Author s response to reviews

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1 Author s response to reviews Title: Dilemma between health and environmental motives when purchasing animal food products: sociodemographic and nutritional characteristics of consumers Authors: Sandrine Péneau (s.peneau@eren.smbh.univ-paris13.fr) Philippine Fassier (p.fassier@eren.smbh.univ-paris13.fr) Benjamin Allès (b.alles@eren.smbh.univ-paris13.fr) Emmanuelle Kesse-Guyot (e.kesse@eren.smbh.univ-paris13.fr) Serge Hercberg (s.hercberg@eren.smbh.univ-paris13.fr) Caroline Méjean (c.mejean@eren.smbh.univ-paris13.fr) Version: 2 Date: 10 Feb 2017 Author s response to reviews: Equipe de Recherche en Epidémiologie Nutritionnelle U1153 Inserm/Inra/Cnam/UP13 February 10th 2017 Dear Editor, Please find enclosed the revision of our manuscript entitled, Dilemma between health and environmental motives when purchasing animal food products: sociodemographic and nutritional characteristics of consumers (PUBH-D R1), originally submitted on August 24th We have examined and taken into account all comments and include point-by-point responses to all comments and issues raised. Changes in the final manuscript appear highlighted yellow. We thank the reviewers for their comments.

2 The material used in this study is original and has not been either published or submitted for publication elsewhere. We confirm that the paper has been read and approved by all authors. There is no conflict of interest. No honoraria, grant awards or other forms of payment had been received by anyone in order to produce the manuscript. We thank you for your continued consideration of this manuscript and will be happy to provide any additional information that might be needed. Sincerely yours, Sandrine Péneau Reviewer #1: The authors analyzed part of the Nutrinet-Santé data base. They report that about 10% of participants seem to grapple with dilemmas when choosing dietary components from a health and an environmental perspective. Importantly, this does not seem to affect dietary quality, rather the contrary. Major Given the finding that dilemma is accompanied by rather better compliance to dietary recommendations it would seem to me that it is plausible that the 10% of participants in whom this was observed are conscious eaters in the sense that they have a more rational approach of what and how much they eat. Seems like this 10% is overall behaving in a more health oriented way, also smoking less, moving more. So one could interpret the finding of dilemma as a positive trait, which suggests a conscious rational approach towards those choices in daily life that have a health and/or environmental bearing. >>> We totally agree with the reviewer. It is likely that individuals with dilemma have a more healthy profile in general. For this reason we have attempted to control for these potential confounding factors in the analyses of the association between dilemma and dietary intake (table 4) and in particular smoking status, physical activity, BMI and energy intake. Although we have attempted to take many potential confounding into account, it may be possible that other confounding were not. We therefore mention this possibility in the limit section of the discussion:

3 In the text: Individuals with dilemma may also have a healthier profile overall, which was partially accounted for in the models by adjusting on smoking, physical activity, BMI and energy covariables. In the Methods it would be good to say something about recruitment strategies used for the inclusion in the overall study. >>> More information on recruitment strategy is now given in the method section In the text: In brief, volunteers are recruited via multimedia campaigns (television, radio, national and regional newspapers, posters, internet) and invited to visit the NutriNet-Santé website. Also, when presenting the new score (mpnns-gs), I suggest to mention the possible range of the score and what scores are considered good and bad. >>> Possible range of the mpnns-gs score is now shown in the method section and in tables 2 and 4. In the text: Briefly, the score has a range of points, with a higher score indicating a better overall diet quality. Minor Line 38, recommendations (plural) >>> Change has been made Line 40, unclear what 'their' refers to (I understand, but it is confusing) >>> their has been changed into of these foods Line 51, rather leave out this acronym here >>> Acronym was removed

4 Line 72 and elsewhere, there are still reference manager codes they need to be transformed >>> We apologize for this mistake. We have removed reference manager codes throughout the manuscript Results section, when presenting the number of participants, please give percentage in brackets when presenting a sub-ensemble. >>> Percentage are now presented in brackets In the text: From the initial 122,091 subjects who received the questionnaire measuring food choice motives regarding sustainable foods, a total of 46,958 (38.5%) completed it. Among them, 402 subjects (0.9%) were excluded due to missing data for BMI, educational level or household composition. An additional 18,056 participants (38.5%) who had less than three dietary records available were excluded and 5,565 participants (11.9%) due to underreporting leaving 22,935 subjects (48.8% of those who completed the questionnaire) available for analysis (17,247 women and 5,688 men). Line 238, what is small, given that it was significant? >>> Given the large population, small differences can appear significant. This was the case here, and that is why we mentioned it. However, we can understand that it could have been confusing, particularly since we do not show the numbers. This sentence part was therefore been removed. Table 2, it looks as if the dilemma group is having 'better' behavior overall, they smoke less and move more. This is worth discussing, see also comment above under major. >>> This aspect has now been discussed (cf above). Finally, a critical clean-up to catch some oddities in the use of English would be necessary >>> English has been checked throughout the manuscript

5 Reviewer #2: GENERAL COMMENTS TO THE AUTHOR: 1. The article aimed to investigate the sociodemographic profiles of individuals reporting health and environmental dilemmas when purchasing meat, fish and dairy products, and comparing diet quality of individuals with and without dilemma. In fact, more quality research is needed examining the healthy lifestyles, such as nutritional habits, for intervention approaches on our populations. 2. In general, the authors did a good effort to improve the manuscript, and therefore, it should be highlighted. >>> This is the first version of the manuscript and therefore the first review. 3. The abstract summarizes the paper properly, emphasising the main results of this study and providing a pragmatic conclusion. >>> We thank the reviewer for these positive comments. 4. In my opinion, at the introduction section, the authors could also add the hypothesis of this study. >>> There are until now virtually no studies looking at health vs environmental dilemma. It is therefore difficult for us to make hypotheses on potential association based on the literature. We could of course make our own assumptions but it is particularly difficult since we have several outcomes. We could also remain vague and mention associations only (without mentioning directions of the associations), but in this case this part would be very redundant with our objectives. We would therefore prefer not to add the hypotheses in the introduction. 5. At the methods, since the authors have reported some instruments with the study of its validation, it would be useful for the potential readers to report those rates. Thus, the reliability/validity testing rates has to be stated in the methods section. >>> We believe that the reviewer refers to the kappas analyses. We have performed these analyses to assess whether individuals having dilemmas for meat were the same than for fish and/or for dairy products. The aim was not to validate our instrument since it could well be that individuals have dilemma for one food product only. We therefore maintain these data in the results section.

6 6. I still have few details about which I would like the authors could provide their opinion/further refinements in the discussion section. In fact, the paper would clearly benefit if authors could still add further sources of variation related to their own results in the nutritional intervention field. >>> Potential source of variation has been added, including: - the fact that the study takes place in France where recommendation do not take into account the environment (In the text: It is likely that the level of dilemma will be lower in these countries) But also - the method that is being used (In the text: The choice of a composite variable might have also influenced the results) - the profile of volunteers (in the text: participants are recruited on a voluntary basis, implying that they might have increased health consciousness and interest in nutritional issues as well as healthier lifestyle. Individuals with dilemma may also have a healthier profile overall, which was partially accounted for in the models by adjusting on smoking, physical activity, BMI and energy.) 7. In general, the quality of writing is satisfactory, but in some places of the manuscript could be clearly improved ( please avoid the active voice; instead, use the passive voice, especially at the methods section!!...etc.). >>> English has been checked throughout the manuscript. More specifically, all occurrence of active voice has been replaced by passive voice, especially in the abstract, method and limit (discussion) sections. 8. According to the findings of the present study, the manuscript would still obviously benefit by including some suggestions ( effective suggestions which could overcome the limitations of the present study) for future research. >>> suggestions for future research has now been included in the conclusion. In the text: However, these results must be confirmed by studies assessing dilemmas in real-life settings. Further work exploring dilemmas across populations from diverse backgrounds, and with different level of concern toward the environment is needed to refine our knowledge when setting up effective nutrition policies.

7 9. References section is ok; however, that section of the manuscript would benefit if authors could add more recent studies in that scientific field ( for example in 55 references, there are just two from the present year of 2016.!). >>> We agree with the reviewer that most included references are quite old, given the paucity of studies in the field. There is however a large number of very recent studies that have appeared very recently (most of them since we submitted our paper) and have therefore included the following 5 references: 14. Macdiarmid JI, Douglas F, Campbell J. Eating like there's no tomorrow: Public awareness of the environmental impact of food and reluctance to eat less meat as part of a sustainable diet. Appetite. 2016; 96: Aleksandrowicz L, Green R, Joy EJ, Smith P, Haines A. The Impacts of Dietary Change on Greenhouse Gas Emissions, Land Use, Water Use, and Health: A Systematic Review. PLoS One. 2016; 11: e Nelson ME, Hamm MW, Hu FB, Abrams SA, Griffin TS. Alignment of Healthy Dietary Patterns and Environmental Sustainability: A Systematic Review. Adv Nutr. 2016; 7: Perignon M, Masset G, Ferrari G, Barre T, Vieux F, Maillot M, et al. How low can dietary greenhouse gas emissions be reduced without impairing nutritional adequacy, affordability and acceptability of the diet? A modelling study to guide sustainable food choices. Public Health Nutr. 2016; 19: Horgan GW, Perrin A, Whybrow S, Macdiarmid JI. Achieving dietary recommendations and reducing greenhouse gas emissions: modelling diets to minimise the change from current intakes. Int J Behav Nutr Phys Act. 2016; 13: 46. Reviewer #3: Thank you for the opportunity to review this paper on ethical dilemmas in food choice. I find it a very interesting paper and a subject, which has not been the choice of many studies or publications. I have only a few minor remarks to the paper: >>> We thank this reviewer for this positive comment on our manuscript.

8 L. 72, 307, 316, 335: Please stick to the reference style in the rest of the paper, i.e. numbers in brackets. >>> We apologize for this mistake. We have removed reference manager codes throughout the manuscript L. 149: Do you mean that the French dietary guidelines were stated for the participants to read? Or that the participants were supposed to recall the guidelines? >>> We meant that the French dietary guidelines were stated for the participants to read. In the text: French dietary guidelines were mentioned for each food group L. 209: The first occurrence of the word "Participants" should probably be deleted. >>> Thank you for pointing out that mistake. The word participant was removed. L. 211: I have only come across the unweighted Kappa statistics in the case of estimating agreement between two independent raters of the same object. Can the authors give a reference to their use of it to estimate agreement between linked observations? >>> We have now added a reference as advised. L. 305: It should be stated that the mentioning of "Women were also more likely to agree..." is from a different study than the present. >>> The sentence has been modified accordingly In the text: In a previous study, women were also more likely to agree that they were not sure whether to buy farmed fish. L : Could the authors give one or more possible explanations to the observed dilemma being more pronounced in subjects with low income than in subjects with higher incomes? >>> We now give possible explanations to this result.

9 In the text: It is possible that individuals with low income perceive more dilemma in general when purchasing foods, since they have to take into account cost barriers, and as a consequence also perceived more health vs environmental dilemmas. In the case of meat, symbolic role of this food, such as its contribution to physical strength and energy, and social norms in low socioeconomic categories could also weight on the decision to maintain its important status in meals in this socioeconomic group [56], and may lead to dilemma related to the knowledge of the high environmental impact of this food. Table 2: Consider to revise the table so that row percents are given instead of column percents. E.g. in the first line in the table it is stated that 76.6 % of women have no dilemma concerning the purchase of meat, while 81.1 % do report a dilemma. This is because more women than men take part in the study, and therefore it is not really very informative on the difference between the genders in reporting a dilemma. >>> We considered making this change. However, we believe that it would lead to a potential confusion for the reader. The first column (all sample) would indeed show column percents whereas other columns would show row percent leading to potential misreading. We believe that differences can easily be seen using column percent (81.1% is greater than 76.6% with a p <0.0001). However, if the reviewer feels that it is a requirement we will make changes accordingly.