Inspraakbijdrage Groene Zorg Alliantie

Beste raadsleden, Graag stuur ik u hierbij mijn ingesproken bijdrage van gisteravond. Daarnaast wil ik graag nogmaals de nadruk leggen op de urgentie van het terugdringen van het gebruik van fossiele brandstoffen en het verminderen van onze consumptie van vlees en vis, mede vanwege de directe gezondheidsrisico’s die hiermee samenhangen. Reclame verbieden zal hier een eerste stap in kunnen zijn. In de bijgevoegde toelichting treft u een aanvullende uiteenzetting. Hieronder een samenvatting voor de drukke agenda's van de raad: "Het document beschrijft hoe klimaatmaatregelen zoals schonere lucht, meer actieve mobiliteit en een voornamelijk plantaardig voedingspatroon niet alleen bijdragen aan het terugdringen van broeikasgasuitstoot, maar ook aanzienlijke gezondheidswinst opleveren. Het benadrukt dat luchtvervuiling, veroorzaakt door onder meer fossiele brandstoffen, verantwoordelijk is voor miljoenen verloren gezonde levensjaren en talrijke chronische aandoeningen. Ook wordt duidelijk dat plantaardige voeding het risico op hart- en vaatziekten, diabetes, kanker en vroegtijdige sterfte substantieel kan verlagen. Verder toont het rapport aan dat meer bewegen—zoals wandelen en fietsen—grote gezondheidsvoordelen biedt en hoge zorgkosten kan besparen.

De auteurs pleiten voor een geïntegreerde benadering waarbij gezondheidswinst en klimaatbeleid gezamenlijk worden benaderd, omdat wat goed is voor de planeet, ook goed is voor de mens." Ik ontvang graag bericht over de uitkomst van de beraadslagingen en de besluiten die de raad hierover heeft genomen. Nogmaals dank voor de geboden gelegenheid om in te spreken.

Met vriendelijke groet, Rosanne Silvis-Ottevanger Community manager | Groene Zorg Alliantie

Het is warm, erg warm. Het is 13 juni, half één ‘s middags — de zomer is nog niet begonnen - en het is wederom de droogste en heetste lente ooit gemeten.​ Ik ben net bevallen van mijn zoon met 32 graden en later deze week wordt het nog 36 graden in Arnhem. En ik maak me zorgen. Goedenavond, mijn naam is Rosanne Ottevanger. Ik ben werkzaam als change-agent in het verduurzamen van de zorg bij de Groene Zorg Alliantie. Ik spreek hier vanuit mijn rol als zorgprofessional, Arnhemmer én als moeder. Klimaatverandering is geen toekomstscenario. Het vindt nú plaats. En ons gedrag heeft hierin een grote impact. Denk aan onze reisbewegingen: fossiele verbranding zorgt immers voor luchtvervuiling. Onze voedselkeuzes leiden tot ontbossing en schade aan ecosystemen op land en in zee. En ook het kopen van fast fashion producten veroorzaakt grote hoeveelheden vervuiling. Al deze effecten samen warmen onze aarde op. Per jaar overlijden nu al zo’n 250 mensen in Nederland aan de gevolgen van hittestress. Tegelijk worden er meer mensen getroffen door welvaartsziekten dan ooit tevoren. Met andere woorden: gedrag beïnvloedt gezondheid - en het zorgsysteem raakt verder overbelast. Gezonde mensen hebben een gezonde planeet nodig - en vice versa. Zorgdragen voor de inwoners van Arnhem is de meest effectieve vorm van preventie en klimaatbescherming.

Daarom spreek ik vanavond over iets wat misschien klein lijkt, maar een enorme invloed heeft: reclame uitingen in de openbare ruimte. Reclame vraagt bewust en onbewust onze aandacht. Reclame voor fossiele brandstoffen, vlees & vis en fast fashion zet aan tot meer consumeren, minder bewegen en daarmee ongezondere inwoners! Vorig jaar zei onze denker des vaderlands: “Aandacht, is het belangrijkste middel waarmee je je leven kunt sturen. Dus hoe lang staan we nog toe dat bedrijven ons bombarderen met afleiding waar we niet om hebben gevraagd?” Arnhem heeft de ambitie om een schone en gezonde stad te zijn. Daar hoort geen straatbeeld bij wat het tegenovergestelde stimuleert. Met dit reclameverbod vervuilen we onze publieke ruimte niet langer met ongezonde afleiding. Mijn zoontje groeit hier op, in deze stad. Ik hoop dat hij later kan zeggen: “Arnhem koos voor gezondheid.” Laten we dit vanaf vandaag samen waar maken. Dank u wel voor uw tijd en aandacht.

Briefing Document commissioned by Real Zero

Healthy People, Healthy Planet The co-benefits of clean air, plant-based diets, and physical ac6vity to human health and climate change.

Authors: Victoria Bion1, Cian Murphy2,3, Donald Pang4, Henry Marshall4, Dhruv Gupta1,5 1

[Real Zero, London, UK] [The Francis Crick InsItute, London, UK] 3 [The Royal Marsden NHS FoundaIon Trust, London, UK] 4 [Barts Health NHS Trust, London, UK] 5 [The London School of Hygiene & Tropical Medicine, London, UK] 2

Correspondence to: dhruv.gupta2@nhs.net Date: 09/05/2025 DeclaraIon of Interests: Nil

Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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Execu&ve Summary In 2019, the UK commiWed to reduce emissions of carbon dioxide (CO2) and other greenhouse gases (GHGs) to ‘Net Zero’ by 2050 (1), in order to minimise the life-threatening impacts of the global heaIng which they cause. However, the pace and scale of acIon has fallen far short of what is required. At the internaIonal negoIaIons in Paris in 2012, countries agreed to reduce GHG emissions by 48% by 2030, and to try to limit the rise in global mean surface temperature to 1.5oC above preindustrial. However, given the conInuing rise in annual GHG emissions (now nearly 58 billion tonnes CO2e/year) and their atmospheric concentraIons (2024 saw the greatest rise on record), its ‘1.5oC threshold’ is now near certainly breached, with a likely 2oC rise by 2030 (2,3). Whilst concern has grown, climate acIon is rarely considered the UK public’s top priority: in September 2023, it ranked 5th, behind the economy, inflaIon, the NaIonal Health Service (NHS)/healthcare, and immigraIon (4). Such low ranking maWers, both because it is reflected in limited individual/personal acIon, and because shihs in public senIment and purchasing choices create a permissive environment into which both poliIcians and businesses can move.

Meanwhile, non-communicable diseases (NCDs) now account for 89% of deaths in the UK and 25,871 disability adjusted life years (DALYs) per 100,000 populaIon in 2019 (5). Poor diet, high body mass index (BMI) and high fasIng plasma glucose lie just behind tobacco as the top drivers of death and disability. Globally, air polluIon, high BMI, and poor diet account for nearly half of the heathy years of life lost. IntervenIons to miIgate these diseases target the same causal pathways as those which miIgate climate change, providing important opportuniIes to generate co-benefits. In other words, low GHG lifestyles reduce the threat of climate change to human health and survival, but are themselves inherently good for health by miIgaIng NCDs. For example: • Adherence to the World Health Organisation (WHO) recommendations on diet (including increased consumption of grains, fruit and vegetables and reduced consumption of red meat and dairy) would save almost 7 million life years in the UK over the next 20 years, with an increase in average life-expectancy of >8 months. Such action would also reduce GHG emissions by 17% (6). • Increasing acIve travel in the UK would yield significant reducIons in the incidence of diabetes, demenIa, heart disease, cerebrovascular disease, and cancer.

Aher adjustment for increased risk of road traffic injuries, increasing average adult daily cycling and walking distances to 3.4km and 1.6km (a 3km and 1km increase from 2010 levels respecIvely) in urban areas would save the NHS some £17 billion aher 20 years, even without factoring in the benefits of cleaner air and GHG emission reducIons (7). • Changes in power generaIon from fossil fuel to renewable sources in line with the 80% reducIon set by the UK 2008 Climate Change Act would result in a 40% reducIon in small parIculate maWer (PM2.5) concentraIons by 2050. The resulIng reducIon in NO2 concentraIon could save 4.89-7.18 million life years by 2154 (8,9). Framing climate change and efforts to address it as health issues is one of the most effecIve ways to engage the public in acIon- acIon which improves health, reduces GHG emissions generally and those from healthcare (given the reducIon in disease burden), creaIng the impetus and opportunity for poliIcians and businesses to act. Many health chariIes seek to protect the public from NCDs, promoIng increased acIve transport, clean air, and plant-based diets to achieve this. Examples include organisaIons working on asthma, cancer, demenIa, diabetes, hypertension, mental health, obesity, stroke and more.

We propose that such organisaIons unite with those ‘environmental’ groups who also advocate for low GHG emissions, to deliver one message: ‘What is good for the planet is good for health’, and its obverse- ‘what is good for health is also good for the planet’. Here, we synthesise core data in support of such a message.

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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INTRODUCTION

Climate change now poses an immediate threat to our survival and to that of our children. Whilst the impacts of heat illness, vector-borne diseases and loss of shelter and food supplies are important, the gravest risk relates to that of societal (economic impacts, mass migraIon and conflict) and ecosystem collapse (10). In response, the UK has commiWed to reducing emissions of carbon dioxide (CO2) and other greenhouse gases (GHGs), and to deliver carbon drawdown (by unspecified methods) to match those that remain, by 2050 (‘Net Zero’) (1). However, enacIng the necessary transport and agriculture policies at the required rate and scale is impossible for poliIcians and businesses without popular support and engagement. Emerging evidence suggests that personal acIon in these areas can be sImulated by making clear their direct health benefits (8). Non-communicable diseases (NCDs) now cause 89% of deaths in the UK and an esImated 25,871 disability adjusted life years (DALYs) per 100,000 populaIon in 2019, and account for nine of the top ten causes of death (lower respiratory tract infecIons, ranking fihh, may of course be predisposed to by NCDs themselves) (5). Their incidence and prevalence is, in many cases, rising (e.g. for obesity, diabetes, asthma, chronic obstrucIve lung disease (COPD), Alzheimer’s disease, and many cancers).

Globally, risk factors including air polluIon, high body mass index (BMI), and poor diets account for nearly half of the heathy years of life lost. Many UK health chariIes seek to protect the public from NCDs, and promote low GHG lifestyles (increased acIve transport, clean air, and plant-based diets) to achieve this. Examples include organisaIons working to prevent asthma, cancers, demenIa, diabetes, hypertension, mental health, obesity, stroke and more. We propose that such organisaIons unite with those ‘environmental’ groups who also advocate for low GHG living, to deliver one message: ‘What is good for the planet is good for health’, and its obverse- ‘what is good for health is also good for the planet’. We here synthesise core data in support of such a message, summarising the impact which acIon to reduce airborne pollutants, increase physical acIvity and improve diet could have on both improving health outcomes and miIgaIng climate change. To this end, we provide a narraIve review of studies that have examined the impact of either air polluIon, diet, or physical acIvity on one or mulIple NCDs, categorised by system (respiratory disease, cardiovascular disease, cancer, endocrine disease and mental ill-health).

METHODS

Searches were run separately for each exposure and disease category. Details of the search strategy are laid out in Table 1. We searched PubMed and Scopus for English language review arIcles (due to the overwhelming literature volume available) published between Jan 1st 2010 and December 31st 2023. This search was performed using the easyPubMed package in R 4.3.3. The populaIon of interest was adults and children from high-income countries (World Bank DefiniIon (11)) to ensure relevance to UK policy. Outcome measures included disease incidence, mortality, disability-adjusted life years (DALYs), years of life lost (YLL), and hospital admissions. Excluded were animal and in vitro studies; publicaIons reporIng intermediary outcome measures (such as biomarkers) or disease risk factors, or that did not measure a health outcome; and those set in low- or middle-income countries. Title and abstract screening was carried out by one reviewer per disease system. Table 1 Search Concept Air polluIon and NCDs Physical AcIvity and NCDs Diet and NCDs

Exposure Search Terms [PolluIon or pollutant* or air quality or parIculate maWer or road polluIon] [Physical acIvity or sport or acIve travel or acIve commuIng or walking or cycling] [plant-based or vegetarian* or vegan* or vegetable* or fruit* or plant* or health* or sustainab* AND diet*]

Outcome Search Terms AND AND AND

[resp* or asthma or COPD or cardio* or hypertension or blood pressure or isch?mic heart disease or heart disease or stroke or CVA or coronary* or diabet* or hyperglyc?m* or non-communicable disease or obesity or BMI or body mass index or mental health or cancer]

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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Searches were limited to Itle only, with abstracts. A snowball search method was then used to obtain relevant arIcles. Grey literature was examined from published governmental websites, intergovernmental organisaIons, and independent public bodies. Given the wealth of literature, diversity of primary research methods and metrics (see Box 1a), a narraIve review was performed. Key evidence is summarised in Table 2. Detailed results for each disease system are presented in Appendix 1.

RESULTS Reducing Air Pollu;on

Health Benefits Air polluIon (caused by parIculate maWer (PM- with a suffix indicaIng diameter in microns)), nitrogen and sulphur oxides (e.g. nitrous Oxide, NO2 ), carbon monoxide (CO), and ozone (O3)) caused the loss of 213 million DALYs in 2019 and has thus been declared a global health emergency by the World Health OrganisaIon (WHO) (5). Impacts may persist across the life-course (12), and relate not only to respiratory diseases, but to diabetes, cancer, cardiovascular, cerebrovascular, metabolic, mental and neurological disease (13). Air polluIon causes 1 in 5 global deaths (14), and fossil fuel use for 82% of these (>5.13 million excess deaths) (13). The main sources of UK air polluIon relate to the combusIon of fossil fuels for industrial processing, manufacturing and construcIon; domesIc heaIng and cooking; and road transport (15). Motorised road transport also contributes via generaIon of brake, tyre and road surface wear. The World Health OrganisaIon (WHO) recommend keeping annual average concentraIons of parIculates with a diameter <2.5microns ([PM2.5 ]) below 5μg/m3: in 2019, London’s outdoor annual mean [PM2.5 ] was between 8 and 15μg/m3, with peaks far higher (16).

Air PolluIon and Pregnancy Air polluIon reduces male ferIlity (sperm count and moIlity), and also causes low birthweight, low gestaIonal age (in London, PM2.5 exposures >13.8 μg/m3 in pregnancy account for 3% of infants with low birthweight), pre-term birth and miscarriage (17–20). Air PolluIon and Children Indoor (home, school) and outdoor (e.g. from school commutes) air polluIon causes hypertension and atherosclerosis, even in adolescents (21–23). It also impacts childhood lung growth: in inner city London (2008-13), mean annual ambient concentraIons of NO2 and PM10 were inversely related to forced vital capacity (FVC - the total amount of air which can be voluntarily exhaled in one breath), with average NO2 exposure associated with an esImated 5% loss of lung volume aher controlling for age, sex, height, BMI, ethnicity, socioeconomic status, and exposure to environmental tobacco smoke (24). Elsewhere, the proporIon of children with smaller than expected lung volume declines when air quality improves (25). Air polluIon is also associated with an increased incidence of asthma diagnosis and exacerbaIons (26). Between 2017 and 2019, air polluIon in London accounted for an esImated 7% (700) of all child asthma hospital admissions (27). It impairs brain development: brain size is inversely related to PM2.5 exposure (28).

Lastly, children exposed to higher levels of polluIon aged 12 are more likely to be diagnosed with major depressive or conduct disorder diagnoses at age 18, aher controlling for confounding variables (smoking, sex, ethnicity, neighbourhood and family socioeconomic status, family psychiatric history, exposure to severe childhood vicImisaIon, relevant age-12 mental health problems (i.e. anxiety, depression, conduct disorder, or ADHD)) (29). Air PolluIon and Adults In adult life, UK air polluIon increases the risk of early death, and of cancer; cardiovascular, cerebrovascular and respiratory disease; demenIa; impaired mental health; and mulIple other chronic illnesses (12). Data from the UK Biobank reveals an associaIon between air polluIon and neurological, respiratory, and cardiovascular morbidity aher adjusIng for socioeconomic status (30). In London between 2008 and 2013, in those exposed to the highest versus lowest PM2.5 concentraIons, the risk of common mental disorders and psychoIc experiences were increased by 1839% and 33% respecIvely (31). The CommiWee on the Medical Effects of Air Pollutants (COMEAP) 2022 review (32)

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concluded that a causal associaIon between air polluIon exposure and demenIa and cogniIve decline likely exists (32). In the UK Biobank Cohort, the risk of cardiovascular disease (atrial fibrillaIon, coronary heart disease, heart failure) was raised by 21% in those exposed to the highest vs lowest quarIles of [PM2.5], and of stroke by 25% for NO2 (30). AddiIonally, stroke hospitalisaIon or mortality may increase by 1.20% (CI: 0.22-2.18) per 10μg/m3 increase in PM2.5, and by 2.24% per 10 parts per billion (ppb) increase in NO2 (33). A 9% increased risk of T2DM, hypertension, and migraine in the highest vs lowest quarIle of [PM2.5], and a 10% increased risk for NO2 was also idenIfied (30). Respiratory impacts conInue into old-age. The elderly face an increased risk of hospitalisaIon, home visits and emergency department aWendance for COPD, asthma and pneumonia with increased short-term exposure to PM10, and increased incidence of respiratory symptoms, reduced lung funcIon, and COPD with increased long-term PM10 exposure (34). In London, polluIon-aWributable respiratory and cardiovascular admissions and mortality cost between £1.4 and £3.7 billion in 2010 (35) and, between 2017 and 2019, caused >1700 adult hospital admissions for asthma and other respiratory disease (27).

Airborne parIculate maWer is a type 1 carcinogen, and the relaIonship between air polluIon exposure and lung cancer has been summarised in the UK COMEAP report 2009 (36). Individuals in areas of high polluIon commonly live with more than one chronic disease. Risk of mulImorbidity is 20% higher among those living with PM2.5 polluIon >10 μg/m3 (30). With an ageing mulImorbid populaIon and a strained health service, improving air quality in the UK can have a significant impact on populaIon health. Climate Benefits Moving power generaIon from fossil fuel to renewable sources in line with the 80% reducIon set by the UK 2008 Climate Change Act would result in a 40% reducIon in PM2.5 concentraIons by 2050 (8). Related reducIons in NO2 concentraIon would save an esImated 4.89-7.18 million life years in the UK by 2154 (9). Cleaner vehicles and acIve travel (discussed in detail below) would contribute to reducing emissions and air polluIon whilst simultaneously reducing the incidence of NCDs. SubsItuIng electrical power (from 100% renewable sources) for gas boilers and cooking stoves would likewise improve health by reducing indoor pollutant exposure (37).

Ac;ve Travel

Health Benefits One in six deaths in the UK may be caused by physical inacIvity, cosIng approximately £7.4 billion annually. Current trends suggest that the 2035 populaIon will be 35% less acIve than in the 1960s (38). Increasing physical acIvity can reduce the risk of all-cause mortality by 30%, cardiovascular disease by <35%, T2DM by <40%, demenIa by <30%, colon cancer by 30%, breast cancer by 20%, and depression by <30% (38). Physical acIvity via commuter cycling or walking can help address this: increasing acIve travel to European best pracIce levels could reduce disease burden of IHD by 7.6%, T2DM by 7.2%, stroke by 7.0%, and demenIa by 5.3% (39). Only 2.5 hours per week of moderate physical acIvity from acIve tansport could yield relaIve risk reducIons of 0.23 for IHD, 0.11 for demenIa, 0.08 cerebrovascular disease, 0.13 for breast cancer, 0.08 for colorectal cancer, 0.07 for depression, and 0.19 for T2DM (40). Doubling the distance walked in London, and increasing the distance cycled eight-fold, would have greater impact, reducing cases of IHD (10–19%), cerebrovascular disease (10–18%), demenIa (7–8%), depression (4–6%), and breast cancer (12–13%).

In keeping, in prospecIve UK cohort studies, cyclist commuters have a reduced risk of cardiovascular disease (HR 0.79 95% CI 0.69-0.90), cancer diagnosis (0.89, 95% CI 0.84 to 0.94), and all-cause mortality (0.88, 95% CI 0.78 to 1.00) when compared with other commuters (41). Evidence from eight randomised controlled trials (RCTs) suggest a posiIve impact of walking for the prevenIon and treatment of clinical depression, with four studies showing a posiIve impact for prevenIon and treatment of anxiety (42). Spanish bicycle commuters have a significantly lower risk of being stressed (RR 0.73) compared to non-bicycle commuters using the Perceived Stress Scale (PSS-4) (43).

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Physical acIvity protects against fracture risk across the life course, increasing bone mineral density in childhood and adolescence (44), and slowing progression of osteoporosis & reducing osteoporoIc fractures in adults (45,46). Traffic collisions and polluIon could parIally miIgate the health benefits of increasing acIve commuIng. Increases in traffic collisions, injuries, and hospital admissions were observed or modelled in several studies (7,41): in London, doubling walking distance and increasing the distance cycled eight-fold, was predicted to cause a 39% increase in road traffic injury (but with absolute numbers remaining very low) (40). However, the health gains from physical acIvity outweigh the increase in trauma cases (47), and a 91% increase in London cycling since 2000 has been associated with a reduc;on in cycling deaths and serious injuries of 33% (7). The benefits of physical acIvity, parIcularly for acIve commuters, far outweigh the negaIve impact of polluIon (48,49), but there remain benefits to addressing both air polluIon and acIve travel simultaneously. Increasing acIve travel in the UK would deliver significant reducIons in cases of T2DM, demenIa, heart disease, cerebrovascular disease, and cancer.

Aher adjustment for increased risk of road traffic injuries, £17 billion in NHS savings would accrue from increased walking and cycling in urban areas, within 20 years (7). This highlights the importance of urban planning to create an environment that promotes acIve travel. Whilst electric vehicles are likely to improve local air quality, overall benefit to climate change can only be achieved if these vehicles are powered from low carbon sources. Shihing to alternaIvely powered vehicles does not address the non-exhaust emissions related to road surface wear and road dust (50). A move away from private motorised vehicles to acIve transport addresses both air quality and physical acIvity, and is likely to be more impac{ul for both climate change and public health. Climate Benefits The mechanised vehicles in which we travel all require power for manufacture and use, and much sIll derives from fossil fuel use. The transport sector alone accounted for 8 billion tonnes CO2e emissions in 2022, or 14% of all emissions worldwide and 24% of the UK’s total emissions in 2020 (406 MtCO2e) (51,52). UK passenger cars emiWed 59.6 million tonnes of carbon dioxide equivalent (MtCO₂e) in 2022, accounIng for >50% of UK transportaIon emissions that year (53).

Plant-Based Diets Health Benefits Sub-opImal diet is an important and remediable risk factor for many NCDs. In the Health Survey for England in 2021, only a minority of the adult populaIon were of healthy weight: a quarter were obese and a further 37.9% overweight. There was a 14% difference in obesity prevalence between affluent (20%) and deprived (34%) areas (54). Global Burden of Disease (GBD) studies, which esImate the proporIon of disease burden aWributable to risk factors including diet, suggest that low intake of whole grains and fruits, and high intake of sodium, together account for more than 50% of deaths and 66% of DALYs lost globally (55). Low intake of nuts, seeds and vegetables account for more than 2% of global deaths. Modelling by the UK Office of Health Economics suggests that a 100% adopIon of a vegan diet would save £6.7 billion per year and 172,735 addiIonal Quality Adjusted Life Years (QALYs) in England, mostly through a reduced incidence of T2DM (56). Achieving the 5-a-day target for fruit and vegetables could increase average UK life expectancy from birth by 7-8 months- 13% of the NHS target to increase average life expectancy by five years by 2035 (57).

A systemaIc review and meta-analysis of 95 cohort studies showed that an increase of 200g/day fruit and vegetables was associated with a reducIon in mortality from coronary heart disease (RR 0.92), stroke (RR 0.84), and total cancer (RR 0.97) (58). Studies examining the impact of diet on cardiovascular disease have been extensively reviewed (59). The AdvenIst Mortality study reported a reducIon in mortality from IHD of 26%, and of 35% for cerebrovascular disease in those following a vegetarian or vegan diet. Vegetarian diets were associated with a 22% reducIon in UK IHD risk, sustained over 18 years of follow-up (60). There is increasing research into plant-based diets (that emphasise foods derived from plants, but which may include a small proporIon of animal foods) rather than strict vegetarian or vegan diets (61). A recent meta-analysis suggested a plant-based diet to be associated with lower cardiovascular and cancer mortality (RR 0.79 and 0.82

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respecIvely), and reduced incidence of T2DM (18% lower in those with a higher adherence to a plant-based diet), cardiovascular disease, and cancer (relaIve risk of prostate, pancreas, digesIve system and breast cancer being 0.87, 0.68, 0.82 and 0.91 respecIvely) (62). Specific food types are associated with altered risk of disease. Meta-analysis suggests an 18% reducIon in cardiovascular mortality and a 12% lower risk of cancer mortality and 26% lower diabetes incidence for those with the highest consumpIon of wholegrains compared to those with the lowest (63). A systemaIc review and metaanalysis of 16 studies (RCT, prospecIve and retrospecIve studies) predominantly from North America or Europe, found regular consumpIon of nuts to be associated with a 24% and 22% lower risk of fatal and non-fatal IHD respecIvely, and a 13% reducIon in risk of incident T2DM, while a four Imes a week consumpIon of legumes is associated with a 14% lower risk of IHD (64). A meta-analysis of prospecIve studies examined fruit and vegetable subtypes and coronary heart disease. Inverse associaIons were noted between high consumpIon of several subtypes (apples, citrus fruits, fruit juices, green leafy vegetables, beta carotene and vitamin-rich fruits and vegetables) and coronary heart disease mortality (58).

In comparison, cardiovascular disease mortality rises with every serving/day of total red meat (HR 1.16 (95% CI 1.12-1.20)), unprocessed red meat (HR 1.18 (95% CI 1.13-1.23)), and processed red meat (HR 1.21 (95% CI 1.13-1.31)) (65). Cancer mortality is greater with a one serving per day increase in total (HR 1.10 (95% CI 1.07-1.13)), unprocessed (HR 1.10 (95% CI 1.06-1.14)) and processed (HR 1.16 (95% CI 1.091.23)) red meat consumpIon. An increase in red meat intake greater than half a serving per day is associated with a 48% elevated risk of T2DM (66). Increasing consumpIon of predominantly plant-based diets clearly has significant benefits to health. While individuals changing from animal to plant-based foods may consume lower quanIIes of protein, this impact is not great at a populaIon level: the EPIC-Oxford study noted inadequate consumpIon of protein in 5% of meat-eaters and in only 8-16% of vegans (60). Aher adjustment for BMI, and when compared with meat-eaters, the risk of hip fracture was greater in vegetarians (HR 1.25 (95% CI 1.04-1.5)) and vegans (HR 2.31 (95% CI 1.66-3.22)), a finding not fully explained by lower calcium intake. Fihy-two percent of vegans had a vitamin B12 concentraIon below 118 pmol/l compared with <1% of meat eaters.

Such data suggest that, in the absence of supplement use, a plant-based diet (in which reduced quanIIes of meat and/or dairy products are consumed) may be opImal. Climate Benefits Overall, the food supply chain accounts for 70-80% of tropical and subtropical deforestaIon (67), reducing GHG draw-down. It also contributes 38% of global GHG emissions. Agriculture alone contributes 10-12% of GHG emissions (mostly due to the producIon of foods from animal sources) (68). Ruminant sources (beef, lamb, muWon, milk) have higher emissions than monogastric sources (pork, chicken, eggs) which in turn are higher than plant sources due to the requirement for cereals and soy for livestock feed (77% of crops are grown to feed livestock globally) (69). In the UK, the food system contributes a fihh of all its emissions. The overall area of land used for UK diets is esImated at 24-38 million hectares (approximately 50% of this is overseas), with 85% of this land being used for animal and dairy farming despite this only providing 32% of the calories we eat (69). Meanwhile 15% of farmland grows crops for direct human consumpIon, providing 68% of our calories. Several strategies related to food producIon, consumpIon, and transportaIon have been proposed to reduce GHG emissions in line with UK targets whilst accruing health benefits. Springmann et al.

(70) modelled different sustainable dietary strategies to quanIfy their impact. Following public health objecIves of low-meat diets in line with guidance on adequate nutrients led to large reducIons in premature mortality (reduction of 19% [95% CI 18–20] for the flexitarian diet to 22% (19–25) for the vegan diet). It also resulted in 54-87% reductions in GHG emissions. A systemaIc review (71) found that adherence to well-known (sustainable) diets including the Mediterranean diet, vegetarian diet, and the Dietary Approaches to Stop Hypertension (DASH) diet promoted better health outcomes and reduced GHG emissions and land, energy and water usage mainly through reductions in meat consumption. Adherence to a 5-a-day target in the UK could reduce GHG emissions by 612Mt CO2e per year (72). The greatest reduction is achieved by prioritising vegetable consumption over fruit, and for blue water footprints, local varieties were key to minimising impact. Adherence in the UK to the WHO recommendations on diet could save 7 million life years over the next two decades, with an increase in average lifeexpectancy of over eight months. Incidental impact on the environment would result in a 17% reduction in GHG emissions (6). Alternatively, adherence to at least five out of the nine Eatwell Guide recommendations (73) was

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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associated with a reduced risk of mortality (RR 0.93; 99%CI 0.90 to 0.97) and 30% lower dietary GHG emissions. Adhering to the recommendation on fruit and vegetable consumption was associated with a 10% reduction in mortality (RR: 0.90; 99%CI 0.88 to 0.93). A modelling study analysed the co-benefits of dietary change until 2050 (74). Compared to the Food and Agriculture Organisation projections on dietary trends, three alternative scenarios were modelled: adherence to a healthy diet according to global dietary guidelines, and two scenarios that also assumed healthy intake based on either vegetarian or vegan diets. All three scenarios reduced avoidable deaths from coronary heart disease by 45-47%, stroke by 26%, cancer by 16-18%, and T2DM by 10-12%. The principal driving factors in order of importance were decreased meat consumption, increased fruit and vegetable consumption, and weight loss. These alternative healthy diets reduced food-related GHG emissions by 29–70% compared with a reference scenario in 2050. Food security is an increasing concern with climate change. Changes in diets have the potenIal to reduce GHG emissions whilst improving health. In the UK almost 2 billion meals a year are served in public sector se•ngs (75).

The government spends and esImated £2.4 billion (5.5% of UK food service sector turnover) on food to schools (29%), further and higher educaIon (29%), hospitals and care homes (25%), armed forces (11%), and prisons (5%) (75). Providing access to and encouraging consumpIon of sustainable healthy meals in these se•ngs can contribute substanIally to reducing GHG emissions, opImising nutriIon, improving health, reducing healthcare costs, and reducing inequality.

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Table 2: Evidence demonstra;ng how key factors in climate change mi;ga;on impact on health outcomes Outcomes Exposure Air Pollution

Respiratory

Cardiovascular

Cancer

Global Burden of Disease in 2015 Cohen et al. 2017 (76)

24·7% of lower respiratory infection Mortality (0.7 million deaths globally)

17·1% of IHD and 14·2% of cerebrovascular disease mortality

16·5% of lung cancer

% Mortality attributable to air pollution Cohort Study Ronaldson UK Biobank 2022 (30)

27·1% of COPD mortality (0.9 million deaths globally) 24-26% higher risk of developing respiratory disease (asthma and COPD)

21% higher risk of cardiovascular disease (Atrial fibrilla[on, CHD, heart failure)

Risk of disease groups in highest pollution quartile compared to lowest

PM2.5: OR = 1.24 (95% CI = 1.16, 1.33)

NO2: OR = 1.26 (95% CI = 1.15, 1.38)

Single outcome studies Respiratory (26,77) Cardiovascular (33,78) Cancer (79-81) Mental Health (31,32)

2-5% higher risk of asthma exacerbation in children NO2 (OR: 1.040; 95% CI: 1.001,1.081), SO2 (OR: 1.047; 95% CI: 1.009,1.086), and PM2.5 (OR: 1.022; 95% CI: 1.000,1.045) 10μg/m3 increase in PM2.5 associated with increased incidence of COPD (HR 1.18 95% CI 1.13-1.23)

Type II Diabetes and Obesity

Mental health

Others / All-cause

4% higher risk of cancer

9% higher risk of diabetes, hypertension, migraine

73% higher risk of alcohol or substance dependency:

OR 1.21 (1.13 to 1.30) <0.001

PM2.5 OR 1.04 (1.02 to 1.07) 0.001

OR 1.09 (1.06 to 1.13) <0.001;

NO2 OR = 1.73, 95% CI = 1.35–2.20

20% higher chance of multimorbidity living in areas where pollution is worse than the 2040 England target of 10 µg/m3

25% higher risk of stroke:

NO2 OR 1.04 (1.01 to 1.08) 0.010

NO2 OR 1.10 (1.05 to 1.15) <0.001

OR = 1.25, 95% CI = 1.02–1.52

Increases in NO2 and PM2.5 associated with a 1.2-2.4% increase in stroke hospitaliza[ons or mortality per 10μg/m3 increase in pollutant. Exposure to PM2.5 associated with hypertension (OR 1.05; 95% CI 1.01-1.09).

Each 10 μg/m3 increase in PM2.5 associated with 8% increase risk of lung cancer mortality 6-17% increase in risk of all-cancer mortality associated with longterm exposure to pollutants. PM2.5 (RR: 1.17; 95% CI: 1.11–1.24; I2: 97.4%), PM10 (RR: 1.09; 95% CI: 1.04–1.14; I2: 45.7%) (Figure 2), and NO2 (RR: 1.06; 95% CI: 1.02– 1.10; I2: 95.5%) This was significant for kidney (35%), bladder (32%), liver (29%) and colorectal cancer (8%)

12% higher risk of depression, anxiety PM2.5 OR 1.12 (1.09 to 1.15) <0.001; NO2 OR 1.15 (1.11 to 1.18) <0.001 Growing evidence that dementia and cognitive decline are associated pollution exposure Air pollutants are associated with 18–39% increased odds of common mental disorders; 19–30% increased odds of poor physical symptoms; 33% increased odds of psychotic experiences

Mortality from liver cancer 1.29 (1.06-1.58), colorectal cancer 1.08 (1.00-1.17), bladder cancer 1.32 (1.07-1.60), kidney cancer 1.35 (1.07.172) mortality Development, Childhood and Adolescent studies

Asthma exacerbations due to air pollution resulted in an estimated 700 paediatric

London adolescents: 1 μg/m3 increase in PM2.5 associated with 1.34 mmHg (95% CI 0.85 to 1.82)

Higher levels of air pollution at age 12 had

Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change. Respiratory (27) Cardiovascular (23) Mental Health (29)

asthma exacerbation admissions are due to air pollution (London, 2017–19) – 7% of all paediatric asthma admissions

increase in systolic BP for girls and 0.57 mmHg (95% CI 0.04 to 1.03) increase in systolic BP for boys

10 greater odds of depression at age 18 PM2.5 OR 1.63 CI1.08– 2.46 0.021p and NO2 OR 1.57 CI1.05–2.35 p=0.029

3.2-3.9% increased risk of asthma hospitalization in children for every 10μg/m3 increase in pollution

Adolescents living in the most polluted areas had 3-4 times the odds of depression at age 18 (compared to areas of lowest pollution (PM2.5: OR = 3.69, 95% CI 1.11–12.25, p = 0.033; NO2: OR = 4.08, 95% CI 0.90–18.60, p = 0.069)

Pre- and neonatal outcomes (17–19)

5-10 % of total PTBs were associated with ambient PM2.5 > 4.3 μg/m3 22 grams (95% UI: 12, 32, p<0.001) lower birth weight, 11% greater risk of LBW (1.11, 95% UI: 1.07, 1.16, p<0.001), and 12% greater risk of PTB (1.12, 95% UI: 1.06, 1.19 p<0.001), per 10 μg/m3 increment in ambient PM2.5 . A reduction is gestational age of between 3-5 days is thought to be attributable to PM2.5 In London estimates that PM2.5 exposures greater than 13.8 μg/m3 in pregnancy accounted for three percent of London-born infants with low birthweight Male fertility: a meta-analysis demonstrating significant decreases in semen volume, motility, and sperm concentration associated with higher air pollution

Plant-based Diets (PBD) Systematic Review and Meta-analysis. (62) 2023

CVD mortality (0.79 95% CI: 0.72– 0.87) and incidence (0.90 [0.85– 0.94])

Cancer mortality (0.82: 95% CI: 0.71–0.93) Cancer incidence (0.88: 0.84–0.92)

Higher adherence to a PBD pattern associated with lower risk of:

CHD risk (0.86 :95% CI: 0.81–0.91), but not with risks of stroke (0.92: 95% CI:0.85–1.00) and heart failure (0.89: 95% CI:0.75–1.06)

Systematic Analysis of the GBD (82) 2017

For a 100g increase in fruit – IHD: RR 0.86 (0.79-0.95); ischaemic stroke RR 0.65 (0.55-0.79);

Breast cancer (0.91: 95% CI: 0.86– 0.95) Digestive system cancer (0.82: 95% CI: 0.72–0.94) Pancreatic cancer (0.68: 95% CI: 0.55–0.84) Prostate cancer (0.87: 95% CI: 0.77–0.99) 100g increase in fruit – tracheal/bronchus/lung Ca RR 0.93 (0.89-0.97); oesophageal cancer RR 0.87 (0.78-0.97).

100g increase in vegetables – IHD: 0.86 (0.78-0.94) 50g increase in Legumes: RR IHD 0.76 (0.65-0.89) ischaemic stroke RR0.87 (0.79-0.97)

100g decrease red meat: colorectal ca RR 0.86 (0.76-0.97).

T2DM incidence (RR 0.82 95% CI: 0.77–0.86)

All-cause mortality (0.84 0.78– 0.92)

100g increase in fruit associated with a reduction in diabetes RR 0.91 (0.84-0.98) 100g decrease in red meat RR 0.8 (0.68-0.97) 50 g decrease in processed meat RR 0.58 (0.47-0.76)

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change. 50g decrease in processed meat: IHD RR 0.56 (0.39-0.97)

Systematic review and meta-analysis Aune et al 2017 (58) Per 200 g/day increment in intake of fruit and vegetables: Systematic Review and Meta-analysis Afshin et al, 2014 (64)

8–16% reduction in the RR of coronary heart disease, 13–18% reduction in the RR of stroke; 8– 13% reduction in the RR of cardiovascular disease

50g decrease Processed meat colorectal cancer RR 0.85 (0.790.91)

3–4% reduction in the RR of total cancer

24% lower risk of fatal IHD (RR: 0.76; 95% CI: 0.69, 0.84)

Systematic Review and Meta-analysis Zong 2016 (63) comparing the highest to the lowest groups of Wholegrain intake:

10–15% reduction in the RR of all-cause mortality

13% lower risk of developing diabetes (RR: 0.87; 95% CI: 0.81, 0.94)

22% lower risk of nonfatal IHD (RR: 0.78; 95% CI: 0.67, 0.92). 4 weekly 28.4-g servings of nuts were associated with:

legume consumption was inversely associated with diabetes (RR: 0.79; 95% CI: 0.71, 0.87)

4 weekly 100-g servings of legumes was associated with 14% lower risk of total IHD (RR: 0.86; 95% CI: 0.78, 0.94) CVD mortality: Pooled RR 0.82 (0.79, 0.85; P<0.001)

Cancer mortality: RR 0.88 (0.83, 0.94; P<0.001)

For diabetes risk, pooled RR (95% Cis) 0.74 (0.69, 0.80)

PAF 11.6% for CVD mortality

PAF 10.2% for Cancer mortality

Each 2–3 servings/day increment associated with 21– 32% lower risk

Lower HR of all cancers 0.90 (0.8440.97), stomach 0.38 (0.2-0.71), haematological 0.64 (0.48-0.84)

Lower risk of diabetes: HR 0.65 (0.55-0.76) although after adjustment for BMI crosses 1 – 0.89 (0.75 -1.05)

UK Cohort Study Key et al. 2022 (60)

IHD HR 0.77 (0.69-0.86) after 18 years follow up

Vegetarians compared with meat eaters:

Combined vegetarian and vegan risk was 22% lower than meat eaters, adjusted for BMI this reduced to 17%

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mean BMIs of vegetarians and vegans in EPIC-Oxford were approximately 1 and 2 kg/m2 lower than those of meat-eaters

Total mortality was RR 0.84 (0.80, 0.88; P<0.001), Estimated PAF were 10.4% for total mortality

Diverticular disease vegetarians compared with meat eaters: HR 0.73 (0.580.92), kidney stones 0.69 (0.48-0.98)

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change. Vegans compared with meat eaters:

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18% lower IHD in vegans but small numbers wide

vegans compared with meat eaters: all cancers HR 0.82 (0.86-1.00)

vegans compared with meat eaters: diabetes HR 0.53 (0.360.79) note this effect appears to be entirely mediated through BMI – adj HR 0.99 (0.66-1.48)

vegans compared with meat eaters: diverticular disease 0.28 HR (0.1-0.74)

Burden of Disease Study 2012 (83)

CHD incidence and leisure activity, RR 1.16 (1.04–1.30)

Breast cancer: Adjusted for BMI, RR 1.33 (1.26, 1.42)

All-cause mortality: RR 1.28 (1.21–1.36), crude RR was 1.47 (1.38–1.57)

Pooled RR associated with inactivity compared with current recommendations

6% of the burden of disease worldwide due to CHD can be eliminated, if all inactive persons become active

The burden of Breast Ca that could be eliminated if all inactive persons become active: 10% (5.6– 14.1%)

T2DM incidence: RR 1.20 (1.10– 1.33) adjusted for BMI Burden of disease was 7% (ranging from 3.9% to 9.6%) due to T2DM

Physical Activity

Population Attributable Fraction was 9%. >5.3 million deaths/year may be averted if all inactive persons become active

Colon cancer: RR 1.32 (1.23–1.39) The burden of Colon cancer that could be eliminated if all inactive persons become active: 10% (5.7– 13.8%) Systematic Review and Meta-analysis Kelly et al. 2014 (84)

For a standardised dose of 11.25 MET.hours per week (or 675 MET. Minutes per week), the reduction in risk for ACM was 11% (95% CI = 4 to 17%) for walking and 10% (95% CI = 6 to 13%) for cycling

London Modelling study Woodcock et al 2009 (40)

Relative Risk reduction in CVD incidence of 23%

Breast cancer incidence Relative Risk reduction 13%

2.5hr per week of moderate intensity physical activity is associated with:

Relative Risk reduction of 23% in Cerebrovascular disease

Relative Risk reduction in Colorectal cancer incidence: of 8%

Pooled prospec[ve UK cohort study 2016 (85)04/12/2025 19:58:00

Swimming associated with reduced risk of CVD mortality of 41% (HR=0.59, 95% CI 0.46 to 0.75) Racquet sports was associated with reduced risk of CVD mortality of 56% (HR=0.44, 95% CI 0.24 to 0.83)

Relative Risk reduction of 19% in T2DM incidence

Relative Risk reduction in Depression of 7% Relative Risk reduction of 11% in Dementia incidence

Although walking and cycling became safer per km travelled the large increase in the total distance walked and cycled led to the road traffic injury disease burden rising by 39%

All-cause mortality Cycling: 15% lower risk (HR=0.85, 95% CI 0.76 to 0.95) Swimming 28% lower risk (HR=0.72, 95% CI 0.65 to 0.80) Racquet sports 47% (HR=0.53, 95% CI 0.40 to 0.69)

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change. Aerobics associated with reduced risk of CVD mortality of 36% (HR=0.64, 95% CI 0.45 to 0.92).

Danish Cohort Study 2015 (86) inverse associations between activity vs non activity: (vs. non participation):

UK Biobank Cohort Study. Welsh et al 2020 (41) Cycling commuters compared with other commuters:

Respiratory mortality Participation in sports: HRs 0.60 (95% CI: 0.47, 0.77) Walking: (HR=0.71; 95% CI: 0.51, 0.97) Cycling HR 0.62 (95% CI:0.50, 0.77) and Gardening HR 0.63 (95% CI: 0.50, 0.79)

CVD mortality Participation in sports: HRs 0.78 (95% CI:0.69, 0.88)

Aerobics 27% (HR=0.73, 95% CI 0.63 to 0.85).

Cancer mortality Participation in sports: HRs 0.82 (95% CI: 0.76, 0.89)

Cycling HR 0.78 (95% CI:0.69, 0.88) and Gardening HR 0.82 (95% CI: 0.72, 0.93)

Reduced risk of cardiovascular disease (HR 0.79, 95% confidence interval 0.69 to 0.90)

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Diabetes mortality Participation in sports: HRs 0.34 (95% CI: 0.21, 0.55.

In general, exposure to high levels of traffic-related air pollution did not modify associations

For cycling HR 0.61 (95% CI:0.42, 0.89) and gardening HR 0.42 (95% CI: 0.28, 0.62)

Reduced risk of cancer diagnosis (HR 0.89, 0.84 to 0.94)

Reduced risk of all-cause mortality (HR 0.88, 0.78 to 1.00) Higher risk of injury (HR 1.45, 95% CI 1.30 to 1.61).

3.42-fold (3.00- 3.90) and 2.62-fold (2.37- 2.91) higher risk of hospital admission due to transport incidents Table1: Studies demonstrating the effect of polluted air, plant-based diets, and physical activity on outcomes grouped by system (respiratory; cardiovascular; cancers; diabetes and obesity; mental health; and overall measures. IHD Ischaemic heart disease, CVD Cardiovascular Disease, CHD Coronary Heart Disease, T2DM Type 2 Diabetes Mellitus, PBD plant based diet, BMI body mass index.

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Climate Policy and the Co-Benefits

The 2018 Intergovernmental Panel on Climate Change (IPCC) clearly describes the magnitude of the effort required to prevent climate catastrophe (87). In 2022, they warned that lack of concerted global acIon meant missing “a brief and rapidly closing window to secure a liveable future” (88). The 2024 State of the Climate report warns that “we are on the brink of an irreversible climate disaster”, that, “much of the very fabric of life on Earth is imperiled” and that we face, “a global emergency beyond any doubt” (89). However, the pace & scale of acIon falls far short of that required. A 1.5°C rise above pre-industrial temperatures is now inevitable. Without rapid reducIons to GHG emissions, we will likely breach a 2°C temperature rise by 2030 (10,90). 2024 was the hoWest year on record, and the first in which every day exceeded 1°C above pre-industrial levels for that Ime of year (2), with temperatures consistently >1.64oC above pre-industrial (91). Due to posiIve feedback loops, the pace of heat gain is rapidly increasing, with extreme weather events more severe and more frequent: climate-related events increased by 83% between 1980-1999 and 2000-2019 (10). One in three species are threatened by exIncIon with rising GHG emissions (10).

In approximately 45 years, one in three of the global populaIon will be exposed to mean annual temperatures of >29oC (currently only found in 0.8% of land surface area) (92). Heat-related mortality has increased by 85% since the 1990s (93). Climate change has caused USD$1.3 trillion global losses over the last decade, and is esImated to cost USD$5 trillion in losses over the next five years (94). Alongside global food insecurity, this can incite migraIon and conflict. Therefore, climate change “threatens our economies and employment, social fabric and security” (10). Consequently, governments face a parIcularly difficult challenge to miIgate climate change whilst aWending to other public services including health. A Grantham InsItute briefing paper summarises the key areas for acIon on climate change and how these are linked to health (95). EffecIvely addressing climate change demands urgent cross-sectoral coordinaIon. Consequently, efforts to address climate change through governmental policy, communiIes and individual acIons should be explicit about the expected effects on health. Public Opinion Economic growth and reducing GHG emissions are ohen falsely piWed against one another as trade-offs (96).

Whilst concern has grown, climate acIon is rarely considered the UK public’s top priority: in September 2023, it ranked 5th behind the economy, inflaIon, the NaIonal Health Service (NHS)/healthcare, and immigraIon (4). Such low ranking maWers, both because it is reflected in limited individual and personal acIon, and because shihs in public senIment and purchasing choices create a permissive environment into which both poliIcians and businesses can move. Public opinion maWers because of its influence on government prioriIsaIon. CommunicaIng the urgency of climate acIon will be far more effecIve and comprehensive if framed around the posiIve benefits for health, rather than focussing solely on environmental damage. Government departments risk addressing each of these issues in isolaIon which ignores the significant co-benefits described here (projected scenarios presented in Table 3). Whilst beyond the scope of this report, evidence supports the co-benefits of climate acIon across other policy areas including employment, economic growth and housing, as well as health (95).

Table 3: Projec&on scenarios demonstra&ng the dual impact of clean air, ac&ve travel, and plant-based diets Co-benefits Climate Benefits Health Benefits Cleaner Air (8,9) Targeted 80% reducIon in GHG NO2 concentraIon reducIon can Changes in power genera;on from fossil emissions by 2050 compared to save 4.89-7.18 million life years fuels to renewable sources 1990 levels (UK Climate Change between 2011-2154. Act, 2008). This would result in 40% reducIon in PM2.5 concentraIons by 2050. Ac&ve Travel (40) 38% reducIon in transport 7332 DALYs saved and 530 If London replaced a propor;on of car CO2 emissions from 1990 levels. premature deaths avoided per travel with ac;ve travel Per person CO2 emissions are million populaIon. 0·69 tonnes. Plant-based Diets (6) EsImated incidental reducIon of Almost 7m years of life lost If the average UK dietary intake were 17% in GHG emissions. prematurely in the UK would be op;mised to comply with the WHO saved over the next 30 years, with recommenda;ons average life expectancy increasing by >8 months.

Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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Inequality The difference in mortality between rich and poor in the UK first received significant aWenIon following the Sir Douglas Black report in the 1980s. Since then, numerous reports, commissions and plans for acIon have aWempted to reduce inequaliIes with limited success. Fair Society Healthy Lives 2010 set out the acIon required to reduce inequality and, following a re-review in 2020, the need to pursue environmental sustainability and health equity together was added (97). InequaliIes persist in exposure to air polluIon and mode of transport. A Sco•sh study idenIfied higher levels of acIve travel in more deprived areas (98). Deprived areas tend to have higher levels of polluIon, mostly caused by congesIon of private vehicles. The adverse impact of air polluIon amongst the poor is further compounded by increased use of public and acIve transport in deprived groups. Evidence shows that those from areas of higher deprivaIon rely heavily on public transport and receive higher exposures to polluIon whilst generaIng less emissions per person (99). These inequaliIes would be addressed through decarbonisaIon of transport and increases in acIve travel. Climate change will have significant impacts on food security. Direct effects include changes in temperature and rainfall distribuIon for agriculture, with extreme weather events causing disrupIon to food systems.

Indirect effects include the reducIon in pollinators and increase in pests and disease vectors. These changes are likely to drive up the price of food. A UK survey found that almost 20% of parents reported that they regularly had to go without food to ensure that their children had sufficient food (100). The poorest 20% of households spend a higher proporIon of income on food and are therefore more vulnerable to changes in food prices (74). Twenty-five percent of households in the most deprived areas report eaIng reduced quanIIes of fruit and vegetables due to cost (101). A public health approach needs to address the widening of inequity between the wealthy and poorest in society. Climate change has its greatest effects on those who have contributed the least, and without intervenIon will worsen the gap through its adverse effects on the social determinants of health (102). Climate change miIgaIon therefore has the potenIal to reduce inequity through the development of effecIve policies.

Conclusions

If decision-makers adequately account for the co-benefits of climate change miIgaIon, faster, more effecIve reducIons in GHG emissions may be achieved with considerable cost-savings. The disconnect between public percepIon on issues that maWer most, and the potenIal role environmental policy can play in addressing these issues, represents an important point of acIon to establishing a health sustainable future. The compeIng prioriIes of different issues and different government departments undervalues the power of a collaboraIve approach to climate change. Focus on the key areas of cleaner neighbourhoods, increasing acIve travel, and consumpIon of plant-based diets provide clear examples where individuals, communiIes, corporaIons, and government can make decisions that benefit both human and planetary health. But we must remember: our lives, and those of our children are under immediate threat if climate change is not averted. The Ime to do so is very limited indeed: the IPCC warn that we risk ‘missing a brief and rapidly closing window to secure a livable future’ (88). We all have a responsibility to act, rather than to be complacent or to conInue ‘business as usual’. Health chariIes can unite in a public message, that ‘what is good for health is good for our planet’. They have a moral responsibility to do so.

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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Key Messages o o o o o o o o

Reducing GHG emissions to miIgate climate change represents a significant challenge for governments facing compeIng issues such as health, economic growth, immigraIon, and inequality. Delayed, inconsistent acIon in response to the climate emergency threatens our lives and livelihoods. A health-centred response can deliver transformaIonal health benefits globally. The health sector is criIcal to climate change: it is the first line of defence, and it has direct control over a porIon of GHG emissions and >10% of the world’s GDP. Focusing on a single risk factor undervalues potenIal impact on health due to synergisIc effects (Increased air quality and physical acIvity with acIve travel). Addressing climate change in isolaIon ignores key wider benefits of miIgaIon. Public discourse should be informed by the co-benefits of reducing air polluIon, reducing animal-source foods, and increasing acIve travel on both personal and planetary health. Joined-up awareness campaigns would reinforce the benefits of moving to a cleaner, healthier society and increase public support.

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Healthy people, healthy planet: The co-benefits of clean air, plant-based diets, and physical ac8vity to human health and climate change.

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Appendix 1: Health System Evidence Respiratory Diseases Air pollu&on Morbidity and mortality from respiratory disease is one of the most direct health effects of air polluIon. Numerous observaIonal studies causally link impaired lung funcIon, asthma, chronic obstrucIve pulmonary disease (COPD), respiratory infecIon, intersIIal lung disease (ILD), pulmonary embolism, and obstrucIve sleep apnoea (OSA) with exposure to air pollutants, with emerging evidence focusing on the causaIve mechanisms. Disorders of the upper respiratory tract (e.g. allergic rhiniIs (AR) and rhinosinusiIs) have not been considered. Lung Func;on Pulmonary funcIon tests (PFTs) provide a standardised measure of different breathing and respiratory parameters to aid idenIficaIon of health and disease, and are subject to internaIonal guidance (e.g. (103)). Lung funcIon in childhood is a predictor of peak lung funcIon in adulthood and later decline; hence, focusing on this group is of lifelong importance (104). A global metaanalysis pooled 25 studies invesIgaIng PM2.5 exposure and lung funcIon in children.

A staIsIcally significant decrease in lung funcIon values – forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak expiratory flow (PEF) – was idenIfied for every 10 μg/m3 increase in PM2.5 concentraIon, with a greater lung funcIon reducIon in long term compared with short term exposure (105). Despite data heterogeneity and small study sizes, this finding appears consistent in adults, where short-term PM2.5 exposure is associated with a fall in FEV1 and FVC (106). Cohort studies have consistently shown that increases in ozone (O3) concentraIon result in short-term reducIon in lung funcIon parameters in children with and without asthma. However, the long-term effects of O3 exposure on lung funcIon are inconclusive (107). Most studies show a negaIve impact of traffic-related air polluIon on lung funcIon, with the effect larger for FEV1 than FVC (104). The Southern California Children’s Health Study demonstrated deficits in FEV1 correlaIng with higher levels of NO2, PM2.5, elemental carbon and acid vapour; FVC deficits associated with NO2 and acid vapour; and significant reducIons in FEV1 and FVC if living within 500m of a freeway (108). Asthma Illness from airborne polluIon can be caused by exposure prenatally and during the early years.

A systemaIc review of birth cohort studies examined ten cohorts exposed to PM and NO2 in pregnancy and idenIfied a consistent associaIon with asthma incidence (109). Referenced cohort studies in the Netherlands and the USA found that exposure to PM2.5 and NO2 at home addresses at birth and during the first three years of life, respecIvely, are associated with increased childhood asthma incidence (110,111). This adds to a substanIal body of evidence linking prenatal and early-year air polluIon to the development of asthma in childhood and later life (109,112–114). A recent metaanalysis reviewed respiratory health effects of prenatal exposure to airborne pollutants. Included studies from the USA and Poland and considered heterogeneous exposures, outcomes and Ime courses. It idenIfied a significant associaIon of exposure to ultra-fine parIculates with asthma, and of exposure to polycyclic aromaIc hydrocarbons (PAH) PM2.5 with wheezing in children (115). In the iniIal cohorts of the Southern California Children’s Health Study, children with homes within 75m of a main road had an increased risk of lifeIme asthma and a 50% increased risk of asthma aher adjusIng for confounders (108). A recent systemaIc review of observaIonal studies including children and adults examined specific pollutant exposure and visits to the emergency department or hospital admissions in the following days.