According to our analysis, more than 190 million tonnes (Mt) of foods related to dietary risks, representing 3–12% of their production, were exported from one country to another in the year 2019 (SI Table 6, SI Fig. 1). Those included 86 Mt (11% of production) of fruits, 58 Mt (5%) of vegetables, 25 Mt (11%) of red meat, 12 Mt (3%) of legumes, and 8 Mt (12%) of nuts. Most fruits, legumes, and nuts were exported from the Americas (42 Mt, 27%; 8 Mt, 3%; 4 Mt, 48%), especially Brazil and Argentina; most vegetables from Asia (22 Mt, 2%), especially China; and most red meat from Europe (12 Mt, 25%), especially Germany.
Food imports increased the availability of these foods in the importing countries when compared to a situation without imports by an average of 3–31 grams per person per day (g/d), representing 5–21% of demand (SI Table 7, SI Fig. 1). Average food availability per person increased by 31 g/d for fruits (14% of demand), 21 g/d for vegetables (5%), 9 g/d for red meat (11%), 4 g/d for legumes (19%), and 3 g/d for nuts (21%). By region, the increases in food availability per person ranged from 4 g/d (2%) of fruits in Africa to 145 g/d (64%) in Europe, 7 g/d (4%) of vegetables to 94 g/d (32%) in Europe, 2 g/d (29%) of legumes in Oceania to 8 g/d (100%) in Europe, 1 g/d (5%) of nuts in Africa to 12 g/d (97%) in Europe, and 1 g/d (4%) of red meat in Africa to 34 g/d (23%) in Europe.
The related changes in food intake were associated with a net reduction in diet-related mortality of 1.2 million deaths (95% confidence interval, 0.8–1.7 million) (Fig. 1). About half of the avoided deaths (53%) were from coronary heart disease, and a quarter each from stroke (25%) and cancer (23%). The trade-related increases in fruit intake were responsible for the largest reductions in mortality (-597,000), followed by vegetables (-380,000), nuts (-300,000), and legumes (-98,000). In contrast, the trade-related increases in red meat intake were associated with an increase in diet-related mortality (+ 147,000).
Of the total reductions in diet-related mortality, more than half were associated with food imports to Europe (-675,000; 55%), especially fruits exported from the Americas and vegetables from other parts of Europe (Fig. 2, SI Table 8). This was followed by imports to Asia (-301,000; 25%) and the Americas (-209,000; 17%), in each case driven by fruits and vegetables exported from within the region. Smaller proportions were associated with imports to Africa (-33,000; 3%) and Oceania (-7,000; 1%), including vegetables from Asia and Europe. When attributing health impacts to the exporting region, the Americas were the largest contributor to diet-related reductions in mortality (-507,000; 41%), followed by Asia (-365,000; 30%), Europe (-231,000; 19%), Africa (-118,000; 10%), and Oceania (-5,000; 0.4%).
At the country-level, imports of health-sensitive foods (i.e., foods related to dietary risks) contributed to health benefits in 152 out of 153 importing countries (Fig. 3, SI Fig. 2). The countries with the greatest health benefits, driven to large degrees by imports of fruits and vegetables, were the USA (-140,000), Russia (-134,000), Germany (-107,000), China (-89,000), and the UK (-61,000). The same set of countries also benefitted from imports of nuts and legumes, and other leading beneficiaries included Italy and India for both nuts and legumes, and Bangladesh and Egypt for legumes (Fig. 4). The only country exhibiting a net increase in diet-related mortality from trade was Papua New Guinea (+ 4 deaths) where the negative health impacts associated imports of red meat exceeded the positive impacts of food imports.
Out of 181 countries that exported health-sensitive foods, 162 (90%) contributed to reductions in diet-related mortality through their exports, and 19 (10%) to increases (Fig. 3, SI Fig. 2). The countries whose exports contributed most to a reduction in diet-related mortality were China (-117,000) driven by vegetables and nuts, the USA (-102,000) driven by nuts and legumes, Brazil (-92,000) and Spain (-86,000) both driven by vegetables and fruits, and Turkey (-69,000) driven by fruits. Other leading exporters were Ecuador and Mexico for fruits; Italy and the Netherlands for vegetables; Argentina and India for nuts; and Canada for legumes (Fig. 4). The countries that contributed to net increases in mortality through high exports of red meat included Germany (+ 10,000), Denmark (+ 7,000), Ireland (+ 3,500), Uruguay (+ 2,000), and Paraguay (+ 1,400).