Planetary Health Enters the International Clinical Guideline Development System for the First Time

Should the environmental impact of a treatment influence clinical recommendations when several options offer similar benefits for patients? A paper published in Annals of Internal Medicine addresses this issue for the first time within the leading methodological framework used internationally to develop evidence-based clinical guidelines. Prepared by the GRADE Working Group with the participation of researchers from the Sant Pau Research Institute (IR Sant Pau) and the GRADE Center Barcelona, the document proposes systematically incorporating planetary health criteria into the development of clinical and public health recommendations.

The article argues that health care decisions should consider not only factors such as the clinical effectiveness, safety, costs, and acceptability of an intervention, but also its impact on the environment and on the so-called planetary boundaries—the natural systems that sustain life and whose disruption can directly affect human health.

Until now, clinical guidelines have not systematically incorporated factors such as emissions associated with certain treatments, water consumption, waste generation, pollution caused by health care products, or impacts on biodiversity. As a result, recommendations involving similar clinical benefits could be made without considering differences in their environmental effects.

“Human health depends directly on the health of natural systems. Clinical guidelines influence millions of health care decisions every day around the world and can therefore also help reduce the environmental impact of health care systems when equally effective alternatives are available to patients,” explains Dr. Pablo Alonso-Coello, head of the Clinical Epidemiology and Health Care Services Research Group at IR Sant Pau and one of the paper’s authors.

A New Criterion Within the GRADE System

The document introduces a new specific criterion within the GRADE Working Group’s Evidence-to-Decision (EtD) framework, one of the most widely used methodological frameworks internationally for developing clinical and public health recommendations. According to the editorial accompanying the article in Annals of Internal Medicine, this addition represents the most significant expansion of the EtD framework since equity was formally incorporated into the GRADE system.

To address this limitation, the new document incorporates a specific criterion into the GRADE system requiring explicit consideration of the environmental impact of health interventions. The framework proposes that guideline development groups assess factors such as greenhouse gas emissions, water consumption, waste generation, pollution, and impacts on ecosystems, integrating this information alongside traditional clinical evidence. Consequently, when two interventions offer similar outcomes for patients, differences in their environmental impact could become an additional factor guiding the final recommendation.

“Many health care decisions have environmental implications that, until now, have not been systematically assessed. The goal is not to replace clinical criteria, but to broaden the assessment to include their potential consequences for planetary health,” adds Javier Bracchiglione, a researcher at Cochrane Iberoamerica and another of the article’s authors.

From Inhaler Use to Dietary Recommendations

To develop and validate the new methodological framework, the GRADE Working Group examined several case studies involving clinical and public health decisions. These included examples related to the use of anesthetics, asthma inhalers, face masks, and dietary recommendations concerning red meat consumption.

One of the cases examined shows how certain dietary recommendations could change when the environmental impact associated with greenhouse gas emissions, land use, or water consumption is considered. Other examples illustrate how two clinically equivalent devices or treatments can have entirely unique environmental footprints.

“We wanted to develop a methodology that could be useful regardless of the medical specialty or type of intervention being assessed. The case studies allowed us to confirm that planetary health principles can be incorporated into extremely diverse contexts without compromising the methodological rigor that characterizes the GRADE system. The best available evidence for patients remains the central element of the recommendations; this framework simply adds a new dimension of analysis that was not previously assessed systematically,” says Dr. Pablo Alonso-Coello.

The authors note that the healthcare sector accounts for approximately 5.2% of global greenhouse gas emissions, with some countries reaching figures close to 10%. They therefore believe that health care recommendations should progressively incorporate criteria that also make it possible to assess their environmental sustainability and effects on planetary health.

A Methodological Shift With Challenges Ahead

The article and accompanying editorial acknowledge that significant methodological challenges remain before this approach can be implemented broadly. These include the lack of international standards for assessing certain environmental impacts, the need to include planetary health experts on guideline development panels, and the limited specialized training many health care professionals have in this field.

The authors also emphasize that incorporating environmental criteria must not increase healthcare inequalities or hinder access to effective treatments in certain settings. The new framework therefore stresses the need to adapt recommendations to each healthcare and geographic context.

“The publication of this framework represents a first step in a process that will likely evolve over the coming years. Incorporating planetary health into clinical guidelines will require new data, tools, and standards, as well as close collaboration among methodology experts, health care professionals, and sustainability specialists. This document establishes a common foundation for moving forward in a rigorous and transparent manner,” says Javier Bracchiglione.

The work was developed by the international GRADE Working Group, a scientific collaboration dedicated to developing methods for evidence-based clinical recommendations that are used by numerous health care organizations and public health agencies worldwide.

Reference Articles:

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