

Acknowledgement {#S0024}
===============

Our sincere thanks to Prof. Abhay Indrayan (Head, Dept. of Biostatistics, UCMS & GTB hospital) for his cooperation for data analysis of this study.


NEUTRAL: See Research Design and Implementation Criteria Checklist below.

Research Purpose:

To evaluate the effect of applying the US Food and Drug Administration (FDA) definition of whole grains to the strength of scientific evidence in support of claims for risk reduction of cardiovascular disease (CVD).

Inclusion Criteria:

Human intervention and observational studies

Studies that measured a validated end-point (i.e., coronary heart disease, myocardial infarction, ischemic heart disease and stroke) or surrogate endpoints (i.e., blood pressure, total cholesterol concentration, and serum LDL-cholesterol) for cardiovascular disease in a healthy US population and populations representative of the US

The restricted analysis included only studies that explicitly described or defined grains according to the FDA definition of whole grains. (The FDA defines whole grains as consisting of the "intact, ground, cracked or flaked fruit of the grains whose principal components—the starchy endosperm, germ and bran—are present in the same relative proportions as they exist in intact grain")

The expanded analysis included studies with a broader definition of whole grains, including studies that added bran or germ along with whole grains or studies that did not explicitly use the term whole grains, but were in fact were conducted with individual whole grains.

Exclusion Criteria:

Reviews, editorials and meta-analysis studies

Animal and in vitro studies.

Description of Study Protocol:

Recruitment

A search of the scientific literature was conducted by searching MEDLINE for articles published through February 2008 using the following search strategy: (whole grain OR whole grains) AND (cardiovascular disease OR heart OR coronary heart disease OR stroke OR blood pressure OR myocardial infarction OR health OR diabetes)

Additional articles were identified from a Web of Science database using the same keywords used for the MEDLINE search

Other studies were identified by bibliographic searched of relevant reviews and articles.

Design

Systematic review.

Dietary Intake/Dietary Assessment Methodology

Not applicable.

Blinding Used

Two scientists independently reviewed each article for inclusion and to ensure that the information was accurately abstracted from the article.

Intervention

Not applicable.

Statistical Analysis

Not applicable.

Data Collection Summary:

There was great variation among the studies regarding variables and measures.

Four studies (two observational and two intervention) conformed to the FDA definition of whole grains and were included in the restricted analysis

The expanded analysis included a total of 29 studies (15 intervention and 14 observational)

Age: Not specified

Ethnicity: Not specified

Other relevant demographics: Healthy US populations and populations representative of the US

Anthropometrics: None

Location: Most studies were conducted in the US (one each in China, Iran, Sweden, England, Germany and Japan).

Summary of Results:

Key Findings

Restricted analysis using FDA definition of whole grains: Although two observational studies found a significant reduction of CVD-related surrogate end-points, the absence of support from intervention studies leads to the conclusion that there is not enough evidence to support a health claim for the reduced risk of CVD

One cross-sectional study observed a decrease in total cholesterol of 0.16mmol/L comparing the highest to the lowest quintile of whole grain intake (P for trend=0.02)

Two randomized, crossover design intervention studies did not observe any significant differences compared to controls when evaluating surrogate endpoints such as total cholesterol, LDL-cholesterol and blood pressure

Expanded analysis: A whole grain and cardiovascular disease health claim is supported using a broader concept of whole grain typically used in the scientific literature that includes whole grain foods containing principal components such as bran

The results of the 14 observational studies included in the expanded definition, regardless of their whole grain source, suggested a protective association between whole grain intake and risk of CVD

A beneficial effect of oats on CVD outcomes was reported in six studies (four with a significant (P<0.05) positive effect), whereas one study showed no effect. The positive studies were also conducted for a longer time period (six to eight weeks vs. three weeks)

Four intervention studies with barley showed reduction in plasma total cholesterol (20-15%) and LDL-cholesterol (21%) levels. The positive effect of barley reported across population, gender, and health status adds strength to the evidence for a beneficial heath effect of barley on plasma total cholesterol and LDL-cholesterol levels.

Other Findings

Health benefits observed from the consumption of one whole grain do not necessarily reflect the same benefit or the same magnitude of benefit from other whole grains

Among the intervention studies included in the expanded definition, only the studies conducted with oats and barley reported reduced cholesterol levels.

Author Conclusion:

When considering only whole grain studies that met the FDA definition, there was insufficient scientific evidence to support a claim that whole grain intake reduces the risk of cardiovascular disease. However, a whole grain and reduced risk of cardiovascular disease is supported when using a broader concept of whole grain to include studies that considered intake of fiber-rich bran and germ as well as whole grain.

Reviewer Comments:

Study Strengths

Two scientists independently reviewed each article for inclusion and to ensure the information was accurately abstracted

Included studies measured a validated end-point or surrogate endpoint for coronary heart disease.

Study Limitations

Trials of individual whole grains, such as oats and rye, were put in the expanded definition group, although it was clear that these met the FDA definition by design

Surrogate outcomes for intervention studies were presented as "significant" with a P-value or not significant, rather than providing estimates and confidence intervals

Review limitations are not described

Potential reasons for differences in individual study results are not well described.

Will the answer if true, have a direct bearing on the health of patients?

Yes

2.

Is the outcome or topic something that patients/clients/population groups would care about?

Yes

3.

Is the problem addressed in the review one that is relevant to nutrition or dietetics practice?

Yes

4.

Will the information, if true, require a change in practice?

Yes

Validity Questions

1.

Was the question for the review clearly focused and appropriate?

Yes

2.

Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described?

Yes

3.

Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified and appropriate? Were selection methods unbiased?

Yes

4.

Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methods specified, appropriate, and reproducible?

No

5.

Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined?

Yes

6.

Was the outcome of interest clearly indicated? Were other potential harms and benefits considered?

Yes

7.

Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently across studies and groups? Was there appropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described?

Yes

8.

Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels of significance and/or confidence intervals included?

Yes

9.

Are conclusions supported by results with biases and limitations taken into consideration? Are limitations of the review identified and discussed?


SHANGRAO, China—Investors were pouring into this sleepy city in southeastern China until late last year to scoop up apartments as new high-rise projects mushroomed.

Then sentiment turned. Unsold units started piling up and developers began cutting prices. Homeowners fearing a housing-price collapse protested at one sales office in October.

The...


Sahara productions interstellar music

Productions connecting East and West
bringing the best of both worlds together.

The sahara desert isn't entirely sand and stones. Despite it's vastness, here and there we discover lush oasis giving men possibility to take a rest. Crossing the sahara is also crossing a culture line.


Dick Doherty

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For over 48 years Dick Doherty's career has taken him on a whirlwind tour around the world, the nation and through time. From New England happy-hour Super Star in the early 60's., to headlining shows at New York's renowned Copacabanna Club in the 70's. Since his first performance at The Improv at Merv Griffin's Resorts International, Atlantic City in the 80's, Dick has established himself as a powerhouse on the national comedy scene. Dick chooses to maintain a devilish yet lovable style which has continued to endear him to comedy audiences of all ages. His successes at major college campuses, national comedy clubs, national conventions and corporate meetings, has established Dick Doherty as the consummate veteran.

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The Ice House Blog

As a kid, I always liked comedy and would listen to albums by George Carlin, Bob Newhart, Bill Cosby, and Lenny Bruce. Despite my enjoyment of these great talents, I decided to pursue an unfunny career and left Los Angeles for San Francisco State College to be a lawyer. When that did not hold my attention, I switched majors and ended up getting a Bachelor of. Art Degree in Communications.


Research in context**Evidence before this study**Several systematic reviews of the sustainable diet literature have been published since 2014. These reviews have suggested that reductions in environmental impacts of food production are generally proportional to reductions in animal-source foods. However, most studies included in the reviews were national case studies from high-income countries with a predominant focus on greenhouse gas emissions as environmental impact, and the studies generally used different reference diets, environmental footprints, and scenario designs, all of which complicates comparisons between studies. With a few exceptions, the health impacts of the sustainable-diet scenarios were often not explicitly analysed beyond adherence to national dietary guidelines or directional changes in nutrient levels. One systematic review of the health impacts of diets with reduced greenhouse gas emissions found no consistent relationship, but some association of such diets with decreased micronutrient content.**Added value of this study**Here, we increase the evidence base beyond summaries of national case studies by using a study design that allows for a consistent and region-specific assessment of the health and environmental impacts of dietary changes for all world regions and more than 150 individual countries. Our study includes a full nutritional analysis, a comparative risk analysis with nine dietary and weight-related risk factors, and an environmental analysis with five domains, including greenhouse gas emissions, cropland use, freshwater use, nitrogen application, and phosphorus application. Our results indicate that energy-balanced, predominantly plant-based dietary patterns that are in line with the current evidence on healthy eating can lead to reductions in environmental impacts in high-income and middle-income countries, while improving nutrient levels and reducing diet-related premature mortality in all regions. In low-income countries, adoption of healthier diets can increase demand for environmental resources, in part due to inefficient production systems and baseline diets high in staple crops. Across regions, the associations between health and environmental benefits are strongest for greenhouse gas emissions, moderate for the demand for cropland, nitrogen, and phosphorus, and small for freshwater use. Our analysis contributes to several open questions in the literature regarding the association between environmental and health impacts, the importance of improving energy imbalances and changing dietary composition, and the generalisability of national case studies.**Implications of all the available evidence**Sustainable diets are context specific. They attain nutritional adequacy and reduce diet-related mortality by addressing both dietary composition and energy balance, and they balance environmental impacts between global and regional scales. Our study shows that a synergistic perspective on sustainable diets would include technological and management-related aspects, in addition to dietary and environmental aspects. Updating national dietary guidelines to reflect the latest evidence on healthy eating is important for improving health and reducing environmental impacts, and can complement broader and more explicit criteria of sustainability.

Introduction {#cesec10}
============

The food people eat impacts their health and the health of the environment. Imbalanced diets low in fruits, vegetables, nuts, and whole grains and high in red and processed meat are responsible for the greatest health burden worldwide and in most regions.[@bib1] In addition to imbalanced diets, about 2 billion people are overweight and obese, 2 billion have nutritional deficiencies, and about 800 million are still suffering from hunger due to poverty and poorly developed food systems.[@bib2] As the dietary transition towards more processed and high-value food products (in terms of cost and perceived value) continues in many regions of the world, these dietary health risks are expected to worsen.[@bib3]

The environmental impacts of food production are similarly daunting. Agriculture is responsible for about a quarter of all greenhouse gas emissions,[@bib4] it occupies about 40% of the Earth\'s surface[@bib5] and uses 70% of all freshwater resources,[@bib6] and the overapplication of fertilisers in some regions has led to pollution of surface water and groundwater and created dead zones in oceans.[@bib7] As a result, the global food system has contributed to the crossing of several of the proposed planetary boundaries that attempt to define a safe operating space for humanity on a stable Earth system.[@bib8] In the absence of dedicated mitigation strategies or changes in demand, many of these environmental impacts are expected to intensify as demand for foods with greater environmental impact, such as meat and dairy, increases and the global population grows from 7 billion to a predicted 10 billion in the next 30 years.[@bib9]

The concept of sustainable diets combines the challenges of creating a food system that supplies healthy diets for a growing population while reducing its environmental impacts and staying within planetary boundaries.[@bib10], [@bib11] The literature on sustainable diets has grown substantially in the past decade,[@bib12], [@bib13], [@bib14], [@bib15] and the concept has been expanded to economic, ethical, and cultural aspects of diets.[@bib10] However, consistent health analyses of commonly proposed diets are scarce,[@bib16] and approaches that are based primarily on health rather than environmental objectives are, with few exceptions,[@bib3], [@bib17] rarely considered.

Here, we use a comprehensive modelling framework for more than 150 countries and regions to analyse the environmental and health impacts of three different approaches to sustainable diets, with a focus on the nutritional implications and impacts on chronic, non-communicable disease mortality, and how they relate to changes in greenhouse gas emissions, cropland use, freshwater use, nitrogen application, and phosphorus application. We distinguish between three different approaches: those that follow the environmental objectives of reducing the impacts of animal-source foods; those that follow the food-security objectives of addressing energy imbalances; and those that follow the public health objectives of encouraging nutritionally balanced dietary patterns based on available evidence on healthy eating.

Methods {#cesec20}
=======

Scenario design {#cesec30}
---------------

In this global modelling analysis, we assessed the effects of three sets of dietary-change strategies ([panel](#box1){ref-type="boxed-text"}; [appendix pp 7--9](#sec1){ref-type="sec"}) on health and environmental factors in more than 150 countries and compare these effects across different regions worldwide.PanelDietary-change strategies for sustainable diets**Reduction of animal-source foods following environmental objectives**Replacement of 25--100% of animal-source foods with plant-based ones at constant total calorie intake (ani-25, ani-50, ani-75, and ani-100); plant-based replacements consist of 75% legumes and 25% fruits and vegetables**Improving calorie intake and weight levels following food-security objectives**Improvement of 25--100% in energy imbalances (kcal-25, kcal-50, kcal-75, and kcal-100) with simultaneous reductions in underweight, overweight, and obesity**Using balanced diet patterns following public health objectives**Nutritionally balanced diet patterns in line with available evidence on healthy eating:•Flexitarian: no processed meat, small amounts of red meat (one serving per week), moderate amounts of other animal-source foods (poultry, fish, and dairy), and generous amounts of plant-based foods (fruits, vegetables, legumes, and nuts)•Pescatarian: replaces meat with two-thirds fish and seafood and a third fruits and vegetables•Vegetarian: replaces meat with two-thirds legumes and a third fruits and vegetables•Vegan: replaces all animal-source foods with two-thirds legumes and a third fruits and vegetables

Our baseline data consists of current and projected levels of food consumption and weight distributions. In our main analysis, we focused on the year 2010 for analysing nutrient adequacy and on the year 2030 for the mortality and environmental analyses to allow for a transition time for dietary and technological changes. Additionally, we used the years 2010 and 2050 in sensitivity analyses to study the effects of technological and socioeconomic changes.

We estimated baseline and projected food intake for more than 150 countries by adapting food demand projections from the International Model for Policy Analysis of Agricultural Commodities and Trade (IMPACT) that were based on a harmonised dataset of country-specific food availability data, and we adjusted those for food waste at the household level ([appendix pp 2--4](#sec1){ref-type="sec"}).[@bib19] For estimating the prevalence of underweight (body-mass index \[BMI\] \<18 kg/m^2^), overweight (BMI ≥25 to \<30 kg/m^2^), and obesity (BMI ≥30 kg/m^2^) in each country, we fitted log-normal distributions to WHO estimates of mean BMI and the prevalence of overweight and obesity using a cross-entropy method that jointly minimised the deviation of the prevalence data,[@bib20] and we projected weight changes using correlations between changes in mean BMI and changes in food availability ([appendix pp 5--6](#sec1){ref-type="sec"}).[@bib20]

In the first diet pattern set that we assessed, which was based on environmental concerns by reducing animal-source products, we progressively reduced the amount of animal-source foods in each country\'s diet by 25% (ani-25), 50% (ani-50), 75% (ani-75), and 100% (ani-100) and replaced it with plant-based foods. On the basis of observational data on food-group substitution across dietary patterns, we chose a substitution rule by which two-thirds of animal-source foods were replaced by legumes and a third by fruits and vegetables. We kept the total energy content of the diets constant to isolate the effects of changes in dietary composition in this set of scenarios. In the second set, based on food security and improving energy balance, we progressively reduced levels of underweight, overweight, and obesity in a simultaneous fashion by 25% (kcal-25), 50% (kcal-50), 75% (kcal-75), and 100% (kcal-100). For adjusting total energy intake, we applied scaling factors to baseline diets that preserved their composition. In the third set, based on public health priorities, we constructed four nutritionally balanced dietary patterns that are in line with evidence on healthy eating.[@bib18] For that purpose, we used energy-balanced varieties of the flexitarian, pescatarian, vegetarian, and vegan dietary patterns defined by the EAT-*Lancet* Commission on Healthy Diets from Sustainable Food Systems ([appendix pp 7--9](#sec1){ref-type="sec"}). The flexitarian dietary patterns contain no processed meat, low amounts of red meat (including beef, lamb, and pork) and sugar, moderate amounts of poultry, dairy, and fish, and generous amounts of fruits, vegetables, legumes, and nuts. The other three dietary patterns replace meat (pescatarian or vegetarian) or all animal-source foods (vegan) with two-thirds either fish and seafood (pescatarian diets) or legumes (vegetarian and vegan diets) and a third fruits and vegetables. We regionalised the public health dietary patterns for each country by preserving the national preferences for types of grains, fruits, red meat, and fish. The diet patterns were all compared with a benchmark diet based on our estimates of current and future food consumption and weight distributions, including increased consumption of high-value products (animal-source foods), in line with income and population changes.

Nutrient analysis {#cesec40}
-----------------

We analysed the nutrient adequacy of the diet scenarios by calculating their nutrient content and comparing these values to international recommendations. For calculating the nutrient content, we paired the consumption of each food group with its nutrient density as reported in the Global Expanded Nutrient Supply dataset,[@bib21] a global dataset of nutrient supply of 23 nutrients across 225 food categories for more than 150 countries, supplemented by nutritional data on pantothenate and vitamin B12 from the nutrient databases maintained by Harvard University and the US Department of Agriculture. For our analysis, we aggregated the nutrient dataset to the commodity and regional detail of our consumption data, and we normalised calorie densities to those of the UN Food and Agriculture Organization for consistency with our diet scenarios ([appendix pp 10--11](#sec1){ref-type="sec"}). We then compared the calculated nutrient content of the diet scenarios to recommendations by WHO. Because the recommendations differ by age and sex, we calculated population-level average values for each nutrient by using the age and sex structure for the year of analysis based on data by the Global Burden of Disease project and forward projections by the UN Population Division. Our estimates of recommended energy intake account for the age-specific and sex-specific energy needs for a moderately active population with US height as an upper bound and include the energy costs of pregnancy and lactation.[@bib22] Our estimates of calcium intake account for the average calcium content of drinking water in line with previous assessments.[@bib23] Because WHO did not set guidelines for phosphorus and copper, we used recommended intakes for these nutrients from the US Institute of Medicine.

Mortality analysis {#cesec50}
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To analyse the implications of dietary change for chronic disease mortality, we constructed a comparative risk assessment framework with nine risk factors and five disease endpoints. The risk factors included high consumption of red meat, low consumption of fruits, vegetables, nuts and seeds, fish, and legumes, as well as being underweight (BMI \<18·5 kg/m^2^), overweight (BMI ≥25 to \<30 kg/m^2^), or obese (BMI ≥30 kg/m^2^). The disease endpoints were coronary heart disease, stroke, type 2 diabetes mellitus, cancer (in aggregate and as site-specific ones, such as colon and rectum cancers), and an aggregate of other causes that are associated with changes in weight. The disease endpoints accounted for about half of all deaths in 2015,[@bib24] and the risk factors were responsible for two-thirds of deaths attributable to dietary risk factors, and for a third of all attributable deaths.[@bib1]

We estimated the mortality and disease burden attributable to dietary risk factors by calculating population impact fractions and applying those to age-specific and country-specific mortality rates ([appendix pp 12--13](#sec1){ref-type="sec"}).[@bib25] Population impact fractions are the proportions of cases of disease that would be avoided when the risk exposure was changed from a baseline situation (the benchmark diet) to a counterfactual situation (the dietary scenarios). We used relative risk estimates from meta-analyses of prospective cohort studies for dietary risks, which relate the risk factors to the disease endpoints, and pooled cohort studies for weight-related risks ([appendix pp 14--20](#sec1){ref-type="sec"}). In line with the meta-analyses, we included non-linear dose--response relationships for fruits and vegetables, nuts and seeds, and fish, and assumed linear dose-response relationships for the remaining risk factors. Because our analysis was primarily focused on mortality from chronic diseases, we focused on adults aged 20 years or older, and we adjusted the relative risk estimates for attenuation with age on the basis of a pooled analysis of cohort studies focused on metabolic risk factors[@bib26] in line with other assessments.[@bib24] In addition to changes in total mortality, we calculated years of life lost ([appendix p 20](#sec1){ref-type="sec"}), but focus on changes in premature mortality among people aged 30--70 years in the main analysis.

Environmental analysis {#cesec60}
----------------------

For analysing the environmental impacts of the diet scenarios, we used a food-systems model that connects food consumption and production across regions ([appendix pp 21--22](#sec1){ref-type="sec"}), and we paired the production estimates with country-specific environmental footprints for greenhouse gas emissions, cropland use, freshwater use, and nitrogen and phosphorus application ([appendix pp 22--24](#sec1){ref-type="sec"}).[@bib9] The food-systems model accounts for trade, feed, and processing of primary commodities and is calibrated with data from the IMPACT agriculture--economic model.[@bib19] The greenhouse gas emissions associated with agriculture included methane and nitrous oxide emissions, but they exclude carbon dioxide emissions which, following the methods of the International Panel on Climate Change, are allocated to the energy sector or others. Freshwater use, as assessed here, denotes the consumption of surface water and groundwater, and nitrogen and phosphorus application are associated with fertiliser use. The footprints for animal-source foods include the indirect impacts associated with feed production and, for greenhouse gas emissions, direct impacts associated with methane emissions. The projection of environmental footprints includes improvements in technology and management practices along different socioeconomic development pathways ([appendix pp 22--25](#sec1){ref-type="sec"}).[@bib9]

In this study, we report on the environmental analysis for contextualisation and focus on the comparison between the health and environmental impacts. For that purpose, we focus on the directional changes in the environmental parameters, which provide a good indication for increased environmental pressures in most regions and globally.[@bib27] Some exceptions exist, especially for fertiliser use where increased application in low-applying regions can lead to increased agricultural yields without major environmental impacts.[@bib28], [@bib29], [@bib30] Our socioeconomic development trajectories include a rebalancing of fertiliser application between overapplying and underapplying regions by 2050,[@bib28] which reduces the potential for such exceptions.

Uncertainty analysis {#cesec70}
--------------------

We accounted for the major uncertainties in each analysis. In the comparative risk analysis, we calculated uncertainty intervals associated with changes in mortality using error propagation and the CIs of the relative risk parameters ([appendix pp 13, 28, 29](#sec1){ref-type="sec"}). In the nutritional analysis, we explicitly calculated low and high supply values of each nutrient on the basis of the reported CIs ([appendix p 26](#sec1){ref-type="sec"}). And in the environmental analysis, we assessed uncertainty by considering different population and income projections, which change the absolute amount and the dietary composition of foods demanded ([appendix p 25](#sec1){ref-type="sec"}).

Role of the funding source {#cesec80}
--------------------------

The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to all the data in the study and the corresponding author had final responsibility for the decision to submit for publication.

Results {#cesec90}
=======

Across the dietary-change scenarios, nutrient availability was generally improved for nutrients that were at low levels at baseline (2010), but with large differences between the scenarios ([figure 1](#fig1){ref-type="fig"}; CIs and regional results are reported in the [appendix pp 26--27](#sec1){ref-type="sec"}). In the scenarios that replace animal-source foods (ani-25, ani-50, ani-75, and ani-100), the macronutrient content of diets changed towards lower protein and fat content, with large reductions in saturated fatty acids. Protein intake remained adequate in high-income and middle-income countries, but they decreased to lower than recommended amounts in low-income countries. Micronutrient intake improved, particularly in high-income and middle-income countries, where large amounts of animal-source foods could be replaced by plant-based ones. In the high-income and middle-income countries, the baseline low levels of vitamin A, folate, iron, potassium, and fibre increased to greater than recommended values, but calcium, pantothenate (B5), and vitamin B12 decreased to less than recommended levels under full substitution. In low-income countries, the small amounts of animal-source foods that were replaced were not enough to sufficiently increase vitamin A and potassium, and calcium and riboflavin also did not achieve recommended values.Figure 1Nutrient supply by diet scenario in 2010Red values are those that are lower than minimum recommendations or higher than maximum recommendations.

In the scenarios focused on improving energy balance (kcal-25, kcal-50, kcal-75, and kcal-100), total energy intake was reduced to achieve recommended values in high-income and middle-income countries, whereas it was increased to achieve recommendations in low-income countries ([appendix p 27](#sec1){ref-type="sec"}). Increased energy intake improved micronutrient intake in low-income countries, but vitamin A, folate, calcium, potassium, and riboflavin remained below recommended values. In high-income and middle-income countries, reductions in energy intake did not improve the baseline low values of folate, iron, potassium, and fibre.

The scenarios based on balanced dietary patterns (flexitarian, pescatarian, vegetarian, and vegan) combined the nutritional impacts of improving energy balance with food-based dietary guidelines for all regions. As a result, most of the nutrients that are at low levels in the baseline diets (vitamin A, folate, iron, potassium, and fibre), increased to recommended values in all four patterns. However, as in the other scenarios based on energy balance or animal-source food substitution, riboflavin remained low, and calcium and vitamin B12 fell below recommended values in the vegetarian or vegan scenarios, or both ([appendix p 27](#sec1){ref-type="sec"}). These nutrients would have to be supplemented to attain the recommended value.

In the comparative risk assessment, premature mortality decreased both with reductions in animal-source foods and with improvements in the energy balance of diets ([figure 2A](#fig2){ref-type="fig"}). Progressively replacing animal-source foods with plant-based foods led to progressive reductions in premature mortality of 4% (95% CI 4--4) in the ani-25 scenario up to 12% (10--13) in the ani-100 scenario in 2030 (absolute values are in the [appendix pp 28--29](#sec1){ref-type="sec"}). More than half of the total percentage reduction was due to increased vegetable consumption (51--58% across the scenarios), a third of the difference was due to increased fruit consumption (29--31%), a fifth due to increased legume consumption (18--23%), and a tenth due to reductions in red meat consumption (8--11%; [figure 2A](#fig2){ref-type="fig"}). Reduction in fish intake led to a 0·3--1% increase in premature mortality across the scenarios. Coronary heart disease (35--36%), stroke (32--34%), and cancer (29--30%) each accounted for about a third of deaths averted, and a small number were from type 2 diabetes (2--3%; [appendix p 30](#sec1){ref-type="sec"}). The reductions in premature mortality were two to three times greater in high-income and middle-income countries (12--14% in the ani-100 scenario), where a larger portion of animal-source foods can be substituted, than in low-income countries (5%; [figure 3](#fig3){ref-type="fig"}).Figure 2Premature mortality and environmental impacts of diet scenarios in 2030(A) Diamonds show reductions in premature mortality due to diet patterns and bars show proportion contributions of individual risk factors to the reduction. Total percentage contributions can exceed 100% because individual risks are attenuated when combined and can be compensated by opposing risk factors. (B) Percentage change in environmental impacts.Figure 3Regional changes in premature mortality and environmental impacts of dietary changeThe scenarios include diets in which all animal-source foods have been replaced by plant-based ones (ani-100; A), diets with optimal energy intake and weight levels (kcal-100; B), and flexitarian diets that are energy balanced and contain small amounts of animal-source foods (flexitarian; C).

Progressively improving the energy balance of diets by reducing both underconsumption and overconsumption, while preserving the overall composition of diets (kcal-25, kcal-50, kcal-75, and kcal-100 scenarios), led to reductions in premature mortality from 2% (95% CI 2--3) in the kcal-25 scenario to 10% (9--11) in the kcal-100 scenario ([figure 2A](#fig2){ref-type="fig"}). Across risk factors, reductions in obesity contributed the most to the overall reduction in premature mortality (61--65% across the scenarios), followed by reductions in underweight (42--43%) and reductions in overweight (excluding obesity; 15--17%). As energy intake was adjusted upwards or downwards, the intake of specific foods increased or decreased, and in aggregate led to a 2% increase in mortality, in particular from reductions in fruit and vegetable consumption. Adjusting weight levels without affecting nutrition-sensitive food groups (eg, by adjusting staple foods) would increase the overall reduction in premature mortality by 19% (to a total reduction in premature mortality of 11%). Across disease endpoints, most averted premature deaths were from non-cardiovascular causes related to weight (about 60% with each of the four scenarios), followed by type 2 diabetes (17%), cancer (9--12%), coronary heart disease (9--11%), and stroke (2--3%; [appendix p 30](#sec1){ref-type="sec"}). The reductions in premature mortality were generally evenly distributed across regions (8--14% across income groups in the kcal-100 scenario), with the greatest reduction in the upper-middle-income (14%) and high-income (12%) countries, which have high burdens of obesity, followed by low-income countries, (12%) which have high burdens of underweight, and lower-middle-income countries (8%) with an intermediate weight profile ([figure 3](#fig3){ref-type="fig"}).

Combining changes in dietary composition with changes in energy balance substantially increased the reductions in premature mortality that each strategy can achieve. Dietary changes to balanced flexitarian, pescatarian, vegetarian, and vegan diets led to reductions in premature mortality of 19% (95% CI 18--20) for the flexitarian scenario to 22% (18--24) for the vegan scenario ([figure 2A](#fig2){ref-type="fig"}). Reductions in underweight, overweight, and obesity contributed similar proportions to reductions in premature mortality (11% across the four diets), as did change in diet composition (9--12%). In the vegetarian and vegan scenarios, small increases in premature mortality (about 1%) from reduced fish intake were compensated (in part in the vegetarian scenario, and in full in the vegan scenario) by reductions in premature mortality from additional intake of legumes, fruits, and vegetables. Increases in nut consumption in the four scenarios, an aspect not included in the other dietary-change strategies, led to reductions in premature mortality (about 3%) in addition to those associated with replacing animal-source foods. Across disease endpoints, the averted premature deaths were about a quarter each from coronary heart disease (25--29%) and non-cardiovascular causes (25--30%), a fifth (19--21%) from cancer, followed by stroke (14--18%) and type 2 diabetes (8--10%; [appendix p 30](#sec1){ref-type="sec"}). The reductions in premature mortality were generally evenly distributed across regions (eg, 19--24% across income groups in the flexitarian scenario), with the greatest reductions in upper-middle-income countries, where diets and energy intake were most imbalanced ([figure 3](#fig3){ref-type="fig"}).

For all 12 of the dietary-change approaches, the changes in environmental impacts differed by environmental domain and region. Progressively replacing animal products with plant-based foods led to large reductions in greenhouse gas emissions (from 20% in the ani-25 scenario to 84% in the ani-100 scenario) because the demand for emissions-intensive animal-source foods was reduced ([figure 2B](#fig2){ref-type="fig"}). However, freshwater use was increased (from 4% in the ani-25 scenario to 16% in the ani-100 scenario) because the demand for water-demanding crops, such as legumes, vegetables, and fruits was increased ([figure 2B](#fig2){ref-type="fig"}; [appendix pp 31--32](#sec1){ref-type="sec"}). Regional analyses showed further differences. In upper-middle-income and high-income countries, replacement of animal-source foods led to reduced cropland use (12% in upper-middle-income countries and 29% in high-income countries), nitrogen application (22% and 38%), and phosphorus application (25% and 35%), in line with reductions in the demand for livestock-related intensive feed production and fertilisation ([figure 3](#fig3){ref-type="fig"}). By contrast, these impacts increased in low-income and lower-middle-income countries (cropland 1% in lower-middle-income countries and 15% in low-income countries; nitrogen application 7% and 1%; and phosphorus application 7% and 3%), which use less intensive feeds and fertilisers and had generally lower yields, so that the impacts of increased demand for legumes and vegetables outweighed feed-related reductions ([figure 3](#fig3){ref-type="fig"}).

Improving the energy balance of diets led to moderate reductions across environmental impacts globally (8--13% in the kcal-100 scenario; [figure 2B](#fig2){ref-type="fig"}; [appendix pp 31--32](#sec1){ref-type="sec"}). Environmental impacts were reduced in high-income and middle-income countries (8--18% in the kcal-100 scenario), where levels of overweight and obesity required a reduction in energy intake. By contrast, impacts were increased (3--8% in the kcal-100 scenario) for greenhouse gas emissions, cropland use, and freshwater use in low-income countries, where levels of underweight required an increase in energy intake ([figure 3](#fig3){ref-type="fig"}).

Globally, moving to the balanced dietary patterns resulted in large reductions in greenhouse gas emissions (54--87% across the scenarios), medium-level reductions in nitrogen application (23--25%) and phosphorus application (18--21%), and small to moderate reductions in cropland (8--11%) and freshwater use (2--11%; [figure 2B](#fig2){ref-type="fig"}; [appendix pp 31--32](#sec1){ref-type="sec"}). Greenhouse gas emissions and nitrogen application were reduced in all regions, but the changes in cropland use, freshwater use, and phosphorus application were split into reductions in high-income and middle-income countries and increases in low-income countries ([figure 3](#fig3){ref-type="fig"}; [appendix p 31](#sec1){ref-type="sec"}), in line with regional differences in yields, water use, and fertilisation intensity.

Several scenarios showed alignment between the health and environmental benefits of dietary change, but large differences existed between regions and dietary-change approaches ([Figure 3](#fig3){ref-type="fig"}, [Figure 4](#fig4){ref-type="fig"}). For the scenarios reducing animal-source foods (ani scenarios), reductions in premature mortality were positively associated with reductions in greenhouse gas emissions and negatively associated with freshwater use. Other environmental domains had mostly positive relationships with mortality in high-income and upper-middle-income countries, and negative relationships in low-income and lower-middle-income countries. For the scenarios aimed at improving energy balance (kcal scenarios), the changes in environmental impacts were positively associated with changes in premature mortality in high-income and middle-income countries, but they were negatively associated in low-income countries ([figure 4](#fig4){ref-type="fig"}). The balanced dietary-pattern scenarios (flexitarian, pescatarian, vegetarian, and vegan) showed the greatest alignment of health and environmental impacts, with positive association for almost all environmental domains in high-income and middle-income countries, but negative associations for cropland use, freshwater use, and phosphorus application in low-income countries.Figure 4Coefficients of association between health and environmental impactsCoefficients were calculated by dividing the percentage changes in environmental impacts by the percentage changes in premature mortality. Positive values (green) indicate that health and environmental changes are aligned (larger values show stronger positive associations), whereas negative values (red) indicate opposing changes (more-negative values show stronger negative associations). Darker shades show stronger associations, whereas lighter shades show weaker associations.

In a sensitivity analysis, we analysed the influence the time period has on the health and environmental impacts of dietary change. Analysing dietary changes in 2050 instead of 2030 resulted in greater alignment of the health and environmental impacts as technologies and management practices improved, particularly for freshwater and cropland use ([appendix p 33](#sec1){ref-type="sec"}). Conversely, analysing dietary changes in 2010 resulted in greater relative increases in cropland and freshwater use than in 2030. Considering data of the emissions of carbon dioxide (based on a global meta-analysis of lifecycle analyses[@bib31]) instead of the data limited to methane and nitrous oxide emissions as in the main analysis, increased greenhouse gas emissions, particularly from fishing, and as a result widened the difference between the pescatarian and vegetarian scenarios ([appendix p 34](#sec1){ref-type="sec"}).

Discussion {#cesec100}
==========

The concept of sustainable diets combines health and environmental concerns. Although many candidates for sustainable diets have emerged, no consistent and joint environmental and health analysis of these diets has been done at a regionally comparative level. Here, we examined three stylised approaches to sustainable diets using an integrated health and environmental modelling framework for more than 150 countries. Our results show that a public health approach focused on dietary changes towards predominantly plant-based diets that are in line with evidence on healthy eating performs better in reducing environmental pressures, potential nutrient deficiencies, and diet-related mortality than approaches motivated only by environmental and food-security concerns.

Our analysis has several strengths. It significantly improves on the methods used in existing global assessments by doubling the number of risk factors and environmental indicators covered.[@bib3], [@bib17] It improves the detail of dietary scenarios by including, in the balanced dietary-pattern scenarios, recommended ranges for all major food groups based on the available evidence on healthy eating as reviewed by the EAT-*Lancet* Commission on Healthy Diets from Sustainable Food Systems. And it covers all major countries and regions in a comparative fashion, which allows for the identification of regional differences that extend the evidence base beyond national case studies.[@bib12], [@bib14], [@bib15]

Where comparisons are possible, our results are consistent with empirical data and other estimates with similar coverage. The nutritional estimates are based on existing datasets, and the assessment of nutritional levels and potential deficiencies is in line with existing analyses for most nutrients, but can differ for calcium for which we used global recommended intake values instead of the sometimes higher national values,[@bib32] and for zinc, for which we assumed medium bioavailability rather than using a function of absorption that is not yet validated.[@bib23] Our mortality estimates from changes in dietary risk factors are similar to those of comparable dietary patterns in cohort studies.[@bib33], [@bib34] However, by analysing the disease burden of dietary patterns in equilibrium, we abstracted from many real-world complexities, such as time lags between adoption of diets and changes in mortality. Although most of the relative risk factors used have been adjusted for major confounding factors, such as smoking, bodyweight, and other dietary risks, residual confounding with other parameters cannot be ruled out completely. In line with our joint focus on the health and environmental impacts of dietary change, we focused on those risk factors that we could include on the basis of food-availability data, and we did not include risk factors, such as processed meat and whole grains, that would have required processing factors on the basis of data derived by a different method.[@bib35] Including those risk factors as part of recommendations to reduce processed meat consumption and increase whole grain consumption would further increase the estimated benefits of dietary change in the dietary-pattern and substitution scenarios ([appendix pp 14--20](#sec1){ref-type="sec"}). The environmental assessment is based on data that reflects current environmental impacts at the country level ([appendix pp 22--23](#sec1){ref-type="sec"}), and the scenario changes are in line with other assessments with similar detail.[@bib9]

Our results highlight the regional differences in the health and environmental impacts of dietary-change strategies. Following an environmental strategy by substituting animal-source foods can be particularly effective in high-income countries for improving nutrient levels, lowering premature mortality, and reducing some environmental impacts, in particular greenhouse gas emissions. However, it can also lead to increased freshwater use, and has little effectiveness in countries with low or moderate consumption of animal-source foods. Following a food-security strategy by improving the energy balance of diets can lead to similar reductions in premature mortality, but in our model scenarios it only moderately improved nutrient levels and led to small reductions in environmental impacts at the global level, with reduced impacts in high-income and middle-income countries, and increased resource use in low-income countries. Following a public health strategy by adopting energy-balanced, low-meat dietary patterns that are in line with available evidence on healthy eating addressed the problems of high regional variability of the animal-substitution scenarios and the low nutritional and environmental effectiveness of the weight scenarios. Adopting the balanced and predominantly plant-based dietary patterns led to an adequate nutrient supply, except for a small number of nutrients (riboflavin, calcium, and vitamin B12), which might have to be supplemented, large reductions in premature mortality, and significant reductions in environmental impacts globally and in most regions, except for some environmental domains (cropland use, freshwater use, and phosphorus application) in low-income countries.

Our analysis has several implications for the study of sustainable diets. First, qualitative differences exist between the health and environmental benefits that can be attained by dietary changes. Our analysis suggests that although a comprehensive and context-specific public health strategy for dietary change can lead to healthier diets in all regions, differences between the environmental impacts and regions are large. Dietary changes towards healthy, low-meat diets can be effective in reducing greenhouse gas emissions, moderately effective in reducing cropland use and fertiliser application in high-income and middle-income countries, but less effective for reducing freshwater use, particularly in low-income countries. Changes in low-income countries depend more strongly on technological improvements and changes in management,[@bib9] suggesting that a synergistic perspective on sustainable diets should include both technological and dietary aspects. Although reducing greenhouse gas emissions is important at the global level for mitigating climate change, changes in the other domains relate to predominantly local environmental impacts. This highlights the need for context-specific strategies that balance environmental impacts between global and regional scales.

Second, addressing dietary composition and energy intake as part of food-based dietary guidelines could be a comprehensive strategy for achieving sustainable diets. Whether food-based dietary guidelines should include sustainability criteria has been a major issue of discussion in several countries.[@bib13], [@bib36] In this study, we find that when food-based dietary recommendations reflect available evidence on healthy eating, including balanced energy intake, low amounts of red meat and sugar, low to moderate amounts of other animal-source foods, and generous amounts of fruits, vegetables, legumes, and nuts, then the resulting diets would be in line with sustainability criteria of reducing environmental impacts in most regions, and they would still improve dietary health in the remaining ones. However, many national dietary guidelines do not reflect this evidence on healthy eating and include no or too lax limits for animal-source foods, particularly meat and dairy,[@bib37] despite an opposing evidence base ([appendix pp 14--20](#sec1){ref-type="sec"}).[@bib38], [@bib39], [@bib40] A general problem is that many nutrient recommendations used to formulate food-based dietary guidelines are based on a few short-term studies with few participants that measure nutrient pass-through in high-consuming individuals instead of lower limits.[@bib41] By contrast, most of the available evidence on healthy eating comes from long-term and large-scale epidemiological cohort studies.[@bib18] Our results show that updating national dietary guidelines to reflect the latest evidence on healthy eating can by itself be important for improving health and environmental sustainability, and can complement broader and more explicit criteria of sustainability.

Some unanswered questions remain. We were not able to include all aspects of importance to sustainable diets, including biodiversity impacts and economic aspects.[@bib10] Although biodiversity impacts are related to land use in a given region, impacts can be expected to differ on the basis of a region\'s biodiversity richness and how land use is managed. With respect to economic aspects, large changes in food demand and supply can be expected to affect production methods, technologies, and commodity prices, which in turn would impact environmental footprints, agricultural incomes, the affordability of diets, and purchasing behaviour. Identifying concrete policy options that could support the dietary changes modelled here is similarly important. Globally, overweight and obesity, as well as consumption of red meat and dairy are projected to increase in the future without dedicated policy approaches.[@bib42], [@bib43] Although informational campaigns and voluntary actions by industry can be important, the literature on behavioural change suggests that they are unlikely to be effective on their own.[@bib44], [@bib45] Instead, crosscutting regulatory approaches that focus on the whole food environment,[@bib46] combine multiple incentives including fiscal ones,[@bib47], [@bib48] and offer support and positive re-enforcement for individuals[@bib49], [@bib50] have been successful in specific contexts, but would need to be upscaled to lead to substantial dietary changes at the population level. Finding effective combinations of policies and approaches that consider local characteristics will be essential for successfully upscaling initiatives and achieving reductions in the health and environmental burden at the population level and globally.

Data sharing {#cesec110}
============

Supplementary Material {#sec1}
======================

Supplementary appendix

Acknowledgments
===============

KW, DM-D and TBS acknowledge funding from the CGIAR Research Program on Policies, Institutions, and Markets (PIM). PS acknowledges support from a British Heart Foundation Intermediate Basic Science Research Fellowship, FS/15/34/31656. MR thanks the British Heart Foundation, grant number 006/PSS/CORE/2016/OXFORD. MS acknowledges support from the Wellcome Trust, Our Planet Our Health (Livestock, Environment and People), award number 205212/Z/16/Z.

MS designed the study, compiled the models, conducted the analysis, interpreted the results, and wrote the manuscript. KW, DM-D, and TBS contributed model components for the environmental analysis. All authors commented on the manuscript draft and approved the final submission.

We declare no competing interests.

The country-level results generated for the study are available on the [Oxford University Research Archive](https://ora.ox.ac.uk/objects/uuid:22032714-8338-4c52-b5d8-ea1ebb254c1c){#interrefs10}. Additional data available on request to MS.


Catalytic conversion of isophorone to jet-fuel range aromatic hydrocarbons over a MoO(x)/SiO2 catalyst.
For the first time, jet fuel range C8-C9 aromatic hydrocarbons were synthesized in high carbon yield (∼80%) by the catalytic conversion of isophorone over MoO(x)/SiO2 at atmospheric pressure. A possible reaction pathway was proposed according to the control experiments and the intermediates generated during the reaction.


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Troy Edwards

Troy Edwards (born April 7, 1977) is a former American college and professional football player who was a wide receiver in the National Football League (NFL) for seven seasons.  He played college football for Louisiana Tech University, became one of the most prolific receivers in college football history, earned All-American honors and won the Fred Biletnikoff Award.  He was selected by the Pittsburgh Steelers in the first round of the 1999 NFL Draft, and he played professionally for the Steelers, St. Louis Rams, Jacksonville Jaguars and Detroit Lions of the NFL, and the Grand Rapids Rampage of the Arena Football League.

Early years
Edwards was born in Shreveport, Louisiana.  He attended Huntington High School in Shreveport, where he played high school football.

College career
Edwards attended Louisiana Tech University, where he played for the Louisiana Tech Bulldogs football team from 1995 to 1998.  As a senior in 1998, he was recognized as a consensus first-team All-American and won the Fred Biletnikoff Award as the best college wide receiver in America at the conclusion of the 1998 season.

In the 1998 season opener versus the Nebraska Cornhuskers, Edwards had 21 catches for 405 yards—the most ever receiving yards in a single game by a college player.  His twenty-seven touchdown catches during his 1998 senior year remains the NCAA Division I-A season record.  He held the NCAA career record for touchdown receptions with fifty until it was broken by the Rice Owls' Jarett Dillard.  His 140 career receptions is the third most in Division I-A history, and his 1,996 receiving yards gained during his senior season remains the second most in Division I-A history.

Professional career
The Pittsburgh Steelers selected Edwards in the first round (thirteenth pick overall) in the 1999 NFL Draft, and he played for the Steelers from  to , followed by a single season for the St. Louis Rams in .  He also played for the Jacksonville Jaguars in  and , and the Detroit Lions in .  In seven NFL seasons, he played in ninety-two games, started twenty-two of them, caught 203 passes for 2,404 yards and eleven touchdowns, and also compiled 1,560 punt return yards.

He finished his professional football career with the Grand Rapids Rampage of the Arena Football League in 2007.

NFL statistics
Receiving Stats

Returning Stats

See also
 List of NCAA major college football yearly receiving leaders
 List of NCAA major college football yearly scoring leaders
 List of Arena Football League and National Football League players

References

Category:1977 births
Category:Living people
Category:All-American college football players
Category:American football wide receivers
Category:Detroit Lions players
Category:Grand Rapids Rampage players
Category:Jacksonville Jaguars players
Category:Louisiana Tech Bulldogs football players
Category:Sportspeople from Shreveport, Louisiana
Category:Pittsburgh Steelers players
Category:St. Louis Rams players