Go to content



In 2016, the Nordic Council of Ministers took the initiative to update the scientific foundation for national nutrient recommendations and dietary guidelines in the Nordic and Baltic countries. The present NNR2023 report has been developed according to the project description and describes the science advice to the authorities in the Nordic and Baltic counties.
The scientific foundation for the NNR2023 report consists of approximately 100 qualified systematic reviews, including 9 de novo qualified systematic reviews, and 57 de novo background reviews on nutrients, food groups, meal- and dietary patterns, physical activity, body weight, food and nutrient intakes, and burden of diseases in Nordic and Baltic countries. In addition, several de novo papers on principles, methodology and environmental impact of food consumption are also essential parts of the scientific foundation of NNR2023 report. Many scientists have contributed to the NNR2023 project as authors of these background papers, served as referees or participated in reference groups. All papers will be available at the website of the Nordic Council of Ministers, and as part of the extended NNR2023 report. While the NNR2023 Committee highly appreciates and acknowledges the considerable and essential contributions and suggestions by these scientists, the present NNR2023 report is the sole responsibility of the NNR Committee.
The NNR2023 report has developed science advice based on the health effects of foods and response to the country-specific public health challenges and burden of diseases, food consumption patterns, as well as the country-specific environmental impacts of food consumption.
The NNR2023 report has not formulated advice on country-specific priorities such as food production and accessibility (e.g., agricultural methods, import and export, self-sufficiency, food security) and sociocultural aspects (e.g., animal welfare) of food consumption. Such topics are briefly discussed in background papers and in relevant sections of NNR2023, but must be dealt with nationally.
Rune Blomhoff, professor, head of NNR2023 Committee,
University of Oslo and Oslo University Hospital


AI: Adequate intake
AR: Average requirement
BEE: Basal energy expenditure
BMI: Body mass index
CDRR: Chronic disease risk reduction
CO2eq: Carbon dioxide (CO2) equivalents
CRC: Colorectal cancer
CV: Coefficient of variation
CVD: Cardiovascular disease
DALY: Disability-adjusted life years
DRV: Dietary reference value
E%: Energy percentage, i.e., percentage of total energy intake
EFSA: European Food Safety Authority
EK-FJLS Executive and Food: Nordic Committee of Senior Officials for Fisheries, Aquaculture, Agriculture, Food and Forestry. Nordic Council of Ministers
FAO: Food and Agriculture Organization of the United Nations
FBDG: Food-based dietary guideline
GHG: Greenhouse gases
HSSD: Healthy, Safe and Sustainable Diet, Nordic Council of Ministers
IOM: Institute of Medicine, USA
IPCC: Intergovernmental Panel on Climate Change
kJ: Kilojoule (1 kJ = 0.239 kcal)
kcal: Kilocalorie (1 kcal = 4.184 kJ)
LCA: Life Cycle Assessment
LNCSB: Low- and no-calorie sweetened beverages
MJ: Megajoule (1 MJ = 239 kcal)
NASEM: National Academies of Sciences, Engineering, and Medicine, USA
NCM: Nordic Council of Ministers
NNR: Nordic Nutrition Recommendations
NNR2023: The sixth edition of the Nordic Nutrition Recommendations (2023)
PAL: Physical Activity Level
PLP: Pyridoxal 5’-phosphate
Provisional AR: provisional average requirement
qSR: Qualified Systematic Review
REE: Resting energy expenditure
RI: Recommended intake
SD: Standard deviation
SDG: The UN Sustainable Developmental Goals (United Nations, 2015)
SR: Systematic review
SSB: Sugar-sweetened beverages
T2D: Type 2 diabetes
UL: Tolerable Upper Intake Level, corresponds to Upper Intake Level and Upper Level
UN: United Nations
UPF: Ultra-processed foods
WHO: World Health Organization


Added sugars: Refined sugars such as sucrose, fructose, glucose, starch hydrolysates (glucose syrup, high-fructose syrup), and other isolated sugar preparations used as such or added during food preparation and manufacturing.
Baltics or Baltic countries: The three Baltic countries (Estonia, Latvia, and Lithuania).
Carbon dioxide equivalents: For assessing the short-term global warming potential of different greenhouse gases by converting them to the equivalent amount of CO2 with the same global-warming potential and the total amount is then summed.
DALY: The overall burden of disease is assessed using the disability-adjusted life years.
Free sugars: Added sugars plus sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.
Indicator: A central step in setting DRVs or FBDGs is identifying and selecting indicators of adequate and excessive intakes. An indicator broadly refers to clinical endpoints, biomarkers, surrogate markers, and chronic disease risk factors. A qualified biomarker is often used as an indicator to derive DRVs for nutrients.
Life cycle assessment: An ISO-standardized environmental management tool to quantitatively assess and compare the overall environmental performance of products, services and technologies.
Life-stage group: The DRVs are expressed as reference values for groups defined by age, sex, pregnancy and lactation.
Monoculture: Intensive large-scale cropping systems with low diversity.
Net zero: GHG emission regimes that do not produce further warming, i.e., no increase in total radiative forcing from atmospheric greenhouse gases.
Nordics or Nordic countries: The five Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden).
Physical activity level: The physical activity level is used to express a person’s total daily physical activity, and is used for estimating total energy expenditure.
Plant-based diet: In this report, the terms plant-based diet is defined as a diet that mostly contain plant foods such as vegetables, fruits, whole grains, pulses, nuts and seeds. Animal foods such as fish, white meat (poultry), red meat, and low-fat dairy can make up a moderate amount of the foods in a plant-based diet.
Qualified biomarker:  When a biomarker is qualified, it means that it has been accepted by the NNR2023 committee as a valid basis for deriving DRVs or FBDGs.
Qualified systematic review: A systematic review defined by the inclusion and exclusion criteria set by the NNR2023 Committee. A qualified systematic review may be used to inform the setting of DRVs or FBDGs.
Ultra-processed foods: Foods in category 4 of the NOVA classification system.
Vegetarian diets: (sometimes referred to as lacto-ovo vegetarian) includes eggs and dairy foods, but no meat, poultry, fish, or seafood.
Vegan diets: includes no animal-source food.

Updating scientific evidence used to set DRVs and formulate FBDGs

Qualified Systematic Reviews are considered as the preferred method to evaluate causality

More than 3 million nutrition science papers published in scientific journals can be retrieved when searching in standard library databases. The study quality varies considerably in these papers, similarly to all other scientific and medical disciplines. When setting DRVs and formulating national FBDGs, only adequately designed studies of high quality should be utilized.
In general, systematic reviews (SRs) are considered the method with highest quality for synthesizing original scientific evidence. The Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network has formulated requirements that must be met in reporting SRs (Liberati et al., 2009; Page et al., 2021).  Several SRs have been published in the field of diet, nutrition and health. However, the quality varies and control of risk of bias does often not meet the standard needed to inform national recommendations.  
Due to sponsorship from commercial entities and ideological organizations, concerns have been raised about bias in the results of such SRs. For example, evidence for substantial bias has been identified in conclusions of industry-sponsored systematic reviews. It has been suggested that industry-sponsored research will result in higher likelihood of a favourable conclusion, compared with government-sponsored research (Hansen et al., 2019; Lundh et al., 2017). While industry-sponsored research is likely to be important for nutrition research also in the future, it is fundamentally important that industry sponsors should have no role in project design, implementation, analysis, or the interpretation of results. This independence minimizes the potential for bias.
The NNR2023 project has considered all SRs. However, to reduce the risk of bias, NNR2023 did not consider SRs commissioned or sponsored by industry or organizations with a business or ideological interest as qSRs. Only SRs commissioned by national food or health authorities, or international food and health organizations, were used as the foundation for setting DRVs and formulating national FBDGs. To evaluate bias and other quality aspects, we developed a guide for working with systematic reviews and formulated specific inclusion and exclusion criteria that had to be met for SRs to qualify as main science base in the NNR2023 project (Arnesen et al., 2020a, b; Høyer et al., 2021).  SRs that met all inclusion and exclusion criteria were designated “qualified SRs” (qSRs) The qSRs identified are shown in Appendix 2.
The following eight steps had to be included when developing qSRs for the NNR2023 project:
  1. Precise definition of the research question
  2. Development of protocol with predefined criteria
  3. Adequate literature search
  4. Screening and selection of studies according to protocol requirements
  5. Data extraction according to protocol requirements
  6. Assessing risk of bias following specific procedures
  7. Synthesis and grading of total strength of evidence following specific procedures
  8. Reporting according to standardized criteria
Details of these steps are described in Arnesen et al. (Arnesen et al., 2020a, b). For example, for the NNR de novo qSRs on randomized controlled trials, a modified version of the Cochrane’s ‘Risk of bias 2.0’ tool (Sterne et al., 2019) was used to critically appraise internal validity, i.e., bias. For non-randomized trials, the risk of bias assessment tool was based on the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) instrument (Sterne et al., 2016), and for observational studies (prospective cohort studies, case-cohort studies, or case-control studies), the recently developed ‘Risk of Bias for Nutrition Observational Studies’ (RoB-NObS) tool, developed by the US Department of Agriculture’s (USDA) Nutrition Evidence Systematic Review (NESR) team (Nutrition Evidence Systematic Review, 2019), was used. These tools, or various other tools of similar quality, were used in all qSRs identified in the present NNR report.

Global collaboration between health authorities

NNR2023 should ideally build on recent qSRs of highest quality for all associations between nutrients and food groups and every relevant health-related outcome. A complete set of qSRs may include the following:
  • qSRs for each of the indicators used to set Average Requirement (AR) for each of the 36 nutrients included in NNR2023
  • qSRs for each of the indicators used to set Upper Limit (UL) for each of the 36 nutrients included in NNR2023
  • qSRs for assessing indicator dose-response and additional candidate indicators for AR and UL
  • qSRs for each of the candidate indicators used to formulate science advice for healthy FBDGs for all the 15 food groups, meal and dietary patterns assessed in NNR2023. A number of indicators should be assessed for each food group, such as various types of cardiovascular diseases and cancers, type 2 diabetes and other relevant chronic diseases. Often, there is also a need for qSRs on several subcategories within each food group.
Thus, recent qSRs of several hundred possible exposure-outcome pairs would be needed in the ideal situation. However, due to the high cost and resources involved in developing qSR, no national authorities have the resources and competence for completing the task on their own. This calls for international harmonization and collaboration between national authorities (Allen et al., 2020; NASEM, 2018; Yaktine et al., 2020). The NNR project is a long-standing example of international harmonization and collaboration.
Such global harmonization is possible since foods and nutrients have identical health effects across nations and regions. Scientific human studies conducted in regions outside the Nordic and Baltic countries are therefore equally relevant as human studies conducted within the Nordic and Baltic countries. There are a few noteworthy exceptions, but many studies on health effects are universally applicable. All exceptions to this general rule were carefully considered in each relevant section in this report. When developing national DRVs and FBDGs, several country-specific issues need to be considered (see discussion later in the report).
Since around 2010, national health authorities and international organizations have gradually started to use qSRs as the preferred method for evidence-based evaluation of causal relations between nutrient or food exposures and health outcomes. Close to 100 SRs (Table 1-2 and Appendix 2) fulfilled the inclusion and exclusion criteria for qSRs and were used as a main fundament when setting DRVs and formulating FBDGs in the NNR2023 project. The Institute of Medicine (IOM), National Academies of Sciences, Engineering, and Medicine (NASEM) (IOM was renamed to NASEM in 2011), the European Food Safety Authority (EFSA) and Nordic Council of Ministers (Nordic Council of Ministers, 2014) are among the authorities that contributed to developing these qSRs.
Table 1 Qualified systematic reviews used for nutrients
A) Macronutrients
Published/commissioned by
Fat and fatty acids
Fogelholm et al. (2012), Schwab et al. (2014), Wolfram et al. (2015), de Souza et al. (2015), Brouwer (2016), Mensink (2016), Balk et al. (2016), Newberry et al. (2016), Te Morenga and Montez (2017), Abdelhamid et al. (2018, 2020), Naude et al. (2018), Brown et al. (2019), Hanson et al. (2020), Hooper et al. (2020a, b), Brainard et al. (2020), Snetselaar et al. (2020a), Donovan et al. (2020a), Deane et al. (2021), Bärebring et al. (2022), Nwaru et al. (2022), Reynolds et al. (2022)
NNR2012, DGE, WHO, AHRQ, DGAC2020, NNR2023
Hauner et al. (2012), Sonestedt et al. (2012), Fogelholm et al. (2012), WHO (2015), SACN (2015), Reynolds et al. (2019), Mayer-Davis et al. (2020), EFSA (2022)
Dietary fibre
Fogelholm et al. (2012), Hauner et al. (2012), SACN (2015), Reynolds et al. (2019), Dierkes et al. (2023), WCRF/AICR (2018j)
Fogelholm et al. (2012), Hörnell et al. (2013), Pedersen et al. (2013), Pedersen and Cederholm (2014), Hengeveld et al. (2022), Arnesen et al. (2022), Lamberg-Allardt et al. (2023b)
NNR2012, Health Council of the Netherlands, NNR2023
Abbreviations: AHRQ: Agency for Healthcare Research and Quality; DGAC2020: 2020 Dietary Guidelines Advisory Committee; DGE: Deutsche Geschellschaft für Ernährung (German Nutrition Society); EFSA: European Food Safety Authority; NNR: Nordic Nutrition Recommendations; WCRF/AICR: World Cancer Research Fund/American Institute of Cancer Research; WHO: World Health Organization.
B) Micronutrients
Published/commissioned by
Vitamin A
Olsen et al. (2023)
Vitamin D
Lamberg-Allardt et al. (2013), Newberry et al. (2014), Dewey et al. (2020), Lamberg-Allardt et al. (2023a)
Buijssen et al. (2014)
Eeuwijk et al. (2012)
Vitamin B6
Eeuwijk et al. (2012), EFSA (2023a)
Donovan et al. (2020b), Åkesson et al. (2023)
Vitamin B12
Bärebring et al. (2023)
Eeuwijk et al. (2012)
Uusi-Rasi et al. (2013), Newberry et al. (2014)
Eeuwijk et al. (2013)
WHO (2012), Eeuwijk et al. (2013), Neale and Clark (2017), Newberry et al. (2018), EFSA (2019b), NASEM (2019)
WHO, EFSA, Australian Department of Health and New Zealand Ministry of Health, AHRQ, NASEM
(Aburto et al., 2013), Newberry et al. (2018), NASEM (2019)
Domellöf et al. (2013), Dewey et al. (2020) 
NNR2012, DGAC2020
Gunnarsdottir and Dahl (2012)
NNR 2012
EFSA (2023b)
Bost et al. (2012)
Phytochemicals and antioxidants
WCRF/AICR (2018a), O’Connor et al. (2022)
Abbreviations: AHRQ: Agency for Healthcare Research and Quality; DGAC2020: 2020 Dietary Guidelines Advisory Committee;  EFSA: European Food Safety Authority; NASEM: National Academies of Science, Engineering, and Medicine; NNR: Nordic Nutrition Recommendations; WCRF/AICR: World Cancer Research Fund/American Institute of Cancer Research; WHO: World Health Organization.
Table 2 Qualified systematic reviews used for FBDGs
Food group
Qualified SR
Published/commissioned by
Victora et al. (2016), WCRF/AICR (2018b), Güngör et al. (2019a, b, c, d, e)
Complementary feeding
Obbagy et al. (2019a, b, c), English et al. (2019a, b, c) Spill et al. (2019), EFSA (2019a), de Silva et al. (2020), Arnesen et al. (2022); Padhani et al. (2023)
Sonestedt et al. (2012), WHO (2015), SACN (2015), WCRF/AICR (2018g),  Mayer-Davis et al. (2020a), Mayer-Davis et al. (2020b), EFSA (2022), Rios-Leyvraz and Montez (2022), Rousham et al. (2022)
Cereals (grains)
Fogelholm et al. (2012), Hauner et al. (2012), Åkesson et al. (2013), SACN (2015), WCRF/AICR (2018b, j), Reynolds et al. (2019)
Vegetables, fruits and berries
Fogelholm (2012), WCRF/AICR (2018j), Stanaway et al. (2022)
Åkesson et al. (2013), SACN (2015)
Fruit juice
SACN (2015), WCRF/AICR (2018b), Mayer-Davis et al. (2020a)
Pulses (legumes)
SACN (2015), WCRF/AICR (2018j), Lamberg-Allardt et al. (2023b), Thórisdottír et al. (2023)
Nuts and seeds
Arnesen et al. (2023)
Fish and seafood
WCRF/AICR (2018e), Snetselaar et al. (2020b, c), Norwegian Scientific Committee for Food and Environment (2022)
WCRF/AICR, DGAC2020, Norwegian Scientific Committee for Food and Environment
Red meat
Fogelholm et al. (2012), WCRF/AICR (2018e), Lescinsky et al. (2022)
White meat
WCRF/AICR (2018e), Ramel et al. (in press)
Milk and dairy products
Åkesson et al. (2013), WCRF/AICR (2018e), Lamberg-Allardt et al. (2023b)
Sweets and confectioneries
EFSA (2022), Mayer-Davis et al. (2020b), WHO (2015), Rousham et al. (2022)
WCRF/AICR (2018h), Mayer-Davis et al. (2020), Canadian Centre on Substance Use and Addiction (CCSA) (2023)
WCRF/AICR, DGAC2020, Health Canada
Dietary patterns
2020 Dietary Guidelins Advisory Committee (2020), Boushey et al. (2020a, b, c, d, e, f, g)
Meal patterns
Heymsfield et al. (2020a, b, c)
Abbreviations: DGAC2020: 2020 Dietary Guidelines Advisory Committee;  EAACI: European Academy of Allergy and Clinical Immunology; EFSA: European Food Safety Authority; GBD: Global Burden of Disease; NNR: Nordic Nutrition Recommendations; SACN: Scientific Advisory Committee on Nutrition; WCRF/AICR: World Cancer Research Fund/American Institute of Cancer Research; WHO: World Health Organization.
These qSRs, some with overlapping topics, have been published in the period 2012-2023. While use of qSRs constitutes the most solid fundament available, it is important to independently review the literature to identify new significant and relevant evidence published after the publication date of a qSR. A key role of the background papers for the 36 nutrients, 15 food groups, and meal and dietary patterns, is to ascertain that NNR2023 is up to date with the most recent scientific evidence.

Selection of topics for de novo qualified systematic reviews

An important aspect of the NNR2023 project was to select the most relevant topics for updating DRVs and FBDGs that had not been covered in a previous recent qSR. The NNR2023 Committee selected 9 topics for development of qSRs by the NNR2023 SR Centre (see "Organization of the NNR2023 project"). In an open call, scientists, health professionals, national food and health authorities, food manufacturers, other stakeholders and the general population in the Nordic and Baltic countries were invited to suggest SR topics. A total of 45 nominations with suggestion for more than 200 exposure–outcome pairs were received in the public call. The process of selecting topics is described in Høyer et al. (2021).
In addition, to search for “hot topics” relevant for setting DRVs and FBDGs, the NNR2023 Committee developed scoping reviews (ScRs) for 36 nutrients, 15 food groups, meal patterns and dietary patterns aimed at identifying potential SR topics. After considering approximately 15,000 review papers, several topics were identified. The NNR2023 Committee shortlisted 52 exposure-outcome pairs based on the call and the ScRs.
The following nine top prioritised topics for de novo SRs were then selected by the NNR2023 Committee in a comprehensive Delphi process (Høyer et al., 2021):
  1. Protein intake in children and growth and risk of overweight or obesity: A systematic review and meta-analysis (Arnesen et al., 2022)
  2. Legume consumption in adults and risk of cardiovascular disease and type 2 diabetes: A systematic review and meta-analysis (Thórisdottír et al., 2023)
  3. Animal versus plant-based protein and risk of cardiovascular disease and type 2 diabetes: A systematic review of randomized controlled trials and prospective cohort studies (Lamberg-Allardt et al., 2023b)
  4. Quality of dietary fat and risk of Alzheimer’s disease and dementia in adults aged ≥ 50 years: A systematic review (Nwaru et al., 2022)
  5. Intake of vitamin B12 in relation to vitamin B12 status in groups susceptible to deficiency: A systematic review (Bärebring et al., 2023)
  6. White meat consumption and risk of cardiovascular disease and type 2 diabetes: A systematic review and meta-analysis (Ramel et al, 2023)
  7. Supplementation with long chain n-3 fatty acids during pregnancy, lactation, or infancy in relation to risk of asthma and atopic disease during childhood: A systematic review and meta-analysis of randomized controlled clinical trials (Bärebring et al., 2022)
  8. Nuts and seeds consumption and risk of cardiovascular disease, type 2 diabetes, and their risk factors: A systematic review and meta-analysis (Arnesen et al., 2023)
  9. Dietary fibre and growth, iron status and bowel function in children 0-5 years old: A systematic review (Dierkes et al., 2023)

The target group for DRVs and FBDGs in NNR2023

Previous editions of NNR and most other national nutrient and diet recommendations (reviewed in NASEM (2022)) have described the “healthy population” or the “apparently healthy population” as the target population, without specifying in detail who are included and who are excluded. In the fifth edition of NNR, it was stated that the DRVs in NNR2012 were intended for the “general population”, “healthy population” and “apparently healthy population” (Nordic Council of Ministers, 2014).  In NNR2012, it was also decided that the DRVs were not intended for groups or individuals with diseases or other conditions that affect their nutrient requirements.
A process to more precisely define the target population for nutrient recommendations has recently been described (NASEM, 2022). In line with NASEM and EFSA, the NNR2023 defines the target population as the general population. The general population encompasses all age groups (i.e., infants, children and adolescents, adults, the elderly, pregnant and lactating women). The target population includes individuals that may absorb or metabolize nutrients from food components to various degrees, or have sensitivities because of specific genetic background, conditions or diseases. While DRVs and FBDGs are intended for most of these individuals, some subpopulations may be excluded. If not identified and excluded specifically in NNR2023, such subpopulations must be considered case-by-case by appropriate health authorities or practitioners.
The DRVs cover increased requirements such as during short-term mild infections or medical treatments. The DRVs are usually not suited for long-term infections, malabsorption and various metabolic disturbances (Christensen et al., 2020).
A significant proportion of the population in the Nordic and Baltic countries are at risk of developing chronic diseases or have already been diagnosed with a chronic disease (e.g., cardiovascular diseases, hypertension, cancers and type 2 diabetes) or with a risk factor (e.g., hypercholesterolaemia, hypertension, or hyperglycaemia) associated with development of these chronic diseases. Chronic disease risk factors and the use of medications are common, particularly among middle-aged and older adults. Individuals with chronic diseases or chronic disease risk factors should be considered as part of the general population unless there is an effect of the disease and/or medications on nutritional status that would alter normal physiologic requirements. In contrast, individuals with diseases, conditions or medications that clearly alter nutrient metabolism or requirements, should not be included in the general population for the DRVs specific to those nutrients. Similarly, individuals undergoing procedures that may alter gastrointestinal function and nutrient absorption might also need to be excluded. 
Importantly, people with overweight or obesity, which represent a large segment of most life-stage groups, are also included in the target population. However, when individuals have severe comorbidities caused by overweight and obesity, they may be excluded from the target population if there is evidence that their condition or medications alter their energy or other nutrient requirements.
For FBDGs, individuals with food allergies, which occur when the immune system reacts with certain components in food, are excluded from the guideline related the specific foods. The same is true for specific foods causing food intolerance, such as irritable bowel syndrome, which is a broad term that is used to describe a wide range of adverse reactions to foods.

Developing background reviews for 36 nutrients and food components and 15 food groups, meal patterns and dietary patterns

The present edition of NNR builds on the solid foundation of the comprehensive and well-recognized previous editions of NNR, including the nutrient reviews (in the form of nutrient chapters in NNR2012 (Nordic Council of Ministers 2014)). Due to a substantial and rapidly developing production of new scientific evidence, all nutrient background papers have been updated in NNR2023. Additionally, since the present edition aimed to develop science advice for setting FBDGs in the Nordic and Baltic countries, new papers were developed for 15 food groups. In addition, papers were added for meal patterns and dietary patterns.
The recruited background paper authors followed an “Instruction to authors” (Nordic Nutrition Recommendations 2022) developed by the NNR2023 Committee. Authors were asked to use the corresponding chapter in NNR2012 and the ScR described above (i.e., scoping reviews for identification of topics for de novo qSRs (Høyer et al. 2021)) as a starting point. Authors were responsible for developing appropriate literature searches and assess significant new relevant evidence published since NNR2012. When available, qSRs were used as the main fundament in the background papers. For exposure-outcome pairs not covered by qSRs, the authors assessed other reviews or original papers. These sections have, as a minimum, fulfilled the requirements for scoping reviews from the EQUATOR network (Tricco et al. 2018). If any of these papers were used as main fundament for setting DRVs or formulating FBDGs, the quality of papers was assessed following standard procedures for randomized controlled trials and observational studies. For quality assessment of systematic reviews that included randomised or non-randomised studies and/or observational studies we adapted a modified version of AMSTAR2 (Shea et al., 2017) (Appendix 3). All background papers were peer-reviewed and submitted to public consultation.
The original search strategy and date is reported in each background paper. The NNR2023 Committee updated all searches on April 15th, 2023. If the NNR2023 Committee considered the new papers especially relevant, it is cited and added to the assessment in the nutrient and food group sections in this report. Of special interest, some new qSRs were identified. These are also incorporated in the assessment in the nutrient and food group sections below.
These background reviews constitute the main scientific update since NNR2012. Especially, they inform about the current status of the specific indicators used in setting DRVs and FBDGs, whether any new indicators should be considered, and they also discuss new qSRs.  They also discuss any new recommendations available from EFSA and NASEM since NNR2012.
Table 3. NNR2023 background papers on nutrients
Fluid and water balance
Iversen and Fogelholm (2023)
Cloetens and Ellegård (2023)
Fat and fatty acids
Retterstøl and Rosqvist (2023)
Sonestedt and Øverby (2023)
Dietary fibre
Carlsen and Pajari (2023)
Geirsdóttir and Pajari (2023)
Vitamin A
Olsen and Lerner (2023)
Vitamin D
Brustad and Meyer (2023)
Vitamin E
Hantikainen and Lagerros (2023)
Vitamin K
Lyytinen and Linneberg (2023)
Strandler and Strand (2023)
Lysne and Strandler (2023)
Freese and Lysne (2023)
Pantothenic acid
Freese, Aarsland and Bjørke-Monsen (2023)
Vitamin B6
Bjørke-Monsen and Ueland (2023a)
Bjørke-Monsen and Ueland (2023b)
Solvik and Strand (2023)
Vitamin B12
Bjørke-Monsen and Lysne (2023)
Vitamin C
Lykkesfeldt and Carr (2023)
Obeid and Karlsson (2023)
Uusi-Rasi and Torfadóttir (2023)
Itkonen and Lamberg-Allardt (2023)
Henriksen and Aaseth (2023)
Jula (2023)
Toft, Riis and Jula(2023)
Domellöf and Sjöberg (2023)
Strand and Mathisen (2023)
Gunnarsdóttir and Brantsæter (2023)
Alexander and Olsen (2023)
Henriksen and Arnesen (2023)
Henriksen and Bügel (2023)
Kippler and Oskarsson (2023)
Oskarsson and Kippler (2023)
Kjellevold and Kippler (2023)
Phytochemicals and antioxidants
Myhrstad and Wolk (2023)
Table 4. NNR2023 background papers on food groups, meal patterns and dietary patterns
Food group
Breastfeeding and complementary feeding
Hörnell and Lagström (2023)
Sonestedt and Lukic (2023)
Skeie and Fadnes (2023)
Vegetables, fruits, and berries
Rosell and Fadnes (2023)
Rosell and Deslisle (2023)
Fruit juice
Rosell and Delisle (2023)
Pulses (legumes)
Torheim and Fadnes (2023)
Nuts and seeds
Fadnes and Balakrishna (2023)
Fish and seafood
Ulven and Torfadóttir (2023)
Meat and meat products
Meinilä and Virtanen (2023)
Milk and dairy products
Holven and Sonestedt (2023)
Virtanen and Larsson (2023)
Fats and oils
Rosqvist and Niinistö (2023)
Sweets and confectioneries
Vepsäläinen and Sonestedt (2023)
Thelle and Grønbæk (2023)
Dietary patterns
Vepsäläinen and Lindström (2023)
Meal patterns
Svendsen and Forslund (2023)

Handling of comments from public consultation

In addition to the standard peer-review process, all background papers on nutrients, food groups, meal and dietary pattern were also submitted to public consultation as well as the background papers developed in the NNR2023 project on environmental aspects of food consumption. A consultation period of 4 weeks was practiced for the first papers. However, the period was extended to 8 weeks for papers submitted to public consultation after May 2022. Thousands of comments were received and forwarded to the authors for consideration. The NNR2023 Committee have considered all consultation comments. All consultation comments have been openly accessible through the NNR2023 website. The responsible authors have briefly formulated a response to each of the comments on nutrient, food group, meal patterns and dietary pattern background papers. All comments to the background papers on environmental aspects of food consumption have been considered by the NNR Committee and the responsible authors. The NNR Committee, in collaboration with the authors, has briefly formulated a response to each of the comments.
Throughout the project period, the public and all interested parties have also been invited to submit their comments to the NNR2023 Committee through the NNR2023 website. The NNR2023 Committee has carefully considered all comments. All comments and the response from the Committee have been openly accessible through the NNR2023 website. 
After the NNR2023 project period, a separate report with all comments and responses to public consultation comments and website comments will be published.

Responsibility of experts and NNR2023 Committee

NNR2023 report

While a substantial number of scientists have contributed to the development of background papers (Appendix 1), the final text and conclusions in the present NNR2023 report are the sole responsibility of the NNR2023 Committee.

Principle and methodology papers

For guidance and transparency in the process of setting DRVs and FBDGs, several methodology papers have been developed by the NNR2023 Committee (Christensen et al. 2020; Arnesen et al. 2020a, 2020b). The final text and conclusions in these papers are the sole responsibility of the NNR2023 Committee.

Background papers

A number of background papers have been commissioned by the NNR2023 Committee, including 53 background papers on nutrient, food groups, meal patterns and dietary patterns, background papers on the local context in Nordic and Baltic countries such as burden of disease, physical activity, food and nutrient intake and body weight, and background papers on environmental aspects of food consumption. The text in all background papers is the sole responsibility of the authors. The NNR2023 Committee have had an editorial role in all background papers while the referees have peer-reviewed the manuscript.  

Collaboration and harmonization of health based DRVs and FBDGs in Nordic and Baltic countries

The NNR2023 report constitutes science advice to the national authorities in Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, and Sweden. The report offers solutions and guidance for national authorities when they develop and formulate their own food and health policies.

Universal health effects of nutrients are the main basis for setting DRVs

The amounts of dietary nutrients needed for nutrient adequacy and the upper levels of dietary intake that will not lead to adverse effects are identical, with few exceptions, among the Nordic and Baltic countries, as well as other countries across the globe (NASEM, 2018). Exceptions were considered and adjusted to the Nordic and Baltic populations when setting DRVs in the NNR2023 project.
Exceptions are reference values for energy intakes and all DRVs where energy, weight and physical activity are included when calculating the recommended intakes.
Dietary iron requirements may also vary depending on inhibitors and enhancers of iron absorption in the same meal, while zinc and iodine requirements vary depending on inhibitors such as phytate and goitrogens, respectively, in the same meal. Additionally, vitamin D requirements are dependent of sun exposure and latitude.
As a general rule, all of these factors are similar in Nordic and Baltic countries, with exception for vitamin D and specific nutrient fortification policies.
The integration of environmental sustainability in NNR2023 may open for more country-specific DRVs for alcohol and added and free sugars, both of which are unnecessary and not required for a healthy diet. Alcohol and added and free sugars, which are traditionally considered “nutrients” because they yield energy, may have substantial environmental impact when intake is high (Harwatt et al. 2023; Trolle et al. 2023).
All information for setting DRVs is summarized in the 36 nutrient background papers listed in Table 3 and in the nutrient summaries in this report.
Background papers of burden of diseases (Clarsen et al., in press), food and nutrient intake (Lemming & Pitsi, 2022), physical activity (Borodulin & Anderssen, in press), and environmental impact (Benton et al. 2022; Harwatt et al. 2023; Eneroth et al. 2023; Jackson & Holm 2023; Trolle et al. 2023) are cited when relevant.
Thus, we recommend that the authorities in the Nordic and Baltic countries adopt all DRVs set in NNR2023. Adaptations may be made in special cases, for example when formulating national recommendations for vitamin D, alcohol and added and free sugar.

FBDGs are based both on universal health effects and several country-specific contexts

FBDGs should provide country-specific guidance on food consumption. The context of the individual country is especially relevant when formulating national FBDGs. While the health effects of foods are more or less universal, the national FBDGs may also respond to the following country-specific contexts:
  1. public health challenges and burden of diseases
  2. food consumption pattern
  3. environmental impact
  4. food production and accessibility
  5. sociocultural aspects 
The NNR2023 report gives science advice that is based on the health effects of foods and respond to the country-specific public health challenges and burden of diseases, and food consumption pattern, as well as the country-specific environmental impact of food consumption.
The NNR2023 report does not give advice on country-specific political priorities such as food production and accessibility (e.g., agricultural methods, import and export, self-sufficiency, food security, food safety) and sociocultural aspects (e.g., animal welfare) of food consumption. Such topics, which are briefly discussed in background papers and in relevant sections of NNR2023, may be dealt with nationally.
The health effects of food groups summarized in this report build on 15 food group background papers as well as the background papers on meal patterns and dietary patterns listed in Table 4. Background papers on burden of diseases (Clarsen et al., in press), food and nutrient intake (Lemming and Pitsi 2022), physical activity (Borodulin and Anderssen, in press), and environmental impact (Benton et al. 2022; Harwatt et al. 2023; Eneroth et al. 2023; Trolle et al. 2023; Jackson and Holm 2023)  are cited when relevant.
Thus, we recommend that the authorities in the Nordic and Baltic countries can use the science advice in NNR2023 as a framework for setting their country-specific FBDGs. The national authorities may consider country-specific food production and accessibility issues, affordability/economic aspects, and sociocultural aspects of food consumption when formulating their country-specific FBDGs. Translation of the science advice in NNR2023 to the public is also entrusted to the national authorities.

Integration of overweight and obesity in NNR2023

The NNR2023 report bases its conclusions on several qualified systematic reviews reporting strong or probable evidence between excessive weight gain, overweight or obesity, and the intake of foods, nutrients, and consumption patterns.
As obesity is a major cause of morbidity and mortality in the Nordic and Baltic countries, the NNR2023 report has special focus on the role of the diet for obesity, and the consequences of the present weight status on national DRVs and FBDGs. As described below, a specific review paper has been developed to describe current knowledge of the relation between nutrients, foods, and body weight (Hjelmesæth & Sjöberg, 2022).
When calculating recommended intake (RI) from the average requirement (AR), the coefficient of variation (CV) of the distribution of the requirement in the population is taken into account (see below). Typically, if normally distributed, the RI is calculated as AR + 2 standard deviations (SD) to cover the requirements of almost all individuals in the whole population (97.5%). The accurate CVs are, however, seldom known. The increase in body weight in the general population may complicate these calculations since it may affect both the AR and the CV.
One example is vitamin C. As discussed in the vitamin C background paper (Lykkesfeldt & Carr, 2023), a lighter body weight group (63 kg) reached the target for vitamin C in plasma (i.e. 50 µmol/L) at an intake of about 50 mg/day, whereas the heavier body weight group (105 kg) required about 175 mg/day to reach the same plasma concentration. Similar concerns can also be raised about for other nutrients.
In general, the basis for setting and scaling of DRVs in NNR2023 is a BMI of 23 kg/m2, and no adjustment is done for obesity in the population. Similar to NNR2023, EFSA (2010a) and IOM/NASEM (2006) do not adjust their DRVs for body weight, except in special cases.
Thus, both ARs and CVs in the various life-stage groups may need to be re-considered due to the growing number of people with larger body weights caused by obesity or other reasons.  It is important to recognize that the recommendations in NNR2023 for energy and nutrients are set for generally healthy body weights.
Maintaining a healthy body weight and body weight stability is recommended in non-pregnant adulthood and for healthy growth in childhood, due to the associated health effects and the serious health risks of underweight, overweight and obesity (Boushey et al., 2020b; Cloetens & Ellegård, 2023). For older adults, the associations between overweight and health outcomes are less clear, and the available data are inadequate to make precise recommendations for optimal BMI in this age group (Cloetens & Ellegård, 2023).
Overconsumption of food and energy is not only associated with increased risk of chronic diseases, it also has a negative environmental impact (Trolle et al., 2023). For example, as discussed in this report, high consumption of discretionary foods, such as sugar, sweets, beverages and animal fat contribute to GHG emissions, deforestation and decreased biodiversity.
When defining science advice for DRVs and framework for FBDGs, overweight, obesity and food overconsumption are important aspects discussed in relation to several nutrients and food groups. The specific role for DRVs and FBDGs are described in the nutrient and food group summaries in the present summary report.

Summary of background papers on country specific health effects in the Nordic/Baltic region

The NNR2023 Committee has developed background reviews on country-specific burden of diseases, nutrient and food intakes, and physical activity in Nordic and Baltic countries, as well as the role of diet on body weight. These papers are partly used as an essential background when formulating science advice for DRVs and FBDGs, but they are also intended to be used by the national health and food authorities when they formulate their national recommendations and guidelines.

Burden of diseases in the Nordic and Baltic countries

The Global Burden of Diseases, Injuries, and Risk Factors study (GBD) is the most comprehensive worldwide observational epidemiological study (GBD Risk Factors Collaborators, 2020; Murray, 2022). Since 1990, there have been 12 iterations of the study, each with increased scope, new data sources and methodological advancements. The most recent iteration, GBD 2021, included 286 causes of death, 369 diseases and injuries, and 87 risk factors, 15 of which were dietary factors. Age- and sex-specific estimates were generated for 990 geographical units including all Nordic and Baltic countries for every year between 1990 and 2021. GBD, with its effort to provide comparative results, offers a useful resource to model trends in diet-related burden of diseases in the Nordic and Baltic countries. It can also provide countries with insight into the potential of reducing disease burden by targeting specific dietary risks.
In the paper commissioned by the NNR Committee by Clarsen et al. (Clarsen, in press), the burden of diet-related diseases and dietary risk factors in the Nordic and Baltic countries were assessed from 1990 to 2021. In particular, a systematic analysis of the GBD 2021 for the NNR2023 project was done. The integration of the GBD 2021 study into the 6th edition of NNR may serve as a model for other countries or regions in their development of national diet recommendations and guidelines.
The paper shows that there is a substantial disease burden attributed to dietary risk factors in the region, particularly from ischemic heart disease, type 2 diabetes, stroke, and colon and rectum cancers. A diet low in whole grains was the highest-ranked dietary risk factor in eight of the nine countries (including Greenland). Across all countries, low whole grains diets were responsible for one fifth of the total burden of disease attributed to dietary factors and it was the greatest overall contributor to ischemic heart disease and colon and rectum cancers.
A diet high in processed meat was the second highest contributor to disease burden in five of eight countries and among the top-4 dietary risk factors in all countries, while a diet low in fruit was the third-highest dietary-related contributor to disease burden in the Nordic and Baltic countries. The Baltic countries have the most to gain from increasing fruit intake because the Baltic countries had higher rates of ischemic heart disease and stroke. Globally, low fruit consumption is the highest-ranked dietary risk factor for disability-adjusted life years (DALYs), and our analyses show that it is also an important factor to focus on in the Nordic and Baltic countries.
A diet high in red meat was the fourth-highest dietary risk factor for DALYs in the Nordic and Baltic countries. It was ranked second highest in Denmark and Iceland, and the third highest in Norway, Sweden and Finland.
Despite the rigorous and advanced methodology, the estimates from the GBD rely on several complex modelling assumptions which can introduce uncertainties (GBD Risk Factors Collaborators, 2020). The NNR2023 project includes a comprehensive assessment of diet exposure in Nordic and Baltic countries, includes more health outcomes, and has a broader scope when assessing the totality of evidence than the GBD project. While using somewhat different methodologies, the main conclusions in the GBD background paper are in full agreement with the conclusions in the NNR2023 report, and additionally describe the dietary-related contributors to disease burden in the Nordic and Baltic countries.

Physical activity in the Nordic and Baltic countries

The understanding of how physical activity and physical inactivity are associated with health outcomes has increased considerably over the past decades. Along with physical activity, the evidence on the associations between sedentary behaviour and poor health has increased, which has resulted in the introduction of recommendations on sedentary behaviour. The level of physical activity influences energy requirements and is therefore associated with nutrition recommendations.
The aim of the background paper developed by Borodulin and Anderssen was to 1) present terminology for physical activity and sedentary behaviour epidemiology, 2) show the relevant scientific evidence on associations of physical activity and sedentary behaviour with selected health-related outcomes and 3) introduce the global guidelines for physical activity and sedentary behaviour by the World Health Organization (WHO) (Borodulin and Anderssen In press). Health-related outcomes include cardiovascular morbidity and mortality, all-cause mortality, glucose regulation, type 2 diabetes, adiposity, overweight, obesity, cancer, musculoskeletal and bone health, brain health and quality of life. These are reflected across age groups and some population groups, such as pregnant and postpartum women. Further, physical activity levels across Nordic countries and over time were discussed. For the NNR2023 project , shared common physical activity guidelines were not developed. Instead, each country has created their own guidelines that are referenced in the article, along with the global WHO guidelines.

Role of food consumption and nutrients for body weight

Obesity is a chronic disease, which is associated with increased risk for several non-communicable diseases (NCDs), including cardiovascular diseases, type 2 diabetes, some cancers and chronic respiratory diseases, including obstructive sleep apnoea. In 2016, the age standardized prevalence of adult overweight (including obesity) in the Nordic-Baltic region varied between 55% (Denmark) and 60% (Lithuania), with an obesity prevalence between 20% (Denmark) and 26% (Lithuania). Using the WHO growth reference, the prevalence of overweight (including obesity) among school-aged children varied from 23% (Estonia) to 31% (Iceland), and among adolescents from 19% (Lithuania) to 27% (Iceland). Despite several action plans to stop the obesity epidemic, the prevalence of overweight and obesity in the WHO European Region has increased, and no member state is on course  to reach the target of halting the rise in obesity by 2025 (World Health Organization 2022). The prevalence data from Iceland has recently been updated, and the prevalence of overweight (including obesity) among school-aged children and adolescents is 25% (Development Centre for Primary Healthcare in Iceland and Primary Health Care of the Capital Area 2022).
The aim of the paper by Hjelmesæth and Sjöberg (2022) was to elucidate the current knowledge for the potential role of body weight for setting and updating DRVs and FBDGs in the NNR2023 project. They observed that the overall body of evidence based on findings from SRs and MAs of observational and clinical studies indicates that changes in intakes of some specific nutrients (sugar, fibre, and fat) and/or foods (sugar sweetened beverages, fibre rich food, and vegetables) are independently associated with modest or small short-term changes (0.3–1.3 kg) in body weight in the general population (with or without obesity/overweight), while long-term studies are generally lacking.  

Food consumption and nutrient intake in the Nordic and Baltic countries

Knowledge about the nutrient intakes and food consumption in the Nordic and Baltic countries is important for the use of DRVs and FBDGs, as part of the NNR2023 project.
Information about the dietary surveys as well as the daily mean intakes was retrieved from the latest national dietary surveys available at that moment in each of the five Nordic and three Baltic countries (Lemming & Pitsi, 2022). Nutrient intake (macronutrients, 20 micronutrients) and food consumption data at a broad level in the adult population were gathered for both sexes. The broad food groups were the following: beverages, cereals, potatoes, vegetables, fruits and berries, fish and seafood, meat and meat products, milk and dairy products, cheese, eggs, fats and oils, and sweets and confectioneries.
There were both similarities and differences in food consumption and nutrient intakes among different countries, which were reflected in the consumption of some foods and nutrients that were either higher or lower than current guidelines and DRVs. For example, the consumption of vegetables and fruits was too low while the consumption of red and processed meat was too high. The most notable similarities and differences among countries in terms of nutrient intake compared with recommended intake (RI) in NNR2012 were as follows:
  • The percentage contribution of macronutrients to total energy was roughly similar among the populations in the Nordic countries as well as in Estonia and mostly in the range of recommendations. Since alcohol was not included in the total energy intake for Latvia and Lithuania, the reported contribution of energy from fat was higher and lower from carbohydrates compared with the other countries.
  • The percentage contribution from saturated fatty acids was too high compared with the recommendation in all countries.
  • Fibre intake was lower than the recommendation in all countries.
In general, mean reported intakes of most vitamins and minerals were above RI in the Nordic countries, but not to the same extent in the Baltic countries. Mean vitamin D and folate intakes were low among most population groups, while mean intake of sodium was too high. Mean iron intake was lower than RI among women in all countries. It is, however, not possible to judge the prevalence of inadequacy based on average intakes below RI. The AR is used for assessing adequacy and this requires the distribution of population nutrient intakes. For more details on use of RI and AR, see Trolle et al. (In press).
The nutrient intake and, especially, food consumption differ among the Nordic and Baltic countries because of differences in food patterns, but also due to factors related to the dietary surveying, food grouping and calculation procedures in each country. To facilitate future comparisons among countries, it would be of interest to harmonize food groupings and the age groups reported.

Science advice on a framework for integrating environmental sustainability

Scope and limitations

Sustainability is a broad and complex concept. Sustainable development has been defined as  development that meets the needs of the present, without compromising the ability of future generations to meet their own needs. At the core of the concept is the 2030 Agenda for Sustainable Development, adopted by all United Nations Member States in 2015, the 17 accompanying sustainable development goals and the “Farm to Fork” strategy from the European Commission (2020). For sustainable development to be achieved, it is crucial to harmonize three core dimensions: environment, economy and the social (including health) dimension. All these elements are interconnected and crucial for the well-being of individuals and societies and may be considered by the national authorities in the eight Nordic and Baltic countries when they formulate country specific FBDGs.
In this edition of NNR, a framework for integrating environmental sustainability has been requested by the NCM. Some countries have included aspects of environmental sustainability into their FBDGs, but no country has integrated systematically the whole range of environmental aspects in their national guidelines. The EAT/Lancet report (Willett et al. 2019) is a landmark in this respect, since it represents a comprehensive assessment on both health effects and environmental impacts of diets. While the EAT/Lancet report has a predominantly global perspective, the major focus of NNR2023 is the local context in the eight Nordic and Baltic countries, and their contributions both to local and planetary boundaries.
When formulating science advice on FDBGs the following governing documents are used as a main fundament for the scope and mandate from the NCM; the Action Plan 2021-2024 Vision 2030 (Nordic Council of Ministers 2020a) and authoritative declarations from the Nordic Council of Ministers (see Box 1). The Action plan 2021-2024 from the NCM builds on the Paris Agreement and UN Agenda 2030.
Box 1: Elements from declaration from the Nordic Council of Ministers
Declaration on Nordic Carbon Neutrality by the Nordic prime ministers (25.01.19)
  • “With this declaration, we commit ourselves to working towards carbon neutrality in the five Nordic states”
  • “We will catalyse global mitigation efforts to limit the increase in the global average temperature to 1.5°C in response to the findings of the IPCC of 1.5°C"
  • "Catalyse the scaling up of Nordic sustainable solutions, reduce global greenhouse gas emissions, maintain or enhance carbon sinks and remove carbon dioxide from the atmosphere"
  • "Encourage climate-conscious consumer choices by developing information on reducing individual climate impacts”
Declaration on Biodiversity from the Nordic Council of Ministers for the Environment and Climate (MR-MK) (03.05.22)
  • We, the Nordic Ministers for Climate and the Environment from Sweden, Denmark, Norway, Finland, Iceland, the Faroe Islands, Greenland and Åland: i) Recognizing that urgent integrated action is needed for transformative change, to halt and reverse biodiversity loss through the sustainable management of land, freshwater and ocean;
    ii) Promoting ways for Nordic consumers to make healthy and sustainable choices, with joint efforts relating to sustainable consumption reducing by at least half the waste, including food waste, and eliminating the overconsumption of natural resources and strengthening sustainable production;
    iii) Reduce our global ecological footprint to a level well within planetary boundaries;
    iv) Promote urgent national action to halt biodiversity loss and strengthen policy measures to mainstream biodiversity into all sectors.
Sustainable food systems by Nordic Council of Ministers for Fisheries, Aquaculture, Agriculture, Food and Forestry (MR-FJLS) (24.06.21)
  • Achieving Agenda 2030 goals including ending hunger, achieving food security, safer food and improved nutrition and promoting sustainable agriculture within planetary boundaries are amongst the greatest challenges facing the world today.
  • A healthy and sustainable diet should be accessible and an easy choice for everyone. Actors along the whole food chain, such as food industry, retailers and market actors, are all responsible.  Nutritional guidance based on scientific evidence is essential in improving diets. The Nordic nutrition recommendations are an internationally recognized benchmark dating back over 40 years. The 2023 update of the NNR will integrate environmental sustainability into the dietary guidelines.
Declaration on Nordic commitment for the global climate agenda
  • (30.04.20) We will work together with all countries to ensure good cooperation and dialogue in the climate negotiations leading to COP26. Climate finance to developing countries is necessary for the effective implementation of the Paris Agreement. The Nordic countries re-affirm their commitment to provide climate finance from a variety of sources. We will work together with all parties to keep up the momentum in the UN climate negotiations.

Summary of background papers on environmental sustainability

The NNR2023 Committee commissioned five background reviews on sustainability issues related to food consumption. Four of these papers review environmental aspects of food consumption, both in relation to global and local impact of Nordic and Baltic food consumption.
These papers represent the main foundation for integrating environmental sustainability in science advice for DRVs and FBDGs. The last sustainability review deals with socioeconomic aspects of sustainability. This paper is a Nordic and Baltic summary of the SAPEA report that was commissioned by the European Commission. While the socioeconomic aspects for sustainability were not requested to be integrated by the Nordic Council of Ministers, the NNR2023 Committee have included this review as a general background that may be used by the national health and food authorities when they formulate and implement their national recommendations and guidelines.
To integrate environmental sustainability, the NNR2023 Committee has in large followed the guiding principles from the Food and Agriculture Organization of the United Nations (FAO) and WHO (FAO/WHO, 2019). Initially, the committee scrutinized recent developments of the health effects of nutrients, foods and dietary patterns. Then, the environmental impact of food consumption, and the corresponding food systems were examined, and the ranges and limits of the healthy FBDGs were considered to encompass both health and environmental goals. 

Assessing the environmental sustainability of diets – a global overview of approaches and identification of 5 key considerations for comprehensive assessments

Sustainability is a complex concept that includes environmental, health, as well as economic and social dimensions. The remit of the paper by Benton et al. (2022)  was to focus on the environmental dimension of sustainability. The paper focuses on global considerations and hence does not consider the local context in Nordic and Baltic countries. The review was developed as a collaboration between the NNR2023 project, Chatham House and an appointed reference group consisting of Nordic and Baltic scientists. The Nordic and Baltic scientists have given significant scientific input, while the members of the NNR Committee have ascertained that the relevance is within the scope of the NNR project.
Assessing the environmental impacts of food, food systems and diets is complex due to the multitude of processes involved, the uncertainty in assessment models, the variability in production systems and the large range of products available. No single assessment method can therefore provide a complete evidence base. However, the increasing number of LCA and food system approach studies, and the relation to integration of planetary boundaries, offers sufficiently precise estimates from which we can draw some robust conclusions, while recognising there is a need for more detailed analyses to capture the inherent nuances of more location and context specific situations.
Despite the complexity of assessing the environmental sustainability of food, diets and food systems, there are a number of key considerations that can be identified and used in the NNR2023 report, and in doing so help to increase utility of the outcomes and limit unintended adverse consequences. Benton et al. (2022) formulated 5 key considerations (the thresholds, the system, the variables, the context and the spill-over) that may be applied when integrating environmental sustainability into FBDGs in the Nordic and Baltic countries. 

Overview of food consumption and environmental sustainability considerations in the Nordic and Baltic region

The paper, which was developed in collaboration with Chatham House, examines environmental impacts related to current food production and consumption using a global and Nordic perspective and discusses the implications across the 8 Nordic and Baltic countries (Harwatt et al., 2023). The aspects are discussed as an overview of each food group within the NNR2023. The content was largely drawn from scientific literature such as major reports, studies, and systematic reviews. The assessment was done partly as an expert elicitation to ensure that the rich body of existing data on the environmental impacts of foods and diets could be best interpreted within the context of the Nordic region. In the paper, data were used from different sources, all based on food availability data of FAOSTAT, and combined with a comprehensive database of environmental footprints, differentiated by country, food group, and environmental impacts. Also, global footprint data are shown.
The paper provides suggestions for overall and food group specific changes in consumption and presents opportunities for food production. Estimates from the studies show that the environmental impacts of current diets in each of the Nordic countries mostly exceed the levels that would be required to stay within the planetary boundaries related to GHG emissions, cropland use, water use, nitrogen use and phosphorus use. Estimates show that shifting to the current national Nordic and Baltic FBDGs would mostly improve the outcomes, but not enough. The estimates presented in the paper indicate that meat and dairy contribute the most to GHG emissions and crop land use. Food waste, a challenge that applies to all food groups, is not covered in this paper (see Trolle et al., 2023).
Given that biodiversity impacts are generally related to agricultural practices but not GHG emission it is important to note that foods associated with low or high GHG emission may have varying impact on biodiversity. As a result, when shifting to food production systems that may lower GHG emission potential consequences for biodiversity and other environmental impact should also be assessed in parallel.
The overarching recommendation for all countries from the background paper (Harwatt et al., 2023) is to shift to more plant-based dietary patterns. The extent to which this is necessary depends on the current consumption patterns.  Priority interventions suggested in the background paper are:
  • Reduce meat and dairy consumption and increase the consumption of legumes/pulses, whole grain, vegetable and fruit, vegetable oils, and nuts and seeds. The substitution process is somewhat dependent on current consumption patterns and potential to shift and should ensure nutritional adequacy and positive health impact at the dietary level.
  • Explore potential shifts to sources of fish and seafood from sustainably managed stocks. Due to the potentially large-scale impacts on ecosystems, a precautionary approach to the fish group is essential – particularly in relation to an increase in consumption.
  • Support a reduction in consumption of animal-source food and increase in provision of plant-based foods through feed-to-food shifts. This is relevant for cereals and pulses, as well as nuts, vegetables, and fruits. In the context where consumption of fruits and vegetables must increase, shifting production methods could help to further reduce environmental impacts (particularly water, pesticide, and fertilizer use). Fruits and vegetables that require less resources to produce could be prioritized in alignment with the requirements of a healthy diet
  • The scientific literature suggests that organic cultivation methods result in greater biodiversity benefits compared to non-organic production. At the global level, it is only possible to convert agricultural production to organic methods in conjunction with substantial shifts in demand for plant-based diets.
  • National strategies to facilitate changes of food consumption and production may benefit from considerations of the complexity of trade-offs and location specific impacts and contexts, including implications for trade, human health and social impacts, animal welfare, and current and emerging threats e.g., antibiotics and zoonotic-driven pandemics and potential changes in environmental conditions.
  • National land use assessment could inform optimal land uses for meeting a range of environmental goals, also accounting for the environmental impacts of food imports in producer countries.
  • While urgent and fundamental changes to food production and consumption are required to help meet climate change and biodiversity goals
    Harwatt, H., Wetterberg, K., Giritharan, A. and Benton, T. G. (2022), Aligning food systems with climate and biodiversity targets: Assessing the suitability of policy action over the next decade, Research Paper, London: Royal Institute of International Affairs, https://doi.org/10.55317/9781784135416
    , tackling such issues does not remove the need for urgent reform in other sectors, including energy. Instead, transformation of food systems must be incorporated as one part of a comprehensive ‘green transition’ plan that includes all systems.

Integrating environmental sustainability into Food-Based Dietary Guidelines in Nordic countries

The background paper provides knowledge for science-based advice for developing Food-Based Dietary Guidelines (FBDGs) that include environmental sustainability within the Nordic and Baltic countries (Trolle et al., 2023). It gives an overview of the recent studies in the Nordics on the environmental impact, including climate and other environmental impacts of foods and dietary patterns, and on the development of FBDGs from the viewpoint of sustainability. Finally, approaches for developing national sustainable FBDGs in the Nordic and Baltic countries are suggested. The paper is a scoping review, based on literature searches regarding Nordic and Baltic studies on sustainability of diets and foods. The paper provides a concise introduction to environmental impact data, with a specific focus on Nordic data in relation to the variation in data within a food group at the global level.
According to the background paper, the Nordic studies conclude that animal-based foods are the largest contributors to dietary GHG emissions and land use in current diets. Modelling, optimization, and intervention studies confirm the potential to reduce negative environmental impacts, like GHG emissions, but also to improve positive impacts e.g., on biodiversity, by shifting towards a predominantly plant-based diet that is both nutritionally balanced and supported by evidence regarding the health-based recommended amount of specific food groups. A sole focus of reducing climate impact may result in nutritionally inadequate diets and may not decrease the biodiversity loss. Similarly, a healthy diet may have large environmental impacts. Thus, health and environmental impact of diets are considered simultaneously. Healthy environmentally sustainable plant-based diets can be characterized as high in a variety of vegetables, fruits and berries, cereal products as mainly whole grain products, vegetable oils, legumes (pulses), and nuts and seeds. Plant-based diets also contain animal-protein sources such as fish from sustainably managed stocks, limited to moderate amounts of low-fat dairy and eggs, and a limited amount of meat, particularly limited in ruminant and processed meats. In addition, the content of discretionary food and drinks, (e.g., sugar-sweetened beverages and alcoholic beverages) should be limited. Food group-specific considerations are essential to simultaneously reduce the environmental impacts and achieve nutritional adequacy. These considerations may include e.g., favouring more robust types of vegetables that store well and within the limited amount of beef and other ruminant meat, favouring meat products from dairy herds and grazing animals if needed to keep landscape open. However, meat from grazing animals should otherwise be limited. Further, food waste is to be decreased or avoided, as well as overconsumption, e.g., excessive consumption. Dominantly or fully plant-based diets, as vegan diet, require solutions beyond dietary guidelines in terms of food fortification and dietary supplementation to ensure nutritional adequacy.
The current FBDGs in the Nordic countries are also described in the paper. They vary in the degree of including environmental sustainability, and there is a need for further development of the country specific sustainable FBDGs. The paper suggests using standardized approaches for developing sustainable FBDGs by the national authorities. The approach should secure nutritional adequacy and health-based evidence regarding food intake and dietary patterns at the population level as boundaries for integrating the different aspects of sustainable development into the FBDGs. The scientific basis should be built by involving experts in the fields of food, nutrition, health promotion, and environmental sustainability. When relevant, insights from food system stakeholders should be included. The paper suggests different approaches for integrating health, nutritional adequacy, and environmental sustainability by national authorities. The transition to sustainable diets must be made affordable and acceptable for consumers. In the Nordic countries, cultural and sociodemographic differences in dietary composition pose challenges in defining and implementing national FBDGs.  Since the transition is urgent, monitoring and evaluation should go hand in hand with public-private partnership initiatives, campaigns, and development and piloting of case-studies to facilitate the transition at consumer level and to involve all food system actors. Examples are presented in the summary of the SAPEA report (Jackson & Holm, 2023).
The background paper concludes that it is possible to develop FBDGs that support the transition to healthier and more environmentally sustainable diets in the Nordic countries. Failing to reduce environmental impacts predisposes the population to another kind of public health threat: the environmental crisis.

Moving food consumption toward sustainable diets in the Nordics: Challenges and opportunities

The overall aim of this background paper is to provide information to be used for science advice for setting sustainable Food Based Dietary Guidelines (FBGDs) in the Nordics (Meltzer et al., 2023). Important challenges and opportunities with current Nordic food systems were identified, summarized, and discussed based on literature reviews and the assessments of Nordic food systems experts. Applying FAO/WHO’s guiding principles for healthy, sustainable diets (FAO/WHO, 2019), the paper evaluated how the Nordic countries are doing on environmental impact (principle #9 - #13) and sociocultural aspects (#14 - #16).  In addition, the paper includes reflections at the food system level, including food security, self-sufficiency and resilience issues.
Historically, the geographical location of the five Nordic countries has determined the characteristics of food production in each country – mirrored in local food heritage. A substantial part of Nordic land is above the Arctic Circle, limiting the growth season and choice of crops. Forests dominate large parts of Nordic lowlands. Iceland and Norway have large patches of mountainous terrains unfit for crop cultivation, yet have large coastal regions suitable for extensive fishing and aquaculture. At high latitudes farming is dominated by dairy and meat production, including cattle, sheep, goats and reindeer. Together with Denmark, the southern parts of Norway, Finland and Sweden are more suitable for growing plant foods such as cereals, oilseeds, legumes and vegetables. Denmark, Finland and Sweden are net exporters of cereal grain.
Although the Nordics score high in overall global assessments like the Sustainable Development Indexes, there is a long way to go to reach net zero emissions and implement thoroughly sustainable practices within food production and consumption (Sachs et al., 2022). Furthermore, when the total global effects of the Nordic consumption are assessed, the countries are not top performers. Thus, for optimizing the total sustainability of Nordic diets, the global food system must be considered (Kinnunen et al., 2020).
According to the background paper, some challenges are unavoidable. Parts of the Nordics are best or only suited for grass production and pastures, utilization of resources resulting in significant methane emissions from ruminant meat and dairy production. In addition, fractions of the crops may be best suited for animal feed due to marginal conditions for grain production. Thus, utilisation of resources needs careful balancing between ensuring local production that can balance demand for dairy and meat on the one hand, but without resulting in a large environmental footprint domestically as well as the indirect impact from import of feed for food production. Production must also conform to net zero climate emissions and limitations on nitrogen and phosphorus spill-over. The issues connected with biodiversity, domestically and directly from import of feed, must also be adequately resolved.

A sustainable food system for the European Union. The SAPEA report – a summary with focus on the Nordic and Baltic countries

This review seeks to outline some of social and economic dimensions of sustainability, based on evidence available in the peer-reviewed literature. The review relies on a recent Evidence Review Report undertaken by an expert group of academics, convened under the auspices of SAPEA (Scientific Advice for Policy by European Academies). The SAPEA report provides an independent review of the evidence required to inform the transition to a more just and sustainable food system for the EU, including the identification of ‘good practice’ examples, some of which are drawn from the Nordic and Baltic countries. The SAPEA report concluded that fundamental, system-wide changes were required to promote the transition towards a fairer, more sustainable and healthier food system. Environmental, health and socio-economic issues are thoroughly interconnected and do not exist in separate silos. Meeting the growing global demand for food will require significant dietary change as well as large reductions in food waste, as technological change or yield increases are unlikely to meet demand alone. Evidence of ‘what works’ in policy terms requires strengthening, including further research on the public understanding of science and consumer acceptance of new technologies.
The SAPEA report identified a series of ‘good practice’ examples where there was strong peer-reviewed evidence of positive long-term impacts including health and sustainability benefits (Jackson & Holm, 2023).  Examples included: state support for the growth of the Danish organic sector (Daugbjerg & Sønderskov, 2012); the RETHINK project in Latvia and Lithuania, an action-research programme which explored the structures and opportunities for small and medium-size agricultural holdings that are not well incorporated into the mainstream market (Šūmane et al., 2015); and the Danish Wholegrain Partnership, which achieved a significant increase in whole grain consumption through a process of multi-sector collaboration involving the Danish Veterinary and Food Administration, the food industry and health NGOs such as the Danish Cancer Society (WholEUGrain, 2021). The SAPEA report also noted a series of other initiatives.
As the foregoing discussion reveals, there are some ‘win-wins’ in the field of health and sustainability policy.  However, difficult choices between competing policy options will occur, like those facing ordinary consumers in their everyday lives.  Being clear about the way food is framed as an issue and how different framings shape policy outcomes is a useful way forward in addressing the inevitable trade-offs and compromises between competing objectives.