Integrating Planetary Health in Health Guidelines (GRADE Guidance 46)

Piggott T, Saadat P, Herrmann A et al.  Ann Intern Med. 2026 May 12. doi: 10.7326/ANNALS-25-04761. Epub ahead of print.

Abstract

GRADE framework for integrating planetary health in health guidelines.

Human health and natural systems are intrinsically linked—stable natural systems enable healthy human life. Health systems aim to promote, restore, and maintain health. Health systems may promote human health while having detrimental effects on natural systems, contributing to the transgression of planetary boundaries, such as biosphere integrity, climate change, and the introduction of new entities like microplastics. To date, the health guideline field lacks methods to assess the impacts of health interventions on planetary boundaries. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group established the Planetary Health Project Group in 2023 to develop formal GRADE guidance for integrating planetary health into guideline recommendations to address this gap.

Guided by the concepts of planetary health and planetary boundaries and following established methods for GRADE guidance development, the project group conducted iterative case study analyses, expert workshops, and a 2-round global Delphi consensus process. Four case studies were selected for application of this guidance before recommendations were finalized. The GRADE Working Group approved the official guidance.

The Planetary Health Project Group presents 7 domains of guidance for incorporating planetary health aspects into the guideline development process, including highly desirable items and optional items. Highly desirable items include formally addressing planetary health in public health and health system guidelines and explicitly justifying its exclusion where it is not addressed. Judgments within the evidence-to-decision (EtD) framework should systematically integrate included evidence across the prioritized planetary boundaries and equity. This guidance aims to support guideline developers and policymakers in making evidence-based, trustworthy recommendations to protect individual and planetary health, while maintaining thoroughness and feasibility for guideline developers within the GRADE approach.

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