2019

Master Thesis

Consumer readiness towards plant-based consumption in selected Latin American Countries. MARÍA ALEJANDRA BRETTI ROBERT

SUPERVISOR: Associate Professor F.J. Armando Perez-Cueto Eulert Associate Professor Christian Ritz

SUBMITTED ON: 08 august 2019

ABSTRACT

Introduction There is a proved association of mal nutrition in all its forms (obesity, undernutrition and other dietary risks) and climate change (Patterson et al., 2019). In the last report of the Lancet Commissions this concept is defined as “Syndemic” due to the synergy that these three main issues have to each other, and this is a global concern. One of the recommendations to fight this situation is move to a plant based diet (Boer, Schösler, & Boersema, 2013). The awareness in the develop countries is growing and some of them have included environmental sustainability in their dietary guidelines, however on Latin American countries, this evidence seems not to be enough to make real and consistent changes in laws and recommendations to fight this syndemic issue.

This thesis was divided in two parts, first a systematic review with the aim of analyse the literature available published on Latin American countries regarding plant-based diet related to climate change and sustainable diet, and secondly a quantitative consumer survey distributed among selected Latin American countries to determine the readiness of the consumer to move towards a plant-based diet.

Material and methods A quantitative consumer survey was carried out through online program surveyXact and distributed among selected Latin American countries, the questionnaire was developed in Spanish and the distribution was made with help of some collaborators in each country. The sampling methods was a non- probability snowball sampling. The inclusion criteria were defined by people from 15 to 99 years old, residents of the selected countries. The results from the survey were analysed using R and Rstudio® software, applying a fully adjustment model and descriptive statistics.

i Results, discussion and conclusion The sample was composed by 827 respondents from three Latin American countries (BL N=245; BR N=260; CL N=322) with a mean age of 30.21 years old, most of the respondents were females and the majority of them have completed higher education. The sample was mostly composed by omnivorous and flexitarians (over 80% in all three countries).

The subjects were asked if they intended to change their diet to a plant- based diet on a scale of Likert from 1 to 7, and the results show responses with a greater tendency to change, over 5 points in most of the sample. Although most of the respondents were omnivorous and flexitarians, a tendency to have a willingness to change was observed, either to improve health or due to the knowledge of global warming. This indicates that a structural change can be made in the public policies of the countries to generate a real change. The willingness to change diet was positively affected by the higher consumption of fruits and vegetables and negatively affected by the higher consumption of red meat, this finding can be due to the deep-rooted customs of consuming meat in Latin American countries as a main course, consumers have a limitation of conceiving food without products of animal origin as the center of the main dish.

Knowledge also affected the will, the more knowledge regarding global warming and association with diet, the more will to change (BR. p 0.0002).and lastly the more awareness of the benefits of a Mediterranean type of diet increased significantly the will of change (CL. p 0.0004).

The association of knowledge, awareness and willingness to change has been seen in other cultures and gives us hope to make changes in education from childhood, awareness campaigns for the population and educate health professionals to have a more educated and awareness countries, to achieve true changes, not only at the health level of individuals, but also globally to fight the damage that the industry generates in the environment.

ii PREFACE

This report presents the work of a master thesis that acts as the final paper in the conclusion of the Master of Science degree in Food Innovation and Health at the faculty of science at the University of Copenhagen.

The first part of the report systematically reviews the literature published on global warming in Latin American countries, diet, and health, and the second part refers to an online survey among selected Latin American countries to determine the readiness to move toward a plant-based diet.

Associate Professor Federico Jose Armando Perez-Cueto Eulert from the Section of Food Design and Consumer Behaviour, University of Copenhagen, and Associate Professor Christian Ritz from the Department of Nutrition, Exercise, and Sports, Pediatric and International Nutrition, University of Copenhagen, supervised the thesis.

The theoretical part of the thesis was conducted at the Department of Food Science, Section of Food Design and Consumer Behaviour at the University of Copenhagen from February to August 2019.

iii INDEX

ABSTRACT i

PREFACE iii

INDEX iv

LIST OF FIGURES AND TABLES vii

LIST OF ABBREVIATIONS ix

BACKGROUND

Definitions 1

Background 2

SECTION 1 8

Systematic review

Introduction 9

Aim 10

Research question 10

Methodology 11

Results 12

Diet and global warming 16

Plant based diet and health 16

Implication and social motivation of vegetarianism and 17 veganism

Undergraduate thesis 20

Discussion 22

Conclusion 24

iv SECTION 2 25

Online survey and analysis to determine readiness to move towards a plant-based diet in Latin American countries

Introduction 26

Research question 28

Study design

Data collection 28

Questionnaire 29

Data analysis 30

Results

Sociodemographic description of the sample 31

Willingness to move towards a PBD 32

Frequency of consumption 33

Willingness to move towards a PBD influenced by frequency of 34 consumption

Willingness to move towards a PBD influenced by knowledge 35

Willingness to move towards a PBD influenced by awareness 37 regarding GW and PBD

Barriers and facilitators 38

Intention to change diet influence by barriers and facilitator 39

Willingness to change diet influence by barriers and facilitator 42

Barriers and facilitators influence by diet 44

Intention to change diet and motives 47

Intention to change diet and motives for parents 50

v Discussion

The sample 53

Willingness to Move Toward a Plant-based Diet 54

Frequency of Consumption 55

Willingness to Move Toward a PBD Influenced by Knowledge 55 and Awareness Regarding GW and PBD

Barriers and Facilitators 56

Intention to Change Diet and Motives 57

Limitations and strength 58

Conclusion 59

REFERENCES 60

APPENDICES 67

Appendix Nº1 survey 67

Appendix Nº2 commands for Rstudio 72

vi LIST OF FIGURES AND TABLES

Tables Table 1: Methodology 11

Figure 1: Screening of articles 12

Table 2: Analysis of articles 13

Table 3: Analysis of included theses 19

Table 4: Socio demographic characteristics of the sample 31

Figure 2: Willingness to move towards a plant based diet 32

Table 5: Frequency of consumption descriptive 33

Table 6: Willingness to move towards a PBD influenced by frequency 34 of consumption of certain groups of food

Table 7: Willingness to move towards a PBD influenced by knowledge 36 of specific statements

Table 8: Willingness to move towards a PBD influenced by awareness 37 regarding GW and PBD

Table 9: Barriers and facilitators descriptive analysis 39

Table 10: Intention to change diet influence by barriers and facilitator 41

Table 11: Willingness to change diet influence by barriers and 43 facilitator

Table 12: Barriers and facilitators influenced by diet (part 1) 45

Table 12: Barriers and facilitators influenced by diet (part 2) 46

Figure 3: Intention to change to a PBD 47

Figure 4: Motives to change to a PBD 48

Figure 5: Motives to NOT change to a PBD 49

vii Figure 6: Intention to change to a PBD for parents 50

Figure 7: Motives to change to a PBD for parents 51

Figure 8: Motives to NOT change to a PBD for parents 52

viii LIST OF ABBREVIATIONS

• W: Willing. • GW: global warming. • PBD: plant-based diet. • WTC: willingness to change. • A: Agreement. • OCDE: organization for cooperation and economic develop (by their Spanish initials). • UK: United Kingdom. • FAO: Food and agriculture organization of the united nations. • EEUU: United states of America. • LATAM: Latin American countries (by their Spanish initials). • BL: Bolivia. • BR: Brazll. • CL: Chile. • FBDG: food based dietary guidelines.

ix BACKGROUND

Definitions

Before starting, it is important to set some definitions for better understanding of this document.

The association of U.K. dietitians defines a plant-based diet as a diet based on foods derived from plants that include a few or no animal products (Garton & Hood, 2017). However, there is still no consensus about the definition of a plant-based diet. Authors define this as minimally processed food, which includes fruits, vegetables, legumes whole grain, nuts and seed and excludes all animal products (Ostfeld, 2017). For this dichotomy, it is important to not only define the concept of a plant-based diet but also the different types of plant-based diets found in the literature.

In this document, a plant-based diet is defined as follows:

“A diet based on foods derived from plants, such as fruits, vegetables, legumes, whole grains, nuts, and seed, and with few or no animal product include.”

The definition of a plant-based diet comprises many diets, which have been defined as follows:

Veganism: this form of diet excludes all types of animal-derived products from its daily plan (Melina, Craig, & Levin, 2016).

Vegetarianism: this form of diet excludes all types of flesh foods, such as meat, poultry, and seafood (Baroni, Goggi, & Battino, 2018).

Pescetarianism: this form of diet contains fish or seafood, but no meat (Dagnelie & Mariotti, 2017b).

Ovo-Lacto vegetarianism: this form of diet includes dairy and eggs, but no meat, poultry, or seafood (Garton & Hood, 2017).

1 Flexitarianism: reduction of meat consumption to a healthy diet once in a while. This form of diet is the most difficult to define due to the “occasional” inclusion of meat products from once in a month to three times per week; therefore, it is important to define the cut-off point in this particular category (Dagnelie & Mariotti, 2017b).

Background There is a proved association between malnutrition in all its forms (obesity, undernutrition, and other dietary risks) and climate change (Patterson et al., 2019). In the last report of the Lancet Commissions this association has been defined as “syndemic” which means a synergistic epidemic cause for more than 2 population problems. In this case, malnutrition and climate change have synergy strongly proved and is affecting the way of living in many places and for many people, therefore this is today a global concern. The lancet commission report presented a list of recommendations to resolve the current problem and found moving toward a plant-based diet as a feasible solution (Boer et al., 2013).

Over the last decade, awareness of the impact of the food industry has become more transparent. The food industry is responsible for 18–31% of the greenhouse emissions: the animal husbandry sector is responsible for 18% (Patterson et al., 2019; Steinfeld et al., 2009), and the rest is attributed to other kinds of food industries. United Nations declare that the world´s population will grow to 9,8 billion people by 2050, this means 30% more individuals than today. This growing will rise the demand for foods, particularly meat, dairy and crops (Food and Agriculture Organization of the United Nations (FAO), 2009). The food industry is responsible for 18–31% of the greenhouse emissions: the animal husbandry sector is responsible for 18% (Patterson et al., 2019; Steinfeld et al., 2009), and the rest is attributed to other kinds of food industries. It is estimated that greenhouse emissions will rise up to 150% of current levels by 2030, (Chai et al., 2019) Therefore, the animal food sector has proven to have a greater environmental impact than other food industries (Benedetti, Laureti, & Secondi, 2018). This is why is an urgent issue find a way to mitigate the current impact of the actual food system. A sustainable diet rises as an alternative to fight the current food system, sustainable diet is one with low environmental impact,

2 protective and respectful of biodiversity and ecosystems, and is nutritionally adequate, safe, healthy culturally acceptable and economically affordable (Chai et al., 2019). And has been proved that this type of is more environment-friendly due to their use of fewer natural resources (Melina, Craig, & Levin, 2016).

The animal food sector impacts the environment due to: 1) normal gas emissions from animals and manure, 2) cultivation of feed crops and pasturing, 3) deforestation of grasslands (for cultivation of feed crops for animals), 4) water use, and 5) transportation and processing of animals, among others (Boer et al., 2013; Raphaely & Marinova, 2014). This uncontrolled growth of the consumption of meat products along with the industrialization of production has led to the steady growth of gas emissions. If developing countries continue following the trend of increasing meat consumption, as they increase their economy, a doubling of animal production will be required by 2050 (Steinfeld et al., 2009).

Since 1991, energy demand has increased to 46% and the rate of gas emissions to 44% due to urbanization, globalization, and economic growth worldwide (Raphaely & Marinova, 2014). These factors also increase the demand for animal products (Nadathur, Wanasundara, & Scanlin, 2016). In Europe, the main source of protein come from meat (Davis, Sonesson, Baumgartner, & Nemecek, 2010) while, in western countries, meat is regarded as a key ingredient for healthy and balanced diets, holding a central position in meals and social relationships (Niva, Vainio, & Jallinoja, 2017). Moreover, meat consumption has risen from 29.6 kg per capita per year in 2000 to 34.4 kg per capita per year in 2017 worldwide according to the OCDE report of 2018. However, the paradigm today is changing, and it has been proven that food consumption and dietary patterns are associated with the quality of life and the environmental impact (Benedetti et al., 2018). In UK 25% of the population had been declared that his meat consumption has been reduce in the past few years and 34% indicate a willingness to eat less meat. In EEUU 37% of the adults declare that they order vegetarian meals when eating out. This numbers just from the UK and EEUU exhibit some degree of plant- based dieting for more than hundred million people (Rosenfeld & Burrow, 2017).

3 On the other hand, the animal food industry also has a direct impact on human health. There is growing scientific evidence confirming the correlation between animal food products and type two diabetes, cancer, and heart diseases (Raphaely & Marinova, 2014; Pino, Cediel, & Hirsch, 2009; Rojas, Figueras, & Duran, 2017; Melina et al., 2016). In 2011, the “world cancer research fund” recommended to limit the intake of red meat to less than 500 g per week and completely avoid processed meat (AICR & WCRF, 2018). Data provide for FAO about the different countries and regions of Latin America show that the higher the income of the families, the higher the consumption of animal products, processed food, which leads to a high density diet, unhealthy and creating an ideal environment for the develop of different diseases, such as cancer, diabetes, obesity and heart diseases (Uauy, 2015).

In Latin American countries, according to the data obtain on the statistical institute of each studied country, the consumption of meat or animal product exceed for much the recommendations of the world cancer research fund mentioned before. In Chile the consumption of flesh meat is 8.,1kg/year per person being men with the highest numbers. Young people between 14-16 years old had the highest consumption of proceed meats with a mean of 44 g/day. The evidence showed before, could explain the obesogenic stage of the country with a 74.2% of the population in overweight or obesity and the increasing numbers of diabetes type 2 and hearth diseases (www.ine.cl). In Bolivia the consumption of flesh meat is 66.48 kg/year and the government assure that that number will rise with the years and the rising economy ( www.ine.gov.bo). Brazil on the other hand is a greater consumer of flesh meat and also a worldwide exporter of meat and crops for the food industry. The consumption per capita per year is 97 kg of flesh meat on 2017 (https://www.ibge.gov.br/). For Latin American countries, the impact of the animal industry is not restricted to the amount of meat consumed per person per year, it has to do, also with the amount of land used to cultivate the crops to feed the animals bred in Europe. Approximately, 70–80% of the feed for animal farms in Europe is imported from Brazil and Argentina (Davis et al., 2010). The production of soya in South America increases the rates of deforestation, soil erosion, and gas

4 emissions, mainly due to the transport of this crop to the final destination (Fearnside, 2008).

As suggested in the previous paragraphs there is a strong evidence that shows that dietary patterns that have low environmental impact also are link to good health. However despite all the evidence most of governments do not take action •The best way for governments to do something on the subject is develop a food based dietary guidelines (FBDGs) concentrate on heath and sustainability objectives (Gonzalez Fischer & Garnett, 2016). A report published by FAO and made for the food research climate network at the university of Oxford found that not all countries have official FBDGs, of any kind, their absence may be link to low income countries. Regarding FBDGs that integrate dietary approaches of sustainability, only four countries where found: Brazil, Sweden, Qatar and Germany. On the other hand, EEUU and Australia have had attempt to include environmental consideration but with no endorsement of the government finally. Other countries as UK, France, Netherlands and Estonia Have non-official guidelines that incorporate sustainability (Cleveland & Gee, 2017) (Gonzalez Fischer & Garnett, 2016). However as is described, this awareness by Latin American countries is not enough; the will of different governments to change laws or recommend fighting this syndemic issue is not consistent with the changes observed around the world. To be able to create systems that promote sustainability, growth and equity national policy plays a critical role, removing barriers and shaping the field with standards for national and local action (Rawe et al., 2019). If the goal is to improve the actual situation of global warming, obesity, and other diseases, it is important to generate awareness about real changes all over the globe.

The last global trends identify by FAO are according to many of the issues described above. One of them is the on growing population, which will increase the demands of the agricultural sector by 2050 by 50% compared to 2013 (Food and Agriculture Organization of the United Nations, 2017). To satisfy agricultural demands food industry will grow and increase the competition for natural resources, the productions of greenhouse gas emissions and therefore further deforestation and land degradation (Sanchez-Sabate & Sabaté, 2019). This trends represent a series of challenges for the food industry and the governments

5 trying to find innovative systems of production that protect and enhance the natural resource base, while increasing productivity (Rawe et al., 2019).

With all the evidence on set, it is important now, look from the consumers perspective and how governments, dietitian’s and public health campaigns can contribute to make this transition more effective for the good of the environment and the populations health. Food consumer behaviours are result from strongly held factors like taste preferences, culinary traditions and social norms (Sanchez- Sabate & Sabaté, 2019) and some evidence found that a large part of the population is not ready to move to a plant-based diet (Lea, Crawford, & Worsley, 2006a). However different authors have found evidence that certain groups are more willing to change, for example, females, older people and higher-level education are more likely to try a healthier diet (Lea et al., 2006a). Among college age students is becoming very popular to choose a plant-based food in their daily meals (Wyker & Davison, 2010) and in EEUU 37% of the adults declare that they order vegetarian meals when eating out (Rosenfeld & Burrow, 2017). The motivations to change can be diminished by the influenced of cultural and social values and by related habits and routines (Austgulen, Skuland, Schjøll, & Alfnes, 2018) but also can be motivated by the prosocial aspects , personal aspects and moral goals of each individual (Rosenfeld & Burrow, 2017).

According to the theory of the stage of change, there is 5 separate stage for complete a behavioral change of the consumers (1) precontemplation, (2) contemplation, (3) preparation (4) action (5) maintenance (Prochaska et al 1992). In this case of changing to a plant based diet consumers on the precontemplation stage have been found more barriers than benefits for fruits and vegetables consumption, this means that they are not ready or even consider to change, on difference from the consumers on contemplation stage or others more advance (Lea et al., 2006a). Just few studies have explored willingness to reduce meat intake and how can consumers can move on the stages of change to create an impact on the food industry and revert the global warming (Sanchez-Sabate & Sabaté, 2019).

6 This thesis aims to evaluate the readiness to move toward a plant-based diet among different Latin American countries and measure the awareness and knowledge regarding environmental issues of diet and health benefits of changing the diet plan to a plant-based diet. The section 1 of the report consists on a systematic review to investigate the material available about published Latin American scientific magazines in Spanish, and the section 2 consists on a consumer study composed by an online survey that was conducted in selected Latin American countries to determine the readiness to move toward a plant- based diet of that population.

7 SECTION M

SYSTEMATIC REVIEW

8 Introduction

The impact of people, diet, and the food industry on climate change and greenhouse gases is very clear nowadays (Boer et al., 2013). To globally impact the reduction of climate change, a change in diet, switching from a traditional western diet to a plant-based diet, reducing or completely avoiding animal products, is recommended (Pérez-Cueto, 2015). There is a strong evidence that shows that dietary patterns that have low environmental impact also are link to good health (Chai et al., 2019) but, this data is mainly obtain from develop countries which not always reflect what is happening on the developing countries or countries with less income. Data provide for FAO about the different countries and regions of Latin America show that population in Latin America is increasing the income of the families and the globalization of the population is creating a change in the population (Food and Agriculture Organization of the United Nations, 2017) the increasing on the salaries have change the way that food is consumed and the life style of the population. Generally is described the higher the income the higher the consumption of animal products, processed food and sugar, fat and salt contain in this product, which leads to a high-density diet unhealthy and creating an ideal environment for the develop of different diseases (Uauy, 2015) this can explain the raising numbers of diabetes type 2, hearth diseases and obesity among the population.

This systematic search was carried out to identify, understand, and analyze the material available in reliable search pages related to plant-based diets and the relationship it has with climate change and the effects on the health of individuals, to further investigate and create real changes on the public policy, consumer behaviour and public health for the population of Latin American countries.

9 Aim

The aim is reviewing the literature available published on plant-based diets in Latin American countries, whether vegan or vegetarian, related to climate change, reduction in the emission of greenhouse gases, and the effect of these forms of diet on the health of the individuals.

Research question

¿Is there a reliable material published in Spanish, in scientific journals in Latin America, which is related to plant-based diet and climate change Which would help to set the scene or that would be neglected by reviewers excluding papers in Spanish?

10 Methodology

A review of the literature published in the search engines SCIELO, which is host of different data bases and journals in Spanish and Portuguese, mostly, that could be compared to web of science but from Latin America and Google Scholar was carried out using the keywords (below), creating combinations among them to achieve as many articles as possible; only articles in Spanish were selected and created or published in Latin America. Once the results of the databases were obtained, the duplicate articles were removed, the rest analyzed, and the non-relevant ones removed from the database.

Articles published after February 2019 were not included in the search.

Table 1. Methodology Keywords Inclusion criteria Exclusion criteria

1. Global warming -Publications in Spanish -Studies carried out on

2. Sustainability Study the population in animals

3. Diet Latin America -Livestock studies 4. Health -Articles published since -Publications found on 5. Sustainable diet 2005 unreliable sites. 6. Ethics 7. Vegan / Veganism -Articles related to the 8. Vegetarian / research question Vegetarian -Publications in scientific 9. Greenhouse effect journals gases 10. Latin America

The information extracted from each document includes the purpose of the publication and a summary of it in addition to the basic information, such as the name of the authors, the year of publication, and the place of publication. The articles were arranged by the year of publication and analyzed.

.

11 Results

Figure 1. screening of articles

Sistematic review

Articles in scielo Articles in GOOGLE Articles added by the (n=57) SCHOLAR (n=98) author (n=2)

Remove after Remove after screening of screening of repetition (n=3) repetition (n=3)

Articles not related or Articles not related or don´t match inclusion don´t match inclusion criteria (n=44) criteria (n=81)

Articles for first Articles for first analysis (n=10) analysis (n=14)

Articles removed Articles removed (n=5) (n=12)

Articles for final Articles for final analysis (n=5) analysis (n=2)

A total of 155 articles were found in both the search engines after a preliminary analysis: reading the article content, determining if the articles meet the inclusion criteria and the research topic, and verifying they are published in renowned scientific journals. Only 7 articles met the final inclusion criteria and were found to be related to the relationship between global warming and a plant- based diet.

In addition, the author selected two undergraduate theses related to the main topic using the search engine of the same university.

12 Table 2 Analysis of Articles Title Countries Author Year Publish Aim Summary or region

Intake of food of animal Chile Ángela Pino L., 2008 Chilean To understand the The western diet is characterized by high consumption of origin versus plant Gustavo Cediel Journal of published studies of food of animal origin, and this is associated with an increased origin and G., and Sandra Nutrition mortality and risk of diabetes mellitus 2 and high blood pressure. cardiovascular risk Hirsch B. cardiovascular risk

related to food intake of

either plant or animal origin.

Sustainable and healthy Chile Federico J.A. 2013 Chilean To Observe the It is well known that the agricultural sector contributes 10- diet? Retrospective and Pérez-Cueto Journal of development of the 12% of gas emissions greenhouse effect and the demand for implications for public Nutrition concept of sustainability food is expected to increase in the coming years. That is why health in the diet and identify a reduction in the consumption diet of products of animal

barriers to the adoption origin can contribute to the reduction of these gases. Latin of this type of diets for America has the advantage that more traditional diets are the population primarily based on plants and legumes, so it is recommended is to go back to the roots to help reduce global warming

Food knowledge of Chile Jerusa 2013 Chilean Determine the The main reasons why the respondents chose their Chilean vegetarians and Brignardello G. Journal of motivations of individuals respective diets were determined: the main cause includes vegans Lisu Heredia P. Nutrition to follow a vegan or ethical and moral principles related to animal abuse followed María Paz vegetarian diet and the by health-related issues. On the other hand, a majority of the

Ocharán S. knowledge they have respondents were informed by the Internet and a minority And Samuel regarding to the food went a specialist regarding their diet. This is why health Durán A. they carry. personnel can guide and help people in the most appropriate way.

13 Psychological meaning Mexico Ligia Maria 2013 Mexican Understanding the This study investigates the perception of subjects regarding of eating meat, Orellana, José ́ Journal of psychological meanings the concept of vegetarianism and its specific attributes, vegetarianism and Andrés Eating that involve eating meat positive or negative. The concept of vegetarianism was found healthy eating in Sepúlveda, and Disorders or being a vegetarian in to be positively associated with health and negatively university students from Marianela university men and associated with sickly. It also highlights the dynamics in natural semantic Denegrí. women genres and the different conceptualizations that define each networks concept

Nutritional advantages Chile Daniela Rojas 2017 Chilean Show recent evidence on Plant-based diets has increased the number of adherents in and disadvantages of Allende, Journal of the benefits and risks of recent years in Western countries. This type of diet is being vegan or Francisca Nutrition vegan or vegetarian diets considered as balanced and healthy, but still generates vegetarian Figueras Díaz, in chronic mistrust in the world of current nutrition for potential

Samuel Duran noncommunicable problems of nutrient deficit. The document describes the Agüero. diseases and in the life critical nutrients in the different stages of the life cycle and cycle the benefits that the adoption of this type of food could have on the health of people.

Vegetarians on Argentina Maria Marta 2017 Journal of Identify and analyze the Qualitative interviews were conducted to determine the Córdoba: a qualitative Andreatta Science and types of vegetarianism diets followed and the motivations of it. The main diets found analysis of practices Technology and their motivations were the flexitarianism, vegetarianism and veganism and and and motivations of the 21st that subjects have to each one with its derivations and personal adjustments. The Carolina M. Century adopt this type of diets main reasons for adopting this type of feeding were animal Camisassa Business empathy, care of the environment, spiritual beliefs and

University health.

14 The water footprint and Mexico Lares-Michel, 2018 Mexican Determine the Along with environmental problems and water scarcity, its relationship with Mariana; system of Relationship between the today Mexico today is facing with a nutritional crisis due to obesity in Mexico Housni, Fatima research in water footprint, the the epidemic of malnutrition due to excess. The food Ezzahra; psychology epidemic of obesity and transition that has been exposed in the last decades changing Aguilera the environmental impact the "traditional" rural diet for a more modern "western" diet

Cervantes, of these in Mexico is the main cause of the latter problem that affects and Virginia cooperates with the first two problems mentioned above,

Gabriela; the environmental and water scarcity. It is suggested that the Michel Nava, development of a hydraulically sustainable diet can have a Rosa María; y positive impact on the reduction of overweight and obesity, Barragán in addition to the environmental impact Carmona,

Maria del Carmen

15 Although only two articles follows to the aim of this review, regarding sustainable diet and its implications (Pérez-Cueto, 2015) and water footprint and how it relates to the health of people (Lares-Michel, Housni, Aguilera Cervantes, Michel Nava, & Barragán Carmona, 2018). The other articles included, have some relation to the subject.

Diet and global warming The article of Lares-Michel of 2018 mentions that although FAO develops and promotes sustainable diets for both health and the environment, water footprint (WF) is not considered as the main factor within the indicators to be measured and can be considered as a sustainable diet. Regarding the measurement of WF of the most common diets, it is known that an omnivorous diet has higher WF than a vegan or vegetarian diet (Rosi et al., 2017). It is also known that the reduction of calories from a diet decreases the WF (Tom, Fischbeck, & Hendrickson, 2016). Keeping this in mind, the document concludes that a diet low in WF can contribute to the health of people and, also, the environment.

Pérez-Cueto mentions in his document the impact of the food industry of animal products on greenhouse gases and how the coordinated reduction of consumption of this type of food greatly benefits public health and the environment. Sustainable and healthy diets benefit everyone—the environment, the individual, and the public health system—since cardiovascular diseases are reduced—diabetes mellitus type 2 and some types of cancer (Pino et al., 2009; Melina et al., 2016; Rojas et al., 2017). In addition to the reduction of greenhouse gases (Sabaté & Soret, 2014), the author also emphasizes the responsibility of health professionals, specifically nutritionists, to promote balanced, sustainable, and healthy diets mainly to ensure a better quality of life, in the broadest sense of the word, for the individual, the population, and the planet Earth.

Plant-based diet and health In relation to the benefits or contraindications of plant-based diets on the health of people, the article published in 2017 determined the advantages and disadvantages of a vegetarian-vegan diet from a nutritional point of view (Rojas et al., 2017), identifying the needs of nutrients through the life cycle and the effects on health. The authors conclude that a vegetarian diet is rich in fiber,

16 vitamin, mineral, and polyunsaturated fatty acid that contributes to good health. However, it is very important to implement a vegetarian diet properly with the guidance of a nutritionist to avoid deficiencies of macro or micronutrients and to adjust to the nutritional requirements according to age, metabolic status, or the stage of the life cycle.

With regard to cardiovascular risk related to the consumption of animal and vegetable origin foods, the authors affirm the scientific evidence that exists about the role of diet on the health of people. The nutritional recommendations are based on the increase of food of vegetable origin and the decrease of food of animal origin. The high consumption of polyunsaturated fatty acids is associated with a reduction in cardiovascular risk, which is ultimately associated with a decrease in mortality.

Implications and social motivations of vegetarianism and veganism In relation to the motivation to follow a plant-based diet, its meaning at a social level, and our knowledge about this type of diet, we have found three articles.

Regarding understanding the meaning of eating meat versus being a vegetarian, it has been found that meat is regarded a symbol of hierarchy and domination both in nature and related to gender, since red meat, especially, is associated with masculinity and power while plant-based diets are associated with femininity and weakness (Orellana, Sepúlveda, & Denegri, 2013). Despite this, vegetarianism is considered as healthy.

When trying to understand the ways to motivate people to follow this type of diet, a qualitative study conducted in Cordoba, Argentina, showed that there are three major areas of motivation to change or maintain a vegetarian or vegan diet: empathy toward animal suffering (ethics), the care of the environment, and health. It is also important to note that this study in particular associates a vegan diet more strictly with ethics and less strictly with health reasons (Andreatta & Camisassa, 2017).

Regardless of the motivations that have led individuals to follow this type of diet or lifestyle, it is necessary to follow the advice of a professional in order to avoid any type of deficiency; since the benefits of the above have been

17 demonstrated, this diet should be health balanced (Walsh, Hebbelinck, Deriemaeker, & Clarys, 2017). A study conducted in Chile found a lack of knowledge of vegetarianism and veganism in most of the respondents and that the main source of information for them is the Internet, in forums or pages, thus giving them low confidence and keeping them less prepared for a balanced and healthy diet.

18 Table 3 Analysis of included thesis Title Countries or Author year Publish Aim Summary (results) region Application of Mexico Georgina 2014 University of the To inform and The author researched and analyzed the sources nutrition in Hernández Piña State of Mexico. To guide about found for each aspect of nutrition and sustainability. sustainable nutrition apply for a nutrition and and explaining the role of the nutritionist in and the role of the bachelor's degree healthy eating and sustainability. The professional can be involved in all nutritionist in caring in nutrition the role of health the chain of food and his role should be find for the environment professionals with alternatives to enhance and improve the actual

regard to caring food system for one more sustainable. On the field

for the of public health, the nutritionist should be oriented environment, and teach to the population to eat in a more through a sustainable way and not let them be influence by bibliographic the industry of highly processed foods. review. Recommendations Ecuador Claudia Salomé 2017 University San The purpose of the These days there are many crises that can be for a sustainable and Torres Caiza Francisco de Quito work is to propose related to one another in different ways: healthy diet as a USFQ. To apply for recommendations overweight and obesity, climate change, loss of support to the a bachelor's for access to a biodiversity, poverty and food waste. All these elaboration of degree in nutrition sustainable and problems generated the creation of a sustainable, Ecuador food guides healthy diet in healthy and affordable diet by FAO. Today in

Ecuador through Ecuador the GABA is under construction and it is food-based dietary fundamental that these guides for the population guidelines using have the sustainability criteria that are being the NOVA food promoted in different countries of the world and classification. contextualized to the reality of the country. Therefore, the author of this document creates a list of 9 recommendations for a sustainable diet according to the reality of the country population.

19 Undergraduate theses The author found it relevant to add some undergraduate theses as a source of information which, although have not been published in renowned journals, have been published in the databases of Latin American universities. Young professionals are taking steps to carry the issues of a plant-based diet and global warming to information networks to create more awareness and to bring about a change.

Table 3 shows the summary of undergraduate theses. The thesis carried out in the Autonomous University of the State of Mexico is a review of the literature found explaining the role of a nutritionist in sustainable nutrition, details the role of the nutritionist in each area of performance of the profession in relation to sustainability and how the professional can promote sustainability (Hérnandez, 2014). It has been identified in the collective food area as an area of great influence since, in this area, the nutritionist is responsible for distributing meals to a certain group of people; therefore, the professional can nudge a sustainable consumption by ensuring sustainability throughout its chain of processes, from the original raw materials to the final product that is delivered to the consumer, going through the entire production line. In clinical nutrition, direct contact with the patient allows the professional to provide sustainable recommendations for each individual. And finally, the incipient incorporation of the nutritionist in the food industry is an advantage to promote sustainability in the diets, since the professional can be directly involved in the development of new products that go follow the principles of sustainability.

At the University of San Francisco in Quito, Ecuador, a student completed her undergraduate thesis with the aim of generating suggestions for constructing a new food-based food guide (GABA by the initials in Spanish) of Ecuador and based on the recommendation for a sustainable and healthy diet (Torres, 2017). Ecuador is a country with a growing population of overweight and obese people, but also face problems such as malnutrition and low birth weight. This reality is not far from the rest of the countries in Latin America. The current diet comprises mostly of ultra-processed foods, meats, dairy products and, to a lesser extent, less processed foods, such as fruits, vegetables, and legumes, making it a nutritionally inadequate diet, which places the individual at the risk of chronic

20 diseases. This type of feeding, moreover, is related to a greater environmental impact (Röös, Karlsson, Witthöft, & Sundberg, 2015). In this document, the author took advantage of the opportunity to build GABA in Ecuador in order to recommend a sustainable diet, thus improving the quality of life of individuals and reducing the environmental impact of the current diets in Ecuador. The recommendations are similar to those given in Uruguay and in Brazil for their respective populations. Some of the suggestions are as follows: (1) basing food on minimally processed, local, and seasonal products; (2) avoiding consumption of food rich in sugar, salt, and fat (ultra-processed); (3) preferring cooking food at home and sharing it with family and friends; (4) reducing the consumption of red meat and fish; (5) if you are going to consume fish, prefer small national producers; (6) reducing the consumption of dairy products and replacing them with other products rich in calcium or vegetable beverages; (7) knowing where your food comes from and be critic with the advertising of new products. In addition, these recommendations not only point to food directly but also the lifestyle, such as reducing the use of plastics, using reusable bottles, and reducing food waste. It is also important to emphasize sharing food with family and friends gives the meal a deeper than merely nutritional essence.

21 Discussion As mentioned in the recent report published by the Lancet Commission today, climate change, obesity, and malnutrition are firmly linked (Patterson et al., 2019). Therefore, we cannot talk about a plant-based diet without talking about its benefits regarding health, such as reducing cardiovascular risks (Williams & Patel, 2017), controlling diabetes (Melina et al., 2016), and reducing the risk of some types of cancer (Dagnelie & Mariotti, 2017a). It also has benefits that can improve or delay climate change, reducing the emission of greenhouse gases (Hallström, Carlsson-Kanyama, & Börjesson, 2015).

Diet and global warming:

Two articles found in this search related to both the topics show the need for more publications in Spanish in Latin American scientific magazines on a subject that are not only trending worldwide but is also one of the most important major concerns for most sectors (Nadathur et al., 2016). Publications of journals in English or other languages have far more studies, reviews, and opinion columns compared to those found in Latin American magazines.

Plant-based diet and health.

As mentioned earlier, one cannot talk about a plant-based diet without mentioning its positive effects on health (Pino et al., 2009; Melina et al., 2016; Rojas et al., 2017). The articles analyzed in this review (n=2) point to a bibliographic review of the benefits and disadvantages of a vegetarian diet for the health of individuals; however, there is no published clinical study conducted in Latin American countries, written in Spanish and published in scientific journals to better understand the reality of each country.

Implications and social motivations of vegetarianism and veganism.

The articles found in this area (n=3) address the most social aspect of plant-based diets, as perceived individuals who follow this type of diet or their peers, Plant-based dieters see their diets as a definition of their identity (Rosenfeld & Burrow, 2017). For society, meat or food of animal origin is still related to hierarchy and domination of male and plants mostly found to be associated with femininity (Orellana et al., 2013). Therefore in western societies

22 meat-based diets are the norm and vegetarians or vegans are the exception (less than 5% of the population in UK and EEUU) (Sanchez-Sabate & Sabaté, 2019).

In this subject, we also find the motivations to change diet, the most relevant of which are ethics, the environment, and health (Andreatta & Camisassa, 2017). These reasons are similar in different countries and authors can find many different motives to follow a PBD. The most commonly reasons include animal ethic, personal health, environmental concern, religious beliefs and some other less common are weight loss, taste, saving money and political matters (Rosenfeld & Burrow, 2017).

A study made in Sweden to understand the attuites of vegetarians and PBD (Corrin & Papadopoulos, 2017) show that Vegetarian diet can be perceived more positive than vegan diet for the consumers, however, vegan diet can be perceived as healthier. Among the consumer the strongest perceived barriers to adopt a plant-based diet is the enjoyment of eating meat (Corrin & Papadopoulos, 2017), and even thought studies have found that a large part of the population is not ready to consume a plant-based diet (Lea et al., 2006a) other studies have found that Values and attitudes towards climate change can be predictors of willingness to reduce meat consumption and choose more sustainable products (Austgulen et al., 2018).

Undergraduate thesis The documents found as undergraduate thesis (n=2) were analyzed separately since they are documents with much more material than an article, and although they are directly related to the topic of diet and global warming, we prefer to analyze them separately. They highlight the role of the health professional in the care of the environment in each of their areas of performance, making it fundamental today to train nutrition professionals on global warming and his relation with diet to make a real impact on the population (Hérnandez, 2014). In the second document analyzed, suggestions are made to change the nutritional recommendations of Ecuador in order to bring about a more sustainable and healthy diet plan (Torres, 2017). A recent study (2016) made a screening world-wide about the food based dietary guidelines (FBDGs) concentrate on heath and sustainability objectives, this research found only four

23 countries had integrate dietary approaches of sustainability, Brazil, Sweden, Qatar and Germany. These included theses bring a light of hope to the new changes. It needs to be understood that the professional nutritionists who are walking on a professional path are worried and are generating initiatives to ensure a change toward a more sustainable and healthy diet.

Conclusion The articles found and analyzed in this bibliographical review are insufficient. It is essential that the scientific teams of Latin America mobilize and conduct studies and publications that can support the symbiosis that exists between climate change and people’s health in order to generate changes in public policies that follow the reality of Latin America.

Undoubtedly, literature published around the world is essential as a base; however, studies need to be conducted in the real local population in order to adjust to the indices of each country and its local reality. It is advised not to use the recommendations for developed countries in the case of developing countries, as their economy, disposition of breath, and geography are completely different.

Although some Latin American have shown progress in trying to change public policies, these actions may be insufficient to generate changes in health and global warming.

24 SECTION C

Online survey and analysis to determine readiness to move towards a plant-based diet in Latin American countries.

25 Introduction

The influence of food choice and the food industry on global warming and greenhouse gas is clear—if we do not bring about a positive change now, climate change and its negative impact will move forward (Boer et al., 2013). Many studies have been published on this subject among European countries; however, in Latin American countries, reliable information published is limited.

Promoting consumers shifting their food consumption towards a plant- based diet has been suggested as a key element to tackle climate change (Pérez- Cueto, 2015). Therefore, it is important to study the population and measure their readiness to change their habits and move forward to a plant-based diet in order to create a global effect and make a real impact on fighting climate change.

According data found on the last OCDE report of 2018 meat consumption has risen from 29.6 kg per capita per year in 2000 to 34.4 kg per capita per year in 2017 worldwide. This demand on the animal food industry could rise by the 2050 (Steinfeld et al., 2009). However, the paradigm today is changing, and consumers are shifting diets and nutrition patterns (Benedetti et al., 2018). In UK 25% of the population had been declared that his meat consumption has been reduce in the past few years and 34% indicate a willingness to eat less meat. In EEUU 37% of the adults declare that they order vegetarian meals when eating out. This numbers just from the UK and EEUU exhibit some degree of plant- based dieting for more than hundred million people (Rosenfeld & Burrow, 2017). The drivers for this change rely in many factors the most relevant of which are ethics, the environment, and health (Andreatta & Camisassa, 2017). These relevant reasons are similar in different countries and across studies and authors can find many different motives to follow a PBD. The most commonly reasons include animal ethic, personal health, environmental concern, religious beliefs and some other less common are weight loss, taste, saving money and political matters (Rosenfeld & Burrow, 2017).

Latin American countries are currently undergoing economic growth, and the consumption of animal-based food has been growing steadily (Godfray et al., 2018). The increasing salaries salaries have changed the way that food is

26 consumed and the life style of the population, on the past few years has been seeing an increasing on the consumption of highly processed foods, with high energetic content, full of sugar, fat and salt. The evidence also show that the consumption of whole grain cereals, fruits, vegetables and legumes has been decreased in the past years. The final result of all these changes combined, is an increasing on the obesity, hypertension and diabetes, some types of cancer and osteoporosis (Uauy, 2015). According to the data obtain on the statistical institute of each studied country the consumption of meat or animal product exceed for much the recommendations. In Chile the consumption of flesh meat is 89,1kg/year per person being men with the highest numbers (www.ine.cl). In Bolivia the consumption of flesh meat is 66,48 kg/year and the government assure that that number will rise with the years and the rising economy ( www.ine.gov.bo). Brazil on the other hand is a greater consumer of flesh meat and also a worldwide exporter of meat and crops for the industry. The consumption per capita per year is 97 kg of flesh meat on 2017 (https://www.ibge.gov.br/).

It is important to clarify the market of plant-based diets and conduct further studies to initiate a change in the population or, even more, in the public policies, to encourage the consumption of plant-based diets and decrease the amount of animal products consumed by the population today, not just regarding global warming but also regarding all the health benefits following a plant-based diet.

This exploratory study was performed in three different counties of Latin America, selected for their position on the geography of the continent, their position on the map allow us to have a global view of Latin American countries from north to south, and from interior land and coast. In addition, the study was performed with collaboration of well positioned universities in each country and for further participants also was used social media. This is a pioneer study from consumers across Latin America therefore the findings can be used as platform for other studies to increase the research on PBD and climate change.

27 Research question

How ready are consumers in Latin American countries towards adopting a plant- based diet?

• Which is the role of the awareness, knowledge and frequency of consumption towards the willingness to adopt a plant-based diet associated to socio demographic characteristics? • Which are the main barriers and facilitators responsible for move towards a plant-based diet in Latin-American countries • Which are the reasons involved for considering whether or not to change the diet? • Which are the reasons involved for considering whether or not to change the diet on family parents?

Study design

Data collection A quantitative consumer survey was carried out through the online program surveyXact and distributed among selected Latin American countries. The survey was pretested in order to check the layout and gain an understanding of it. The questionnaire was developed in Spanish and Portuguese (the native language).

Data was collected in university classrooms via social media and online services with the help of collaborators in Bolivia, Brazil, and Chile. The selected sampling method was a non-probability snowball sampling. The inclusion criteria were defined by 15 to 99-year-old residents of selected countries. The results from the survey were exported to Excel for further analysis, and segmentation was conducted using the R and Rstudio® software.

28 Questionnaire The survey was elaborated in Spanish and Portuguese. An unofficial English translation of the questionnaire is enclosed in Appendix Nº1. The average time to answer is 5–10 mins and consists of 16 questions. At the beginning of the questionnaire, the definition of a plant-based diet is given:

“a plant-based diet is a diet that includes mostly fruits, vegetables, legumes, and cereals, ideally food minimally processed. Low amount or no presence of food form animal sources (meat, chicken, pork, fish, dairy, or eggs)” (Garton & Hood, 2017; Ostfeld, 2017)

The first part of the questionnaire focused on the sociodemographic aspects of the respondent, such as country (Bolivia, Brazil, or Chile), gender (female or male), age (y), education level (elementary, secondary, or superior), residential area (rural, semi-urban, or urban), household members, and presence of children in the household.

The second part of the survey started off with the type of diet, the frequency of consumption for different types of food groups, one question about knowledge, one question about awareness, and one question on barriers and facilitators to follow a plant-based diet.

The third and last part of the questionnaire comprised the dependent variables of the research question asking about the willingness and the intention to change to a plant-based diet considering health and environment care, and one question was based only for parents regarding the intention to change the thinking of their children and improve the health of the whole family and the environment for the future of their kids.

29 Data analysis After gathering all the respondents, the data was exported to Excel, cleansed and made suitable for data analysis using the R and Rstudio® software.

The data erased surveys that were incomplete and did not meet the inclusion criteria. To make the database suitable for analysis, recodes were incorporated into the answers, granting the knowledge questions based on whether they were correct or not to perform a knowledge score. The frequency questions were assigned a score according to the chosen frequency to obtain an average of the consumption.

First, descriptive statistics was applied: proportions and percentages were used for categorical data, means, and standard deviations to describe continuous symmetric data, and medians and IQRs for skewed data.

The respondents were analyzed by the countries Bolivia, Brazil, and Chile and profiled using logistic regression models when the dependent variable was dichotomic and linear regression when the independent variable was a scale.

The above mentioned two logistic regression models were fully adjusted to the parameters of age, gender, educational level, residence, and type of diet.

For each analysis, an odds ratio (OR) and a confidence interval (CI) were computed; also, the p-value, which is considered statistically significant when lesser than 0.05, was calculated.

30 Results Socio demographic description of the sample Table 4 shows the socio-demographic characteristics of the sample, which consists of 827 respondents who completed the survey from three different Latin American countries (Bolivia, Brazil, and Chile). As shown in Table 1, Chile was found to be the country with the maximum number of respondents (N 322). The mean age of the participants for Brazil and Chile was over 30 years and for Bolivia lower than 22 years. Most of the respondents were female in all three countries, and a majority of them had completed higher education. The largest number of respondents resided in urban locations in all three countries. Regarding the type of diet, the majority of the respondents defined themselves as omnivores (80%– 74%) followed by flexitarians (between 8% and 20%); and a very few declared themselves to be vegans or vegetarians.

Table 4 Socio-demographic characteristics of the sample Country Bolivia Brazil Chile Respondents N=245 N=260 N=322 Age Mean 22.39 31.64 36.6 SD 5.41 10.19 20.03 Gender F 124 51% 211 81% 283 88% M 121 49% 49 19% 39 12% Education level Basic 0 0% 0 0% 1 0% Secondary 33 13% 12 5% 19 6% technical 13 5% 5 2% 35 11% Higher 199 81% 243 93% 267 83% Residence Urban 173 71% 247 95% 292 91% Semi urban 54 22% 9 3% 15 5% Rural 18 7% 4 2% 15 5% Diet Flexitarian 21 9% 20 8% 66 20% Omnivores 213 87% 193 74% 226 70% Pescatarian 3 1% 8 3% 17 6% Vegan 3 1% 9 3% 3 1% Vegetarian 3 1% 29 11% 10 3% Other 2 1% 1 1% 0 0%

31 Willingness to move toward a plant-based diet Figure 2 shows the willingness of the participants to change their type of diet toward a more plant-based one. There is a trend toward a greater willingness to change, as most respondents rated their responses as a yes between 5 and 7 on the Likert scale.

Figure 2 Willingness to move towards a plant-based diet QUESTION: You would like to change to a diet with fewer animal products and more plant-based in the short term for the benefit of the environment and your health

35% 33% 33%

30% 27% 26% 25% 24%

20% 19% 19% 17% 15% 15% 13% % OF SUBJECT 12% 11% 10% 10% 7% 7% 6% 5% 5% 5% 5% 3% 2%

0% 1 2 3 4 5 6 7 WILLIGNESS TO CHANGE ON LIKERT SCALE

Bolivia Brazil Chile

32 Frequency of consumption Table 5 shows the descriptive results of the frequency of consumption. Red meat in Chile is consumed almost two days per week (mean 1.69 days per week), Bolivia more than three days per week (mean 3.27 days per week), and Brazil was in the middle with almost three days (mean 2.69 days per week).

Of all the types of fresh meat consulted, the least consumed was found to be fish with less than one day per week in all countries.

On the other hand, with respect to fruits, Brazil and Chile were found to consume fruits more than five days on average (mean BL 5.32; CL 5.33) while Bolivia four days (mean 4.33). Regarding vegetables, the difference in consumption between the three countries was found to be approximately one day per week: Bolivia 4.94 days per week, Brazil 5.58 days per week, and Chile 6.25 days per week, these differences were highly significant (p <0,0001).

Table 5 Frequency of consumption descriptive Bolivia Brazil Chile ANOVA Mean SD Mean SD Mean SD p-value Red meat 3 3.27 1.67 2 2.69 2.10 1 1.69 1.36 <0.0001 White meats 2 3.05 1.60 2 2.33 1.65 1 1.95 1.22 <0.0001 2 fish 0.67 0.83 3 0.66 0.83 1 0.93 0.83 <0.0001 1 Sausages 1.26 1.41 0.19 0.36 2 1.25 1.78 <0.0001

Dairy products 1 3.58 2.30 4.57 2.44 2 4.25 2.53 <0.0001

Eggs 3.07 1.89 3.35 2.17 3.28 1.85 0.233 2 Fruits 4.33 2.04 5.32 2.13 1 5.33 2.06 <0.0001 2 Vegetables 4.94 1.99 3 5.68 1.82 1 6.25 1.28 <0.0001

Legumes 3.34 2.20 5.13 2.08 1.47 1.08 <0.0001

Nuts and seeds 3 1.93 1.86 2 2.42 2.28 1 2.84 2.33 <0.0001

Cereals (rice 2 and pasta) 4.72 2.11 1 5.65 2.11 3 3.52 1.94 <0.0001

*Superscript 1, 2, 3 indicate significantly difference between groups, in order from the most significantly difference (1) to the least significantly difference (3), following Anova F-test with post-hoc Bonferroni factor of correction.

33 Willingness to move towards a PBD influenced by frequency of consumption Table 6 displays an overview of the willingness to move towards a plant- based diet influenced by the frequency of consumption of certain food groups. It shows foods that positively affect the willingness to move towards a PBD and others that affect negatively.

On the negative side, it has clearly been shown that a high level of consumption of animal products decreases the will to change to a plant-based diet (red meat, white meat, fish, sausages, dairy products, and eggs) while, on the positive side, consumption of plant-based foods such as fruits vegetables, legumes, nuts, and seeds and cereals increases the will to change.

For example, Table 6 shows that in Chile, for each day of increase in red meat consumption, the subject is significantly less willing to change their diet by -0.26 (p 0.0002) point on Likert scale. Likewise, in Brazil, for each day of increase in legume consumption, the subject is significantly more willing to change to a plant-based diet by 0.17 (p <0.0001) point on the Likert scale (willingness from 1–7)

Table 6 Willingness to move towards a PBD influenced by frequency of consumption of certain groups of food Bolivia Brazil Chile

W 95% CI p-value W 95% CI p-value W 95% CI p-value

Red meat -0.06 -0.19 0.07 0.38 -0.12 -0.25 0.00 0.04 -0.26 -0.40 -0.13 0.0002 White meats 0.00 -0.14 0.13 0.96 0.06 -0.10 0.22 0.44 -0.03 -0.19 0.12 0.68 fish 0.10 -0.35 0.15 0.42 0.01 -0.25 0.27 0.94 -0.03 -0.17 0.23 0.74 Sausages 0.03 -0.12 0.18 0.66 -0.34 -0.94 0.25 0.26 0.05 -0.15 0.04 0.29 Dairy 0.02 -0.07 0.12 0.61 -0.04 -0.13 0.05 0.37 -0.04 -0.11 0.03 0.22 products Eggs -0.04 -0.15 0.08 0.53 0.06 0.03 0.16 0.19 -0.03 -0.12 0.06 0.49 Fruits 0.07 -0.03 0.18 0.16 0.15 0.05 0.25 0.002 0.03 -0.05 0.11 0.45 Vegetables 0.01 -0.01 0.20 0.07 0.23 0.12 0.35 <0,0001 0.05 -0.08 0.18 0.44 Legumes 0.02 -0.08 0.12 0.67 0.17 0.08 0.26 0.001 0.13 -0.04 0.29 0.13 Nuts and 0.08 -0.03 0.20 0.15 0.15 0.06 0.24 0.002 0.02 -0.05 0.09 0.63 seeds Cereals (rice -0.05 -0.15 0.05 0.35 0.00 -0.09 0.10 0.95 0.02 -0.06 0.11 0.59 and pasta)

* Linear regression model adjusted by age, gender, education level, residence and diet *W: willingness to change. Correspondent to the Bcoefficient of the change

34 Willingness to move towards a PBD influenced by knowledge First, the knowledge score of each country was obtained to have a sharper picture of the knowledge of each country. The results show that Chile achieved the highest score with an average of 6.84 points out of 9 questions (SD 1.89) followed by Brazil with an average of 6.57 (SD 1.57) and Bolivia with an average of 5.56 (SD 1.88).

Table 7 shows the willingness to move toward a plant-based diet influenced by knowledge of specific statements. The table is organized to show the true and false statements and analyzed the willingness to change the diet based on the influence of the knowledge. The analysis shows that for each correct answer, whether true or false, the willingness to change increased on the Likert scale (willingness from 1–7). For example, according to the statement “PBD can be beneficial for health”, in Bolivia, there is almost one point of increase on Likert scale of willingness if the answered was correct (p 0.001) and more than one point of increase on the willingness for Chile on the same question (W 1.52; p < 0.0001).

35 Table 7 Willingness to move towards a PBD influenced by knowledge of specific statements

Bolivia Brazil Chile

W 95% CI p-value W 95% CI p-value W 95% CI p-value

True Statement

Relation between Global 0.46 -0.07 0.99 0.091 0.46 0.07 0.98 0.0002 0.23 -0.14 0.61 0.223 warming and meat consumption

Modification of the diet 0.15 -0.28 0.57 0.506 0.02 -0.52 0.47 0.925 0.41 0.05 0.78 0.027 and fighting GW

PBD can be 0.96 0.40 1.52 0.001 1.40 0.63 2.17 0.0004 1.52 1.01 2.02 <0.0001 beneficial for health

PBD Can 0.65 0.20 1.09 0.005 0.79 0.31 1.28 0.001 0.75 0.38 1.12 <0.0001 prevent cancer

PBD can prevent 0.59 0.12 1.06 0.015 1.15 0.52 1.79 0.0004 1.02 0.58 1.47 <0.0001 diabetes & Hta False Statement

GW is an 0.05 -0.47 0.57 0.847 0.31 0.82 1.45 0.590 -1.66 -3.10 -0.23 0.024 invention of the industry

PBD can 0.85 0.43 1.26 <0.0001 0.82 0.33 1.30 0.0009 0.88 0.56 1.20 <0.0001 cause malnutrition

PBD can affect the 0.71 0.29 1.13 0.001 0.77 0.40 1.15 <0.0001 immune system

PBD is hard to follow for 0.41 -0.05 0.88 0.083 0.97 0.57 1.37 <0.0001 0.86 0.55 1.18 <0.0001 children and elderly

* Linear regression model adjusted by age, gender, education level, residence and diet *W: willingness to change. Correspondent to the Bcoefficient of the change

36 Willingness to move towards a PBD influenced by awareness regarding GW and PBD Table 8 displays the willingness to move toward a plant-based diet influenced by the awareness of the respondents according to a series of statements related to global warming, plant-based diet, and health.

For instance, as shown in the table 8, an increase in agreement on the “effect of the meat industry on GW” by one point on the Likert scale implies an increase in the willingness to change significantly by 0.24 point (p 0.001) in Chile. An increase in the agreement on the statement “following a PBD can lead to a protein deficiency” by a point on the Likert scale resulted in a decrease in the willingness to change diet by -0.24 points (p 0.001) in Bolivia.

Table 8 Willingness to move towards a PBD influenced by awareness regarding GW and PBD Bolivia Brazil Chile W 95% CI p-value W 95% CI p-value W 95% CI p-value

The effect of the 0.24 0.10 0.38 0.001 0.19 0.02 0.37 0.027 0.24 0.10 0.38 0.001 meat industry on GW

Use of water for 0.15 0.01 0.29 0.043 0.42 0.22 0.63 <0,0001 0.15 0.01 0.29 0.043 producing meat products

WG can be fight 0.25 0.11 0.39 0.001 0.24 0.09 0.39 0.002 0.25 0.11 0.39 0.001 with a PBD

Mediterranean diet can be 0.28 0.13 0.43 0.0004 0.19 0.01 0.37 0.040 0.28 0.13 0.43 0.0004 beneficial for health and environment

PBD can treat chronic 0.19 0.05 0.34 0.008 0.36 0.22 0.50 <0,0001 0.19 0.05 0.34 0.008 noncommunicabl e diseases

Following a PBD can lead to a -0.24 -0.37 -0.11 0.001 -0.30 -0.41 -0.18 <0,0001 -0.24 -0.37 -0.11 0.001 protein deficiency

* Linear regression model adjusted by age, gender, education level, residence and diet *W: willingness to change. Correspondent to the Bcoefficient of the change

37 Barriers and facilitators Table 9 show the descriptive analysis of the barriers and facilitators for change to a plant-based diet. The table is organized to show the barriers and facilitators and the average degree of agreement of the participants of each country (1 to 7 on Likert scale).

P-value was calculated with Anova test to see if the differences were significant between countries and, as is show on the table the differences between Bolivia and Chile were more significant.

Regarding the barriers the participants state that they are not very much in agreement in the statement “It is difficult to cook plant-based products (natural or processed)” showing in the three countries a level of agreement under the 4 points. In contrast to this when is showed the statement “It's good for the environment to eat plant – based” the level agreement on all the countries was over the 4 points being closer of the 5 and 6 point on average.

38 Table 9 Barriers and facilitators descriptive analysis Bolivia Brazil Chile ANOVA Mean SD 95% CI Mean SD 95% CI Mean SD 95% CI p-value Barriers

It is difficult to cook plant- 1 3.56 1.40 3.38 3.73 2.64 1.56 2.45 2.83 2 2.84 1.45 2.68 3.00 <0.0001 based products (natural or processed)

Plant-based 1 3.65 1.45 3.47 3.83 2.67 1.62 2.47 2.87 2 2.82 1.46 2.66 2.98 <0.0001 food is boring

It is more 1 4.20 1.63 4.00 4.41 3 3.37 1.85 3.14 3.59 2 3.91 1.77 3.72 4.10 <0.0001 expensive to eat plant-based

It is difficult to

find plant-based 1 4.08 1.55 3.88 4.27 3.62 1.93 3.38 3.85 2 3.85 1.72 3.66 4.04 0.013 products in the supermarket

It's hard to eat 4.52 1.57 4.32 4.71 4.38 1.78 4.16 4.60 4.60 1.67 4.42 4.79 0.282 plant-based at social gatherings

It is difficult to eat plant -based 1 4.22 1.54 4.03 4.41 3 3.23 1.70 3.02 3.44 2 3.66 1.60 3.48 3.83 <0.0001 with children in the house

Facilitators

Plant-based 2 4.48 1.39 4.31 4.66 5.23 1.50 5.04 5.41 1 5.41 1.37 5.26 5.56 <0.0001 food is tasty

It's healthier to 1 4.63 1.47 4.44 4.81 5.23 1.53 5.04 5.42 2 5.12 1.34 4.97 5.27 <0.0001 have a plant- based diet

It's good for the

environment to 2 4.38 1.38 4.20 4.55 5.29 1.41 5.12 5.46 1 5.25 1.32 5.11 5.40 <0.0001 eat plant – based

*Superscript 1, 2, 3 indicate significantly difference between groups, in order from the most significantly difference (1) to the least significantly difference (3), following Anova F-test with post-hoc Bonferroni factor of correction.

39 Intention to change diet influence by barriers and facilitator Table 10 displays the likelihood of the respondent to change to a plant- based diet influenced by barriers and facilitators.

As is shown in the table, the barriers present less likely change diet. For example, a respondent from Bolivia who believed that plant-based food is boring, was 28% less likely to change diet (p 0.002), similar number in Chile (31%, p 0.0001).

In contrast to that, the facilitators are more likely to change diet, the respondents who believed that is healthier to have a plant-based diet increase their probabilities to change to a plant-based diet. In Bolivia the likelihood was 106% (p < 0.0001), Brazil 64% (p < 0.0001) and Chile 98% (p < 0.0001).

The respondent who think that “It is good for the environment to eat plant- based” are significantly more likely to change diet in all three countries Bolivia 29% (p 0.002), Brazil 77% (p < 0.0001) and Chile 83% (p < 0.0001).

40 Table 10 Intention to change diet influence by barriers and facilitator Bolivia Brazil Chile

OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value

Barriers to adopt a

PBD It is difficult to cook plant-based products 0.91 0.74 1.11 0.35 0.80 0.66 1.04 0.019 0.90 0.76 1.06 0.20 (natural or processed) Plant-based food is 0.72 0.58 0.88 0.002 0.97 0.63 0.91 0.0043 0.69 0.57 0.83 0.0001 boring It is more expensive 0.93 0.78 1.10 0.38 0.87 0.74 1.02 0.089 0.91 0.79 1.04 0.16 to eat plant-based

It is difficult to find plant-based products 0.97 0.81 1.17 0.77 0.99 0.85 1.14 0.85 0.97 0.84 1.11 0.64 in the supermarket It's hard to eat plant- based at social 0.96 0.80 1.15 0.64 0.87 0.73 1.03 0.106 0.90 0.78 1.05 0.18 gatherings It is difficult to eat plant -based with 0.95 0.79 1.14 0.56 0.76 0.63 0.91 0.003 0.78 0.66 0.91 0.0021 children in the house Facilitators to adopt a

PBD Plant-based food is 1.66 0.02 1.17 <0.0001 1.28 1.05 1.58 0.018 1.57 1.29 1.92 <0.0001 tasty It's healthier to have 2.06 1.61 2.72 <0.0001 1.64 1.32 2.09 <0.0001 1.98 1.59 2.51 <0.0001 a plant-based diet

It's good for the environment to eat 1.29 1.05 1.62 0.0201 1.77 1.38 2.32 <0.0001 1.84 1.49 2.30 <0.0001 plant - based

* Logistic regression model adjusted by age, gender, education level, residence and diet

41 Willingness to change diet influence by barriers and facilitator Table 11 Shows the willingness of the respondents to change diet, influenced by barriers and facilitators (1 to 7 on a Likert scale). As is shown in the table, be on agreement by 1 point on Likert scale with the statement “plant-based food is boring” leads to be significantly less willing to move towards a plant-based diet in all three countries, Bolivia -0.27 points (p 0.0002), Brazil -0.24 points (p 0.0003), Chile -0.34 points (p <0.0001). When it presented the results of the facilitators to follow a diet based on plants, it becomes evident that these increase the willingness of the respondents to change their diet. This means that for each point in favour, on a Likert scale, the respondents are with the specific statement, they increase the will to change. In the case of the three statements, the results in all the countries studied are significant (p < 0.0001). The respondents who agreed on Likert scale with the sentence “Plant- based food is tasty” in Bolivia were 0.52 more likely to change, in Brazil by 0.38, and in Chile by 0.32. Regarding the statement “It is healthier to have a plant- based diet” Bolivia was 0.59 more likely to change, Brazil by 0.36 and Chile 0.41. And as is shown in the table the statement “It is good for the environment to eat plant-based” had similar values and were all significant.

42 Table 11 Willingness to change diet influence by barriers and facilitator Bolivia Brazil Chile

Change Change Change 95% CI p-value 95% CI p-value 95% CI p-value in WTC in WTC in WTC

B arriers to adopt a PBD It is difficult to cook plant-based products -0.06 -0.21 0.01 0.435 -0.23 -0.36 -0.11 0.0004 -0.13 -0.24 -0.01 0.029 (natural or processed) Plant-based food is -0.27 -0.42 -0.13 0.0002 -0.24 -0.37 -0.11 0.0003 -0.34 -0.45 -0.22 <0.0001 boring It is more expensive to 0.05 -0.18 0.08 0.492 -0.20 -0.31 -0.09 0.001 -0.06 -0.16 0.03 0.184 eat plant-based It is difficult to find plant- based products in the 0.01 -0.13 0.15 0.890 -0.09 -0.19 0.01 0.09 0.01 -0.09 0.10 0.903 supermarket It's hard to eat plant- based at social 0.03 -0.16 0.10 0.646 -0.11 -0.22 0.005 0.06 -0.07 -0.17 0.03 0.181 gatherings It is difficult to eat plant - based with children in -0.10 -0.24 0.04 0.175 -0.24 -0.36 -0.12 <0.0001 -0.14 -0.25 -0.04 0.006 the house Facilitators to adopt a

PBD Plant-based food is tasty 0.52 0.38 0.66 <0.0001 0.38 0.25 0.52 <0.0001 0.32 0.20 0.44 <0.0001 It's healthier to have a 0.59 0.46 0.72 <0.0001 0.36 0.22 0.49 <0.0001 0.41 0.29 0.53 <0.0001 plant-based diet It's good for the environment to eat plant 0.38 0.23 0.53 <0.0001 0.34 0.19 0.49 <0.0001 0.36 0.24 0.49 <0.0001 - based

*W.T.C willingness to change * Graduated on a 7-point Likert scale * Linear regression model adjusted by age, gender, education level, residence and diet

43 Barriers and facilitators influence by diet Table 12 shows the reduction of agreement, on the Likert scale, influenced by the diet of the respondents, taking as reference the omnivorous diet.

As it is possible to see on the table, with respect to the barriers, in the majority is presented a reduction in the agreement and regarding the facilitators, a greater agreement with the statements is presented by the respondents.

As is displayed in Table 12 part 1, vegans from Chile were less 2.01 points on Likert scale (p 0.016) than omnivorous with the statement “It is difficult to cook plant-based products (natural or processed)”. On another example, flexitarians from Brazil were –1.30 points less agreement with the statement “It's hard to eat plant-based at social gatherings” (p 0.002).

Table 12 part 2 shows the facilitators to change to a PBD, and vegetarians from Chile and Brazil were more than 1 point according to the statement “It's good for the environment to eat plant-based” (p < 0.0001) in comparison to the omnivores.

44 Table 12 Barriers and facilitators influenced by diet (part 1)

Bolivia Brazil Chile

A 95% CI p-value A 95% CI p-value A 95% CI p-value

Barriers to adopt a PBD

Flex -0.07 -0.71 0.57 0.832 -0.27 -0.97 0.44 0.455 -0.36 -0.75 0.03 0.069

It is difficult to Ot 0.27 -1.72 2.37 0.788 0.57 -2.58 3.73 0.721 cook plant-based Pesc -1.31 -3.01 0.40 0.134 -0.56 -1.62 0.50 0.305 -1.07 -1.76 -0.37 0.003 products (natural or processed) Vegan -0.97 -2.60 0.66 0.245 -1.83 -2.87 -0.78 0.001 -2.01 -3.64 -0.38 0.016 Vegt 0.15 -1.47 1.77 0.857 -1.23 -1.83 -0.63 <0.0001 -1.29 -2.19 -0.39 0.005 Flex -0.34 -0.99 0.31 0.313 -0.83 -1.52 -0.13 0.020 -0.58 -0.94 -0.21 0.002 Ot -1.43 -3.47 0.60 0.169 -0.56 -3.68 2.56 0.725 Plant-based food Pesc -0.54 -2.28 1.20 0.546 -1.94 -2.99 -0.89 0.000 -1.72 -2.37 -1.07 <0.0001 is boring Vegan -1.80 -3.46 -0.13 0.036 -1.81 -2.84 -0.77 0.001 -1.30 -2.83 0.22 0.095 Vegt -0.91 -2.57 0.74 0.282 -1.53 -2.13 -0.94 <0.0001 -1.76 -2.60 -0.92 <0.0001 Flex -0.92 -1.64 -0.19 0.014 -0.34 -1.17 0.48 0.415 -0.64 -1.12 -0.17 0.009 Ot -0.73 -3.01 1.54 0.527 -3.70 -7.41 0.01 0.052 It is more expensive to eat Pesc -2.21 -4.16 -0.27 0.027 -0.79 -2.04 0.45 0.213 -0.59 -1.45 0.27 0.179 plant-based Vegan -0.85 -2.71 1.01 0.369 -1.59 -2.82 -0.36 0.012 0.68 -1.32 2.69 0.504 Vegt -0.82 -2.67 1.03 0.384 -1.52 -2.23 -0.82 <0.0001 -1.56 -2.66 -0.45 0.006 Flex -0.12 -0.81 0.57 0.738 -0.08 -1.00 0.83 0.857 0.18 -0.29 0.66 0.449

It is difficult to Ot -1.50 -3.66 0.67 0.176 1.66 -2.44 5.76 0.428 find plant-based Pesc -0.87 -2.73 0.98 0.356 -0.45 -1.82 0.93 0.525 -0.05 -0.90 0.81 0.914 products in the supermarket Vegan -0.02 -1.80 1.75 0.978 -0.88 -2.24 0.47 0.203 0.20 -1.80 2.20 0.848 Vegt -0.33 -2.09 1.43 0.717 -0.80 -1.58 -0.02 0.045 -0.59 -1.69 0.51 0.294 Flex -0.76 -1.46 -0.06 0.034 -1.30 -2.11 -0.49 0.002 0.09 -0.36 0.54 0.697 Ot -2.05 -4.25 0.14 0.068 0.01 -3.63 3.65 0.996 It's hard to eat plant-based at Pesc -1.44 -3.32 0.44 0.134 -1.79 -3.01 -0.57 0.005 -0.28 -1.10 0.53 0.494 social gatherings Vegan -1.13 -2.93 0.66 0.217 -0.70 -1.91 0.50 0.255 -1.94 -3.84 -0.04 0.457 Vegt -1.55 -3.33 0.24 0.090 -0.83 -1.53 -0.14 0.019 -0.58 -1.62 0.47 0.281 Flex 0.10 -0.59 0.79 0.785 -0.25 -1.01 0.51 0.521 -0.29 -0.72 0.14 0.181 It is difficult to Ot -0.93 -3.09 1.23 0.401 -2.69 -6.09 0.71 0.122 eat plant -based Pesc 0.43 -1.42 2.28 0.649 -1.51 -2.66 -0.37 0.010 -1.12 -1.89 -0.35 0.000 with children in the house Vegan -0.76 -2.52 1.01 0.404 -1.46 -2.59 -0.33 0.011 -1.81 -3.61 -0.02 0.048 Vegt -1.70 -3.46 0.06 0.060 -1.02 -1.67 -0.38 0.002 -1.57 -2.56 -0.58 0.002

*A: agreement on Likert scale. Correspondent to the Bcoefficient of the change *Reference omnivores *Flex= Flexitarians; Ot= Other; Pesc= Pescatarian; Vegt= Vegetarian *Linear regression model adjusted by age, gender, education level, residence and diet. * Graduated on a 7-point Likert scale

45 Table 12 Barriers and facilitators influenced by diet (part 2)

Bolivia Brazil Chile

A 95% CI p-value A 95% CI p-value A 95% CI p-value Facilitators to adopt a PBD Flex -0.38 -0.99 0.24 0.231 0.34 -0.24 1.03 0.226 0.60 0.24 0.96 0.001

Ot -1.88 -3.81 0.05 0.057 0.58 -2.29 3.44 0.693 Plant-based food is tasty Pesc -0.83 -2.49 0.82 0.323 1.64 0.68 2.60 0.001 1.00 0.36 1.64 0.003 Vegan -0.22 -1.80 1.36 0.783 1.82 0.88 2.77 0.000 1.76 0.26 3.26 0.022 Vegt 0.81 -0.76 2.38 0.314 1.49 0.95 2.04 <0.0001 1.34 0.51 2.17 0.002 Flex -0.25 -0.89 0.40 0.454 1.08 0.44 1.72 0.001 0.61 0.25 0.96 0.001

It's healthier to Ot -2.07 -4.09 -0.06 0.045 2.36 -0.50 5.23 0.107 have a plant- Pesc -1.44 -3.17 0.28 0.102 0.88 -0.08 1.84 0.074 1.09 0.45 1.73 0.001 based diet Vegan 0.48 -1.18 2.13 0.573 2.22 1.27 3.17 <0.0001 1.30 -0.19 2.79 0.088 Vegt 0.09 -1.55 1.73 0.916 1.37 0.83 1.92 <0.0001 1.45 0.63 2.27 0.001 Flex -0.20 -0.80 0.41 0.524 0.68 0.08 1.28 0.028 0.48 0.14 0.82 0.005 It's good for the Ot -0.08 -1.97 1.80 0.930 -0.06 -2.74 2.63 0.967 environment to Pesc -0.34 -1.96 1.27 0.676 0.77 -0.13 1.67 0.096 1.21 0.60 1.81 0.0001 eat plant - based Vegan -0.13 -1.68 1.41 0.865 2.06 1.17 2.95 <0,0001 1.92 0.51 3.33 0.008 Vegt -0.17 -1.71 1.36 0.827 1.25 0.74 1.76 <0.0001 1.64 0.87 2.42 <0.0001

*A: agreement on Likert scale. Correspondent to the Bcoefficient of the change *Reference omnivores *Flex= Flexitarians; Ot= Other; Pesc= Pescatarian; Vegt= Vegetarian *Linear regression model adjusted by age, gender, education level, residence and diet. * Graduated on a 7-point Likert scale

46 Intention to change diet and motives As of the last set of questions on the survey, participants were consulted for the intention of changing diet for a more plant-based one and their intentions to answer yes or no, Figures 2, 3 and 4 show these results.

Figure 3 shows how many participants were considered to change, as is evident in all three countries that the majority of participants had thought about changing.

Figure 3 Intention to change to a PBD

QUESTION: Have you considered to change your current diet towards a plant based diet 80%

69% 70% 62% 63% 60%

50%

40% 38% 37% 31%

% OF SUBJECTS 30%

20%

10%

0% Bolivia Brazil Chile

Yes No

47 Figure 4 displays the motives of the participant to think on change diet, and in all countries, more than 50% state that improves health was a motive, also the quality of life was very important. On the less voted was animal respect on Bolivia and Chile but in Brazil, more than 50% selected this statement.

Figure 4 Motives to change to a PBD

Motives for change to a plant based diet

80%

68% 70% 65%

60% 54% 54% 50% 51% 48% 50% 42% 40% 32%

% OF SUBJECTS 30% 24% 20% 20% 16%

10%

0% Improve your health Improve the quality of life Improve the environment Animal respect

Bolivia Brazil Chile

48

Figure 5 shows those respondents who had not considered changing their diet for a more plant-based and the reasons for their response. Most of them (over 50% in all three countries) said that they did not intend to change their current diet, followed by it is very difficult to make the change (between 30 and 57%) and finally the minority answered that they were already following a diet based on plants (2 to 12%).

Figure 5 Motives to NOT change to a PBD

Motives for NOT change to a plant based diet

70% 65%

60% 57% 52% 51% 50% 41% 40% 30% 30% % OF SUBJECTS 20% 12% 9% 10% 2% 0% I´m already follow a plant-based I’m not interest on changing my Is too hard to change diet current diet

Bolivia Brazil Chile

49 Intention to change diet and motives for parents

This section reports results for the subgroup of respondents who answered that they had children at the beginning of the questionnaire were asked if they had thought about changing their diet and that of their families for one more based on plants and the reasons for their response, whether positive or negative.

Figure 6 shows how many participants with children were considered to change his, and their family’s diet, as is clearly showed Bolivia had more parents who had thought on change. However, the numbers in the other countries were quite similar.

Figure 6 Intention to change to a PBD for parents

QUESTION: Since the birth of her children had you considered changing your diet and that of your family, for one based on plants 70% 63% 60% 57% 52% 50% 47% 42% 40% 36%

30% % OF SUBJECTS 20%

10%

0% Bolivia Brazil Chile

Yes No

50 Figure 7 express the motives for change diet of the family and in all three countries improve health and quality of life was the most selected by participants, also for the participants in Brazil was important the preservation of the environment and the respect for the living beings on the planet.

Figure 7 Motives to change to a PBD for parents

Motives to parents for change to a plant based diet

90%

80% 77%

70% 68% 64% 65%

60% 57% 55% 52% 50% 42% 40% % OF SUBJECTS

30% 23% 20% 14% 14% 15%

10%

0% Improve your health and your Improve the quality of life of Preserve the environment in Respect for the living beings of family the hole family which my childr en will grow the earth

Bolivia Brazil Chile

51 Figure 8 shows those parents who had not considered changing their diet for a more plant-based and the reasons for their response. most of them (over 50% in all three countries) said that they did not intend to change their current diet, followed by it is very difficult to make the change, and finally, the minority answered that they were already made the change for all their family.

Figure 8 Motives to NOT change to a PBD for parents Motives to parents for NOT change to a plant based diet

60% 57%

52% 50% 50% 50%

42% 40%

30% 24% 24%

20%

13%

10% 6%

0% We already made the diet change my I'm not interested in changing the current It is very difficult to change diet. whole family diet we have

Bolivia Brazil Chile

52 Discussion The following discussion will evaluate the implications and impacts of the above-mentioned results in relation to the research question and findings from other studies, and some limitation observed during the development of this thesis.

The sample To begin, it is necessary to place it in the reality of each country in order to understand the sociodemographic differences or similarities of the sample, Bolivia has a population of 11.216.000 of which 50.1% are women and 49.3% are men according to the data processed by the household survey 2017. The 58.4% of the population is between 15 and 59 years old (www.ine.gob.bl). Chile has a population of 18.729.160 of which 49.3% are men and 50.7% are women. The 68,7% of the population is between 15 and 64 years old (www.ine.cl). Brazil has a population of 207.999.646, it is important to mention that just the metropolitan region of São Paulo has more population than Bolivia and Chile with 19.509.000 people. 69,16% of the population is between 15 and 59 years old and 49,1% were men and 50,8% were women according to the data processed by the statistical institute of Brazil (www.ibge.gov.br).

The sample had certain differences that could explain some results later. The mean age for Bolivia was 22.4 years old, Brazil 31.6 years old and Chile 36.6 years old. Bolivia particularly has a lower range of age. This difference could affect the level of knowledge, awareness and the frequency of consumption of certain groups of food. Since the respondents of Bolivia are mostly referred to as the z generation, since they have had most of their lives access to computers with internet, which allows them to be more informed and more aware of the problems that affect the world and not only to your country (K. C. Williams & Page, 2011). On the other hand, in Brazil and Chile they can be considered as first generation millennials since they exceed 30 years old , this group of individuals have already started working and forming families, which traditionally leads them to be more aware of their health and the environment that surrounds them, but not always the globalized world in which we live today (K. C. Williams & Page, 2011).

The sample In Brazil and Chile is led by women with a large difference, contrary to Bolivia which is mostly even between women and men. This difference

53 can generate a bias in the results as it is shown in some studies that is socially associated with women lower consumption of red meat and higher consumption of vegetables and fruits (Orellana et al., 2013). Also, Women are more aware of the impact of the meat industry on the environment therefore they change more their diet than men (Sanchez-Sabate & Sabaté, 2019).

The educational level of most of the participants was higher education level (over 80% in all three countries) and this has a significant correlation with a healthier diet, a lower body weight and higher concern for organic products and the environment (Lê et al., 2013) this aspect of the sample could affect the results regarding reasons of knowledge, awareness, and willingness to change diet, this may not be representative for all sectors of the population.

Willingness to Move Toward a Plant-based Diet As is presented in the results, most of the sample in all three countries were willing to change diet for a more plant-based one, based on health benefits and environmental aspects. Is well documented the correlation between the high consumption of animal products and type two diabetes, cancer and heart diseases (Raphaely & Marinova, 2014; Pino et al., 2009; Rojas et al., 2017; Melina et al., 2016). In relation to the environmental aspects, we can say that Over the last decade awareness of the impact of the food industry have become more transparent to population. The food industry is responsible for between 18- 31% of the greenhouse emissions (Patterson et al., 2019) and the animal husbandry sector by itself is responsible for the 18% (Steinfeld et al., 2009) in contrast to that plant-based diets are proved to be more environmental friendly due the use of fewer natural resources (Melina, Craig, & Levin, 2016). therefore, it makes sense that well-educated people are aware of these warnings and wish to make a change in their diets to improve or maintain their health and have a lesser impact on global warming. However, as we can see on the sociodemographic results of the sample the most of them recognizes itself as omnivorous or flexitarians. Studies had found that there is a group of consumers that are not ready to give up meat but who are willing to reduce or change their meat consumption (Sanchez-Sabate & Sabaté, 2019). This give us an idea that even though they want to change there is something that prevents or retains them in traditional diets, this could be explained by two sources , the first one is on the

54 European population that still maintain the main source of proteins on diets from meat (Davis et al., 2010) and in western countries meat, maintain his position as a key ingredient for healthy and balanced diets as the central position in meals and social relationships (Niva et al., 2017).

Frequency of Consumption In relation to the frequency of consumption of different groups of foods, the average consumption is very close to the dietary recommendations of each country being red and white meat more consumed than fish, fruits and vegetables with a high average consumption and Cereals and pasta consumed more than half of the week Willingness to move towards a PBD influenced by frequency of consumption (source :OMS /OPS www.paho.org).

The willingness to move towards a plant-based diet is influence negatively or positively by the frequency of consumption. On the side of the negative influence we can find all the animal products as meat, sausages, dairy products, and eggs, this could be explained by the position of the animal products on the idea of a healthy and balanced diet and as a central ingredient for meals and the primary source of proteins (Davis et al., 2010) (Niva et al., 2017).

Willingness to Move Toward a PBD Influenced by Knowledge and Awareness Regarding GW and PBD A closer examination regarding the knowledge of the participants and the relation of that with the willingness to move towards a plant-based diet makes clear that more knowledge gives the individual significantly more will to change to a plant-based diet.

In relation to the awareness of the participants about the global warming and how plant-based diet can fight this issue is evident on the results that the more awareness exists a significant difference on the will to change on all three countries. Willingness to reduce meat consumption is influenced by cultural and social values and is highly related to habits and routines (Austgulen et al., 2018) and some studies had found that women are more aware of the impact of the meat industry on the environment and therefore they are more willing to change than men (Sanchez-Sabate & Sabaté, 2019). This correlation between knowledge, awareness and will to change is used to create public policies among

55 the developing countries, one example is Sweden how have been included in their dietary guidelines environmental sustainability (Cleveland & Gee, 2017).

These results indicate that we can increase the knowledge and awareness in the population on the topics of global warming, health, and plant-based diet to encourage the population to make changes in the diet, which would benefit both, their health and the environment.

Barriers and Facilitators Similar to the result showed by the authors on Denmark (Reipurth et al, 2019) the respondents agreed mostly with the barriers and facilitators proposed by the authors that we used for this study.

The main barriers identified which can affect the willingness to change to APB were regarding taste and convenience. On the other hand, the main drivers to adopting a PBD are related to taste for the participants, this is very similar to the result obtain in demark (Reipurth et al, 2019) other studies confirm the findings. In EEUU a study related to the attitudes and perceptions of PBD found that the strongest perceived barriers to adopt a plant-based diet is the enjoyment of eating meat and the frequency of consumption of meat (Corrin & Papadopoulos, 2017).

The intention to change influenced by the barriers and facilitators shows an association between the barriers and less likely to change. In the case of considering that it is difficult to eat plant based on social gatherings the participants had less intention of change, this takes relevance when we observe that other authors also describe as a great barrier any change of diet the difficulty of access to products, whether in the supermarkets, restaurants or any convenience store(Niva et al., 2017; Lea, Crawford, & Worsley, 2006a).

In relation to the willingness to change influence by barriers and facilitators, there is also an association between the option of the participants and the will to change. Talking about the facilitators, exist a positive effect on the will to change diet, the participants who agreed with the statement “Plant-based food is tasty” in Bolivia where 0.52 more likely to change, in Brazil by 0.38 and in Chile by 0.32. This could be explained by how the participants feel about the plant- based diet and their attitudes towards this type of food (Rothgerber, 2017).

56 Intention to Change Diet and Motives As of last part of the survey, the participants were consulted about their intention to change to a more plant-based diet and which were the motives for their positive or negative answer being able to select more than one reason.

In this case the majority of respondents from all three countries said yes to change diet (over 60% in all countries), this could be caused by the awareness or the knowledge of the participants regarding health issues or environmental reasons as was explained above, or just explained by the high educational level of the sample that makes them more exposed to the information and globalization (Lê et al., 2013; Vogel et al., 2017).

The main reasons for saying YES is to improve the quality of life and health, and is proved that a plant-based diet is healthier than a western diet (Melina et al., 2016) (Lea, Crawford, & Worsley, 2006b).

The principal reasons for saying NO is the lack of interest in changing, associated to think that is too hard to change diet, this could be associated with the barriers to adopting a plant-based diet and the perception of the respondents about the change (Reipurth et al, 2019), also is important to mention the lack of suitable campaign for make a change on the behaviour and the social consciousness of the population (Verain, Sijtsema, Dagevos, & Antonides, 2017).

For the group of parents, the responses were mostly the same with a tendency to change diet for the entire family and the reasons were almost the same as for the other group, therefore we can say that it does not matter if you are parent or not, the intention to move towards a plant-based diet exists. However new generations of parents are more conscious about the influence of their choices on their children, therefore they are consciously more plant based foods at family meals and by consequence to their daily diet.(Foods, 2019).

57 Limitations and Strength This study is an exploratory consumer, supported by different universities on each studied country study, therefore a limitation could be selection bias and the result could not be representative of the population.

The differences in age between countries could be influenced by the results given as a result of similar conclusions on Brazil and Chile and so different in some analysis in Bolivia. Apparently also the economic differences between countries also could affect the results, even though el three are developing countries, the economic model is different in Bolivia compared to Chile and Brazil.

Is important to mention the educational level of all the sample, more than 80% in all countries was from a highly educated group of people, and this could be unrepresentative of the entire population of Latin American countries, however the sample was made by snowballing sampling to avoid this bias but the respondents were similar between them.

The strength of this study, is indeed, the fact that is an exploratory study, and that the subject is wildly studied among develop countries but not among developing countries. The snowballing method for the sampling is a strength that allow us to make an estimation for the sample size for future consumer studies.

58 Conclusion This exploratory study gave insight about the willingness to move towards a plant-based diet in selected countries in Latin-America.

The findings follow the world trending about plant-based foods, saying that more people are willing to change to a plant-based diet, taking in to consideration aspects as health, global warming and sustainability, to start this transition.

Frequency of consumption of different groups of foods impacts significantly the willingness to change to a more plant-based diet. Also, knowledge and awareness of subject such as health, global warming and sustainability generate significant differences in the willingness to change, the more knowledge and awareness in these subjects, the more chances to change to a plant-based diet.

The differences on the economic develop of the countries state a difference between the willingness to change of the consumer, with a clear tendency to have less willingness to change by respondents of Bolivia, country how had less economic develop than their neighbours Brazil and Chile, how show more willing and awareness.

The principal barriers to change to a plant-based diet found were related to the “good taste of meat” and also meat consumption is associated with routine and habits. This translated into simple words means that people are used to eating meat since childhood and it is part of their daily routine. This is due the food based dietary guidelines that governments give to the population that normally are based on animal products as mainly source of proteins and healthy food. This should put us think the need of a deeper change, for create a real impact on the diet of the population, governments need to make changes on their politics and develop a food based dietary guidelines (FBDGs) concentrate on heath and sustainability objectives no matter what the industry of food says.

These findings can inspire further researches for the reasons of the differences between countries, and find approaches to motivate the population, the governments and the health care system to change their current diet recommendations in benefit of the world environment and people’s health.

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66 APPENDICES

Appendix Nº1 Survey (non-official translation) Thank you very much for participating in this study.

It will take you 5 to 10 minutes to complete the survey. The objective of this study is to determine the reality of the Latin American community on plant-based diets. All those over 15 years old are welcome to answer it. Complete this survey participate in this study, as part of an investigation to perform the thesis of magister at the University of Copenhagen, Denmark. All the data delivered are anonymous.

As definition for this survey:

Diet based on plants, a diet that includes fruits and vegetables, legumes and cereals, ideally minimally processed foods. With very little or no presence of food of animal origin (fresh beef, pork, turkey, chicken, fish, dairy products and their derivatives)

Mediterranean diet, a diet with a higher intake of fruits, vegetables, legumes, olive oil as the main fat, fish, nuts, bread and other cereals as the basis of food, maintaining a low consumption of meat and its derivatives and products highly processed

1. Country of residencies o Argentina o Bolivia o Brazil o Chile o Ecuador o Paraguay o Perú o Uruguay

2. Age Number: ______3. Gender o F o M

67

4. Educational level o Basic education o Secondary education o Superior technician o University education (bachelor's, master's, doctorate)

5. My permanent residence is in o Urban o Semi urban o Rural

6. How many people live with me (me included) n=______7. There are children (under 12 years old) living with me

o Yes o No

8. Do you have kids o Yes o No

9. What is your type of diet currently

o Omnivore (consumes some type of product of animal origin, more than 3 days per week) o Flexitarian (consumes some type of product of animal origin, less than 3 days per week) o Pescatarian (does not consume meat or sausages, but fish and seafood) o Vegetarian (does not consume meat products, but dairy products and eggs) o Vegan (does not consume any type of products of animal origin) o Other _____ (specify)

68 10. Could you indicate how often you eat this product

1 o 2 1 2 3 4 5 6 7 Is not times days days days days days days part of day per per per per per per per my diet per month week week week week week week week

Red meats

White meats

fish

Sausages

Dairy products

Eggs

Fruits

Vegetables

Legumes

Nuts and seeds

Cereals such as rice and pasta

11. could you indicate that you think of these affirmations, they are true or false for you.

true False

The consumption of products of animal origin contributes to global warming x

Global warming is an invention of the industry to generate more sales x

Modifying the diet can generate a change in global warming x

Having a plant-based diet can be beneficial for my health x

A diet based on plants can cause problems of malnutrition x

A plant-based diet can prevent cancer x

A diet based on plants can weaken my immune system x

A plant-based diet can prevent and treat type 2 diabetes and high blood pressure x

A plant-based diet is harder for children and the elderly to follow because of their nutritional x needs

69 12. Could you indicate how much you agree or disagree with the following statements?

Totally Slightly Disagree Neither Agree Slightly Totally disagree disagree agree agree agree nor disagree The effect of the meat industry on global warming is great The use of water for the production of processed meats is very large Global warming can be combated with a plant-based diet A Mediterranean-type diet can be beneficial for the health of people and the environment A plant-based diet can treat chronic noncommunicable diseases such as type 2 diabetes and high blood pressure If I follow a plant-based diet I may have protein deficiency

13. Could you indicate how much you agree or disagree with these statements?

Totally Slightly Disagree Neither Agree Slightly Totally disagree disagree agree agree agree nor disagree It is difficult to cook plant-based products (natural or processed) Plant-based food is tasty Plant-based food is boring It is more expensive to eat plant- based It is difficult to find plant-based products in the supermarket It's healthier to have a plant-based diet It's hard to eat plant-based at social gatherings It's good for the environment to eat plant - based It is difficult to eat plant -based with children in the house

70 14. You would like to change to a diet with fewer animal products and more plant-based in the short term for the benefit of the environment and your health Where 1 is no intention and 7 is much intention

1 2 3 4 5 6 7

15. Have you considered to change your current diet towards a plant-based diet o Yes o No

Why? (yes)

o Improve your health o Improve the quality of life o Improve the environment o Animal respect Why? (no)

o I´m already follow a plant-based diet o I’m not interest on changing my current diet o Is too hard to change 16. Since the birth of her children she has considered changing her diet and that of her family, for one based on plants

o Yes o No

Why? (yes)

o Improve your health and your family o Improve the quality of life of the whole family o Preserve the environment in which my children will grow o Respect for the living beings of the earth

Why? (no)

o We already made the diet change my whole family o I'm not interested in changing the current diet we have o It is very difficult to change diet. Comments ______

71 Appendix nº2 Commands used in Rstudio for full adjusted model

#Q14 VS Q10 BR.Q14vsQ10.1 <- glm(Q14 ~ Q10.1 + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5) + as.factor(Q9) , data = DATA.BR2.R.) # linear regression summary(BR.Q14vsQ10.1) confint(BR.Q14vsQ10.1)

#Q14 VS Q11 BR.Q14vsQ11.1 <- glm(Q14 ~ Q11.1 + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5) + as.factor(Q9) , data = DATA.BR2.R.) # linear regression summary(BR.Q14vsQ11.1) confint(BR.Q14vsQ11.1)

#Q14 VS Q12 BR.Q14vsQ11.1 <- glm(Q14 ~ Q11.1 + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5) + as.factor(Q9) , data = DATA.BR2.R.) # linear regression summary(BR.Q14vsQ11.1) confint(BR.Q14vsQ11.1)

#Q15 VS Q13 BR.Q15vsQ13.1 <- glm(Q15 ~ Q13.1 + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5) + as.factor(Q9), data = DATA.BR2.R., family = binomial) #Logistic regression summary(BR.Q15vsQ13.1) confint(BR.Q15vsQ13.1) exp(-0.10406) # odds ratio (OR) exp(c(-0.2935459 ,0.08192473)) # confidence interval for the OR

#Q14 VS Q13 BR.Q14vsQ13.1<- glm(Q14 ~ Q13.1 + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5) + as.factor(Q9), data = DATA.BR2.R.) # linear regression summary(BR.Q14vsQ13.1) confint(BR.Q14vsQ13.1)

#Q13 VS Q9 BR.Q13.1vsQ9 <- glm(Q13.1 ~ relevel(Q9,"OMN ") + Q2 + as.factor(Q3) + as.factor(Q4) + as.factor(Q5), data = DATA.BR2.R.) # linear regression summary(BR.Q13.1vsQ9) confint(BR.Q13.1vsQ9)

*BR is replaced for Bl and Cl to obtain all countries data

72