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Health & Environment
Co-benefits: concepts and recommendations for clinical practice

Julia Gonzalez Holguera & Nelly Niwa and Pr. Nicolas Senn
Introduction

Planetary boundaries, Health, and Co-Benefits

It is urgent that we recognize the health impact of global environmental degradations. Health professionals have a specific part to play in this. There are indeed tangible links between human health and ecosystem functioning that are well-established. The notion of “co-benefits” highlights long- and short-term benefits on human health stemming from concrete actions that contribute to reduce our environmental impact. This approach provides an opportunity to accelerate the societal changes that are necessary to diminish environmental degradation and make our societies more sustainable

Planetary boundaries

The health of ecosystems and human health are closely linked. These links are formalized in concepts and initiatives such as “OneHealth,” “EcoHealth,” and “Planetary Health”, that highlight the relation of interdependence between living organisms, both human and non-human, and their ecosystems. And yet, we are living in a time when human activity is leading to profound global environmental degradation. “Planetary boundaries” describe thresholds of ecosystem transformation that should not be exceeded on a global scale.

Areas where planetary boundaries apply

1.Climate change 2.Erosion of biodiversity 3.Perturbation of the nitrogen and phosphorus biogeochemical cycle 4.Deforestation and changes in land-use 5.Chemical pollution 6.Acidification of oceans 7.Depletion of the ozone layer 8.Degradation of drinking water 9.Aerosol pollution.
Below the limit In an uncertain zone
(growing risk) Uncertainty threshold crossed
(high risk)

Credit: J. Lokrantz/Azote, based on Steffen et al., 2015. Back-translation by Christopher Seder.

But several of these thresholds have been exceeded or are in a zone of uncertainty and concern, compromising the ability of natural systems to provide the ecosystem services that support life on Earth. With this in mind, some reports, and particularly the Lancet Countdown report, have been sounding the alarm in the face of the major threats to global populations and future generations that stem from current climate change trends and global environmental degradations.
At the same time, while our lifestyles largely contribute to the over-exploitation of resources and the degradation of natural ecosystems, it is also clear that a certain number of health problems that societies face today also result from those same lifestyles. For instance, the increased prevalence of type 2 diabetes, cardiovascular disease, and obesity is related to consuming hyper-processed foods that are full of saturated fats and sugars and to the increasingly sedentary lifestyle of the population, which use their cars for everyday commutes, or struggles to commit to outdoor physical activity.

The concept of co-benefits

What can doctors and healthcare professionals do in the face of these major upheavals? Given the fact that certain aspects of our modern lives, on the one hand, contribute to climate change and the degradation of ecosystems around the world and, on the other, lead to the growth of so-called “lifestyle diseases”, some changes in individual and societal behavior can directly benefit both human health and environmental preservation. The scientific literature refers to this concept by using the term “co-benefits.” Doctors and healthcare professionals are firsthand witnesses of the deleterious impacts that environmental degradations can have on the health of both individuals and the overall population. They could thus contribute to making environmental stakes more tangible and encourage both individual behavioral changes and structural transformations at the public community level.

HUMAN HEALTH
DEPENDS ON THE HEALTH
OF THE ENVIRONMENT.

Co-benefits
Actions that have a two-fold benefit. They directly benefit human health and reduce environmental degradations. As humans depend on natural systems, humans doubly benefit from the preservation of the environment.

Co-benefits: a clinical definition

«Daily choices and key changes that people/patients can make within their own lives that will ultimately benefit both their own health and that of the environment.»

Source : WONCA (World Organization of General Practitioners/Family Physicians)
HEALTH AND ENVIRONMENT CO-BENEFITS CAN PRIMARILY BE DIVIDED INTO THREE AREAS:
1.

Co-benefits and nutrition

Environmental impact of food production

Food production is a major source of environmental degradation around the world and is contributing to exceeding the thresholds of several planetary boundaries. It is currently estimated that agriculture and livestock farming are responsible for 20 to 30% of global greenhouse gas emissions. Natural habitats being converted to farmland is the leading cause of deforestation, of the fragmentation of natural habitats and biodiversity loss.

The environmental footprint, and particularly the carbon footprint, of food varies widely. Animal-based food production is generally more intensive, in terms of the resources it uses, and emits more greenhouse gases than plant-based products.

50%
The percentage of non-frozen land on earth that is used for agriculture and livestock farming.
20 to 30%
Of the food produced globally is wasted as it travels along the supply chain or at the consumer level
2050
Will see the global population grow by 30% and an increase in food-related greenhouse gas emissions of 80 to 90%

Nutrition and harmful effects on health

Overall, malnutrition problems fall into two paradoxical categories: undernutrition and obesity. On the one hand, food deficit affects around 820 million people around the world, and two billion people suffer from micronutrient deficiency. On the other hand, over two billion people around the globe are struggling with being overweight and obesity in a way that is linked to diets that are too calorie-rich with too much refined sugars, meat, and animal and hydrogenated fat. This has gone hand-in-hand with a rise in the prevalence of chronic diseases. It is estimated, for instance, that diabetes cases have doubled in the past 30 years and affect over 10% of the Western population, that high blood pressure affects around one third of the global population, and hypercholesterolemia, one quarter.

Red meat has a high environmental impact, much higher than that of other sources of protein
Consuming too much red meat is associated with heart disease and cancer

Sustainable changes in diets and modes of production – health benefits

Because a large portion of the global population is malnourished, and food production strongly contributing to planetary thresholds being crossed, and because these trends are on an increase globally, diets must change both in the interest of the population’s health as to ensure the sustainability of the food production system.

1.The EAT-Lancet commission has studied the dilemma of feeding the global population a diet that is both healthy and sustainable. It recommends a diet that mostly features vegetables, fruits, whole grains, legumes, nuts and seeds, unsaturated fats, includes a small or medium amount of sea food and poultry, a small amount of dairy products, little or no red meat and no processed meats, added sugars, or refined grains. From an environmental point of view, its authors base themselves on the significant impact that animal-based products, particularly red meat and dairy, have on all environmental indicators, including greenhouse gas emissions. The authors also note the importance of balanced caloric intake and weight, which is a place where sustainability and health challenges can converge. Indeed, once nutritional needs have been met, questioning the need to consume more offers an additional path for lowering one’s environmental footprint. In countries with moderate to high incomes, following national nutritional guidelines, including when it comes to reducing red meat, hyper-processed food and calorie intake is to a certain extent aligned with environmental goals.

However, the EAT-Lancet's recommendations and national ones differ, as the latter generally do not allow us to sufficiently reduce our impact on the environment. The fundamental difference between national dietary recommendations and EAT-Lancet's is the recommended animal-based product intake, particularly when it comes to red meat and dairy, which EAT-Lancet recommends we should be eating less of.

13-25%
Reduction in greenhouse gas emissions if national recommendations were followed


In countries with moderate to high incomes, following national nutritional guidelines, including when it comes to reducing red meat, hyper-processed food, and calories, is to a certain extent aligned with environmental goals.

However, EAT-Lancet's recommendations and national ones differ, as the latter generally do not allow us to sufficiently reduce our impact on the environment. The fundamental difference between national dietary recommendations and EAT-Lancet's is the recommended animal-based product intake, particularly when it comes to red meat and dairy, which EAT-Lancet recommends less of.

Fruits & vegetables Whole grains Legumes Unsaturated fats
Starchy vegetables Dairy products Animal proteins Added sugar
Fruits & vegetables Protein foods Floury foods

Delorme et al., RMS 2020

2.Several studies show that organic products contain less pesticides, nitrate residues and antibiotic-resistant bacteria, even though the clinical implications of this remain poorly understood. Organic farming and agroecology could feed the global population without increasing deforestation if they are combined with reducing food waste and lowering meat consumption.

Clinical implications

While it must be recognized that when it comes to modifying eating behaviors in a clinical environment, the results of studies are often disappointing, and that there is no approved practical tool for practitioners, beyond the EAT-Lancet's detailed recommendations and the Swiss Nutritional Society’s food pyramid, healthcare professionals nonetheless play an important part in accompanying patients and in contributing to the dissemination of quality and objective nutritional information. And while interventions on an individual level do not necessarily bring about easily measurable behavioral change, they do contribute to helping along societal change. Such is the case, for instance, with tobacco, where the combination of public health efforts, structural measures (banning smoking in public spaces), and individual counselling has been synergetic, and contributed overall to less tobacco consumption. Furthermore, healthcare professionals can base themselves on quality documentation to help along and reassure patients who wish to consume less or no meat when it comes to there being any potential risks of deficiencies or harmful effects on health. Numerous studies show the positive impact of meatless diets on morbidity.

Summary
Summary Nutrition and environment co-benefits

Examples of co-benefits for health and the environment when it comes to adopting a sustainable diet.

A

Clinical recommendations.

B

Structural measure recommendations.

2.

Co-benefits and mobility

Impact of motorized mobility

1.Mobility is a major source of carbon emissions around the world. In Switzerland, transportation uses up 38% of total energy consumption and is therefore responsible for emitting 14.8 million tons of CO2 (not including international air traffic), which is the equivalent of one third of nationwide greenhouse gas emissions. Of those 14.8 million tons of CO2, 73% of emissions are attributed to private cars.

2.Motorized vehicles emit various pollutants, such as nitrogen oxide, fine particles, and various volatile organic composite materials, which contribute to ozone (O3) peaks, increase the decay of natural environments, and affect plant growth.

3.Tire-rubbing and abrasion from brakes also produce particles and micropollutants that contribute to polluting terrestrial and aquatic ecosystems.

4.Before they even start being used, the production of vehicles and the construction of road infrastructure requires non-renewable resources to be extracted, contributes to the fragmentation of natural spaces to the detriment of the plant and animal species that inhabit them, and to the emissions of atmospheric pollutants and greenhouse gases.

Harmful effects on health

1.Air pollution, which thermic vehicles contribute to, is responsible for cardiovascular and respiratory illnesses. A study conducted by the Federal Office for Territorial Development (ARE) estimates that air pollution in Switzerland causes 2,200 premature deaths per year.

2.The use of cars reinforces the sedentary lifestyle of the population (by reducing the amount of time people devote to physical activity when they are sitting in the car), which is associated with a whole array of non-communicable diseases.

3.Road traffic congestion, the use of public space by roads and parking places, barrier effects related to those infrastructures, as well as the heat islands they generate, all contribute to the degradation of living environments, to the detriment of both green and meeting places, thereby weakening social capital.

Active mobility’s benefits on health

Active mobility refers to modes of transportation that use human energy as their primary source of energy, and therefore refers in particular to cycling (on mechanical or electrically-assisted bikes) and walking. By allowing us to combine commuting times and physical activity, as for instance when one bikes to get to work, bike mobility can contribute to making physical activity a part of people’s daily routines, thereby making it notably beneficial in terms of public health.

In many studies, active mobility is associated with reducing cardiovascular disease, cancer, and all causes of death. Users also mention the mental benefits that come with biking regularly. The health benefits of more physical activity are especially pronounced in individuals who are the least active.

Encouraging active mobility and reducing the use of cars allows us to reduce air and noise pollution, reduce the risk of traffic accidents, and to make cities more pleasant. Active mobility costs local governments much less than other modes of transportation.

Reduction in health costs related to active mobility
-1.4 BILLION
CHF IN SWITZERLAND
The costs induced by private cars
+7.6 BILLION
CHF IN SWITZERLAsND

Individual behavioral changes or structural ones?

If both environmental and health arguments suggest that promoting active mobility makes sense, then how can this change in transportation modes be encouraged? The accessibility of these modes is largely dependent on the built environment (i.e., the existence and quality of bikeable and walkable infrastructure), transportation policies, and social norms regarding different modes of transportation. For instance, it is well established that safe, continuous bikeable infrastructures make it possible for a wider array of people to use them, particularly as far as gender, age brackets, abilities, and motivation go. In areas where there is sufficient infrastructure (e.g., Copenhagen, Amsterdam), choosing to use a bike is seen as a logical choice for ease, speed, and financial reasons.

So, even if many active mobility encouragement programs are set up, individual motivation is not enough. It must be accompanied by structural change.

Riding a bike:
one example of a health & environment co-benefit
Structural measures
Creating bike lanes can help ensure that physical activity among adolescents increases.

(Ref: Pan, X., L. Zhao, J. Luo, Y. Li, L. Zhang, T. Wu, M. Smith, S. Dai and P. Jia (2020). "Access to bike lanes and childhood obesity: A systematic review and meta-analysis." Obes Re)
Economic/health impact
Creating bike lanes has a favorable cost-benefit impact on health.

(REF: Kriit, H. K., J. S. Williams, L. Lindholm, B. Forsberg and J. Nilsson Sommar (2019). "Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden." BMJ Open)
Individual measures
Individual clinical interventions make it possible to change patient behavior as it relates to physical activity.

(REF: USPSTF 2017, Patnode, C. D., C. V. Evans, C. A. Senger, N. Redmond and J. S. Lin (2017). 318(2): 175-193.
Environmental impact
Going from having 7% to 23% of trips being carried out by bike in cities would allow us to reduce annual global CO2 emissions by 300 megatons.

(Ref: Global high shift scenario, 2015)
Summary
active mobility and health co-benefits

Examples of active mobility co-benefits for health and the environment.

A

Clinical recommendations.

B

Recommendations in terms of structural measures.

3.

Co-benefits and contact with nature

Consequences of the degradation of natural ecosystems

The term “biodiversity” describes the diversity of living organisms on Earth, the way they form communities, and their interactions with their ecosystems. Around the world, we are seeing a massive decrease in biodiversity. Biodiversity loss includes loss of species, genetic losses, and losses and degradation of natural habitats.

25%
of animal and plant species are endangered
68%
is how much global populations of mammals, fish, amphibians, and reptiles have declined by since 1970

The mass erosion of biodiversity compromises nature’s ability to provide the ecosystem services that life, including human life, depends on in order to live healthily.

The Covid-19 health crisis is a reminder of the links between disturbing natural ecosystems and increased risks of zoonosis. Even though those links remain complex and insufficiently understood, there are elements of proof that show that destroying natural habitats and making changes in ground use destabilizes interactions between different species, including host organisms and pathogenic vector species, and thus risks contributing to the emergence of zoonotic diseases.

Recognizing and better defining the links between the integrity of ecosystems and human health could allow us to bolster efforts to preserve natural spaces and biodiversity.

This includes recognizing human dependence on ecosystem services and the irreplaceability of these services. This recognition will have to go hand in hand with a transformation of our relationship with nature, through recognizing the biosphere’s ecological limits, and a renewed sensitivity to non-human living beings and natural ecosystems.

This can begin by recognizing the benefits of contact with nature for both individuals and populations.

Beneficial effects on health of contact with nature

The notion of “biophilia” describes a supposed inherent tendency in human beings to connect with parts of nature or natural processes. These links supposedly originate in evolutionary adaptations to natural environments in which humans have evolved. There may thus be benefits to pursuing activities in nature that have to do with the relationship that binds individuals to their environment. Individuals must then adapt their movement to the variability that is inherent to a natural context, choose what opportunities are the most appropriate, and adapt to the wealth of information they receive. This dynamic relationship requires an individual to engage on a sensory, emotional, bodily, and cognitive level with their environment – one that is not present in, say, gyms.

Many studies show that contact with nature is associated with both short- and long-term benefits on human health. These multiple benefits probably often stem from a combination of effects, which may have short- or long-term consequences, which are difficult to measure and can be hard to uncouple when researching the correlation between contact with nature and health.

Studies suggest that there are links between contact with green spaces and lowered blood-pressure, heartrate, salivary cortisol, instances of type II diabetes and strokes, as well as positive effects on pregnancy, cholesterol rates, and self-reported healthiness.
There has also been shown to be a correlation between exposing children to nature and a positive impact on mental health (stress, ADHD...).
As they provide pleasant and calm places and meeting points, green spaces, parks, and urban gardens encourage physical and leisurely activities and contribute to strengthening social capital.
In urban areas, green spaces hinder the heat island effect and thus improve quality of life during heatwaves.
An emerging area of research points to the part biodiversity plays in regulating the human immune system. Numerous studies draw a link between lowered exposure to microbial biodiversity and the growing prevalence of allergies and chronic inflammatory diseases in urban populations around the world.

One example: community gardens

Community gardens have known benefits on individuals and populations. People’s primary motivation for getting into gardening is to have a pleasant, outdoor activity they can commit to, one that can occasionally provide food and that helps them evacuate stress. Having a concrete and tangible goal to focus on – producing food, for instance – as well as the aesthetic experience that gardens provide both contribute to creating meaning, satisfaction, a feeling of pride, and values for gardeners, and thus encourage feelings of well-being. Community gardens also contribute to strengthening social bonds and community involvement, by providing spaces to interact with friends and relatives and other gardeners. These social and emotional benefits, coupled with the benefits that come with physical activity and eating fresh, unprocessed food, are good for both physical and mental health.

Summary
co-benefits of contact with nature and health

Examples of co-benefits of encouraging contact with nature for health and the environment.

A

Clinical recommendations.

B

Structural measure recommendations.

Conclusion

The current predominant economic model, including healthcare services, which is built based on a productivist logic and short-term yields, is incompatible with a sustainable vision of ecosystems and of our societies. The pressures of planetary boundaries thus pose a challenge to all human activities, including healthcare professionals’ practices – since human health depends on respecting the biosphere’s limits, how do we improve it without contributing to environmental degradation? How to define health and design health services within a framework that fits strictly within planetary limitations? How can the health sector contribute to making our lifestyles more sustainable, including through interventions that are based on the concept of health & environment co-benefits?

The concept of co-benefits recognizes the interdependence of humans and their environment. It combines the short-term and long-term benefits, here and elsewhere, that come with reducing environmental degradation with tangible and short-term effects on public health. This concept-tool could thus encourage individual behavioral changes as well as the implementation of structural measures, with the goal of providing two-fold benefits: improving individual and populational health and reducing environmental degradations.

The concept of co-benefits also questions certain foundational notions in medicine:

1.It leads to approaching “environmental health” from a new angle. The environment is often seen as external to humans, conditioning their health in a one-way manner. The “co-benefits” approach emphasizes the dynamic, two-way nature of this relationship. It invites us to rethink our connection to the environment from a perspective of the interdependence of living beings.

2.Recognizing the interdependence of human health and ecosystem health challenges the very definition of health, given how it is presently reduced to individual biomedical instances, and removed from the individual’s and the population’s environment. Recognizing it also introduces an additional dimension to health, which one might term a “longitudinal” one: what are the costs and benefits of an action on the health of the individual it directly affects, but also on the community, humanity, and the environment, both present and future, both here and at the other end of the planet.

3.It opens up a completely new field of collaboration between disciplines that are hardly used to working together. It requires collaborating to create new understandings and a participative approach that focuses on the actions of health workers, natural and environmental science experts, philosophers, sociologists, psychologists, economists, as well as on political representatives and communities who will need to be active participants in this new approach. It will be a matter of outlining answers to the numerous questions that will necessarily emerge: how will patients and individuals react to this approach? Should caregivers become politically engaged and speak out on linked issues of health and environment? How will healthcare professionals perceive these new roles? What benefits are to be expected for humans and for the environment?

While the concept of co-benefits offers a promising approach, its application in concrete clinical settings requires further research. It is imperative that we gain a better understanding of what interventions would be most effective, and what types of actions to favor, based on the geographic and socioeconomic contexts of patients and individuals. What is more, gaining a better understanding of how different areas of intervention can be articulated in relation to one another could also contribute to mutually strengthening them.

Intersections of mobility, nutrition, and contact with nature through the allocation of public space.

Finally, the full achievement of the concept of co-benefits will be attain in a clinical context only if the intersection of interventions on individual levels and structural levels (legislation, infrastructure, social norms...) is carefully thought out, so as to guarantee the effectiveness of those interventions. Indeed, the effectiveness of promoting certain behaviors is largely limited if structural frameworks and social norms do not also encourage those behaviors.

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