A Systematic Review on Food Baskets Recommended in the Eastern Mediterranean...

[Full title: A Systematic Review on Food Baskets Recommended in the Eastern Mediterranean Region]

Citation: Pourghaderi, M.; Houshiarrad, A.; Abdollahi, M.; Al-Jawaldeh, A.; Esfarjani, F.; Khoshfetrat, M.-R.; Fadavi, G.; Mohammadi-Nasrabadi, F. A Systematic Review on Food Baskets Recommended in the Eastern Mediterranean Region Sustainability 2023 , 15 , 14781. https://doi.org/ 10.3390/su 152014781 Academic Editor: Francesco Sottile Received: 19 April 2023 Revised: 5 June 2023 Accepted: 13 June 2023 Published: 12 October 2023 Copyright: © 2023 by the authors Licensee MDPI, Basel, Switzerland This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/) sustainability Systematic Review A Systematic Review on Food Baskets Recommended in the Eastern Mediterranean Region Mona Pourghaderi 1 , Anahita Houshiarrad 2 , Morteza Abdollahi 2 , Ayoub Al-Jawaldeh 3 , Fatemeh Esfarjani 4 , Mohammad-Reza Khoshfetrat 4 , Ghasem Fadavi 5 and Fatemeh Mohammadi-Nasrabadi 4, * 1 Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran 1416833481, Iran 2 Department of Nutrition Research, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 1981619573, Iran 3 World Health Organization Regional Office for the Eastern Mediterranean, World Health Organization, Cairo 7608, Egypt 4 Research Department of Food and Nutrition Policy and Planning, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 1981619573, Iran 5 Food, Halal and Agricultural Products Research Group, Research Center of Food Technology and Agricultural Products, Standard Research Institute, Karaj 3174734563, Iran * Correspondence: f.mohammadinasrabadi@sbmu.ac.ir Abstract: To assist in providing a robust regional set of data and international comparisons, a systematic review was conducted to identify and characterize food baskets (FBs) in the Eastern Mediterranean Region (EMR) countries. Electronic databases of peer-reviewed literature, including PubMed, Scopus, ISI/WOS and Google Scholar, and also, online grey literature, were systematically searched from January 2000 to September 2021. The quality of included studies was assessed using the Joanna Briggs Institute’s (JBI) Critical Appraisal checklists for analytical cross-sectional studies A total of 20 studies and reports were identified as eligible for inclusion in this systematic review Linear & goal programming is used in many studies to estimate the FB groups. According to the recent recommendations based on sustainability, less consumption of red meat is proposed, and the poultry group, along with eggs, plays an important role in supplying animal protein in EMR FBs More than 30 g of legumes has been suggested based on the dietary habits of this area, whereas consumption of more than 30–40 g of oils and fats will not be appropriate for the region. The research results are not comparable due to differences in the tools, protocols, and methods; hence, there is a need for a standardized regional approach Keywords: survival/minimum cost/expenditure food basket; healthy/sustainable food basket; systematic review; Eastern Mediterranean Region 1. Introduction A healthy diet is an integral part of the concept of health [ 1 , 2 ]. Dietary risks are among the major causes of death and their effects on diseases and disability are the second leading cause of Disability-Adjusted Life Years (DALYs) worldwide [ 3 ]. According to theGlobal Burden of Disease Study, 11 million deaths and 255 million DALYs were attributed to dietary risk factors in 2017 [ 4 ]. In addition to conflicts, displaced populations and political instability, people in the Eastern Mediterranean Region (EMR) also suffer from a severe burden of malnutrition. Some countries continue to experience high levels of food insecurity, malnutrition, and micronutrient deficiencies. At the same time, half of the adult population is overweight or obese, and unhealthy diets are the major risk factor for non-communicable diseases, which account for two-thirds of deaths in this region [ 5 ]. The focus of global policy on promoting healthier food choices has increased the need for data on comparative components and affordability of healthy foods [ 6 ]. Healthy food Sustainability 2023 , 15 , 14781. https://doi.org/10.3390/su 152014781 https://www.mdpi.com/journal/sustainability

Sustainability 2023 , 15 , 14781 2 of 20 baskets (HFBs) are constructed based on the cost of basic healthy eating that represents current nutrition recommendations and average food purchasing patterns to monitor both the affordability and accessibility of foods. They can address and analyze diet-related health inequalities [ 7 – 9 ], and a commitment to using their results could promote a healthy diet at minimal cost for vulnerable groups [ 10 , 11 ]. On the other hand, according to the latest data on environmental degradation, sustainable diets can be achieved through HFB designing, too [ 12 ]. A variety of food baskets (FBs) have been developed for a variety of purposes at state, regional, and community levels, including serving as the basis for the maximum nutrition assistant program benefit allotments [ 13 ], examining the cost difference of healthy and unhealthy foods [ 14 , 15 ], comparing the price of healthy foods in remote or rural versus metropolitan locations [ 16 , 17 ], mapping the availability of healthy foods in different locations [ 18 – 20 ], calculating the minimum cost of an adequate diet for social policy planning [ 21 ], developing educational material on low-cost healthy eating [ 22 ], calculating the environmental costs associated with different food patterns [ 23 ], examining trends on food costs over time [ 24 , 25 ], and monitoring the changing affordability of a healthy diet compared to income and welfare support [ 26 – 28 ]. Given these different objectives, there have also been a variety of methods employed to define HFBs. Some have developed mathematical optimization models to define the FBs that meet nutrition recommendations for minimum cost [ 29 ] while others have restricted the baskets to a few key food groups such as fruits and vegetables, or basic food staples [ 30 , 31 ]. Nutritional adequacy, health promotion, non-communicable disease prevention, sustainability, and cultural acceptance are all limitations that should be considered in the design of FBs [ 32 ]. Healthy eating and lifestyle recommendations will not be practical or acceptable unless they address the human need for social activism, too [ 33 ]. A review of the determinants of household FB composition revealed three categories of factors affecting the contribution of different food groups in the household FB: demographic, socioeconomic, and environmental. Accordingly, we can say that these factors determine the healthiness ofahousehold diet [ 34 ]. To assist in providing a robust regional set of data and conductinginternational comparisons, we conducted a systematic review to determine similarities and differences, as well asthemethods used in designing FBs in EMR countries 2. Materials and Methods 2.1. Identification of Relevant Studies Electronic databases of peer-reviewed literature, including PubMed, Scopus, ISI/WOS, and Google Scholar, as well as online grey literature, were systematically searched from January 2000 to September 2021 using the PRISMA approach (Appendices A and B ) [ 35 ]. The same search strategy was applied in all electronic databases. Key terms were categorized into three groups and used in combination with each other as follows: (healthy OR standard* OR affordable OR minimized OR adequate OR “low cost” OR optim* OR sustainable OR reference OR survival OR nutritious OR thrifty OR basic OR balance*) AND (“food basket” OR diet OR “food plan” OR “food aid”) AND (AfghanistanOR- Bahrain OR DjiboutiOREgyptORIranORIraqORJordanORKuwaitORLebanonORLibyaORM oroccoORPalestineOROmanORPakistanORQatarOR“SaudiArabia”ORSomaliaOR SudanO RSyriaORTunisiaOR“United Arab Emirates”ORYemen OR “Middle East”) 2.2. Inclusion and Exclusion Criteria Articles, protocols, and reports relating to healthy, optimum, sustainable, survival, and minimum expenditure FBs with different costs in EMR were considered. There was no limitation for the target group selection in terms of household size, FB composition, and also, documents in other languages than English. Due to the predominance of the Arabic language in the region, in addition to Persian and English languages, Arabic sites, sources, articles, and documents were also searched and translated. We did not use any automation

Sustainability 2023 , 15 , 14781 3 of 20 tools for the exclusion of records; rather, all of this process was done by the researchers. Search results for the same journal article or web links to the same report were excluded as duplicates. However, discrete journal articles and reports related to the same collected data set were included. After omitting the duplicates, the titles and abstracts of all identified texts were read to exclude those that were irrelevant. Searching and choosing the final eligible studies and reports were conducted independently by two reviewers (F.M.N. and M.P.). Following the identification of pertinent results, reference lists were also reviewed and hand searching identified other known documents. This process added four new records. Missing data required for review were requested by emailing the correspondent authors a maximum of two times with at leastaone-week interval 2.3. Data Extraction, Synthesis, and Quality Assessment For selected articles and reports, all the data relating to year, country, FB constructing method, source of data, target group, reported results, and components of FBs (food groups in gram), including bread, macaroni or pasta, rice, potato (or starchy vegetable), vegetable, fruit, milk and dairy products, red meat, poultry, fish, egg, legume (or pulse), nut, fat and oil, sugar and sweet were extracted and summarized in data extraction table A descriptive analysis of the findings was performed Quality assessment of the included studies was done by using the Joanna Briggs Institute (JBI) Critical Appraisal checklists for analytical cross-sectional studies. Each study was rated high (H), medium (M), or low (L) according to the number of Yes options selected from the checklists. The score ranges of 0–3, 4–6, and above 6 were considered as low, medium, and high-quality studies, respectively [ 36 ]. 3. Results 3.1. Study Selection Process A total of 6457 studies were identified by searching the initial databases and 21 additional records were identified through searching other sources, including websites and organizations, as well as citation searching. After the removal of 5889 duplicates, 568 studies remained. A total of 552 out of the remaining articles did not meet the selection criteria, so they were excluded after screening the titles and abstracts because they were irrelevant. Out of the remaining 28 studies and reports retrieved, eight of them were excluded after reviewing their fulltext because their results did not comply with the objectives of the current study. Finally, 20 studies and reports were eligible for inclusion in this systematic review (Figure 1 ). Moreover, three FBs recommended by international organizations were reviewed as a basis for comparison 3.2. Study Characteristics Table 1 shows the components of FBs designed with different costs in EMR, which were included in the review. Most studies ( n = 7) in the field of optimum FB have been registered from Iran [ 37 – 45 ], and then Lebanon [ 46 – 48 ] and Pakistan [ 49 – 51 ] with three, and Yemen with two studies [ 52 , 53 ].Other countries in the region with one study were as follows: Syria [ 54 ], Iraq [ 55 ], and Jordan [ 56 ]. Except for Iran and Pakistan/Afghanistan, other food baskets developed in the countries of this region are Survival Minimum Expenditure Baskets (SMEB) Three other included documents in Table 2 are the Guidelines of the UN Refugee Agency and World Food Program (WFP) for the Survival Minimum Expenditure Basket [ 57 , 58 ], and the Global Healthy Reference Diet, which have been proposed to be sustainable [ 59 – 61 ].

Sustainability 2023 , 15 , 14781 4 of 20 Sustainability 2023 , 15 , x FOR PEER REVIEW 4 of 20 Figure 1. PRISMA 2020 flow diagram [35]. Figure 1. PRISMA 2020 flow diagram [ 35 ].

Sustainability 2023 , 15 , 14781 5 of 20 Table 1. Characteristics of healthy, optimum, sustainable, survival, and minimum expenditure food baskets with different costs in the Eastern Mediterranean Region No. Author, Date Constructing Method Source of Data/Population Results Based on Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat & Oil Sugar &Sweet Iran 1 Ghasemi et al., 1996 Min basket providing energy, Max basket providing all nutrients Food consumption survey, 1991–5 & Income and Expenditure Survey data from SCI a 1995 Per capita daily g in households Min 2465 Kcal 350 10 107 - 266 169 145 81 20 18 - 34 50 High Max 2548 Kcal 275 30 120 - 350 250 240 110 15 30 - 30 50 2 Kiani K, et al., 2004 Linear programming Food consumption survey, 2001 (Iranian households Province/2728 Kcal 320 20 100 70 280 260 225–240 48 50 24 26 - 35–40 45–55 High 3 Pourkazemi M & Souzandeh M, 2009 Goal programming Income and Expenditure Survey data from SCI a 2011, Iranians households 1–3 years 4–6 years 7–9 years 10–14 years 15–18 years 19–50 years >51 years/Sex Rural: 8399 Kcal, 196.1 87.6 91 36.6 142 441.3 537 10 32 62.1 10.7 31.3 20 38.7 11.1 Medium Urban: 9686 Kcal 148.9 146 69.3 85.5 99.3 478.7 554.6 11.6 24.6 41.5 12.9 56.9 20 31.8 30.1 4 Salehi F, et al., 2013 Mean requirement of energy, protein, and key nutrients (Iron, Vitamin A, Riboflavin & Calcium) Food balance sheet adapted by food consumption coefficients 2011 (7158 Iranian households) Sex 2–3 years 4–5 years 6–11 years 12–17 years 18–29 years 30–60 years >60 years/ 2573 Kcal 310 20 95 70 300 280 250 38 64 35 26 - 35 40 High 5 Nasari A, et al., 2017 Weighted goal programming Income and Expenditure Survey data from SCI/Rural Iranians households Income deciles/2500 Kcal 454.1 149 87.5 288.5 143.9 29.4 124.8 - 75.6 87.9 Medium 6 Eini- Zinab H, 2021 Water & carbon food print; linear & goal programming Income and Expenditure Survey data 1991–2011 from SCI, Iranians households Adult male/2800 Kcal 267.0 153.3 77.1 207.7 256.6 231.6 7.8 81.2 4.1 10.4 34.0 5.3 44.5 72.2 Medium

Sustainability 2023 , 15 , 14781 6 of 20 Table 1. Cont No. Author, Date Constructing Method Source of Data/Population Results Based on Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat & Oil Sugar &Sweet 7 Soltani A, et al., 2020 SSM-iCrop 2 model Plant production with the Water and Production modules Demand for products to feed the Country as a function of population, diet, food loss and waste Population diet/2573 Kcal 364 63 109 228 212 190 19.1 49 18 25 30 - 46 66 High Lebanon 8 WFP & UNHCR & UNICEF, 2014 Cash Working Group discussed and endorsed MEB f after consolidation and analyzing Secondary data on expenditures collected by 17 agencies WFP ration to meet nutrient needs + 2100 Kcal/month 70 (+130 Bulgur Wheat) 50 100 - 95 - 20 38 20 60 - 33 50 Medium 9 WFP & UNHCR & UNICEF, 2014 Cash Working Group discussed and endorsed SMEB g after consolidation and analyzing Secondary data on expenditures collected by 17 agencies WFP vouchers. Quantities to cover 2100 Kcal/day 130 (Bulgur Wheat) 50 200 - - - - 38 - 50 - 33 50 Medium 10 El Koury and Hajal. 2016 FGDs b with the refugees who are classified as vulnerable for the quantitative section, item ratings, and item removal WFP ration to meet nutrient needs Minimum Food Expenditure Basket per HH c 2100 Kcal/month (MEB d ) 200 50 100 - 95 - 20 38 30 60 - 33 50 Medium

Sustainability 2023 , 15 , 14781 7 of 20 Table 1. Cont No. Author, Date Constructing Method Source of Data/Population Results Based on Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat & Oil Sugar &Sweet 11 El Koury and Hajal. 2016 FGDs with the refugees who are classified as vulnerable for the quantitative section, item ratings, and item removal, Based on WFP vouchers The Survival Minimum Expenditure Basket to cover 2100 Kcal/day (SMEB e ) 130 50 200 - - - - 38 - 50 - 33 50 Medium 12 UNHCR, WFP, Save The Children, Relief International, UNICEF, and LOUISE, 2020 Based on the Survival and Minimum Food Expenditure Basket defined by WFP to meet the minimum nutritional and caloric requirements Refugee populations in Lebanon Required NFIs per households of five persons to cover 2100 Kcal/day 220 +60 (Brown Bulgur) 65 90 60 20 (Tomato paste) + 10 (Canned Green Pea) + 100 (Cabbage) + 20 (Carrot) 60 10 (Powder Milk) + 10 (Canned Cheese) 10 10 10 10 30 (Lentie) + 10 (White Bean) + 20 (Chickpea) - 17 20 High Pakistan/Afghanistan 13 Rubin V, 2011 Focus group discussion was done to identify ‘normal consumption patterns and identify key dietary boundaries (LOCAN Diet) g , Pakistan Market surveys to identify the lowest cost diet that meets the needs for energy and micronutrients CMWG h by Family includes 2 adults (1 man and 1 woman), and 5 children (Daily Quantity (g)) 47.3 - 184.8 - 302.7 - 269 - 15.7 - - 21.1 - 36.6 18 Medium

Sustainability 2023 , 15 , 14781 8 of 20 Table 1. Cont No. Author, Date Constructing Method Source of Data/Population Results Based on Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat & Oil Sugar &Sweet 14 Ministry of Planning, Development and Reform Planning Commission, 2016 Estimating the cost of the nutritious diet (CoD) and a staple adjusted nutritious diet by the COD software, Pakistan The Household Integrated Economic Survey HIES) 2013–2014 The edible weight and cost of the selected food for family of 6 (the whole year)/average energy need of 2350 Kcal 359.8 - - - 301.2 6.2 297.4 - 35.3 137.6 - 2.3 5.9 Medium 15 Dizon et al., 2019 CoRD i of achieving the recommended diet based on FBDGs in Afghanistan and Pakistan The price of each food item and information on FBDGs j An average adult man/99% 2725 Kcal Min 280 300 107 200 50–90 70 - 30 - High Max 533 433 213 300 120–200 107 60 Yemen 16 CMWG h , 2017 Multisectoral market assessment, which covered 97 districts in 12 Governorates What an average family of seven in Yemen would need, as a minimum, to survive for one month SMEB (grams/per person/per day) for 1663 Kcal energy need (80% of the monthly household food needs) 357 - - - - - - - - - - 48 - 38 12 Medium 17 Food Security and Agriculture Cluster (FSAC), 2019 A series of technical working group meetings The food commodities market price data SMEB) for 1676 Kcal energy need (80% of the monthly household food needs) 312 - - - - - - - - - - 45 - 38 14 Medium Syria

Sustainability 2023 , 15 , 14781 9 of 20 Table 1. Cont No. Author, Date Constructing Method Source of Data/Population Results Based on Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat & Oil Sugar &Sweet 18 Cash Based Responses Technical Working Group Syria, 2014 Basic survival commodities as a criterion & standardized process for determining the value of the SMEB Food commodities in northern Syria Recommended daily energy requirements of 2100 Kcals per person per day 200 80 100 - 30 - - 30 30 100 - 40 25 Medium Iraq 19 Cash Working Group, 2018 The analysis on the single items, the review of available data and the Joint Price Monitoring data Using vulnerability assessment data on the monthly expenditures of an average household of 6 individuals The Survival Minimum Expenditure Basket (SMEB) for covering 2100 Kcal 227.7 - 227.7 - - - - - - 61 - 33.3 33.3 Medium Jordan 20 UNHCR f , 2019 Based on the nutritional value that key commodities provide Data from the parents of children attending formal schools, extreme/overrated values SMEB for a daily diet of 2100 Kcal (11.6 g of protein and 19.2 g of fat per person/per day 200 50 150 - 20 - 8 - 30 - 19 40 - 33 33 Medium a SCI: Statistical Centre of Iran, b FGDs: Focus Group Discussions, c HH: Household, d MEB: Minimum Expenditure Basket, e SMEB: Survival Minimum Expenditure Basket, f UNHCR: UN Refugee Agency, g LACON diet: Locally Appropriate Cost-Optimized Nutritious diet, h CMWG: Cash and Markets Working Group, i CoRD: The Cost of a Recommended Diet, j FBDGs: Food-based dietary guidelines.

Sustainability 2023 , 15 , 14781 10 of 20 Table 2. Characteristics of healthy, sustainable or survival minimum expenditure food baskets recommended by international organizations No. Author, Date Designing Method Source of Data/ Population Results Based on/Energy Provided Components of Food Basket (Food Groups in g) Quality of the Study Bread Macaroni/ Pasta Rice Potato (Starchy Veg) Vegetable Fruit Milk &Dairy Products Red Meat Poultry Fish Egg Legume (Pulse) Nut Fat&Oil Sugar &Sweet Nutrition Guidelines 1 UN Refugee Agency (UN- HCR), 1995 Recommended ration for the classic full food basket Refugees or displaced people The Survival Minimum Expenditure Basket to cover 2261 Kcal/ day 400 (Cereal: maize) + 100 (Fortified Cereal Blend: corn soya blend) - - - - - - - - 60 - 25 15 Medium Minimum expenditure basket 2 World Food Program (WFP), 2020 Hybrid approach (mix of an expenditurebased and a rights-based approach) Crisisaffected populations Scaling to 2100 kcal per person per day, with 10–12 percent of daily energy intake from protein and 17 percent from fats 424 - 182 6 1 81 - 24 - 33 6 High Global Healthy Reference Diet 3 Willet et al., 2019 Meeting all requirements of 20 essential nutrients Generally healthy individuals aged 2 years and older A healthy 60 kg woman at 30 years old, in energy balance at 2503 kcal per day 232 50 (0–100) 300 (200– 600) 200 (100– 300) 250 (0–500) 14 (0–28) 29 (0–58) 28 (0–100) 13 (0–25) 75 (0–100) 50 (0–75) 51.8 (20–91.8) 31 (0–31) High

Sustainability 2023 , 15 , 14781 11 of 20 3.3. Historical Perspective and Constructing Methods Based on the identified documents, only three countries (Iran, Lebanon, and Yemen) have had edits on one food basket based on price changes and updated dietary guidelines. In Iran, the most widely used National FB was presented in 2013 [ 42 ] based on the amendments of two previous ones [ 38 , 39 ], and the final stages of revising this FB are underway. In Lebanon, estimation of the needs through expenditure baskets for Syrian Refugees was first introduced in 2014 [ 48 ] andwas edited twice, in 2016 [ 46 ] and 2020 [ 47 ]. In addition, 2006 Pakistan’s FB and 2012 Yemen’s Food Security and Agriculture Cluster (FSAC) minimum FB were mentioned in the FB documents, which could not be accessed in the searches Linear & goal programming was used by 9 studies to estimate the FB groups [ 39 – 42 , 44 , 49 , 50 , 60 , 61 ]; however, focus group discussion ( n = 5) [ 46 – 48 , 51 , 53 ], mean requirement of energy, protein, and key nutrients ( n = 5) [ 38 , 42 , 54 – 56 ], and market assessment ( n = 1) [ 52 ] also contribute to FB studies in the region. Most of the baskets are uprooted from the national income and expenditure surveys [ 37 , 40 , 41 , 46 – 49 , 55 ], market surveys (to identify the healthy and lowest cost diet that meets the needs for energy and micronutrients) [ 50 , 51 ], food consumption data [ 38 , 39 ], food balance sheets [ 42 ], the nutritive value (provided by pivotal food goods) [ 56 ]. In addition to suggesting a healthy or low-cost FB for the population, some studies have presented their baskets based on age–sex groups [ 41 , 42 ], income deciles [ 40 ], or a vulnerable household [ 51 , 52 ].Four countries (Lebanon [ 46 – 48 ], Syria [ 54 ], Iraq [ 55 ], and Jordan [ 56 ]) out of the seven countries developing FBs in the region have used the typical starting point for establishing a minimum expenditure basket (MEB) to estimate the cost of acquiring enough food to meet energy requirements, usually 2100 Kcal per person per day based on the Sphere Standard [ 62 ], the World Bank’s Handbook for Poverty and Inequality, the WFP (World Food Program) guidance note for minimum expenditure baskets [ 58 , 63 ], or The United Nations High Commissioner for Refugees (UNHCR) [ 57 ]. Others often have used energy estimates based on their country’s age–gender composition, which generally leads to higher estimates in the range of 2300 to 2800 Kcal. Exception for a few FBs, such as Yemen’s proposed SMB [ 52 , 53 ], which provides 80% of energy and micronutrients, other baskets claim to provide most of the required micronutrients 3.4. Data Synthesis Although it is assumed that the EMR countries have similar eating habits and patterns, suggested amounts of food items in the FBs are very variable. Survival and minimum baskets have lower quantities of food groups compared to optimum and sustainable baskets The lowest energy and number of food groups in the FB were found in Yemen Bread, Macaroni/pasta, Rice, and Starchy vegetables: The bread and cereal group are presented together in the Global Healthy Reference Diet and several other baskets. However, the recommended range is very different. Bread as the main staple food of the region has been included in all baskets (130–357 g per capita per day in moderate to high-quality studies). The coming food groups are rice (about 100 g), Macaroni/pasta, and Starchy vegetables (potato), respectively Red meat, Poultry, Fish, and Egg: With a few exceptions, the consumption of sea foods in this region is not common; as a result, in some baskets, chicken, fish, and in some cases, meats are presented as a whole Legumes and Nuts: In most baskets of the region, legumes are estimated in combination with nuts. The lowest and the highest recommended values belong to Iran (18 g) and Pakistan (137.6 g), respectively; whereas FBs established by the international organizations (Table 2 ) recommend 24–75 g legumes. Nuts were mentioned as a separate food group only in global recommendations (0–75 g) and a few of Iran’s baskets (7.4–20 g) Fat and oil, Sugar and sweets: The distance between the minimum and maximum limits is estimated to be very large; however, by removing the outlier numbers, the range is almost close to the global recommendations.

Sustainability 2023 , 15 , 14781 12 of 20 3.5. Quality of the Reviewed Studies Most of the studies included in the review were of the medium to low quality mostly due toafailure to identify confounders and use strategies to deal with them. Figures such as 11 g of sugar in Iran [ 41 , 45 ] and 3 g of fat and oil in Pakistan [ 49 ], which are far from other estimates and the usual consumption of society, indicate the weakness of the estimates, too 4. Discussion The present systematic review found 20 estimations of FBs in EMR, of which about half of them provide the optimum FBs [ 37 – 42 , 44 , 45 , 49 , 51 , 61 ] and the other half provide the Survival Minimum Expenditure Baskets (SMEB) [ 38 , 46 – 48 , 54 – 56 ]. A few studies have also considered principles of sustainability in designing the baskets [ 37 , 44 ]. According to the recommendations based on sustainability in recent years, less consumption of red meat had been proposed due to its environmental effects. The poultry group, along with eggs, plays an important role in supplying animal protein in the region. According to the Mediterranean diet, consumingtwoservingsof fish and other seafoodsweekly along with reducing the consumption of red meat and saturated fat are of importance intheprevention of non-communicable diseasesand can be a practical and effective choice among the available practical dietary strategies to achieve the maximal benefits for human and environmental health [ 58 – 61 ]. Therefore, it is better to put them as a separate group in recommended FBs for more emphasis Despite the traditional production of some nuts (e.g., walnuts, almonds, and pistachios) in the Middle Eastern countries, their recommendation to the public based on regional dietary guidelines [ 64 ] is not possible due to their high price. However, considering the dietary habits of this region and the variety of traditional foods that are cooked with legumes, more than 30 g daily is suggested. Since most of the oils and fats consumed are not of high quality in terms of fatty acid content, and high trans-fatty acids in food products are still a nutritional problem in these countries [ 65 ], consumption of more than 30–40 g of oil and fat will not be appropriate for the region Countries such as Lebanon [ 47 ] have reduced their sugar intake recommendations in recent years in line with WHO guidelines, ref. [ 66 ] implying the limitation offree sugars intake to less than 10% of total energy intake, while the amount of sugar in Iran’s recent FBs has been estimated at a higher level by considering both conditions of cost minimization and stability maximization [ 44 , 67 ]. The biggest contributors to sugar consumptionin children and adolescents of this region have beensugar-sweetened beverages, biscuits, and chocolates [ 68 ]. It seems that in adults, consuming sugar and sweets along with hot drinks contributes the most to free sugar consumption IntheWestern Mediterranean region, updating the Spanish Healthy Food Reference Budget (SHFRB) to include the dimensionof sustainability resulted in a sustainable basket cheaper than current recommendations [ 69 ]. A shift towards plant-based foods, especially whole grains, legumes, and nuts, along withareduction in the level of meat with the exception of fish, is a characteristic of these baskets, which is consistent with the EAT- Lancet report [ 70 , 71 ]. Some of these sustainable baskets consider proximity, packaging, and seasonalitycriteria to stress environmentally friendly food consumption, too [ 69 ]. Estimation of FBs provides amounts from the categories of nutrient-dense foods and beverages in purchasable forms, as well as associated costs within calorie limits to support a healthy and nutritious diet, which can help individuals achieve and maintain good health and reduce the risk of chronic diseases throughout all stages of life. The process of developing the FBs in the developed countries can be described in two phases, each with multiple steps: (1) Identifying and preparing data sources, developing the Modeling Categories, and establishing the inputs and constraints, and (2) Running the optimization model and constructing the minimum FB [ 13 ]. A minimum expenditure basket is constructed by estimating the cost of acquiring adequate food and adding the cost of other essential non-food expenditures [ 58 ].

Sustainability 2023 , 15 , 14781 13 of 20 It is, generally, attemptedto design FBs in accordance withthe common consumption and current price of food items to ensure and increase their public acceptability. However, qualitative and quantitative studies on the acceptability of the suggested FBs in different income groups in different countries could be a topic for future investigations. Further research investigating other barriers towards compliance with Food-based dietary guidelines (FBDGs) among consumers would allow more targeted implementation and promotion of guidelines [ 72 ]. Exclusion from the review was mostly due to the lack of information about FBs or lack of access to it. Including some food items in the basket (e.g., processed meat and hydrogenated oils) based on the dietary patterns of the studied communities lowered the quality of one of the reviewed studies [ 37 ], whereas neglecting the current diets led to a decrease in the quality of others despite using high statistical analysis methods [ 44 ]. The cooperation of experts in various fields like food economics, health education, and nutrition can help reduce the problems of baskets and make them more comprehensive Strengths and limitations: Although this study has aimed to gather and summarize studies conducted on food baskets in EMR to provide evidence in a common FB in this region, this review did not result in such evidence due to the heterogeneity of the available data. However, it provides a comprehensive assessment of the food baskets of the region by country 5. Conclusions Estimation methods of 20 healthy or minimum FB studies found in EMR were different in all criteria and most of them are not fully consistent with the recommendations of the current guidelines. Study results are not comparable due to differences in the tools, protocols, and methods; hence, there is a need for a standardized regional approach. Assessment of the price and affordability of healthy (recommended) and current diets would provide more robust and meaningful data to reform health and fiscal policies in EMR Achieving overall health goals and societal outcomes of recommended FBs will depend on the efforts of nutritional health boards in collaboration with many other community partners, including non-governmental organizations, local and municipal governments, government-funded agencies, and the private sector. The health of individuals and communities in EMR is significantly affected by complex interactions between socio-economic factors, the physical environment, and individual behaviors and conditions Author Contributions: F.M.-N. and M.P. contributed to all phases of the review; A.H., M.A. and A.A.-J. mostly contributed to conceptualizing and reviewing the documents; and M.-R.K., F.E. and G.F. contributed to data gathering and extracting. All authors have read and agreed to the published version of the manuscript Funding: This work was supported by the National Nutrition and Food Technology Research Institute (NNFTRI, 00.28238), Faculty of Nutrition Sciences and Food Technology; Shahid Beheshti University of Medical Sciences, Tehran, Iran Institutional Review Board Statement: This study was conducted according to the PRISMA systematic review guidelines and approved by the Ethics Committee of National Nutrition and Food Technology Research Institute (IR.SBMU.NNFTRI.REC.1400.050) Informed Consent Statement: Not applicable Data Availability Statement: Not applicable Acknowledgments: The authors would like to thank the NNFTRI for the funding support, and all the researchers, who made this review possible with their valuable research on food baskets in the Eastern Mediterranean Region. We also thank Mansoor Ranjbar and Marzieh Soleymaninejad from the regional office of the WHO in Iran, and Ibrahim Parvin, for their detailed review of the manuscript.

Sustainability 2023 , 15 , 14781 14 of 20 Conflicts of Interest: The authors declare no conflict of interest.The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results Appendix A Table A 1. Search strategy of food baskets recommended in the Eastern Mediterranean Region PubMed ((healthy OR standard OR affordable OR minimized OR adequate OR “low cost” OR optimized OR sustainable OR optimum OR reference OR minimum OR survival OR nutritious OR thrifty OR basic OR balanced) AND (“Food Basket” [Title/Abstract] OR “food plan” [Title/Abstract] OR diet [Title/Abstract] OR “diet plan” [Title/Abstract] OR “dietary advice” [Title/Abstract] OR “food plan” [Title/Abstract] OR “food aid” [Title/Abstract])AND (“Afghanistan “ [Title/Abstract] OR “Bahrain” [Title/Abstract] OR “Djibouti“ [Title/Abstract] OR “Egypt“ [Title/Abstract] OR “Iran” [Title/Abstract] OR “Iraq” [Title/Abstract] OR “Jordan “ [Title/Abstract] OR “Kuwait“ [Title/Abstract] OR “Lebanon“ [Title/Abstract] OR “Libya“ [Title/Abstract] OR “Morocco“ [Title/Abstract] OR “Palestine“ [Title/Abstract] OR “Oman“ [Title/Abstract] OR “Pakistan “ [Title/Abstract] OR “Qatar” [Title/Abstract] OR “Saudi Arabia “ [Title/Abstract] OR “Somalia“ [Title/Abstract] OR “Sudan“ [Title/Abstract] OR “ Syria“ [Title/Abstract] OR “Tunisia“ [Title/Abstract] OR “United Arab Emirates“ [Title/Abstract] OR “Yemen “ [Title/Abstract] OR “Middle East “ [Title/Abstract])) Scopus TITLE-ABS-KEY ((healthy OR standard OR affordable OR minimized OR adequate OR “low cost” OR optimized OR sustainable OR optimum OR reference OR minimum OR survival OR nutritious OR thrifty OR basic OR balanced) AND (“food basket” OR diet OR “diet plan” OR“dietary pattern” OR“dietaryadvice”OR“food plan” OR “food aid”)AND(afghanistanORbahrain OR djiboutiORegyptORiranORiraqORjordanORkuwaitORlebanonORlibyaORmoroccoORpalestineORomanORpakistanORqatarORsaudiAND arabiaORsomaliaORsudanORsyriaORtunisiaOR“united arabemirates”ORyemen OR “Middle East”)) ISI/WOS ((healthy OR standard OR affordable OR minimized OR adequate OR “low cost” OR optimized OR sustainable OR optimum OR reference OR minimum OR survival OR nutritious OR thrifty OR basic OR balanced) AND (“food basket” OR diet OR “diet plan” OR “dietary pattern” OR “dietary advice”OR“food plan” OR “food aid”) AND (afghanistanORbahrain OR djiboutiORegyptORiranORiraqORjordanORkuwaitORlebanonORlibyaORmoroccoORpalestineORomanORpakistanORqatarORsaudiAND arabiaORsomaliaORsudanORsyriaORtunisiaOR“unitedarabemirates”ORyemen OR “Middle East”))Timespan= All years. ANDIndexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC= All years Appendix B Table A 2. PRISMA 2020 Checklist Section and Topic Item # Checklist Item Location Where Item Is Reported Title 1 Identify the report as a systematic review Title Page, lines 1–2 ABSTRACT Abstract 2 See the PRISMA 2020 for Abstracts checklist Page 1, lines 1–23 INTRODUCTION Rationale 3 Describe the rationale for the review in the context of existing knowledge Page 2, lines 27–45 Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review addresses Page 2, 3, lines 46–62

Sustainability 2023 , 15 , 14781 15 of 20 Table A 2. Cont Section and Topic Item # Checklist Item Location Where Item Is Reported METHODS Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses Pages 4, 5, lines 77–89, 99 Information sources 6 Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted Page 3, lines 64–69 Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used Appendix A , search strategies Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process Page 4, lines 77–89 Data collection process 9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process Page 4, lines 77–91 Data items 10 a List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect Page 5, lines 99–103 10 b List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information - Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process Pages 4, 5, lines 82–83; 90–98 Effect measures 12 Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results Synthesis methods 13 a Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)) Pages 4, 5, lines 77–89, 99 13 b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions - 13 c Describe any methods used to tabulate or visually display results of individual studies and syntheses -

Sustainability 2023 , 15 , 14781 16 of 20 Table A 2. Cont Section and Topic Item # Checklist Item Location Where Item Is Reported 13 d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used - 13 e Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression) - 13 f Describe any sensitivity analyses conducted to assess robustness of the synthesized results - Reporting bias assessment 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases) - Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome - RESULTS Study selection 16 a Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram Pages 5, lines 105–116 16 b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded Pages 5, 6, lines 117–125 Study characteristics 17 Cite each included study and present its characteristics Tables 1 and 2 Risk of bias in studies 18 Present assessments of risk of bias for each included study The last column of Tables 1 and 2 Results of individual studies 19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/ credible interval), ideally using structured tables or plots Table 1 ; Pages 6,7, lines 126–176 Results of syntheses 20 a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies Page 10, lines 177–181 20 b Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect - 20 c Present results of all investigations of possible causes of heterogeneity among study results - 20 d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results - Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed - Certainty of evidence 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed - DISCUSSION Discussion 23 a Provide a general interpretation of the results in the context of other evidence Pages 9, lines 193–229

Sustainability 2023 , 15 , 14781 17 of 20 Table A 2. Cont Section and Topic Item # Checklist Item Location Where Item Is Reported 23 b Discuss any limitations of the evidence included in the review Page 10, lines 230–231 23 c Discuss any limitations of the review processes used Page 10, lines 231–234 23 d Discuss implications of the results for practice, policy, and future research Page 10, lines 234–239 OTHER INFORMATION Registration and protocol 24 a Provide registration information for the review, including register name and registration number, or state that the review was not registered The review was not registered 24 b Indicate where the review protocol can be accessed, or state that a protocol was not prepared Page 11, lines 256–259 24 c Describe and explain any amendments to information provided at registration or in the protocol - Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review Page 12, lines 263–265 Competing interests 26 Declare any competing interests of review authors Page 11, line 262 Availability of data, code and other materials 27 Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review Page 11, lines 260–261 Ref: [ 31 ]. References 1 Healthy Diet—Key Facts. Available online: http://www.who.int/en/news-room/fact-sheets/detail/healthy-diet (accessed on 21 February 2022) 2 Health Impact Assessment—The Determinants of Health. Available online: http://www.who.int/hia/evidence/doh/en (accessed on 23 February 2022) 3 Stanaway, J.D.; Afshin, A.; Gakidou, E.; Lim, S.S.; Abate, D.; Abate, K.H.; Abbafati, C.; Abbasi, N.; Abbastabar, H.; Abd-Allah, F. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017 Lancet 2018 , 392 , 1923–1994 4 Afshin, A.; Sur, P.J.; Fay, K.A.; Cornaby, L.; Ferrara, G.; Salama, J.S.; Mullany, E.C.; Abate, K.H.; Abbafati, C.; Abebe, Z. Health effects of dietary risks in 195 countries, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017 Lancet 2019 , 393 , 1958–1972. [ CrossRef ] [ PubMed ] 5 WHO Strategy on Nutrition for the Eastern Mediterranean Region 2020–2030 ; World Health Organization, Regional Office for the Eastern Mediterranean: Cairo, Egypt, 2019. Available online: https://apps.who.int/iris/handle/10665/330059 (accessed on 28 February 2022) 6 Lee, A.; Mhurchu, C.N.; Sacks, G.; Swinburn, B.; Snowdon, W.; Vandevijvere, S.; Hawkes, C.; L’Abb é , M.; Rayner, M.; Sanders, D Monitoring the price and affordability of foods and diets globally Obes. Rev 2013 , 14 , 82–95. [ CrossRef ] [ PubMed ] 7 Carrillo- Á lvarez, E.; Penne, T.; Boeckx, H.; Storms, B.; Goedem é , T. Food reference budgets as a potential policy tool to address food insecurity: Lessons learned from a pilot study in 26 European countries Int. J. Environ. Res. Public Health 2019 , 16 , 32 [ CrossRef ] 8 Goedem é , T.; Penne, T.; Hufkens, T.; Karakitsios, A.; Bern á t, A.; Franziskus, A.; Simonovits, B.; Á lvarez, E.C.; Kanavitsa, E.; Parcerisas, I.C.; et al. What does it mean to live on the poverty threshold? Lessons from reference budgets. In Decent Incomes for the Poor? Improving Policies in Europe ; Cantillon, B., Goedem é , T., Hills, J., Eds.; Oxford University Press: Oxford, UK, 2019 9 La í n, B.; Riutort, S.; Juli à , A. The B-MINCOME project. Municipal innovation on guaranteed minimum incomes and active policies Barc. Soc 2019 , 23 , 1–8 10 Carrillo- Á lvarez, E.; Cuss ó -Parcerisas, I.; Anguera-Salvatella, M.; Muñoz-Martinez, J.; Riera-Roman í , J Guia per a una Alimentaci ó Saludablei de M í nim Cost per a Fam í liesamb Infants ; Ajuntament de Barcelona: Barcelona, Spain, 2020 11 Cornellis, I.; Vandervoort, B LEKKER & GEZOND, Meersmaak met Minder Centen ; Borgerhoff&Lamberigst: Gent, Belgium, 2011.

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