Methods

A systematic approach was used to identify, collect, and analyze FBDGs across countries in the FAO European region. The methods comprised 3 main components: 1) identifying and reviewing FBDG documents; 2) assessing the inclusion of sustainability-related messaging within these guidelines based on 2 established frameworks(the Sustainable Healthy Diets Guiding Principles and the One Blue Dot Sustainable Diet Recommendations); and 3) extracting and analyzing quantitative recommendations for meat and legume/pulse consumption. Only the recommendations aimed toward the general adult population were included in this analysis; FBDG documents aimed at children and/or pregnant/lactating women or older adults were not included.

FBDG documents

A search for European FBDGs and supporting documents was conducted between 25 July, 2025, and 10 August, 2025. The FAO’s online repository of FBDGs [35] and the European Commission’s Health Promotion and Disease Prevention Knowledge Gateway [36] were used to identify countries with published FBDGs. Where possible, the source documents were obtained from the links provided in these repositories. When required, additional searches to find the relevant FBDG documents were completed. This ensured the most recent documents were used in the data extraction and analysis. A Google search was also conducted to find newer versions of any FBDGs, using the following terms: “food-based dietary guidelines + [country],” “nutrition recommendations + [country],” and “[country] + ministry of health.” To identify background documents, which are sometimes published separately from the FBDGs, an additional search was conducted using: “food-based dietary guidelines + [country] + background document” and “food-based dietary guidelines + [country] + scientific report.”

Three types of FBDG documents were reviewed: consumer-facing documents, health care professional (HCP) documents, and background/scientific reports/documents (Supplemental Table 1). These were defined as follows: 1) consumer documents were typically the main documents, written in lay language, and often used graphics to depict the recommendations; 2) the HCP documents offered scientific details supporting the nutritional guidance presented in the consumer documents; and 3) the background documents provided a description of the methodology used to develop the guidelines, or the scientific rationale. If, for the same country, > 1 FBDG document fell into 1 of the 3 categories, all relevant documents were reviewed, and their data were then combined.

Following identification and access of the documents, Google Translate (Google Translate LLC, 2023) was used to translate documents that were not available in English. A Microsoft Excel spreadsheet (Version 2401) was developed to compile the extracted data using both established sustainable diet criteria, as detailed below. All FBDG documents were systematically screened by 2 independent reviewers to determine if, and how, they addressed each individual criterion listed in the sustainability framework. Each criterion was considered within each document and classified into 1 of 3 categories: 1) included with a direct reference to environmental sustainability (explicit message); 2) included without reference to environmental sustainability (general message); or 3) not mentioned. In cases of uncertainty regarding whether an FBDG met a given criterion, discussions were held between the research team (RF and FS) to reach consensus. Additional information extracted included the year of publication, whether sustainability was mentioned, and whether a related term was used, based on the following search terms: “sustainability,” “sustainable,” “environment∗,” “climate,” and “planet∗.”

Sustainability criteria

An initial search was conducted to find existing guidelines on healthy and sustainable diets using the search engines PubMed, Google Scholar, and OneSearch. The search yielded a number of guidelines, 2 of which were selected to form the basis of the sustainability inclusion criteria used in this review. The first set of selected guidelines was the Sustainable Healthy Diets Guiding Principles developed by the FAO and the WHO [22]. This set of 17 goals was selected as it provides universally applicable guidelines to achieve sustainable diets and address malnutrition, serving as a framework for policymakers worldwide. It sets out 16 principles of healthy and sustainable diets belonging to 3 categories, namely health, environmental impacts, and sociocultural aspects. For the purpose of this study, these were amended to exclude the first guiding principle about breastfeeding being preferred because the focus was on adults, and the sociocultural criteria were excluded as they were not within the scope of this study. The second set was The One Blue Dot Sustainable Diet Recommendations from the British Dietetic Association (BDA) [37]. These were developed as part of the One Blue Dot project based on the Sustainable Diets Policy, which aims to translate national and international guidelines on healthy and sustainable diets. It was selected because it is similar to the FAO’s Guiding Principles while demonstrating applicability to the European region. In addition, the BDA’s guidelines were initially created for dietitians and therefore provide more diet- and food-specific sustainable recommendations.

Across these 2 sets of guidelines, a total of 18 sustainability criteria were considered, including recommendations to choose local or seasonal fruits and vegetables, increase consumption of whole grains, reduce consumption of red and processed meats, limit consumption of processed foods and beverages high in fat, salt, and sugar (HFSS), moderate dairy consumption and consume dairy alternatives, recycle waste, and minimize food packaging. The 18 adapted criteria included in this study were mapped to the original terminology used in the source documents (FAO or BDA), as shown in Supplemental Table 2.

For each country, all relevant FBDG documents were reviewed against these criteria and categorized as described previously. The number of mentions was tabulated across 38 countries and assessed separately for consumer documents, documents for HCPs, and scientific background documents. All criteria were weighted equally.

Total meat, red and processed meat, and pulse recommendations

To identify the association between the presence of environmental sustainability messaging and recommendations for meats and legumes/pulses, total recommended daily gram amounts of meat (including poultry), red and processed meat, and legumes/pulses were extracted from the consumer-facing FBDG documents, where available. These food groups were selected because they are broadly representative of environmental considerations to reduce meat (in particular, red and processed meats) and increase plant-based food consumption consistent with the EAT-Lancet recommendations. Meat, particularly red and processed meat, is widely recognized as a major contributor to GHGEs, whereas pulses are commonly promoted as a sustainable, nutrient-dense, and cost-effective plant protein alternative [38,39]. Other plant-based protein sources, such as nuts, seeds, and wholegrain cereal-based products, were less consistently represented as such across FBDGs and were therefore not included in this secondary analysis.

Values were obtained either directly from stated daily totals or indirectly derived from weekly totals and/or from guidance combining portion size and recommended consumption frequency. Because many FBDG documents do not clearly specify whether recommended meat quantities refer to raw or cooked weights, it was assumed that reporting may vary across guidelines. For meat, where both raw and cooked values were available, they were averaged to ensure harmonized reporting and comparability across FBDGs, whereas for pulses, cooked weights were retained when provided. Therefore, reported amounts for legumes and pulses refer to cooked weights, whereas meat values represent the mean of raw and cooked weights when both were provided.

The detailed methodology used to derive portion sizes and frequencies has been described previously [40].