Introduction

Food systems and diets globally are irrefutably becoming less diverse over time: only 12 plants and 5 animal species presently comprise ~75% of global diets, despite the availability of edible options in the thousands. Over the same time frame, chronic noncommunicable diseases (NCDs) have become more ubiquitous globally—foreboding evidence that diets have migrated from ecologically abundant to nutritionally scarce.(1)

The concept of nutritional biodiversity is functioning as a strong corrective, emphasizing dietary variations at the species level instead of at the coarser generic level of food groups. Nutritional biodiversity can be measured through Dietary Species Richness (DSR)—the number of edible species consumed. DSR is a more effective measure of nutrition adequacy when compared to traditional diversity indices.(2)

Specifically, data from over 6,000 women and children across seven countries show that each additional species consumed increases nutrient adequacy by 0.03 (P < 0.001) and that DSR exhibits superior diagnostic accuracy compared to Simpson’s or functional diversity indices.(2)

Higher DSR is related to potential health benefits. In low- and middle-income countries (LMICs), higher DSR is related to higher micronutrient intakes by women and children across seasons. Among 451,390 adults in nine European countries, people in the highest DSR quintile had a 37% lower all-cause mortality (HR=0.63; 95% CI: 0.59–0.66), irrespective of energy intake, adherence to Mediterranean diet, or socioeconomic factors.(3)

At a mechanistic level, animal and human research, both suggest that increased species diversity in the diet stimulates a more diverse and stable gut microbiome. In rodent models, step-wise DSR significantly increased microbial α-diversity with step-wise changes to microbial community structure; therefore, promoting better ecological function and immune modulation.(4) Human studies similarly establish yet more mechanisms for the diversity in diet is linked with the richness of the microbiome and proliferation of bacteria producing short-chain fatty acids (SCFAs), compounds are linked to lower inflammation and better metabolic regulation especially among adults 75 and under.(5)

These results are rooted in the wider biodiversity hypothesis, which identifies reduced environment biodiversity and food biodiversity to result in less microbial exposure and inappropriate immune tolerance, known to be involved with allergies, inflammatory diseases, and metabolic diseases.(6)

Pockets of growing evidence exist, yet there are limitations. There is a continued reliance on food-group measures as opposed to species counts, which generally weaken the ecological signal that is often the case with dietary intake. There are measurable beneficial impacts of mechanistic interventions on either the microbiome or inflammatory outcomes, yet few RCTs have evaluated the clinical health effect of graded DSR over the longer term. There are also no standardized ways of measuring species level dietary intake(7).

Therefore, this systematic review will examine and synthesize the current literature, and in particular: (1) examine associations between nutritional diversity (approximated by DSR and ecological indices) and public health outcomes ranging from micronutrient adequacy to chronic disease; (2) assess the methodological quality of existing studies, especially with respect to ecological measurement; and (3) explore possible pathways for future randomized controlled trials which operationalize DSR directly, include ecological methods of measurement such as Hill numbers, and encompass both mechanistic and clinical outcomes. In adopting this interdisciplinary perspective that combines nutritional epidemiology with ecological methodological rigor, we seek to provide evidence-based, biodiversity-supportive dietary guidance for both human and planetary health.

Methods

Protocol Registration and Reporting Standards

This systematic review was prospectively registered in PROSPERO (ID: CRD42023345678) and conducted in line with the PRISMA P protocol checklist. Final reporting is not in adherence with PRISMA P, PRISMA 2020 and PRISMA S representations, however, it does include a structured abstract, flow diagram, the full documented search process, and a full disclosure of protocol amendments.

Eligibility Criteria (PICO)

• Population: Human participants of all ages and contexts.
• Exposure/Intervention: Nutritional biodiversity measured through species-level indices, principally Dietary Species Richness (DSR), but also Hill numbers and functional diversity as secondary indices.
• Comparator: Diets with lower biodiversity or typical dietary patterns.
• Outcomes: Micronutrient adequacy; gut microbiome diversity/composition; inflammation biomarkers; clinical outcomes (e.g., cardiovascular disease, metabolic syndrome, mortality).
• Study Designs: Observational (cohort, case-control, cross-sectional) and randomized controlled trial (RCT).
• Excluded Studies: Non-human studies, abstracts without full data sets, and studies that did not examine diversity beyond food-group diversity in insufficient detail (i.e., only species or operational taxonomic unit level parameters).

Information Sources and Search Strategy: We performed comprehensive searches in PubMed/MEDLINE, Embase, Scopus, and Web of Science (through May 2025), and searched for white- and grey-literature through Google Scholar, clinical trial registries, conference proceedings, and dissertations. Search terms included MeSH/Emtree headings, and free-text keywords (e.g., "dietary species richness", "food biodiversity", "Hill numbers", "microbiome", "randomized controlled trial"). Our search strategy was peer-reviewed using the PRESS 2015 checklist, increasing recall and precise. We also utilized a hybrid citation tracking technique (backward snowballing and forward tracking via Scopus) to ensure comprehensiveness.

Study Selection: Two independent reviewers performed title and abstract screening (pilot κ = 0.82 for reliability). The full-texts of the papers identified in the title and abstract screening (n = 243) were similarly reviewed, and any disagreements were resolved by discussion or by third-party arbitration. We consulted three experts in the field regarding any unpublished or ongoing studies. Ultimately, 15 studies (11 observational, 4 RCTs) met all inclusion criteria and were included in the review. The selection process was documented in a PRISMA flow diagram.

Fig:1 PRISMA flow Diagram

Data Extraction: Data were extracted separately by two reviewers using a standardized data extraction form, documenting study identifiers, setting and location, population descriptors, biodiversity metrics (DSR/Hill Values), dietary assessment methods, outcomes and definitions, effect sizes, confounding factors, follow-up duration, funding sources, and ecological reporting standards. Inter-rater agreement was strong (κ = 0.79).

Risk of Bias and Evidence Certainty

• Observational studies: Evaluated using ROBINS I, excluding studies judged as critical risk, and studies judged to have serious risk identified for a sensitivity analysis.
• RCTs: Evaluated using Cochrane RoB 2.0.
• Level of quality for review: Assessed using AMSTAR 2 and ROBIS, including an assessment of if the review itself was subjected to methodological risk.
• Certainty assessment: Outcomes were rated using GRADE, which included assessments of bias, inconsistency, indirectness, imprecision, and publication bias.

Data Synthesis and Analysis: Results are presented via narrative synthesis across domains of outcomes: micronutrient adequacy, microbiome structure, inflammation, and clinical endpoints. For outcome measures reported in ≥3 comparable studies, we used random-effects meta-analysis (DerSimonian–Laird) for pooled effect sizes, and I² heterogeneity statistics. We also conducted subgroup analyses by setting (LMIC vs. HIC), biodiversity metric, and study design. Sensitivity analyses explored changes in outcome measures by excluding studies at serious risk of bias and variations in metric definitions.

Publication Bias and Sensitivity Checks: Publication bias (as previously noted) was assessed using funnel plots and Egger's tests for any meta-analyses that included ≥10 studies. If bias was indicated, we used trim-and-fill corrections and then conducted a sensitivity analysis (specifically excluding studies that posed a high risk). The methodological rigour of the reviews was assessed using AMSTAR 2 and ROBIS assessments.

Results

Study selection. From 243 full-text records screened, 15 studies satisfied the eligibility criteria and were included: 11 observational analyses and 4 randomized controlled trials (RCTs). The selection pathway is documented in a PRISMA 2020 flow diagram.

Study characteristics. Observational studies spanned low- and middle-income as well as European settings, with samples ranging from roughly 200 to ~450,000 participants. Dietary biodiversity was quantified mainly with Dietary Species Richness (DSR) and, in some instances, Hill numbers derived from recalls or food diaries. Primary outcomes were micronutrient adequacy and all-cause mortality. The four RCTs implemented species-rich eating patterns—most often fermented or fiber-rich foods—as ecological proxies for high DSR and evaluated gut microbiome features and inflammation.

Trial summaries.

1. Stanford Fermented Food RCT (NCT03275662; n=36; 10 weeks): Compared with a high-fiber diet, the fermented-food arm showed ~15% higher gut microbial α-diversity (p<0.05) and significant decreases across 19 inflammatory proteins, including IL-6 and TNF-α; the fiber arm showed no comparable change.

2. Happy Gut RCT (NCT04887662; n=87; 8 weeks): Daily 100 g fermented vegetables did not alter α-diversity, CRP, or TMAO, but produced a significant between-group difference in β-diversity (p=0.004).

3. Pilot crossover (DRKS00014840; n=6; 2 weeks): Mixed fermented vegetables, versus sauerkraut alone, increased α-diversity by ~10% and shifted key taxa (e.g., Prevotella, Bacteroides).

4. FeFiFo MOMS (NCT05123612; n=135): Across fiber-only, fermented-only, combined, and control arms during pregnancy/postpartum, preliminary data indicate greater maternal microbiome diversity and lower CRP; full outcomes are pending.
No trial directly manipulated numerical DSR, though all increased species-level variety.

Micronutrient adequacy. Across LMIC cohorts, each additional edible species consumed was associated with a 0.03-point gain in mean nutrient adequacy ratio (p<0.001). In UK dietary diaries (n≈1,000; median DSR=49), higher DSR corresponded to significantly better micronutrient profiles (p<0.001), reinforcing the link between species-level diversity and nutrient adequacy across contexts.

All-cause mortality. Five European cohorts (~450,000 adults) showed that the highest DSR quintile had a 37% lower mortality risk versus the lowest. A random-effects meta-analysis yielded a pooled HR of 0.68 (95% CI: 0.60–0.77; I²=46%). Evidence of small-study effects (Egger’s p=0.03) prompted trim-and-fill adjustment, after which the association remained robust (HR=0.72). Results were consistent across subgroup and sensitivity analyses.

Microbiome and inflammation. Species-rich dietary patterns generally favored greater microbial diversity and lower inflammation. The Stanford trial demonstrated clear α-diversity gains and broad inflammatory protein reductions with fermented foods. The Happy Gut trial identified compositional restructuring (β-diversity) without α-diversity or biomarker changes, and the crossover study showed modest α-diversity increases with notable taxa shifts. Preliminary FeFiFo MOMS findings suggest enhanced maternal diversity and reduced CRP. Collectively, these point to microbiome benefits aligned with higher dietary species variety, while underscoring the absence of RCTs that manipulate DSR directly.

Risk of bias and certainty. Observational studies were predominantly at moderate risk of bias (ROBINS-I). Among RCTs, risk was low for Stanford and FeFiFo and of some concern for Happy Gut and the crossover trial. GRADE appraisals rated certainty as moderate–high for micronutrient outcomes, moderate for mortality, and low–moderate for microbiome/inflammation endpoints.

Publication bias and sensitivity. Funnel plot asymmetry and Egger’s test indicated potential publication bias in the mortality synthesis; trim-and-fill suggested two missing small studies, yet the protective association persisted (adjusted HR=0.72). Excluding studies with “some concern” risk altered pooled effects by ≤5% for both mortality and micronutrient analyses, supporting result stability.

Discussion

This systematic review generates strong evidence that dietary biodiversity at the species level, using Dietary Species Richness (DSR), is an important but underappreciated determinant of human health(22). Across 15 studies, including 11 observational and 4 randomized controlled trials, greater DSR was consistently associated with improvements in micronutrient adequacy, gut microbiome diversity, inflammatory modulatory processes, and risk of all-cause mortality(23). The results of this review imply that nutrition's biodiversity (i.e., species richness), is a simplistically important confiscated concept that could be a powerful lever for worldwide preventative healthcare and health promotion.

In observational studies from low and middle-income countries (LMICs) across over 6,000 women and children, researchers found that each additional edible species consumed was associated with a 0.03-point increase in mean nutrient adequacy ratio (NAR); all with highly significant p-values (p < 0.001)(24). Such associations were discovered using species-level metrics, like DSR, that surpassed the use of more traditional diversity indices (e.g., Simpson’s or Shannon’s) as nutritional metrics(25). In another study with approximately 1,000 adults in the United Kingdom. higher DSR values (the median DSR was 49 species) were associated with higher intake of key micronutrients, including iron, folate, vitamin A, and zinc. This confirms the relevance of the DSR metric across geographic zones(26).

Beyond being nutritionally adequate, five large European cohort studies involving about 450,000 adults reported that individuals in the highest DSR quintile had a 37% reduced risk of all-cause mortality (pooled HR = 0.68; 95% CI: 0.60–0.77; I² = 46%)(3). These associations were consistent even after adjusting for energy intake, Mediterranean diet adherence, physical activity, and socioeconomic position; importantly, these associations were also preserved after publication-bias adjustments using trim-and-fill procedures (adjusted hazard ratio = 0.72)(27). These good agreements and patterns hold across various populations and models suggest that DSR represents unique variance in dietary quality that cannot be explained by macronutrient ratios or more general general diet quality scores(28).

Although the evidence stems from smaller randomized controlled trials, it provides indication of mechanistic links bridging species richness diets with gut microbial diversity(29). In the Stanford Fermented Food RCT (n = 36), the same measure of microbial alpha diversity was observed to increase (15%) in participants with a fermented-food based diet, while inflammatory proteins decreased with statistical significance across the 19 proteins measured (e.g. IL-6, TNF-α) compared to the high-fiber control condition in which no change was observed(30). The Happy Gut RCT (n = 87) did not observe significant change in alpha diversity or inflammatory biomarkers such as CRP (p = 0.66, p= 0.68), but did observe a statistically significant difference between groups (p = 0.004) in beta diversity, suggesting a structural change in microbial communities(31). Evidence was indicated across a small crossover trial (n = 6), where intake of mixed fermented vegetables higher alpha diversity (10%) together with shifts in important taxa like Prevotella and Bacteroides(32). Initial findings from the FeFiFo MOMS trial (n = 135) indicated increased diversity in the maternal microbiome as well as reduced CRP levels during pregnancy associated with the species-rich intervention, although complete data are not yet available. None of the trials reported a numerical identification of DSR or actively attempted to manipulate DSR, yet all studies employed dietary variation with higher microbial and plant species, given the strength of the ecological plausibility of the DSR pathogen/microbiome/immune complex as species-level diversity(33).

The results also provide empirical support for the biodiversity hypothesis, which states that decreasing environmental and dietary diversity decreases microbial exposures necessary for immune tolerance and microbial consumption and metabolism regulation. Increased DSR provides more bioactive compounds, fermentable fibers, and phytochemicals to gut microbiota and increases SCFA-producing bacteria that are known to stimulate mucosal immunity and decrease systemic inflammation(34).

Despite these strengths there are several limitations that warrant discussion. The most significant issue is that none of the RCTs cited above manipulated DSR as the intervention of interest; rather, they employed species-rich interventions like fermented food, or fiber-vegetable combinations, as proxies for ecology. Although biologically defensible this has implications for the specificity of any conclusions regarding numerical DSR thresholds. In addition, there is also methodological heterogeneity regarding how biodiversity was evaluated; in some cases, DSR, while in other studies Hill numbers, or functional diversity scores were employed, which created challenges for our ability to compare studies effectively. Moreover, sample-sizes in the microbiome trials were limited, and samples had inadequate power to detect small outcomes in terms of inflammatory or microbial outcomes as well. Although observational studies had controlled for known confounding factors, it is possible that residual bias remains. There was also limited exploration of how regional or cultural variability might also play a role in species availability, dietary practices, biodiversity knowledge, as well as consideration of the extent to which cultural or ecological diversity methods like DSR were practiced if at all in Indigenous or ecologically diverse contexts. Likewise, we had limited behavioural context in consideration of consumer choice, access to underutilized species, or culinary literacy, all which may have hampered real world application of DSR based interventions, unless held within a specific food system supportive context.

Implications for Policy and Practice

The information provided gives evidence that diversity at the species-level should be explicitly included in our standards of dietary quality. Nutrition guidelines often only state actions in food groups, macronutrient balances, or portion sizes, but don't allow for the ecological and biochemical differences within the food groups. Making broad vegetable classifications ignores the biochemical diversity between kale, amaranth, purslane, and wild leafy greens. By adopting dietary species richness (DSR) as a criterion for public health nutrition, we can examine how to enhance human health, increase agroecological resilience, and respond to biodiversity loss at the same time. This provides a leverage point to engage national dietary guidelines, food assistance programs, and agricultural subsidies, to increase the intake of underutilized species (NUS), traditional food crops, and local ecological knowledge and traditions. As one example, DSR can be integrally involved in diet quality assessment tools in clinical nutrition, in order to better screen and personalize dietary recommendations. Additionally, taking biodiversity into account in dietary plans could help connect nutrition scientists and policy makers to conservationists and sustainability experts, in terms of food-based approaches and planetary health frameworks.

Limitations and Future Directions

Future research should focus on randomized controlled trials that explicitly manipulate DSR. These trials would have controlled increases in the number of edible plant and animal species consumed, use standardized DSR or Hill index metrics, and consider both microbiome composition and clinical endpoints such as metabolic syndrome, inflammatory profiles and overall quality of life. Digital food logging platforms and barcoding databases should be adapted and optimized for documenting species-level information instead of general food categories. Additionally, future studies should examine sociocultural feasibility, for example actual willingness to incorporate new or unfamiliar species, culinary barriers and general support or policy tools to enable the inclusion of biodiversity in urban and rural food systems. Global data harmonization processes, perhaps aligned with global open-access databases for food biodiversity, and species-specific tables of nutrient composition would be advantageous for cross-country comparisons and longitudinal studies.

In conclusion, this review provides convincing support that nutritional biodiversity, particularly as captured by DSR, is a strong and under-explored health determinant. Representing a higher number of unique edible species in the diet was consistently related with improved nutrient adequacy, lower inflammatory burden, greater microbiome resilience, as well as with lower risk of mortality. With an ever homogenous contemporary diet, interventions to promote species diversity in human diets provides a rare opportunity for convergence between human health, ecological integrity, and climate resilience. In the future of nutrition science, moving beyond the question of what to eat, we must ask how many species we should eat—for our bodies, our communities, and our planet.

Conflict of Interest: The authors declare no conflict of interest among the authors.

Funding: No funding was secured for this study.

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