# Nutritional and health benefits and risks of plant-based substitute foods

François Mariotti

► To cite this version:

François Mariotti. Nutritional and health benefits and risks of plant-based substitute foods. Proceedings of the Nutrition Society, 2025, 84 (1), pp.110-123. 10.1017/s0029665123004767. hal-04261367

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# Nutritional and health benefits and risks of plant-based substitute foods

François Mariotti

Université Paris-Saclay, AgroParisTech, INRAE, UMR PNCA, 91120, Palaiseau, France

Correspondence: Prof. François Mariotti, AgroParisTech, UMR PNCA, 22 Place de l'Agronomie, CS 20040, 91123 Palaiseau. Email: [francois.mariotti@agroparistech.fr](mailto:francois.mariotti@agroparistech.fr)

Short title: Plant-based substitutes in nutrition/health

Keywords: meat: dairy products; dietary proteins; iron; zinc; calcium; iodine; Vitamin B12; diet, vegetarian.

## Abstract

Plant-based substitutes (PBS) are seen as a convenient way to transition to a more plant-based diet, but their potential health benefits and nutritional concerns remain debated. Based on a review of the literature, it is concluded here that the primary risk of insufficient nutrient intake with PBS concerns iron and calcium, which are critical to the nutritional value of PBS. Other risks were identified but these would depend on the characteristics of the overall diet, as is the case for iodine in a diet containing no seafood or dairy, and vitamin B12 in a vegetarian/vegan diet. Conversely, the use of PBS is also expected to confer some benefits for long-term health because it would result in higher fiber intakes (in the case of meat PBS) and lower SFA intakes (but higher PUFA/MUFA intakes), but attention should be paid to a potential increase in sodium intake with PBS of meat products. In fact, a recurring finding in this review was that PBS is a very heterogeneous food category involving considerable variations in ingredient and nutrient composition, and whose design could be improved in order to foster nutritional and health benefits. The latter also depend on the animal food that is being replaced and are only deemed likely when PBS replace red meat. The fortification of PBS with key nutrients such as iron and calcium may constitute an actionable public health solution to further shift the balance in favor of PBS in the context of the current dietary transition in Western countries.
Introduction

In higher income countries, there is growing interest in diets that might improve human and planetary health. There are also a growing number of people who are concerned by animal welfare. There is therefore a marked trend towards the adoption of diets that are more plant-based, which indeed cover a broad spectrum, ranging from those which are simply lower in meat, to a “flexitarian” diet (with very occasional meat/fish consumption, similar to a semi-vegetarian diet), and vegetarian diets (which comprise lacto-ovo vegetarian and vegan diets) (¹). This spectrum of diets thus involves a partial or total reduction in meat, fish and dairy products, associated with either a complete revision of the diet in favor of traditional plant-based food categories (grains, legumes, vegetables, nuts and seeds, etc.) or the utilization of plant-based food analogs that usually facilitate the direct substitution of animal food products. The two ways to adopt a plant-based diet also coexist; either that seen in traditional vegetarian populations (e.g. ²) or a second way whose popularity has been increasing, as indicated by change to the foods offered to the general population (³). Plant-based substitutes (PBS) have indeed been developed for vegetarians (⁴). More recently, PBS have moved out the vegetarian market niche to enter the mainstream market and be proposed to a variety of consumers (⁵). The market trend is surprisingly high, especially in countries with little tradition of vegetarianism and a food culture largely built on animal products, such as France. By contrast, in countries where vegetarianism has long been non-anecdotal, such as the UK, this trend is not new, and a wide variety of PBS are entering a growing market and becoming increasingly popular among consumers (⁶, ⁷).

People concerned by animal welfare may find that the benefits of using PBS are trivial. The benefits regarding environmental impact have been discussed, and may depend on the production systems used for animal products and the ingredients and degree of processing of PBS, but overall it is considered that using PBS results in lower environmental pressures, and particularly lower greenhouse gas emissions, land use and water use (⁸⁻¹¹). By contrast, the benefits of PBS regarding nutrition and health have been and remain the subject of much debate. Recent studies have shed some light on the benefits and risks of PBS. Here, when for discussing the benefits and risks of plant-based milk alternatives (PBMA), the review will first focus on the potential impact of PBS on nutritional status, based on the expected effects on nutrient displacement. Then the review will deal with essential nutrients whose requirements need to be covered and the nutrients with upper references that must not be exceeded; focusing on nutrients that may affect health, either in the short-term (deficiency) or over the long term (regarding the risk of chronic diseases). Then, the review will address the issue of changes to other characteristics of the overall dietary pattern, such as the type of substitutions, potential increases in the share of ultra-processed foods and changes to the consumption of food categories that might enable improvements in compliance with food-based dietary guidelines.
## Potential impact on the adequacy of intake of indispensable nutrients

Because of the marked increase in PBS availability on the market, there have been many reports on their nutrient content compared to the animal foods they are designed to replace. These reports usually concern PBS as sold in specific countries or geographic areas. One limitation to these studies is that the information on nutrient contents is usually restricted to the information shown on the pack (12); i.e. the standard mandatory nutrient list (depending on national regulations) and any additional information linked to the use of a nutrient-content claim.

## Nutrients of little concern: the case of protein

Meat, and dairy, make an important contribution to protein intake in the general population in western countries (13, 14). Many reports on plant-based substitutes for meat, milk and cheese have emphasized their lower protein contents than the animal foods they are intended to replace (15-17). The protein content varies considerably depending on the type of milk substitute, with soy-based drinks containing similar amounts to milk, while others such as almond or rice drinks contain very low levels (18, 19). Likewise, the protein content in meat substitutes also varies and is often higher in PBMA designed to mimic meat because those PBMA are often made of protein isolates, which are concentrated sources of protein. The protein content in PBMA may also be a marketing argument, presented as a claim such as "rich in protein" or highlighting the amount of protein in a serving of the product. This could be seen as a simplified way to tell consumers that the PBMA is nutritionally equivalent to meat; consumers mostly represent meat as protein, and protein as strength and vitality, connected to masculinity (20, 21), although this may also vary according to cultural background. Cutroneo et al. estimated that 68% of PBMA in Italy displayed a protein content claim while this figure could be as high as 94% in the USA (16, 22). Although the protein content in some PBMA may be similar to that of red meat, it is somewhat lower in most products and this has been viewed as a nutritional drawback. Yet a simple comparison of the substitutes and substituted products offers very limited and indeed biased information. This simplistic approach does not take account of the impact of product substitution on the overall diet and the baseline situation regarding the nutrients at issue. If a PBMA that is lower in protein replaces meat, the resulting decrease in protein intake is not anticipated to be a problem because the high protein intake seen in high and middle-income countries actually far exceeds the reference value for adults (23, 24). For instance, in France, the proportion of adults with insufficient protein intake in their usual diet is <0.5% (25). Therefore, substituting meat with PBMA, even completely, cannot be expected to result in protein insufficiency (26). One reason is that PBMAs remain a source of protein, and indeed, as shown by diet modelling studies, the removal of meat tends to reduce protein intake but does not result in a protein shortage if the remainder of the diet includes other sources of protein (of whatever origin) (27). The substitution of milk is unlikely to have a significant effect on protein intake, even with low-protein
milk analogs, because milk contributes little to protein intake (~6% in France, vs ~38% for the contribution of meat to protein intake) (13, 25). Insufficient protein intake may be anticipated if all animal protein foods are replaced with plant-based foods that are low in protein, but not if the plant-based protein sources are diverse and include legumes, whole-grain, nuts and seeds (25). Likewise, we have shown that lowering the animal:plant protein intake in a nutrient-adequate diet is limited (to ~15%, without food fortification or alternate plant-based food sources) but not because of the total level of protein in the diet (28). Indeed, the protein intake from different food groups mediates the benefits and risks of transiting toward a more plant-based diet because of the nutrient package that is conveyed (29). Finally, reports on protein intake in lacto-ovo vegetarian and even vegan diets (as observed in dietary surveys) have not revealed any insufficient intakes (23, 30). This could be ascribed to the fact that people eating a more plant-based diet and vegetarians classically use legumes and PBMA where others would classically eat meat (31).

It should be noted that the risk of protein insufficiency is very low in adults and virtually null in children, but it is higher in the elderly and important in the frail elderly with low energy and protein intakes (32). In these populations, like those in low-income countries, there remains a risk of protein-energy undernutrition, which contrasts with the situation pertaining to the general population in western countries.

## Analyzing which nutrients matter

Meat, and dairy, are sources of protein and are also associated with clusters of nutrients that are directly supplied by these food groups (known as the “protein package”) or indirectly associated with the overall dietary pattern (13, 29). Replacing meat or dairy can cause marked changes to the nutrient profile of the diet. The risks (or benefits) associated with these changes depend on the amount of nutrients provided by the rest of the diet, the effect size of the replacement (i.e. the difference in nutrient content conveyed by the substitution, which itself depends on the level of consumption of the animal food and the degree of replacement), and lastly the importance to health that a given nutrient is consumed in quantities that comply with reference values. No direct simple answer can therefore be obtained from a direct comparison between some PBSs and the animal foods they are intended to replace. As observed for protein, such decreases are not expected to result in insufficient intakes. The same applies to other nutrients, despite important differences between PBS and the corresponding animal foods. For instance, the vitamin B3 content in meat is ~10 times higher than in PBMA, but virtually the entire population consumes sufficient vitamin B3 when account is taken of the conversion of tryptophan into niacin in populations in western countries with a very high tryptophan intake (25), so using PBMA would have no effect on the virtually null probability of an insufficient vitamin B3 intake (26). As for vitamin B5, the content in meat is around twice that found in PBMA, resulting in a
decrease in vitamin B5 intake as compared to the reference value when simulating replacement (26).

However, this reference value for vitamin B5 is an *Adequate Intake* based on observed intakes, and no signs of deficiency being found within the range of vitamin B5 intakes among adults in western countries (33).

By contrast, when the animal foods that are replaced are important contributors to nutrient intake and the nutrient status is marginal in the population, then significant differences between PBS and the animal foods are expected to result in a nutritional risk.

## Vitamin B12 and riboflavin

The nutritional risk may depend on the specificity of the animal food category as a contributor to nutrient intake and, again, of the overall diet profile. Since vitamin B12 is high in meat and absent in unfortified PBMA, using the latter will result in a lower vitamin B12 intake (34) whatever the PBMA; although in the observed population vitamin B12 intakes are above the requirement, this would ultimately increase the proportion of people not reaching the reference value (26). Such an effect would depend on the overall diet profile and in particular of the consumption of other important sources of vitamin B12, such as seafood which, with offal, are the richest sources of vitamin B12. In the lower meat or meat-free diets modelled by Dussiot et al., concurrent increases in seafood resulted in high vitamin B12 levels in these diets. By contrast, in diets devoid or meat and fish, such as lacto-ovo-vegetarian diets, a low intake of vitamin B12 can result in higher plasma homocysteine concentrations, which can be expected to translate into an increase in the risk of cardiovascular diseases (35). Under a scenario that replaced all meat and dairy with plant-based analogs and some other alternative foods, Sieves et al. found a ~35% decrease in vitamin B12 intake, despite the fact that some PBS were fortified with this vitamin (36). In the general population, when simulating the full replacement of meat with PBMA, the risk of overt vitamin B12 deficiency increased slightly, on average by ~5% (26). This suggests that, apart from vegetarians and vegans, there may be a risk of inadequate vitamin B12 status in that part of the general population with low seafood intakes and using unfortified PBMA. The fortification of PBMA with vitamin B12 appears to be rare; Melville et al. found a proportion of 15% in an Australian survey (37).

Some potential impacts of using PBS have been suggested regarding other nutrients that have been much less explored. This is the case for riboflavin when using either PBMA or milk analogs. Riboflavin intakes are quite high in the general population but it is largely conveyed by animal products (meat, fish, eggs and dairy) (38, 39). Plant-based milk alternatives are naturally low in riboflavin (legume-based alternatives) or very low (grains or coconut-based), and fortification was very rare in Europe until recently when adopted by a few brands. Based on food composition data from the Australian market,
as reported by Zhang et al., it can be calculated that whereas 250mL milk would supply 33% of the reference value for riboflavin, using (unfortified) legume-based alternatives would only supply 6% and mixed milk alternatives just 1% (40). Using PBMA has been shown to largely reduce riboflavin intakes, leading to a suggested insufficient intake in part of the population, including a slight increase in the risk of overt deficiency (26). This risk varies depending on the type of substitute, and was lower with PBS that included legumes (26). The prevalence of overt deficiency, namely ariboflavinosis, is virtually null in high-income countries, and the characterized adverse effect on health of milder forms of riboflavin remains uncertain. However, riboflavin plays an important role in one-carbon metabolism, and riboflavin subdeficiency has been associated with hypertension, especially in individuals with the MTHFR 677TT genotype (41, 42). Therefore further study are needed to better characterize the adverse effects of low riboflavin intake in high-income countries.

The review will now turn to nutrients for which a risk of shortfall has long been identified when using PBS; namely calcium and iodine for dairy product analogs and iron and zinc for meat analogs.

Calcium and iodine

Dairy is well known as an important contributor to calcium intake and a significant part of the general population has a calcium intake below their estimated requirements (43). Among people consuming no dairy products, there is a very high risk of shortfall (44). Although this has long been disputed, recent findings pointed out that vegans have a higher risk of osteoporotic fractures, and this could be ascribed to insufficient calcium intake (45). Indeed, the risk was high among vegans who are not taking calcium supplements, whereas it was not significant in those using calcium supplements (45). The risk to bone health in vegans may be due to insufficient intakes of the many nutrients and foods that can affect BMD and/or the risk of fracture, which of course include calcium from sources other than dairy, such as fortified plant-based milks (e.g. soy milk, firm calcium-set tofu), other fortified foods such as fortified breakfast cereals, natural foods such as dark leafy greens or mineral water, or blackstrap molasses (46). When fortified with calcium, dairy analogs such as plant-based ‘milk’ usually contain the same level of calcium as their dairy counterpart, so no important impact on calcium intake is expected. However, in many countries, milk analogs are rarely fortified and cheese analogs almost never, especially in countries such as France (19, 40, 47). In the Netherlands, Seves et al. found that a scenario involving no meat and dairy would decrease calcium intake by 25%, even though some dairy analogs were fortified with calcium (36). When simulating the replacement of milk with PBS in France, we found a marked increase in inadequacy and a risk of deficiency for calcium when considering the total set of milk analogs studied but, as expected, this risk was almost null when considering the smaller (one-third) subset of fortified milk analogs (26). It is interesting to mention that conversely, we also found that using meat analogs resulted in a reduction in the level of inadequacy for calcium, so such meat analogs could
compensate for the adverse effects of milk and dairy dessert analogs (26). However, it might be
expected that using also other unfortified dairy analogs, such as plant-based alternatives to cheese,
and not using plant-based alternative sources of calcium could result in a marked increase in calcium
inadequacy, with a resulting risk to long-term bone health.

Less emphasis has been placed on iodine when considering the nutritional quality of dairy analogs in
general surveys. Dairy products are an important source of iodine in the general population (48). The
importance of dairy is less specific regarding iodine than it is for calcium because another important
contributor is seafood. When diets are low in or devoid of both dairy and seafood, as in the case of
vegan diets, few specific products high in iodine are consumed, such as fortified salt and seaweed, and
soils are poor in iodine, its intake can be very low and clearly inadequate (49-51). The contribution of
dairy products to iodine nutrition can be important, as shown recently by Nicol et al. who reported
that three portions of dairy products (milk/yoghurt/cheese) per day supply 124µg iodine (close to the
reference intake of 150µg) whereas three portions of alternative dairy products including 2, 1 or 0
iodine-fortified products only provide 84, 51 and 3µg iodine (52). Although this marked contrast is the
result of extreme scenarios, it suggests the potential magnitude of the effect of replacing dairy with
analogs because few of them are fortified with iodine. Iodine was one of the nutrients showing the
greatest decrease in scenarios concerning an increased use of milk analogs (53). We also showed that
there was an increased risk of iodine deficiency when simulating the utilization of milk analogs or, to a
lesser extent, dairy dessert analogs (26). The prevailing risk for iodine indeed constitutes one of the
highest risks of overt deficiency in the general population at baseline (54) and the simulated increase
with milk substitute was the greatest of all nutrients (26). This situation is probably due to a combination
of factors, including an insufficient consumption of seafood, the insufficient fortification of iodine in
salt (both because iodine is incorporated at a low level in France and fortification is restricted to
household salt, not that used as an ingredient in the food chain), suboptimal levels of iodine in soils
which result in low intakes of iodine from plant products, and, finally, the anecdotal consumption of
seaweed (48). Dineva et al. reported that the population exclusively consuming milk-alternative drinks
could be classified as iodine deficient based on median urinary concentrations, whereas non-exclusive
consumers of milk analogs and milk consumers were not classified as deficient (55). Again, this could be
explained by the same series of reasons, to which it should also be added that although 70% of the
consumers of milk analogs in this cross-sectional study in the UK were eating fish (55), they may have
had lower intake of iodine from seafood. Also, in both the UK and in France, the salt iodization program
is little effective (56).

As far as iodine in milk or dairy analogs is concerned, it should be noted that the iodine fortification of
dairy products is very rare. Iodine fortified milk analogs such as soy drinks have been commercialized
in recent years in the UK, with levels differing little from those in milk (although iodine levels in milk vary considerably depending on areas and seasons)^(57, 58). A recent UK survey found that, not even accounting for organic products (which cannot be fortified in the EU and UK), 28% of milk alternatives and 6% of yoghurt alternatives were fortified with iodine^(52). However, in other European countries such as France, milk analogs fortified in iodine do not appear to be on the market. For instance, a well-known brand of soy milk fortified with vitamins B2, B12 and D is available in France, Portugal, Spain and Italy, but not the version fortified with iodine that is on the UK market (based on the information found in company's national websites and the OpenFoodFact database).

## Iron and Zinc

Iron and to a lesser extent zinc, have been the focus of numerous studies because their intakes are largely provided by meat consumption. However, iron is also high in many plant-based products and comparisons between meat and plant-based meat substitutes have often reported similar amounts of total iron, or even higher amounts in PBMA^(59) which led to a higher iron intake when simulating the substitution of meat and dairy with PBS^(36). However, this did not take account of the well-known differences in absorption (often referred to as “bioavailability”) of plant and animal sources, which were only alluded to in these studies (and indeed not in all cases). Few studies have compared the levels of bioavailable iron in meat and PBMA. Some attempts have been made using average estimates of absorbable iron from animal-based or plant-based meals/diets, such as 16% absorption from meals/diets containing meat and 10% absorption from plant-based meals/diets^(60). However, there remain many uncertainties in those estimates, because iron bioavailability can vary markedly depending on the content of the meal and whether the equation or algorithm used to estimate iron absorption take into account multiple factors in a variable manner^(61-63). Taking account of changes in bioavailability and using simulation techniques on all individuals in a French representative survey, we were able to show that replacing all meat with varied plant-based meat analogs would decrease absorbed iron from the diet, and therefore raise the risk of insufficient intake and result in a slight increase in the probability of over-deficiency (i.e. iron deficiency anemia)^(26). Because the bioavailability of zinc is also dependent on animal sources such as meat, zinc bears many similarities with iron. In this simulation study, we found decrease in absorbed zinc from the diet when PBMA replaced meat, but no increase in the risk of overt deficiency^(26).

Recent findings in the literature have shown that iron nutrition, and to a lesser extent zinc nutrition, are critical when considering a general shift toward a plant-based diet. Again, this was revealed in studies accounting for the bioavailability of iron and zinc, using equations or algorithms to estimate iron absorption^(62). In this context, we showed using optimization models that imposing a modelled healthy diet conveying sufficient bioavailable iron to cover the estimated physiological requirements
of the population markedly limited the healthiness of the modelled diet, as it led to incomplete
reductions in red meat consumption (conveying bioavailable iron) and incomplete increases in whole
grain products (conveying phytates which inhibit iron absorption) <sup>(64)</sup>. This resulted in suboptimal
reductions in morbidity/mortality risks as assessed as DALYs using a comparative risk assessment
model. By contrast, when the constraint on dietary absorbable iron was relaxed, the optimally healthy
modelled diet was almost devoid of red meat and all grain products were whole grains, leading to
further important reductions in the long term health risk. This was at the price of a projected increase
in iron-deficiency anemia (from 2% in the observed population to 5% in the flexible optimal model) but
the increase in morbidity (as DALYs) due to anemia was much lower than the reduction due to benefits
on long-term health <sup>(64)</sup>. During this study, bioavailable iron and bioavailable zinc were dually
constraining modelled diets, since iron and zinc were found to mostly to be contributed by the same
sources and their bioavailability was influenced similarly. Recently, Van Wonderen et al. showed
convincingly that taking account of bioavailable iron was important when modelling diets. Using meal
planning optimization from a selection of meals, and applying several methods to estimate total iron
absorption from these meals, they showed that modelled diets with constant absorption factors (as is
usually done) finally conveyed much less absorbed iron than diets modelled using specific diet-
dependent absorption equations <sup>(63)</sup>.

The question of insufficient iron intake is specific to diets containing no meat. Meatless diets that are
healthy tend to lead to critical levels of bioavailable iron, since other classical healthy food categories
convey iron with low bioavailability (such as legumes and whole grains) or are not consumed enough
to make a sufficient contribution to intakes of iron of good bioavailability (such as seafood) <sup>(27)</sup>.
Vegetarian diets can be designed to supply enough bioavailable iron <sup>(65)</sup>, but the iron status of
vegetarians is low, although evidence of iron deficiency, such as a higher risk of iron-deficiency anemia,
is lacking <sup>(66)</sup>. The relationship between vegetarian diets and iron status appears to vary considerably,
and one source of variation might be the nature of the food consumed instead of meat, which in
traditional vegetarian populations (such as in the UK and among north-American Adventists) is
legumes and vegetarian alternatives <sup>(31, 67)</sup>. In populations that have turned more recently towards a
meatless diet in western countries, PBMA is probably a more common alternative <sup>(4)</sup>, raising possible
concerns about nutritional quality in general <sup>(68)</sup>. A second source of variation might be the level of iron
fortification in the food chain (such as flour being fortified with iron) and the fortification of food items,
and of course, particularly PBMA. In Europe, the UK is the only country to fortify flour with iron.

Because the composition of PBMAs is variable, as discussed above, so is the amount of iron and
absorbable iron they contain. We found that the simulated impact of using PBMA on the risk of iron
deficiency in the population varied according to the type of PBMA (being higher with plant-based
breaded foods than with plant-based patties) and the nature of the main protein ingredient (being
higher with cereal-based analogs rather than with soy-based analogs) (26). Few data are available on
the potential contribution of PBMA to dietary bioavailable iron because reports based on a
composition survey included limited information on vitamins and minerals as the information was
missing from the pack, and there was no information regarding the bioavailability of iron. Therefore,
most reports have simply mentioned that PBMA contain higher amounts of total iron than meat (59, 69)
or that the replacement of meat and dairy with PBS will lead to increases in population iron intake (70).
Some studies have however taken account of expected differences in bioavailability, such as 45% less
absorption (meaning an 80% higher dietary requirement or reference value) reported by Pointke and
Pawelzik, who nevertheless found that PMBA sold in Germany made a potential contribution to iron
nutrition that was similar to meat (17). Labba et al. went one step further by analyzing the iron and
phytate contents in a series of PBMA on the Swedish market and used this information to categorize
the PMBA according to their expected bioavailability, determined using the phytate:iron content in the
PBMA (71). Their results showed that except for a few items, PBMAs contained very high phytate:iron
ratio, indicating very low bioavailability. It is noteworthy that these authors found one exception
among the PBS, tempeh, for which they estimated a high content in bioavailable iron, because of both
its high iron content (similar to meat) and low phytate content; this could be explained by the fact that
tempeh is a food fermented with a fungus that produces the phytate-degrading enzyme phytase.
Similar results were found for zinc, with probably low bioavailable zinc as assessed from the
phytate:zinc estimates. Here also there was one notable exception, found with the mycoprotein
product analyzed as being very high in zinc and virtually devoid of phytate. Finally, the literature data
do not provide a clear and uniform answer regarding the risk of insufficient levels of bioavailable iron
in the PBS on the market, but this generally appears to be considerable when products are not fortified,
and may vary depending on the type of product and the country/area market.

Overall, PBS with the potential to be valuable sources of iron and zinc are either very traditional
products (such as Tempeh) or highly innovative products such as the recent PBMAs that incorporate
iron in a form that is not sensitive to inhibitors such as phytate and tannins. This is the case of PBMAs
that incorporate haem iron from plant sources (soy leghemoglobin) as a bioengineered ingredient.
Although this ingredient is used to better imitate the color and taste of meat in these PBMA (69, 72, 73),
the haem-iron form is expected to supply highly bioavailable iron, irrespective of the amounts of
phytate in the PBMA (74). Likewise, there are many reports on how food products could include large
amounts of bioavailable iron and zinc, including but not limited to the case of phytate, and using
biofortification, ingredient selection, and a broad range of treatments (germination, soaking,
fermentation, enzymatic treatment) (75-77).
However, on average, and within the current range of products on the market, absorbable iron levels appear to be low in PBMA. This raises the question whether a PBMA could be designed with the usual ingredients to be sufficiently rich in iron, or would it need to be fortified with iron? In a model that minimized environmental impacts, Van Mierlo et al. found that iron fortification was necessary when seeking to match the nutritional composition of beef (but not chicken), although it appeared to be limited to the non-haem iron content, and that the result could be sensitive to changes in the bioavailability of iron due to interactions with the inhibitors and enhancers of iron absorption found in the diet (78). We searched for the best theoretical recipe for a pulse-based meat analog to improve overall diet quality using a list of ingredients and technological constraints (79). The final recipe resulted in a marked improvement in nutrient-based diet quality, which was ~4-fold higher than the effect of the best of the PBMA found in our benchmark database. However using this overall “optimal” PMBA would lower the absorbable iron content in the diet and increase the probability of an insufficient iron intake, although the increase in the risk of deficiency (when compared to the threshold for the risk of iron-deficiency anemia) was almost unchanged. Indeed, the absorbable iron content of the PBMA, although relatively high, remained lower than that found in the meat it was entirely replacing under our scenario. Among the binding constraints for optimization, we found higher levels of herbs, spices, nuts and seeds that were good sources of iron but had to be restricted in the recipe for the sake of their expected acceptability. In a subsequent work, we further elaborated on the importance of iron (and zinc) fortification in PBMA in the perspective of building healthiest diets that included lowering red meat levels (80). As the general aim was to investigate the nutritional benefits of plant-based meat substitutes and covered different alternatives, various dietary changes were allowed, both within a food category (such as the partial or total replacement of any type of meat with plant-based meat substitutes) and between food categories; however, the latter were hampered by the search for a healthier dietary pattern that would remain close to current eating habits (80). Without fortification, the average meat substitute was not incorporated in the model diet to any significant extent, showing that its nutrient composition was insufficient to act as a nutritional lever. By contrast, fortification with iron and zinc resulted in introducing more PBMA in the modelled diets, along with major reductions to the levels of red meat, processed meat and poultry. The PBMA that we had already optimized on a nutrient basis was more readily introduced into these modelled diets, but not so much at the expense of meat, whereas when it was fortified with iron and zinc, a higher level of inclusion were reached together with marked decreases in beef (80). As in our study, Mertens et al. modelled substitutions for meat under the background hypothesis that PBMAs were taken as substitutable for meat with no cost regarding acceptability (81). In their model designed to improve adherence to dietary guidelines and then maximally reduce GHGs, these authors also found that theoretical fortifications in iron (and some vitamins) led to larger quantities of meat substitutes and smaller quantities of meat in the modeled
diets compared to those involving non-fortified meat substitutes. Interestingly, with the same objectives of achieving the highest diet quality, the amount of PBMA in modelled diets varied between countries (81), which may reflect differences in the background diet and associated nutrient intake.

**The case for the fortification of meat analogs with iron and dairy analogs with calcium.**

From the above, it appears that nutrient security related to the use of PBS by the general population mostly concerns calcium and iron. But as discussed earlier, these are not the only nutrients at issue, although for others the risk would be less specific as dependent on the consumption of other food categories (such as seafood for iodine) and vary according to the background diet (e.g. animal products for vitamin B12). Although this does not mean that they should be disregarded (but rather that they should be further studied), the hazard characterized and hence the estimated risk is also lower for other nutrients where overt deficiency has been poorly characterized or is rare in western countries with no protein energy undernutrition, such as zinc or riboflavin. By contrast, the calcium intake in the general population is insufficient while iron intake appears to be marginal in some women with high requirements, leading to a greater risk of deficiency if calcium and iron decrease following the use of PBS. As also illustrated, although the fortification of PBS varies between countries, it remains low inasmuch as it would be insufficient to alleviate the risk. Fortification requires an in-depth knowledge of the technological issue of acceptability and the optimum form to achieve high bioavailability, but considerable progress has already been achieved (82, 83). PBS fortification would seem to be the most appropriate method to avoid decreases in nutrient intakes when shifting from animal products, but, if this is not made mandatory by regulations, it would be necessary to determine solutions so that more manufacturers will adopt this measure. Alternatively, fortification could be introduced as a general public health initiative based on the fortification of agricultural commodities (e.g. flours) or staple / mass market foods (e.g. salt), including PBS, which would thus improve the nutrient status of the entire population (84, 85). And indeed, the two approaches could be interestingly combined. However, fortification scenarios need to be closely monitored beforehand to ensure that the goals are attained while not causing any excessive exposure to nutrients of concern in this respect. In particular, iron fortification should reduce rates of iron deficiency anemia in at-risk females without leading to iron exposure that would become excessive in male meat-eaters (86, 87). PBMA is the food fortification vehicle that could be prioritized to avoid this risk. However, for calcium, multiple vehicles could be considered in order to ensure more general improvements to intake, given the absence of an upper level. As we have argued elsewhere, in view of the development of PBMA as one way to move towards a more plant-based diet would be to take the opportunity of using PBMA as a vehicle for fortification with nutrients that tend to be too low in plant-based diets (4). If fortification is not made mandatory, rendering effective in the general population remains an issue (88). On the one hand, because consumer
attitudes have been shown to depend on the perceived appropriateness of fortifying a given food product (89), and notably the perceived healthiness of the food vehicle (90). Since PBS are seen as replacing animal products, fortification of PBS could be legitimate from the consumers' perception. This could indeed be the rationale for the marketing of the nutritional equivalence, which however today mostly limited to protein for PBMA and calcium for plant-based dairy analogs. However, the perceived relevance for consumers is also related to perceived personal benefits and problem awareness (89), which may explain why the protein claim has gained popularity (although it is less relevant to public health nutrition) and may hinder the promotion of other nutrient claims, such as iron in PBMA or iodine in dairy PBS, because of they are less recognized, despite their greater public health importance. The promotion of fortification could also be fostered by the structure-function claims (in the USA) or standard health claims (Article 13 in the EU) but, as expected, these claims are mostly used for marketing purposes and involve multiple pitfalls from a public health nutrition perspective (91, 92). The appeal for fortified products varies; some consumers consider that fortification shifts the plant-based product away from the naturalness spontaneously attached to it, unless it is assured using natural ingredients (90). There is therefore a risk that the voluntary fortification of PBS will fail to secure the nutrient status of a large proportion of people who would prefer PBS to be devoid of any ingredients and supplements which they deem are not natural, or consume organic foods, which cannot be fortified in the EU and UK.

## Nutrients with a potential impact on long-term health

Fiber is only found in plant-based products and it is a clear and consistent dimension of the nutrient cluster associated with plant:animal protein or, more generally, a plant-rich dietary pattern (93, 94). While there is no fiber in the animal foods that they are replacing, most PBS contain fiber, although in variable amounts. For instance, Labba et al. reported on analyzed total fiber contents and found values ranging from 3.5g to 9.5g per 150g PBMA (71). Cutroneo et al. also reported a very broad range but the average fiber content was not high among red meat or poultry analogs (1.9g/100g), whereas average values were high in analogs of burgers or meatballs (4.7 and 4.5g/100g) (16). Similar figures were reported in Australia, with burger analogs containing 4.5g/100g, meatball analogs 3.8g/100g and plain poultry analogs 4.7g/100g (37), and in other countries (15). The variability was considerable, as shown by the 95% confidence intervals in fiber content, e.g. [2.4-7.1] in the latter category (37). The amount of fiber was found to be much lower in plant-based milk or dairy analogs, at ~0.5g/100g in milk analogs and ~1g/100g in yoghourt analogs in Norway and France (15, 26). As expected, given the virtually null level of fiber in meat products, the significant levels in PBMA, and the high levels of meat consumption in observed diets, we found that replacing meat with PBMA led to a significant reduction in the risk of inadequacy for fiber, and the effect was maximal when using pulse-based substitutes or plain cooked
pulses (which were taken as a reference) (26). By contrast, this reduction remained very small when milk and yoghurt/desserts were replaced with their PBS counterparts (26). Under a scenario that reduced or replaced both meat and dairy with PBS, the fiber intake rose markedly, by up to one-third in the replacement scenario (36).

The importance of fiber to human health is now widely acknowledged (95). Insufficient fiber intake has been rated as an important contributor to the burden of diet-related disease in high-income countries; its impact is less than that of most dietary factors but greater than that of a high consumption of sugar-sweetened beverages or a low consumption of vegetables (96). Therefore, given the importance of fiber per se, and the projected increase in fiber when using PBS instead of their animal-based counterparts, they could have a favorable impact on long-term health.

Like fiber, amounts of SFA are usually largely associated with the level plant:animal content in the diet. As expected, SFA contents are usually low in PBMAs and, on average in country markets, SFA content in PBMA are between half (37) and one-third (6, 17, 97). More specifically, the SFA content in PBMA varies markedly as a function of product type, and also depends on specific items within this type. For instance, Labba et al. reported SFA values of 0.2 g/100 g in a mycoprotein filet and 3.5 g/100 g in a pea burger (71). The SFA content varied considerably depending on the type of added fat, being much higher when shea butter or coconut or palm oil was used, compared to canola oil or sunflower oil (6, 71). High levels of fat and the use of coconut oil can lead to high SFA levels in some PBMA products (98). Finally, generally marked effects on the saturated fatty acid intake can be expected from the use of PBMA rather than their animal counterparts, inasmuch as the differences in contents are significant, meat intake is high, and SFA intake is excessive in a large part of the population. Accordingly, in a simulation study, we found that such a substitution would lower the risk of excessive SFA intake in the population (26).

As for dairy and SFA, dairy is usually an important contributor to SFA intakes but SFA levels in dairy products vary considerably. SFA contents in plant-based drinks are often one-third or one-quarter of those found in semi-skimmed milk (15, 26). The SFA content varies little in plant-based drinks, with the notable exception of coconut drinks where amounts similar to, or even much higher than, those in whole milk have been reported (15, 99). Nonetheless, because the average SFA content is low, substituting milk with plant-based drinks does not appear to change significantly the risk of excessive SFA intake at the population level (26). The issue may be slightly different where other PBS are concerned, such as analogs of dairy desserts and cheese, but the composition (and SFA levels) of both dairy products and plant-based analogs vary considerably. For instance, we found that replacing dairy desserts with sweet plant-based desserts would markedly lower excessive SFA intakes whereas replacing them with a plant-based mousse would in fact cause the opposite (26). Comparisons based
solely on SFAs contents may remain difficult since fat consumed in the form of cheese has a differential
effect on blood lipid responses relative to some other dairy food structures, although there is
considerable heterogeneity and relatively few comparisons with other varied matrices of dairy
products (100) and obviously with cheese PBS.

When simulating the combined substitution of meat and dairy with PBS, Temme et al. (70) showed a
marked decrease in SFA, from 13.2% of the population average energy intake to 9.2%E, which would
mean that the proportion of the population complying with the recommendation (<10%E) would
increase from 20% to 62%. Such a change is consistent with the known contribution of meat and dairy
to excessive SFA intake (101) and it would be expected to have an important impact on long-term health.

We will only make rapid reference to the expected effects of PBS on the profile and overall intake of
fatty acids other than SFA. The aforementioned trends seen for improvements in SFA levels are
associated with similar trends regarding MUFA+PUFA, resulting from the fact that the fatty acid
composition of PBS is naturally strongly reflected by the utilization of vegetable oils in the recipes.
Indeed, even for PBMA that might contain SFA levels similar to those of meat, the fatty acid profile
was (4-fold) richer in PUFA (98). So alongside the improvement in SFA levels, PBS could be viewed as a
way to replace animal fats with vegetable oil. The type of vegetable oil is of course important when
defining PBS. In a modeling study, we found that the optimal recipe for a PBMA integrated rapeseed
oil, and sensitivity analysis revealed that this ingredient was by itself one of the most important in
improving diet quality (79). Higher levels of α-linolenic acid, resulting from the use of rapeseed oil,
proved to be important to incorporating a PMBA in a healthy diet containing lower quantities of red
meat (80).

Lastly, sodium levels in PBS have been a matter of debate. Many reports have warned about the high
level of sodium in PBMA, which are higher than in meat and meat-based products (6, 17), but some
reports have found similar or lower levels (37, 102). In more detail, studies have found that the sodium
content varied depending on the PBMA category (6, 59). For instance, sodium in plant-based mince has
been reported to be twice or even 6-fold higher than in meat mince, while conversely meat sausages
contained ~66% more sodium than plant-based sausages (6, 12). Because processed meat is usually high
in added salt, it is not surprising that the plant-based analog displayed lower levels. By contrast, sodium
levels were found to be consistently higher in PBS for unprocessed meat. Nevertheless, sodium
contents do not account for the salt added by consumers, which is expected to be higher with meat
than with PBMA, where salt has been added beforehand into the recipe. The amount of salt probably
added by consumers cannot be estimated and thus taken into account, even in simulation/modelling
studies (26, 36, 79). In our simulation study which did not take account of salt added to meat, the
substitution of meat by PBMA resulted in an average increase in sodium intake from initially 3200 mg/d
to 3400 mg/d (26). Although such levels are far higher the recommended upper level of 2300mg/d, such an increase would further worsen the situation of excessive intake, which is indeed known as an important public health nutrition issue, because excessive sodium is both the usual situation and is detrimental to health, leading to a very high contribution to the burden of diseases. Being the most binding constraint in diet modelling (27, 28), appropriate levels of sodium in the diet require an in-depth reorganization of the dietary pattern, which would not be expected from limited and simple swaps with PBS.

It remains difficult to determine how far the use of PBS will result in changes to nutrient intake that will achieve effects on long-term health. In addition, the nutrient compositions of all PBS are quite varied (103). However, an important and consistently higher fiber intake and lower SFA intake, and a probable higher PUFA intake would be expected to result in major benefits to health, although these might be somewhat limited by a potential increase in sodium intake. We are currently investigating how these factors may weight in the final health benefit.

## Impact of using PBS on the healthiness of the dietary pattern

The benefits of using PBS should also be considered at the overall dietary level, in terms of changes to the intake of food categories that are related to long-term health. Although the use of PBSs leads to relatively specific changes in the diet which facilitate the prediction of possible benefits, their ultimate effect may depend on the subtype of food they replace, leaving open the eternal question for nutritionists: "instead of what?" (104). Given the adverse effects of red meat (total and processed) on health (105), its replacement by PBMA should result in a benefit. However, PBMA are also made to replace other types of meat, including poultry, and poultry has not been shown to be associated with a higher risk of disease (105, 106). Replacing poultry with PBS would also be expected to have much less impact on SFA intake (as reviewed above), because poultry contributes less SFA than red meat. However, the final impact on atherogenic lipoprotein may remain high with poultry (107).

In contrast, there is limited evidence on which to base speculation regarding the expected effects of decreasing dairy products, and indeed milk and yogurt have been associated with reductions in some health risks (108). The overall benefit may outweigh the detrimental effect of their contribution to SFA intake (109). Cheese could be a better subtype to be decreased by replacing it with PBS, based on current dietary guidelines, but the reasoning is mostly based on the level of nutrients (with the high contribution of cheese to SFA and sodium) and the energy density of higher-fat dairy (110). However, cheese analogs are not yet well developed, and their composition varies considerably (103). While some plant-based cheese analogs are ultra-processed foods that include palm oil, others are traditional tofu-based products or based on simple fermented nuts (such as cashew) (47, 111, 112). The latter may offer a
more valuable option given the health benefits of nuts, not to mention their good nutrient quality (112). Clearly, there is insufficient information to describe the potential health effects of substituting cheese with plant-based analogs.

A final question at issue regarding the expected effects of plant-based food analogs on long-term health concerns their classification as mostly ultra-processed foods (UPF), and particularly PBMA (103). The consumption of ultra-processed foods, according to the NOVA classification, has received much attention, and there is a large body of evidence regarding its adverse effects on health. The consumption of ultra-processed foods has reached high levels in western countries, reaching 55% in the US (113) and 31% in France (114), and increasing the use of PBS would further increase the share of UPF in the diet. In France, when compared to non-vegetarians, the share of UPF is higher in vegetarians and vegans (~6.5%-points higher), and notably as they are younger vegetarians (115). Likewise, we have estimated that substituting meat or dairy desserts with PBS would increase the share of UPF by up to ~10%-points, depending on the type of substitute, and replacing milk with analogs would increase it by ~5%-points. There has been much concern that a transition towards a plant-based diet using UPF PBS might result in "missing the point" when compared to the recognized benefits of a traditional plant-based diet based on whole-foods (68, 116, 117). However, although mostly classified as UPF (37, 103), PBMA little share the features that have often been highlighted as potentially explaining the adverse effects of UPF; further, these features as potential mechanism still remain speculative (118). This topic was reviewed by Messina et al. who argued that soy-based meat and dairy alternatives do not have a higher energy density, glycemic index and hyper-palatability, and do not have a lower satiety potential (119). Moreover, UPF are often criticized for their adverse nutrient content, but hardly applies to the PBS reviewed here, although some types of PBS do contain high levels of SFA, sugar or sodium. De las Heras-Delgado et al. found that, within UPF, most PBS had a better nutrient profile than their animal-based homologs, and their overall nutritional quality, assessed using the modified FSA score, was only slightly lower than that of unprocessed animal-based foods (103). PBS are generally recognized as convenient and desirable plant-based foods to encourage dietary change and which, by means of their diversity, may help to maintain a plant-based diet with higher share of plant:animal protein (4, 68). Attention should be paid to ensuring that PBS have a good nutritional composition, helping to reduce excessive amounts of some nutrients (such as SFA and sodium), increasing the amounts of nutrients with long-term impacts on health such as fiber and PUFA, and avoiding nutritional risks, such as those concerning iron and calcium (117). PBS which are as little "(ultra)processed" as possible should be considered as more desirable until we have gained further insight into the mechanisms underlying the adverse effects of UPF. Finally, it should be made clear that, all other things being equal, replacing animal foods with whole plant foods such as legumes, whole grains, nuts and seeds, offer clear
evidence of beneficial effects on long-term health that is lacking when considering ultra-processed plant-based analogs.

Conclusion

PBSs convey potential risks and benefits. Some risks may depend on the characteristics of the overall diet, as is the case for iodine in a diet devoid of seafood and dairy, and vitamin B12 in a vegetarian/vegan diet. Except in the frail elderly, the risk of an insufficient protein intake is deemed to be very low inasmuch as their diet includes alternatives that remain sources of protein, which is the case for PBMA. Some nutrients may be insufficiently consumed but the final health implications remain insufficiently clear, as is the case for riboflavin and zinc, which require further studies to characterize their impact. The most important concerns regarding nutrient shortages with PBS relate to iron and calcium, which are critical to the nutritional value of PBS. While some PBMAs containing sufficient bioavailable iron exist or could be produced, the low bioavailable iron content in PBMAs seems to limit their broad utilization as a good substitute for meat in actual diets and modelled healthier diets, especially among women with high menstrual losses. Although there may be a risk of iron overload in other populations, this situation makes the case for fortifying PBMA with iron, and putting forward claims on iron rather than protein. The bioavailability of iron, and also zinc, in PBMA could also be improved by lowering levels of inhibitors such as phytate. While some dairy substitutes are fortified with calcium, the proportion of fortified products is very low in some countries. Insufficient calcium intake is a public health issue in the general population, causing a greater risk of osteoporosis in people following diets devoid of dairy products and not taking supplements. Attention should be paid to providing alternative foods that are rich in calcium. Again, a clear case is made for the calcium fortification of dairy substitutes, and other products, and even mandatory public health fortification, since, unlike iron, there is apparently no risk of a high calcium intake causing adverse effects in the population. Conversely, the use of PBS is also expected to convey some benefits for long-term health, because it would result in a higher fiber intake with PBMA, and a lower SFA intake (with a higher PUFA/MUFA intake), but attention should be paid to the possible increase in sodium intake with PBMA.
As recently illustrated by others (103), a recurring finding of this literature review is that PBSs are extremely heterogeneous, both within and between countries, in terms of their ingredients and nutrient composition – just as the nutritional profiles of consumers also vary – so it remains difficult to issue general statements about the quality of PBS. Health benefits could also derive from changes at the level of the dietary pattern, inasmuch as PBMA are specifically replacing red meat. PBMA that would convey healthy food categories as ingredients, such as legumes and vegetables, would offer further benefits for long-term health. The long-term benefits of dairy substitutes are much less evident, except maybe for cheese if legumes are used as a basis in fermented analogs. Lastly, PBS have
also been criticized as being ultra-processed, although most of them do not share the attributes of UPF that might explain the adverse effects of UPF consumption on health. Although using whole plant foods remains the reference for nutrition and health, PBS in general are recognized as convenient and desirable plant-based foods that will encourage dietary change and through their diversity will help to maintain a plant-based diet. Attention should be paid to their composition in ingredients and nutrients so that any risks are restricted and the benefits can be the greatest. It is also necessary for fortification with iron and calcium to become an important public health nutrition consideration in our transitional diets, to the point of becoming a clear public policy objective.

Financial Support: None.

Conflicts of interest: FM declare the following as potential sources of conflict of interest. FM has received research grants for PhD fellowships under his direction by AgroParisTech and INRAE from Terres Univia and Ecotone Foundation, under the aegis of the Foundation de France. Terres Univia is the professional association for oilseeds and protein-rich plants in France, which are mainly used as livestock feeds. The Ecotone Foundation for biodiversity was founded by the Ecotone Group that sells mainly organic and plant-based foods.
References

1. Dagnelie PC & Mariotti F (2017) 1 - Vegetarian Diets: Definitions and Pitfalls in Interpreting Literature on Health Effects of Vegetarianism. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 3-10 [F Mariotti, editor]: Academic Press.

2. Haddad EH, Berk LS, Kettering JD et al. (1999) Dietary intake and biochemical, hematologic, and immune status of vegans compared with nonvegetarians. *The American journal of clinical nutrition* 70, 586S-593S.

3. Aschemann-Witzel J, Gantriis RF, Fraga P et al. (2021) Plant-based food and protein trend from a business perspective: markets, consumers, and the challenges and opportunities in the future. *Critical reviews in food science and nutrition* 61, 3119-3128.

4. Messina M, Duncan AM, Glenn AJ et al. (2023) Plant-Based Meat Alternatives Can Help Facilitate and Maintain a Lower Animal to Plant Protein Intake Ratio. *Advances in nutrition*.

5. Boukid F (2021) Plant-based meat analogues: from niche to mainstream. *Eur Food Res Technol* 247, 297-308.

6. Curtain F & Grafenauer S (2019) Plant-Based Meat Substitutes in the Flexitarian Age: An Audit of Products on Supermarket Shelves. *Nutrients* 11.

7. Alae-Carew C, Green R, Stewart C et al. (2022) The role of plant-based alternative foods in sustainable and healthy food systems: Consumption trends in the UK. *Sci Total Environ* 807, 151041.

8. Nijdam D, Rood T Westhoek H (2012) The price of protein: Review of land use and carbon footprints from life cycle assessments of animal food products and their substitutes. *Food Policy* 37, 760-770.

9. Shanmugam K, Bryngelsson S, Östergren K et al. (2023) Climate Impact of Plant-based Meat Analogues: A Review of Life Cycle Assessments. *Sustainable Production and Consumption* 36, 328-337.

10. Smetana S, Mathys A, Knoch A et al. (2015) Meat alternatives: life cycle assessment of most known meat substitutes. *The International Journal of Life Cycle Assessment* 20, 1254-1267.

11. Bryant CJ (2022) Plant-based animal product alternatives are healthier and more environmentally sustainable than animal products. *Future Foods* 6, 100174.

12. Romao B, Botelho RBA, Torres ML et al. (2023) Nutritional Profile of Commercialized Plant-Based Meat: An Integrative Review with a Systematic Approach. *Foods* 12.

13. Camilleri GM, Verger EO, Huneau JF et al. (2013) Plant and animal protein intakes are differently associated with nutrient adequacy of the diet of French adults. *The Journal of nutrition* 143, 1466-1473.

14. Hoy MK, Murayi T Moshfegh AJ (2022) Diet Quality and Food Intakes among US Adults by Level of Animal Protein Intake, What We Eat in America, NHANES 2015-2018. *Curr Dev Nutr* 6, nzac035.

15. Tonheim LE, Austad E, Torheim LE et al. (2022) Plant-based meat and dairy substitutes on the Norwegian market: comparing macronutrient content in substitutes with equivalent meat and dairy products. *J Nutr Sci* 11, e9.

16. Cutroneo S, Angelino D, Tedeschi T et al. (2022) Nutritional Quality of Meat Analogues: Results From the Food Labelling of Italian Products (FLIP) Project. *Front Nutr* 9, 852831.

17. Pointke M & Pawelzik E (2022) Plant-Based Alternative Products: Are They Healthy Alternatives? Micro- and Macronutrients and Nutritional Scoring. *Nutrients* 14.

18. Paul AA, Kumar S, Kumar V et al. (2020) Milk Analog: Plant based alternatives to conventional milk, production, potential and health concerns. *Crit Rev Food Sci Nutr* 60, 3005-3023.

19. Angelino D, Rosi A, Vici G et al. (2020) Nutritional Quality of Plant-Based Drinks Sold in Italy: The Food Labelling of Italian Products (FLIP) Study. *Foods* 9.

20. Rothgerber H (2017) 2 - Attitudes Toward Meat and Plants in Vegetarians. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 11-35 [F Mariotti, editor]: Academic Press.
21. Rozin P, Hormes JM, Faith MS et al. (2012) Is Meat Male? A Quantitative Multimethod Framework to Establish Metaphoric Relationships. *Journal of Consumer Research* 39, 629-643.

22. Lacy-Nichols J, Hattersley L Scrinis G (2021) Nutritional marketing of plant-based meat-analogue products: an exploratory study of front-of-pack and website claims in the USA. *Public health nutrition* 24, 4430-4441.

23. Mariotti F & Gardner CD (2019) Dietary Protein and Amino Acids in Vegetarian Diets-A Review. *Nutrients* 11.

24. Mariotti F (2016) Protein Intake Throughout Life and Current Dietary Recommendations. In *Molecular Nutrition of Amino Acids and Proteins*, pp. 13-25 [D Dardevet, editor]. London: Academic Press Ltd-Elsevier Science Ltd.

25. de Gavelle E, Huneau JF, Bianchi CM et al. (2017) Protein Adequacy Is Primarily a Matter of Protein Quantity, Not Quality: Modeling an Increase in Plant:Animal Protein Ratio in French Adults. *Nutrients* 9.

26. Salome M, Huneau JF, Le Baron C et al. (2021) Substituting Meat or Dairy Products with Plant-Based Substitutes Has Small and Heterogeneous Effects on Diet Quality and Nutrient Security: A Simulation Study in French Adults (INCA3). *The Journal of nutrition* 151, 2435-2445.

27. Dussiot A, Fouillet H, Perraud E et al. (2022) Nutritional issues and dietary levers during gradual meat reduction - A sequential diet optimization study to achieve progressively healthier diets. *Clinical nutrition (Edinburgh, Scotland)* 41, 2597-2606.

28. Fouillet H, Dussiot A, Perraud E et al. (2022) Plant to animal protein ratio in the diet: nutrient adequacy, long-term health and environmental pressure. *medRxiv*, 2022.005.2020.22275349.

29. Perraud E, Wang J, Salome M et al. (2022) Plant and Animal Protein Intakes Largely Explain the Nutritional Quality and Health Value of Diets Higher in Plants: A Path Analysis in French Adults. *Front Nutr* 9, 924526.

30. Dietrich S, Trefflich I, Ueland PM et al. (2022) Amino acid intake and plasma concentrations and their interplay with gut microbiota in vegans and omnivores in Germany. *Eur J Nutr* 61, 2103-2114.

31. Papier K, Tong TY, Appleby PN et al. (2019) Comparison of Major Protein-Source Foods and Other Food Groups in Meat-Eaters and Non-Meat-Eaters in the EPIC-Oxford Cohort. *Nutrients* 11.

32. Mariotti F (2017) Plant Protein, Animal Protein, and Protein Quality. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 621-642 [F Mariotti, editor]: Academic Press.

33. EFSA Panel on Dietetic Products N & Allergies (2014) Scientific Opinion on Dietary Reference Values for pantothenic acid. *EFSA Journal* 12, 3581.

34. Vatanparast H, Islam N, Shafiee M et al. (2020) Increasing Plant-Based Meat Alternatives and Decreasing Red and Processed Meat in the Diet Differentially Affect the Diet Quality and Nutrient Intakes of Canadians. *Nutrients* 12.

35. Elmadfa I & Singer I (2009) Vitamin B-12 and homocysteine status among vegetarians: a global perspective. *The American journal of clinical nutrition* 89, 1693s-1698s.

36. Seves SM, Verkaik-Kloosterman J, Biesbroek S et al. (2017) Are more environmentally sustainable diets with less meat and dairy nutritionally adequate? *Public health nutrition* 20, 2050-2062.

37. Melville H, Shahid M, Gaines A et al. (2023) The nutritional profile of plant-based meat analogues available for sale in Australia. *Nutr Diet* 80, 211-222.

38. Food I & Board N (1998) Dietary Reference Intakes: Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Institute of Medicine: National Academy Press, Washington DC, USA.

39. Field MS, Bailey RL, Brannon PM et al. (2022) Scanning the evidence: process and lessons learned from an evidence scan of riboflavin to inform decisions on updating the riboflavin dietary reference intakes. *The American journal of clinical nutrition* 116, 299-302.

40. Zhang YY, Hughes J Grafenauer S (2020) Got Mylk? The Emerging Role of Australian Plant-Based Milk Alternatives as A Cow's Milk Substitute. *Nutrients* 12.
41. McAuley E, McNulty H, Hughes C et al. (2016) Riboflavin status, MTHFR genotype and blood pressure: current evidence and implications for personalised nutrition. *The Proceedings of the Nutrition Society* 75, 405-414.

42. Ward M, Hughes CF, Strain JJ et al. (2020) Impact of the common MTHFR 677C→T polymorphism on blood pressure in adulthood and role of riboflavin in modifying the genetic risk of hypertension: evidence from the JINGO project. *BMC Med* 18, 318.

43. Mensink GB, Fletcher R, Gurinovic M et al. (2013) Mapping low intake of micronutrients across Europe. *Br J Nutr* 110, 755-773.

44. Bakaloudi DR, Halloran A, Rippin HL et al. (2021) Intake and adequacy of the vegan diet. A systematic review of the evidence. *Clinical nutrition (Edinburgh, Scotland)* 40, 3503-3521.

45. Thorpe DL, Beeson WL, Knutsen R et al. (2021) Dietary patterns and hip fracture in the Adventist Health Study 2: combined vitamin D and calcium supplementation mitigate increased hip fracture risk among vegans. *The American journal of clinical nutrition* 114, 488-495.

46. Mangano KM & Tucker KL (2017) Bone Health and Vegan Diets. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 315-331 [F Mariotti, editor]: Academic Press.

47. Craig WJ, Mangels AR, Brothers CJ (2022) Nutritional Profiles of Non-Dairy Plant-Based Cheese Alternatives. *Nutrients* 14.

48. ANSES (2018) OPINION of the French Agency for Food, Environmental and Occupational Health & Safety on the risk of excess iodine intake from the consumption of seaweed in foodstuffs (ANSES Opinion Request No 2017-SA-0086).

49. Combet E (2017) 42 - Iodine Status, Thyroid Function, and Vegetarianism. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 769-790 [F Mariotti, editor]: Academic Press.

50. Brantsæter AL, Knutsen HK, Johansen NC et al. (2018) Inadequate Iodine Intake in Population Groups Defined by Age, Life Stage and Vegetarian Dietary Practice in a Norwegian Convenience Sample. *Nutrients* 10, 230.

51. Neufingerl N & Eilander A (2021) Nutrient Intake and Status in Adults Consuming Plant-Based Diets Compared to Meat-Eaters: A Systematic Review. *Nutrients* 14.

52. Nicol K, Thomas EL, Nugent AP et al. (2023) Iodine fortification of plant-based dairy and fish alternatives: the effect of substitution on iodine intake based on a market survey in the UK. *Br J Nutr* 129, 832-842.

53. Lawrence AS, Huang HY, Johnson BJ et al. (2023) Impact of a Switch to Plant-Based Foods That Visually and Functionally Mimic Animal-Source Meat and Dairy Milk for the Australian Population-A Dietary Modelling Study. *Nutrients* 15, 16.

54. Salome M, Kesse-Guyot E, Fouillet H et al. (2021) Development and evaluation of a new dietary index assessing nutrient security by aggregating probabilistic estimates of the risk of nutrient deficiency in two French adult populations. *Br J Nutr* 126, 1225-1236.

55. Dineva M, Rayman MP, Bath SC (2021) Iodine status of consumers of milk-alternative drinks v. cows' milk: data from the UK National Diet and Nutrition Survey. *Br J Nutr* 126, 28-36.

56. Bath SC, Button S, Rayman MP (2014) Availability of iodised table salt in the UK - is it likely to influence population iodine intake? *Public health nutrition* 17, 450-454.

57. Roseland JM, Phillips KM, Patterson KY et al. (2020) Large Variability of Iodine Content in Retail Cow's Milk in the U.S. *Nutrients* 12.

58. Lamand M & Tressol JC (1992) Contribution of milk to iodine intake in France. *Biol Trace Elem Res* 32, 245-251.

59. Bryngelsson S, Moshtaghian H, Bianchi M et al. (2022) Nutritional assessment of plant-based meat analogues on the Swedish market. *International journal of food sciences and nutrition* 73, 889-901.

60. Fairweather-Tait SJ & Collings R (2010) Estimating the bioavailability factors needed for setting dietary reference values. *International journal for vitamin and nutrition research Internationale Zeitschrift fur Vitamin- und Ernahrungsforschung* 80, 249-256.
61. Hurrell R & Egli I (2010) Iron bioavailability and dietary reference values. *The American journal of clinical nutrition* 91, 1461S-1467S.

62. De Carli E, Dias GC, Morimoto JM et al. (2018) Dietary Iron Bioavailability: Agreement between Estimation Methods and Association with Serum Ferritin Concentrations in Women of Childbearing Age. *Nutrients* 10.

63. van Wonderen D, Melse-Boonstra A Gerdessen JC (2023) Iron Bioavailability Should be Considered when Modeling Omnivorous, Vegetarian, and Vegan Diets. *The Journal of nutrition* 153, 2125-2132.

64. Dussiot A, Fouillet H, Wang J et al. (2022) Modeled healthy eating patterns are largely constrained by currently estimated requirements for bioavailable iron and zinc-a diet optimization study in French adults. *The American journal of clinical nutrition* 115, 958-969.

65. Kesse-Guyot E, Alles B, Brunin J et al. (2022) Nutritionally adequate and environmentally respectful diets are possible for different diet groups: an optimized study from the NutriNet-Sante cohort. *The American journal of clinical nutrition* 116, 1621-1633.

66. Moretti D (2017) Plant-Based Diets and Iron Status. In *Vegetarian and Plant-Based Diets in Health and Disease Prevention*, pp. 715-727 [F Mariotti, editor]: Academic Press.

67. Orlich MJ, Jaceldo-Siegl K, Sabate J et al. (2014) Patterns of food consumption among vegetarians and non-vegetarians. *Br J Nutr* 112, 1644-1653.

68. Macdiarmid JI (2022) The food system and climate change: are plant-based diets becoming unhealthy and less environmentally sustainable? *The Proceedings of the Nutrition Society* 81, 162-167.

69. Bohrer BM (2019) An investigation of the formulation and nutritional composition of modern meat analogue products. *Food Science and Human Wellness* 8, 320-329.

70. Temme EH, van der Voet H, Thissen JT et al. (2013) Replacement of meat and dairy by plant-derived foods: estimated effects on land use, iron and SFA intakes in young Dutch adult females. *Public health nutrition* 16, 1900-1907.

71. Labba ICM, Steinhausen H, Almius L et al. (2022) Nutritional Composition and Estimated Iron and Zinc Bioavailability of Meat Substitutes Available on the Swedish Market. *Nutrients* 14, 19.

72. Fraser RZ, Shitut M, Agrawal P et al. (2018) Safety Evaluation of Soy Leghemoglobin Protein Preparation Derived From Pichia pastoris, Intended for Use as a Flavor Catalyst in Plant-Based Meat. *Int J Toxicol* 37, 241-262.

73. Santo RE, Kim BF, Goldman SE et al. (2020) Considering plant-based meat substitutes and cell-based meats: A public health and food systems perspective. *Frontiers Sustainable Food Systems* 4, 134.

74. Proulx AK & Reddy MB (2006) Iron bioavailability of hemoglobin from soy root nodules using a Caco-2 cell culture model. *Journal of agricultural and food chemistry* 54, 1518-1522.

75. Clemens S (2014) Zn and Fe biofortification: the right chemical environment for human bioavailability. *Plant Sci* 225, 52-57.

76. Lonnerdal B (2009) Soybean ferritin: implications for iron status of vegetarians. *The American journal of clinical nutrition* 89, 1680S-1685S.

77. Gupta RK, Gangoliya SS, Singh NK (2015) Reduction of phytic acid and enhancement of bioavailable micronutrients in food grains. *J Food Sci Technol* 52, 676-684.

78. Van Mierlo K, Rohmer S Gerdessen JC (2017) A model for composing meat replacers: Reducing the environmental impact of our food consumption pattern while retaining its nutritional value. *Journal of Cleaner Production* 165, 930-950.

79. Salome M, Mariotti F, Nicaud MC et al. (2022) The potential effects of meat substitution on diet quality could be high if meat substitutes are optimized for nutritional composition-a modeling study in French adults (INCA3). *Eur J Nutr* 61, 1991-2002.

80. Salome M, Mariotti F, Dussiot A et al. (2023) Plant-based meat substitutes are useful for healthier dietary patterns when adequately formulated - an optimization study in French adults (INCA3). *Eur J Nutr* 62, 1891-1901.
81. Mertens E, Biesbroek S, Dofková M et al. (2020) Potential Impact of Meat Replacers on Nutrient Quality and Greenhouse Gas Emissions of Diets in Four European Countries. *Sustainability* 12, 6838.

82. Hurrell RF (2021) Iron Fortification Practices and Implications for Iron Addition to Salt. *The Journal of nutrition* 151, 3s-14s.

83. Sabatier M, Grathwohl D, Beaumont M et al. (2020) The bioavailability of iron picolinate is comparable to iron sulfate when fortified into a complementary fruit yogurt: a stable iron isotope study in young women. *Eur J Nutr* 59, 1371-1378.

84. Sadighi J, Nedjat S Rostami R (2019) Systematic review and meta-analysis of the effect of iron-fortified flour on iron status of populations worldwide. *Public health nutrition* 22, 3465-3484.

85. Sjöberg A & Hulthén L (2015) Comparison of food habits, iron intake and iron status in adolescents before and after the withdrawal of the general iron fortification in Sweden. *European journal of clinical nutrition* 69, 494-500.

86. Swanson CA (2003) Iron intake and regulation: implications for iron deficiency and iron overload. *Alcohol* 30, 99-102.

87. Scientific Advisory Committee on Nutrition (2010) *Iron and Health*. Available at: https://www.gov.uk/government/publications/sacn-iron-and-health-report. London.

88. Itkonen ST, Erkkola M Lamberg-Allardt CJE (2018) Vitamin D Fortification of Fluid Milk Products and Their Contribution to Vitamin D Intake and Vitamin D Status in Observational Studies-A Review. *Nutrients* 10.

89. Jahn S, Tsalis G Lähteenmäki L (2019) How attitude towards food fortification can lead to purchase intention. *Appetite* 133, 370-377.

90. Baker MT, Lu P, Parrella JA et al. (2022) Consumer Acceptance toward Functional Foods: A Scoping Review. *Int J Environ Res Public Health* 19.

91. Verrill L, Wood D, Cates S et al. (2017) Vitamin-Fortified Snack Food May Lead Consumers to Make Poor Dietary Decisions. *Journal of the Academy of Nutrition and Dietetics* 117, 376-385.

92. Mariotti F, Kalonji E, Huneau JF et al. (2010) Potential pitfalls of health claims from a public health nutrition perspective. *Nutrition reviews* 68, 624-638.

93. Woodside JV, Sun Q, de Roos B et al. (2022) Meeting report: plant-rich dietary patterns and health. *The Proceedings of the Nutrition Society* 81, 288-305.

94. Mariotti F (2019) Animal and Plant Protein Sources and Cardiometabolic Health. *Advances in nutrition* 10, S351-S366.

95. Veronese N, Solmi M, Caruso MG et al. (2018) Dietary fiber and health outcomes: an umbrella review of systematic reviews and meta-analyses. *The American journal of clinical nutrition* 107, 436-444.

96. Diseases GBD & Injuries C (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. *Lancet* 396, 1204-1222.

97. Alessandrini R, Brown MK, Pombo-Rodrigues S et al. (2021) Nutritional Quality of Plant-Based Meat Products Available in the UK: A Cross-Sectional Survey. *Nutrients* 13.

98. De Marchi M, Costa A, Pozza M et al. (2021) Detailed characterization of plant-based burgers. *Scientific reports* 11, 2049.

99. Vanga SK & Raghavan V (2018) How well do plant based alternatives fare nutritionally compared to cow's milk? *J Food Sci Technol* 55, 10-20.

100. Pradeilles R, Norris T, Sellem L et al. (2023) Effect of Isoenergetic Substitution of Cheese with Other Dairy Products on Blood Lipid Markers in the Fasted and Postprandial State: An Updated and Extended Systematic Review and Meta-Analysis of Randomized Controlled Trials in Adults. *Advances in nutrition*.

101. Westhoek H, Lesschen JP, Rood T et al. (2014) Food choices, health and environment: Effects of cutting Europe's meat and dairy intake. *Global Environ Change* 26, 196-205.

102. Boukid F & Castellari M (2021) Veggie burgers in the EU market: a nutritional challenge? *Eur Food Res Technol* 247, 2445-2453.
103. de Las Heras-Delgado S, Shyam S, Cunillera E et al. (2023) Are plant-based alternatives healthier? A two-dimensional evaluation from nutritional and processing standpoints. *Food Res Int* 169, 112857.

104. Gardner CD, Mehta T, Bernstein A et al. (2021) Three Factors That Need to be Addressed More Consistently in Nutrition Studies: "Instead of What?", "In What Context?", and "For What?". *Am J Health Promot* 35, 881-882.

105. Papier K, Knuppel A, Syam N et al. (2023) Meat consumption and risk of ischemic heart disease: A systematic review and meta-analysis. *Critical reviews in food science and nutrition* 63, 426-437.

106. Papp RE, Hasenegger V, Ekmekcioglu C et al. (2023) Association of poultry consumption with cardiovascular diseases and all-cause mortality: a systematic review and dose response meta-analysis of prospective cohort studies. *Critical reviews in food science and nutrition* 63, 2366-2387.

107. Bergeron N, Chiu S, Williams PT et al. (2019) Effects of red meat, white meat, and nonmeat protein sources on atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: a randomized controlled trial. *The American journal of clinical nutrition* 110, 24-33.

108. Kiesswetter E, Stadelmaier J, Petropoulou M et al. (2023) Effects of Dairy Intake on Markers of Cardiometabolic Health in Adults: A Systematic Review with Network Meta-Analysis. *Advances in nutrition* 14, 438-450.

109. Givens DI (2023) Dairy foods and cardiometabolic diseases: an update and a reassessment of the impact of SFA. *The Proceedings of the Nutrition Society* 82, 329-345.

110. Poppitt SD (2020) Cow's Milk and Dairy Consumption: Is There Now Consensus for Cardiometabolic Health? *Front Nutr* 7, 574725.

111. Lima M, Costa R, Rodrigues I et al. (2022) A Narrative Review of Alternative Protein Sources: Highlights on Meat, Fish, Egg and Dairy Analogues. *Foods* 11.

112. Fresán U & Rippin H (2021) Nutritional Quality of Plant-Based Cheese Available in Spanish Supermarkets: How Do They Compare to Dairy Cheese? *Nutrients* 13.

113. Zhang Z, Jackson SL, Martinez E et al. (2021) Association between ultraprocessed food intake and cardiovascular health in US adults: a cross-sectional analysis of the NHANES 2011-2016. *The American journal of clinical nutrition* 113, 428-436.

114. Salome M, Arrazat L, Wang J et al. (2021) Contrary to ultra-processed foods, the consumption of unprocessed or minimally processed foods is associated with favorable patterns of protein intake, diet quality and lower cardiometabolic risk in French adults (INCA3). *Eur J Nutr* 60, 4055-4067.

115. Gehring J, Touvier M, Baudry J et al. (2021) Consumption of Ultra-Processed Foods by Pesco-Vegetarians, Vegetarians, and Vegans: Associations with Duration and Age at Diet Initiation. *The Journal of nutrition* 151, 120-131.

116. Wickramasinghe K, Breda J, Berdzuli N et al. (2021) The shift to plant-based diets: are we missing the point? *Global Food Security* 29, 100530.

117. Tso R & Forde CG (2021) Unintended Consequences: Nutritional Impact and Potential Pitfalls of Switching from Animal- to Plant-Based Foods. *Nutrients* 13.

118. Valicente VM, Peng CH, Pacheco KN et al. (2023) Ultra-Processed Foods and Obesity Risk: A Critical Review of Reported Mechanisms. *Advances in nutrition*.

119. Messina M, Sievenpiper JL, Williamson P et al. (2022) Perspective: Soy-based Meat and Dairy Alternatives, Despite Classification as Ultra-processed Foods, Deliver High-quality Nutrition on Par with Unprocessed or Minimally Processed Animal-based Counterparts. *Advances in nutrition* 13, 726-738.