Cost-Effectiveness of a New Nordic Diet as a Strategy for Health Promotion

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1 Downloaded from orbt.dtu.dk on: Dec 21, 2017 Cost-Effectveness of a New Nordc Det as a Strategy for Health Promoton Jensen, Jørgen Dejgård; Saxe, Henrk; Denver, Sgrd Publshed n: Internatonal Journal of Envronmental Research and Publc Health Lnk to artcle, DOI: /jerph Publcaton date: 2015 Document Verson Publsher's PDF, also known as Verson of record Lnk back to DTU Orbt Ctaton (APA): Jensen, J. D., Saxe, H., & Denver, S. (2015). Cost-Effectveness of a New Nordc Det as a Strategy for Health Promoton. Internatonal Journal of Envronmental Research and Publc Health, 12(7), DOI: /jerph General rghts Copyrght and moral rghts for the publcatons made accessble n the publc portal are retaned by the authors and/or other copyrght owners and t s a condton of accessng publcatons that users recognse and abde by the legal requrements assocated wth these rghts. Users may download and prnt one copy of any publcaton from the publc portal for the purpose of prvate study or research. You may not further dstrbute the materal or use t for any proft-makng actvty or commercal gan You may freely dstrbute the URL dentfyng the publcaton n the publc portal If you beleve that ths document breaches copyrght please contact us provdng detals, and we wll remove access to the work mmedately and nvestgate your clam.

2 Int. J. Envron. Res. Publc Health 2015, 12, ; do: /jerph OPEN ACCESS Artcle Internatonal Journal of Envronmental Research and Publc Health ISSN Cost-Effectveness of a New Nordc Det as a Strategy for Health Promoton Jørgen Dejgård Jensen 1, *, Henrk Saxe 2 and Sgrd Denver 1 1 Department of Food and Resource Economcs, Unversty of Copenhagen, Rolghedsvej 25, 1958 Frederksberg C, Denmark; E-Mal: sd@fro.ku.dk 2 DTU Management Engneerng, Global Decson Support Intatve, Dansh Techncal Unversty, Produktonstorvet, Buldng 424, 2800 Kgs. Lyngby, Denmark; E-Mal: henrsa@dtu.dk * Author to whom correspondence should be addressed; E-Mal: jorgen@fro.ku.dk; Tel.: Academc Edtor: Paul B. Tchounwou Receved: 27 Aprl 2015 / Accepted: 25 June 2015 / Publshed: 30 June 2015 Abstract: Inapproprate dets consttute an mportant health rsk and an ncreasng envronmental burden. Healthy regonal dets may contrbute to meetng ths dual challenge. A palatable, healthy and sustanable New Nordc det (NND) based on organc products from the Nordc regon has been developed. Ths study assesses whether a large-scale ntroducton of NND s a cost-effectve health promoton strategy by combnng an economc model for estmatng the utlty-maxmzng composton of NND, a lfe cycle assessment model to assess envronmental effects of the detary change, and a health mpact model to assess mpacts on the dsease burden. Consumer expendture for food and beverages n the NND s about 16% hgher than currently, wth the largest relatve dfference n low-ncome households. Envronmental loads from food consumpton are 15% 25% lower, and more than 18,000 dsablty-adjusted lfe years (DALY) wll be saved per year n Denmark. NND exhbts a cost-effectveness rato of about 73,000 94,000 per DALY saved. Ths cost-effectveness mproves consderably, f the NND s emphass on organc and Nordc-orgn products s relaxed. Keywords: New Nordc Det; envronmental mpact; publc health; cost-effectveness

3 Int. J. Envron. Res. Publc Health 2015, Introducton Inapproprate dets low n fruts, vegetables, whole gran products and seafood omega-3 fatty acds and hgh n meat, sugar and saturated fats consttute an mportant rsk factor for several dseases, and hence for mortalty, morbdty, qualty of lfe and socetal costs [1]. Increasng globalsaton of food sourcng s furthermore consdered to consttute a growng envronmental burden. One proposed soluton to ths dual challenge for socety s the development of healthy, regonal dets based on local products, such as e.g., the Medterranean det [2]. Inspred by recent years success of the New Nordc Cusne n gourmet restaurants [3], a New Nordc Det (NND) has been developed based on products from the Nordc regon, wth a hgh score n palatablty, healthness and sustanablty. Consumer nterest s expected to be drven by a clear Nordc gastronomc dentty, whch could make the det appealng and trendy. The prncples of the New Nordc Det have been delneated n Mthrl et al. [4] (supplement Table S1), and are descrbed by the followng overall ambtons and gudelnes: - Gastronomc potental and Nordc dentty dshes based on hgh-qualty organc food products wth a Nordc orgn and cultural hertage. Tastes from arctc seafood, and colour and flavor varaton from plant foods, such as berres, cabbages, roots, legumes, potatoes and herbs should contrbute to creatng a Nordc dentty. - Health relatvely low meat ntake and hgh ntake of legumes, vegetables, frut, whole grans, seafood, potatoes, nuts, herbs, etc., compared wth the average det n many Western countres, ncludng Denmark. Ths detary composton should contrbute to the preventon of health dsorders such as weght gan, type 2 dabetes, cardovascular dseases and cancer, but should also help mantanng and mprovng general physcal, mental and socal well-beng va. - Sustanablty use of locally grown foods to mnmze transport of food stuffs, use of organc products (whch are perceved by many as more sustanable than non-organc products due to more natural producton methods nvolvng organc sol management, abandonment of pestcdes and artfcal fertlzers, hgher anmal welfare, etc.) and foods sourced from the wld countrysde, shft from meat to plant products and focus on mnmzng food waste (by developng a few hundred recpes ncorporatng reuse) should contrbute to reducng envronmental mpacts assocated wth food producton. Several studes and revews [5 10] suggest that a healthy det wth hgh emphass on nutrtous, low-energy components such as fruts, vegetables and seafood tends to be more costly for consumers, and ths can pose an mportant barrer for a healthy lfestyle, especally for consumers n economcally and socally deprved households. Aganst ths backdrop, and usng Denmark as an llustratve example, the objectve of ths study s to nvestgate the cost-effectveness of a full-scale mplementaton of the New Nordc Det as a health promoton nterventon, when takng nto account consumer expendtures, as well as envronmental and dstrbutonal mpacts, and hence to ndcate, whether promoton of the NND as a strategy to mprove publc health could be a relevant alternatve to other health promoton strateges from a health economc perspectve.

4 Int. J. Envron. Res. Publc Health 2015, Data and Methods We apply a combned system of smulaton models to assess the long-term cost-effectveness of a natonwde NND as a health promoton strategy, compared wth the current Average Dansh Det (ADD), from a socetal perspectve. An economc model for consumers food expendture determnes the det composton. Ths det composton s then analysed n a consequental lfe-cycle assessment (LCA) model to determne envronmental mpacts, whch are monetzed and ncluded n the cost calculaton, and n an epdemology-based model for food-related non-communcable dsease rsks to assess publc health mpacts. The analyss dstngushes between two categores of publc health effects: (1) nutrton-related publc health effects, whch consttute the effect componenent n the cost-effectveness analyss; and (2) envronment/polluton-related publc health effects, whch are ncorporated n the cost component of the cost-effectveness analyss Data The target populaton of the study s the entre Dansh populaton (the NND det outlned n Supplement Table S1 for 4 75 year-olds s assumed to be mplemented n the entre populaton). The Consumer Survey from Statstcs Denmark [11] serves as the bass for constructng the ADD scenaro. The survey s based on a representatve sample of Dansh households and shows the sze of annual consumpton expendture and ts dstrbuton on 55 food and 11 beverage categores for dfferent groupngs of households, ncludng fve household ncome classes. Accordng to the survey, an average Dansh household n the perod conssted of 1.6 adults and 0.6 chldren (below 18 years) and had annual food and beverage expendtures of DKK 31,206 (about 4200) and DKK 10,812 ( 1450), respectvely, ncludng sales taxes but excludng consumpton n restaurants, canteens etc. All monetary fgures are presented n 2010 prce level, usng an exchange rate of 7.45 between and DKK [11]. Expendture data were translated nto physcal quantty data by dvdng the respectve cost tems by average retal prces per kg. To enable ths, the expendture data were dsaggregated as much as possble, usng supplementary (and more detaled) 2010-data from GfK Consumer Trackng Scandnava ( a demographcally representatve consumer panel contanng data from approxmately 3000 households, whch keep detaled weekly records of ther shoppng expendture and volumes. Prce estmates for each of these dsaggregated commodtes were obtaned by dvdng expendture by volume of these commodtes, and these prce estmates were used to translate dsaggregated expendture tems from the Consumer Survey nto physcal quanttes, whch were then aggregated to a level sutable for the models Models Ratonal consumers are assumed to adapt to NND n accordance wth budget-restrcted utlty maxmzaton (where utlty s derved from the consumpton of products, wthout concern for these products mpacts on future envronment and health prospects). Ths mples that the resultng consumed quanttes of ndvdual commodtes wthn the commodty groups of the NND prncples (e.g., mx of dfferent fruts or vegetables) are algned wth the consumers preferences as much as

5 Int. J. Envron. Res. Publc Health 2015, possble and that quanttes of commodtes not mentoned n the NND prncples wll also be adjusted to yeld the hghest possble utlty to the consumers, whle n accordance wth the NND prncples. Overall, consumed quanttes are adjusted such that the margnal utltes of dfferent products are proportonal to the perceved prces of these products (whch reflect the costs of supplyng these products to the consumers). If consumers are ratonal utlty maxmzers, the observed average stuaton n (assumed to represent 2010) can be nterpreted as the perceved optmal consumpton from the average consumers ponts of vew, gven the prces, ncomes, etc. at that tme (ADD scenaro). Hence, ths consumpton s the soluton to the frst-order condtons for constraned utlty maxmzaton: U = λ p, = 1,..., N x p x y ADD ( p, y) Expresson (1) states that the margnal utlty U derved from the consumpton of commodty s equal to the prce of ths commodty p adjusted for the extent to whch the budget constrant y s bndng, as represented by the Lagrange multpler λ. For many consumers, ths utlty maxmzaton outcome s not consstent wth the NND prncples. In order to estmate a preference-based det fulfllng the NND prncples, we ntroduce addtonal detary constrants to the utlty maxmzaton problem: - Unchanged total energy ntake (coeffcent e represents energy content n commodty x ) - maxmum lmts S j to ntake of some foods or nutrents (coeffcent s j characterzes commodty x wth respect to constrant j ), and - mnmum lmts Q h to ntake of some other foods or nutrents (coeffcent q h characterzes commodty x wth respect to constrant h ) The three types of constrants have assocated Lagrange multplers (ψ, η j 0, θ h 0 ) representng the degree to whch they are perceved bndng for the consumers choces. Hence, the NND consumpton s the soluton to the augmented frst-order condtons for constraned utlty maxmzaton: U x = λ p NND p + ψ e x + ψ + λ e + p x y e x j NND j s q η s j h j = x S e x x Q j ηj s j + λ + j h h h θ h ADD q h θh qh, y = x λ, = 1,..., N NND ( ~ p, y) In ths framework, an mposton of the New Nordc Det alters the perceved relatve (mplct) prces (ncludng mpacts of the Lagrange multplers) of dfferent food and beverage commodtes. Compared wth market prces, the relatve mplct prces of commodtes to be promoted wll be lower (because θ h 0 ), and mplct prces of commodtes contanng substances to be reduced wll be hgher (because η j 0). (1) (2)

6 Int. J. Envron. Res. Publc Health 2015, The shape of the hence derved demand functons depends on the shape of the margnal utlty functon U, { 1,..., N}. Normally, U s expected to be a convexly decreasng functon of x, whereas the relatonshp between U and the consumed quantty of another good x g depends on substtutablty or complementarty between goods and g. These relatonshps are reflected n ownand cross-prce elastctes of consumers demands for these products. The economc model conssts of a matrx of such prce elastctes for all combnatons of food and beverage prces and quanttes, whch was estmated on the bass of household-level panel data from GfK ConsumerTrackng Scandnava for fve ncome categores of households, correspondng to the ncome groups n Statstcs Denmark s Consumer Survey. Gven own- and cross-prce elastctes for the demand of the respectve commodtes, ε j, the vectors of Lagrange multpler ratos ( ψ λ, η λ, θ λ ) can be determned by solvng the equatons: e x s q j h 0 x 0 x g g ε g g ε ε g e g g e g e ψ + g ψ + ψ + v s v v vg s s vg η vg v λ p g η v λ p η g v λ p + g + + w w q w wg q q wg wg θ w θ w θ = w = S j = Q e x For example, f the maxmum recommended ntake of added sugar (an element n S ) s lower than the actually observed ntake, the Lagrange multpler of ths restrcton wll be postve, and hence the mplct prces of commodtes contanng added sugar wll be hgher than the observed market prces provdng an mplct ncentve to consume less of these commodtes and vce versa for goods, whch should be promoted accordng to the NND prncples. Havng determned the Lagrange multplers, we can calculate the mplct prces of all 97 commodtes n the model: ~ p p + ψ λ e + ηv λ sv + θw λ q, { 1,..., N} = (4) v w w These mplct prces would gve the consumer the ncentve to choose a combnaton of foods and beverages adherng to the NND prncples. Usng the estmated prce elastctes, we can calculate the consumed quanttes n the NND: ~ ~ pg pg x = x0 1+ { N} g g, 1,..., ε p (5) g From the ambtons of Nordc gastronomc dentty and envronmental sustanablty the NND prncples suggested that 75% of the food should be organc and 95% of Nordc orgn [4]. Based on the GfK dataset, we have estmated average prces for both organc and non-organc varetes of each commodty, where possble. In order to determne those goods that would most lkely be organc f consumers are economcally ratonal, we calculated prce dfferentals (per calore) between organc and non-organc varetes. These prce dfferentals ranged from per cent for some vegetables (e.g., peas, frozen/processed vegetables), dary and gran products, to per cent for some other vegetables (e.g., cabbage, cucumbers, onons), fruts and meat products. We assumed that current h 0 (3)

7 Int. J. Envron. Res. Publc Health 2015, choces of organc varetes for each commodty would be mantaned (as a mnmum), and that addtonal choce of organc varetes would occur from the low end of prce dfferentals, untl 75% of total calores were reached. The avalable data materal dd not allow dstncton between goods of Nordc versus non-nordc orgn. For many lvestock products, large shares of the domestc consumpton are of domestc orgn and for those products, no sgnfcant prce dfferentals were assumed. In contrast, mports consttute consderable shares of domestc frut and vegetable consumpton, and restrctons to only nclude Nordc produced fruts and vegetables would mply hgher prces, although the NND prncple of utlzng seasonal varaton n supply wll tend to reduce ths prce dfferental. In the calculatons, we assumed average prce dfferentals of 10% for fruts and vegetables, whch are suppled from both mports and domestc producton (e.g., apples, pears, plums, strawberres, tomatoes, cucumbers, bell peppers, cabbage), whereas no prce dfferental was assumed for goods wth a currently hgh domestc share (e.g., roots, onons, potatoes). The prce dfferentals between organc and non-organc, and between Nordc and non-nordc, varetes were used to obtan adjusted prces pˆ that reflect these prce dfferentals. These adjusted prces were used to calculate the households NND food budget as: p ˆ ~ x for each of the fve ncome groups. Envronmental mpacts of the ADD and the NND were evaluated for 15 mpact categores (human toxcty from carcnogens and non-carcnogens, respratory organcs and norgancs, onzng radaton, ozone layer depleton, aquatc and terrestral ecotoxcty, aquatc and terrestral eutrophcaton, nature occupaton, global warmng, acdfcaton, photochemcal ozone effect on vegetaton, and non-renewable energy, cf. Supplement Table S2), based on consequental lfe cycle assessment (clca) usng the Smapro 8 software wth kg food or beverage as the functonal unt, and the nternatonal Econvent 3 [12] and the Dansh LCA food databases [13], supplemented wth adequate data from the lterature where needed. The lfe cycle assessment (LCA) model focused on the envronmental characterstcs of dfferent commodtes, dstngushng between domestc and mported goods. Commodtes were aggregated nto compostes based on ther envronmental characterstcs [14]. Because the aggregaton of the LCA model devated from the COICOP aggregaton used n Statstcs Denmark s data, lnkages between the COICOP classfcaton and the LCA model classfcaton were establshed usng the more dsaggregated GfK data materal, thus enablng a translaton of results from the economc smulaton to the LCA framework to assess envronmental mpacts of the detary dfferences between NND and ADD. In order to aggregate envronmental mpacts and budgetary mpacts for the consumers, we attempt to monetze the envronmental effects, although t s recognzed that such monetzaton may be consdered as controversal, and that the results of the monetzaton may depend on the methodology used. Dfferent approaches to monetzaton exst, ncludng: (1) Cost-of-llness/cost-of-damage approaches, evaluated on the bass of productvty effect estmates or on preference measurement [15]; or (2) Abatement cost approaches (e.g., [16]). Due to the controversal nature of the subject, we apply two alternatve monetzatons, both based on the Stepwse method [17,18], where a cost-of-llness/costof-damage productvty loss approach has been used (Supplement Table S2). One monetzaton s taken from Wedema [18], who based on the lterature translated envronmental effects wth human health mpacts nto loss of qualty adjusted lfe years (QALY). Assumng that a QALY represents the loss of

8 Int. J. Envron. Res. Publc Health 2015, one person-year productvty, the value of one QALY was estmated as the maxmum annual earnng potental (estmated as the US GDP/capta equvalent to 74,000 n 2003-prce level [18] or 77,000 n 2010-prce level adjusted upwards for long-run removal of varous mperfectons n the US economy) from a global perspectve as several of the envronmental mpacts are of a global nature. Effects on ecology and bodversty were measured n bodversty-adjusted hectare years (BAHY), assumng that the value of one BAHY s equvalent to the value of 0.02 QALY, based on prevous work by Wedema [18]. In the alternatve monetzaton, we have used the unadjusted US GDP/capta as a measure for the value of one QALY (wth derved consequences for the value of one BAHY). Other envronmental valuaton prncples are used n the lterature, but most of the estmates le wthn the ranges used here [15]. An mpact fracton model was developed and lnked to the dfference n food and beverage consumpton from ADD to NND to assess potental health rsk effects of ths detary shft. Assumng that a detary behavor (e.g., frut and vegetable consumpton below a certan threshold) can be consdered as hgh-rsk, the relatve rsk (RR) represents the rato of a certan health rsk (e.g., for death due to stroke) for below- and above-threshold consumpton, respectvely. If α b and α a represent the shares of ndvduals exposed to the consdered rsk factor before and after the change, respectvely, the mpact fracton (IF) can be calculated as [19]: IF d ( αb αa ) + RR ( αa αb ) ( α ) + RR α = (6) 1 b b Ths mpact fracton represents the relatve change n aggregate health rsk (or dsease burden) for dsease d followng from a change n rsk factor exposure, gven by the dfference: α a αb. We focus on the mpacts of 10 detary factors on the rsks of up to 6 det-related non-communcable dseases (cardovascular dsease, stroke, dabetes, stomach cancer, lung cancer and breast cancer). A systematc search for lterature on assocatons between these detary factors and health rsks was conducted, and the fndngs were syntheszed nto relatve rsk fgures [20 53] (Supplement Table S3). A shft from ADD to NND wll tend to ncrease the average ntake of fruts and vegetables. Ths wll (from a partal perspectve) reduce the rsk of all the consdered chronc dseases represented by RR-parameters below 1. Hence, most of the prncples wthn the NND seem to mply lower health rsks (whch s also one of the man objectves of the NND). Despte an a pror presumpton that sugar would also consttute a rsk factor for some of these dseases, no studes wth RR estmates for sugar (except for sugared drnks) were found. Nevertheless, f the a pror presumpton holds, we may underestmate the health beneft from a detary change towards NND. Usng Statstcs Denmark s Consumer Survey and results from the Natonal Detary Survey [54], we estmate normal dstrbutons of the above 10 detary components n the Dansh adult populaton (assumng that the same relatve varaton holds for chldren), and hence the shares of rsk-exposed ndvduals n the ADD, α b, to represent the heterogenety n households food consumpton patterns. Assumng that the NND nterventon wll modfy the mean values of these dstrbutons leavng the standard devatons and shape of the dstrbutons unaffected we then calculate the correspondng shares of rsk-exposed ndvduals n the NND, α a, and are thus able to calculate the mpact fracton for each combnaton of rsk factor and health rsk usng expresson (6). We translate these mpact fractons nto absolute health effect Δ H usng the expresson:

9 Int. J. Envron. Res. Publc Health 2015, ΔH = d IF d DALYd deaths EUR,2004 a EURa,2004 d deaths DK,2010 d (7) where dsease-specfc mpact fractons ( IF d ) are multpled by estmates of the dsease burden (DALY) n Denmark for the respectve health rsks, obtaned by ratos between the most recent (2004) WHO-fgures on DALY and number of deaths n Western Europe ( EUR a ) [55], whch are multpled by number of deaths from the respectve dseases n Denmark n 2010, where the rato between DALY and number of deaths for the respectve dseases was assumed to have been stable from 2004 to If the ntroducton of NND would also narrow the dstrbutons of detary patterns, the potental postve health mpacts would presumably be larger than those presented n the calculatons below. Hence, we have annual fgures for the costs (net of envronmental benefts) and the health effects of the NND, compared to the ADD. As the health effects of detary change are lkely to occur wth several years tme lag, we have dscounted the health effects by 10 years n the calculaton of cost-effect ratos. Followng recommendatons from several authors n health economcs (e.g., [56]), we have used a relatvely low dscount rate for these health effects,.e., an annual dscount rate of 1%. 3. Results Solvng the utlty maxmzaton problem for the NND (2) yelds mplct prces assocated wth constrants for detary components such as fruts ( per kg lower than the average market prce), seafood ( per kg below average market prce), meat ( per kg above average market prce), saturated fat (upward prce adjustment of per kg saturated fat), etc., where the ntervals represent varaton across the fve ncome groups. These mplct prces represent the prce structure that would gve the average consumers wthn the fve ncome groups the economc ncentve to consume a det consstent wth the NND prncples. The overall composton of the natonal food budget n the ADD and the NND s shown n Table 1. Table 1. Aggregate consumpton effects, 1000 tonnes and mllon. Consumed Quanttes (1000 tonnes) Expendture, mll. ADD NND ADD NND Gran-based foods Meat Seafood Dary and fats Fruts and vegetables Other foods Foods total 10,948 12,821 Beverages Total 13,591 15,719 The NND consumpton of gran-based foods, seafood, fruts and vegetables s hgher than n the ADD scenaro (wth an ncrease n whole gran consumpton consttutng the dfference for gran based foods), whereas the consumpton of meat, dary products, fats and other foods s lower. Although

10 Int. J. Envron. Res. Publc Health 2015, consumpton of gran-based foods s hgher, the expendture s not hgher, because the consumpton s more on grans, flour etc. and less on ndustrally produced bread and pasta. Overall, the NND consumer expendture for food and beverages s about 1.87 bllon and 0.25 bllon hgher, respectvely, totalng an ncrease n food and beverage expendture of about 16%. Out of ths, the use of 75% organc products accounts for about 0.9 bllon, and the requrement of 95% products of Nordc orgn contrbutes by 0.4 bllon. The expendture for fruts and vegetables shows the largest ncrease, but also the expendtures for seafood and gran-based foods ncrease, whereas the expendtures for meat and dary products decrease. In addton to the effects of ncreased organc and Nordc-orgn shares wthn consumpton, the effects also represent changes n consumed quanttes, as represented by the above-mentoned system of prce elastctes. Wthn fruts and vegetables, an ncrease n consumpton of fruts s determned n the NND (n lne wth the NND-prncples), but the largest ncrease takes place for bananas and ctrus fruts (whch cannot be produced n the Nordc countres), because of relatvely strong consumer preferences for these frut types. Hence, the prncple of 95% Nordc orgn s satsfed n other product categores such as meat, dary, vegetables and gran-based commodtes. We can estmate the consequences of the changes on dfferent envronmental ndcators usng the above-mentoned clca framework. Measured n monetary values, fve envronmental ndcators stand out: Nature occupaton, global warmng, respratory norgancs, non-carcnogenc human toxcty and terrestral eutrophcaton. Together, these fve ndcators account for about 97% of the monetzed value of the 15 envronmental ndcators, wth nature occupaton, global warmng and respratory norgancs as the most sgnfcant, n the ADD baselne. Fgure 1 llustrates the relatve changes n the three most mportant envronmental ndcators, decomposed nto contrbutons from changes n consumpton of beverages and anmal- and plant-based foods. For all three ndcators, the NND has more favorable envronmental outcomes than the ADD: 17% lower for nature occupaton, 16% for global warmng, and 12% for respratory norgancs. These envronmental mprovements stem prmarly from the reduced consumpton of anmal-based products, whereas ncreased consumpton of plant-based products reduces ths effect. Non-carcnogenc human toxcty s however sgnfcantly reduced (74%) due to the hgh share of organc products n the NND. Dependng on the method of monetzaton, the monetary value of the envronmental mprovements was estmated to be bllon, whch could be deducted from the above-calculated food expendture ncrease to obtan a socetal net fgure for the cost ncrease. Based on the mpact fracton methodology descrbed above, we have calculated the effects of the detary change (from ADD to NND) on the dsease burden from the 6 mentoned chronc dseases (Fgure 2). For example, the detary change s calculated to save about 6500 DALY/year from cardovascular dsease, wth man contrbutons from ncreased consumpton of frut and vegetables, reduced consumpton of meat and reduced consumpton of sugared drnks, but mnor effect from changed consumpton of fats. The detary change s also estmated to have a marked effect on dsease burdens from stroke and dabetes, whereas about 3000 and 1200 DALY/year are calculated to be saved from colorectal cancer and lung cancer, respectvely. In total, an estmated DALY wll be saved per year n Denmark from these sx chronc dseases.

11 Int. J. Envron. Res. Publc Health 2015, % 10% per cent of total ADD emsson 5% 0% -5% -10% -15% -20% Nature occupaton Global warmng Respratory norgancs Beverages Anmal-based foods Plant-based foods All foods/beverages -25% -30% Fgure 1. Effects of NND on most mportant envronmental externaltes. Saved DALY/year Unsat. Fat Sat. Fat Sugared drnks Meat Fsh Frut/veget. Fgure 2. Saved DALY per annum n Denmark from selected det-related health problems. Combnng the aggregate consumpton expendture, monetzed envronmental benefts and dscounted calculated health outcomes, the cost-effectveness of the New Nordc Det as a publc health promoton tool was calculated. Usng the monetzaton of envronmental effects by Wedema [18], we obtan ( 2.1 bll. 0.9 bll.)/18396 DALYs ~ 73,000/DALY, whereas the alternatve monetzaton yelds 94,000/DALY. Havng modelled fve ncome classes of households enables assessng some dstrbutonal effects of the detary shft (Table 2). For ease of comparson between households wth dfferent compostons, economc fgures are measured on a per adult-equvalent bass (one chld s assumed equvalent to 0.7 adults). On average, the addtonal budgetary spendng on food and beverages s 417 per adult-equvalent, correspondng to about 16% of the ADD spendng on food and beverages. In absolute terms, ths food and beverage budget ncrease s smlar across ncome groups, and s hence relatvely larger for the

12 Int. J. Envron. Res. Publc Health 2015, lower-ncome groups (16.2% 17.2% for low-ncome households versus 15.2% 15.7% for hgh-ncome households). ADD Table 2. Dstrbutonal effects, /adult-equvalent/year. NND /adult_equvalent/ year Envronmental Beneft /Adult Equvalent Net Cost/DALY Food and Beverage Expendture Dsease Reducton (DALY) per cent Dfference per cent Reducton I II III IV V All ncome classes Note: Income classes I: < DKK 150,000 (< 20,000), II: DKK ,999 ( 20 40,000), III: DKK ,999 ( 40 67,000), IV: DKK ,999 ( ,000), V: > DKK 800,000 (> 108,000). Counterbalancng the value of envronmental benefts ( per adult-equvalent per year assumed equally dstrbuted across ncome groups) reduces the net cost to a range between 238 and 307 per adult-equvalent. The health effects dsplayed n Fgure 2 translate nto an average reducton n aggregate dsease burden from the sx dseases by 13.8%, whch s dstrbuted across ncome groups accordng to ther relatve health rsks estmated from current (ADD) detary patterns. Except for the lowest ncome group, the health promotng effect of the detary shft tends to be decreasng wth ncome level, as measured by percentage reducton n the number of DALY. And takng nto account that the dsease burden s relatvely low n hgh-ncome groups for most of the consdered dsases [57], ths decreasng trend n health promotng effect wth ncome level prevals when the health effect s measured n absolute terms. The relatvely low health effect n the lowest ncome group s explaned by dets that are somewhat healther n ths ncome group (ncludng lower ntake of meat, fat and sugared drnks) and some of the responses to the ADD-NND shft are smaller (e.g., the consumpton of sugared beverages). Combnng these fgures to consder the cost-effectveness of NND as an nterventon to reduce dsease burden from the sx dseases, we fnd a net cost of 73,000 94,000 per saved DALY (dependng on the valuaton of envronmental benefts). Ths cost-effectveness measure shows some varaton across ncome groups, wth the most favorable cost-effectveness ratos for medum-ncome households, and the least favorable rato for households wth relatvely hgh or low ncomes. 4. Dscusson The study combnes smulaton models from dfferent subject areas nto a model system whch s used for evaluatng the cost-effectveness of a large-scale transton from the current detary pattern to a healthy and sustanable regonal det (New Nordc Det) as a health promoton nstrument at populaton level. The combnaton of models represents a relatvely unque approach to such cost-effectveness analyses, whch yelds the opportunty of takng both drect and external net costs

13 Int. J. Envron. Res. Publc Health 2015, nto consderaton. We fnd that a full-scale mplementaton of the New Nordc Det n Denmark mght reduce the dsease burden from cardovascular dseases, dabetes and four cancer types by more than 18,000 DALY per year n Denmark, compared wth the current average Dansh det, wth a cost-effect rato of 73,000 94,000 per DALY, when account of envronmental benefts s taken (and almost 128,000 per DALY f these envronmental benefts are dsregarded). The NND assumes that organc products consttute at least 75% of the det, and ths attrbute contrbutes substantally to the costs (but s not assumed to contrbute to the publc health effects n terms of the consdered dseases, as no strong evdence was found to support such effects). If ths requrement were dsregarded (as a senstvty analyss), some of the envronmental benefts (ncludng nature occupaton and respratory norgancs) would be slghtly hgher and some (e.g., global warmng) would be lower, and the cost-effect rato reduced from 128,000 to 74,000 per DALY (gnorng envronmental benefts). The fndng that some envronmental benefts would be hgher wthout the organc requrement s due to the lower ntensty (yeld per hectare or per anmal-year), mplyng that emssons that are related to hectares or anmals wll come out hgher when measured per output unt n organc farmng even though emssons per hectare or per anmal may be lower for organc than for conventonal producton. And f the addtonal requrement that 95% of the det should be of Nordc orgn were also dsregarded, ths cost-effect rato would be reduced to about 50,000 per DALY, whch s wthn the sze of the monetzed envronmental benefts dependng on the prncples for monetzng these benefts. These fgures may be compared wth estmated costs, effects and cost-effectveness propertes of other communty- or populaton-based health promoton nterventons n the lterature. Several other studes have found comparable costs for healthy dets compared to less healthy dets [8,9,58,59]. Trchopolou et al. [2] found a sgnfcantly lower mortalty for ndvduals adherng to the Medterranean det. Hence, one may expect postve cost-effect ratos, as we found n the present study. However, studes wth comparable nterventons and outcome measures are relatvely hard to fnd n the lterature. Many studes address health promotng detary nterventons targeted towards hgh-rsk ndvduals (e.g., [60 62]) and show better cost-effectveness propertes (whch should also be expected, because the potental average health effects are relatvely larger). Other studes may be populaton-based but use more narrow cost concepts (e.g., drect mplementaton costs for health promoton or health care sectors, but gnorng detary costs for consumers) than ours, also showng relatvely hgh effectveness per cost unt [63 65]. WHO recommendatons suggest nterventons wth a cost n the range from one to three tmes GDP per capta to be consdered as cost-effectve [66]. Wth a Dansh GDP per capta of 43,500 n 2010, ths suggests a threshold of about 130,000 per DALY, whch mght ndcate that the NND nterventon can be consdered as cost-effectve, especally when envronmental mpacts are taken nto account. When comparng the fndngs of the present study wth those of other health promoton studes, t should be kept n mnd that the NND s not purely a health promotng nterventon, but also carres broader vsons n felds such as gastronomc dentty, lfestyle, famlarty wth nature s resources etc., whch could be presumed to add further but non-quantfable value to the New Nordc Det, as compared wth other health promoton nterventons. We have assumed that consumers gnore envronmental and future health mpacts of the consumpton n ther decson makng. If parts of these mpacts are nternalzed n ther baselne consumpton decson, ths may ntroduce uncertanty to our cost-effectveness calculatons. Our cost

14 Int. J. Envron. Res. Publc Health 2015, estmates do not nclude any mplementaton or transacton costs n connecton wth the consdered detary change (e.g., promoton actvtes, preparaton of recpes, etc.). The NND mples sgnfcant changes n detary habts for a consderable share of the populaton, and ths rases a number of ssues related to adaptablty or acceptablty [67]. Such ssues may have mplcatons for the transacton costs assocated wth mplementng such detary changes. Hence, the presented fgures may under-estmate the total costs of such a major change. In order to ease consumers adopton of the NND, substantal effort has been devoted to the development of easy-to-apply recpes and to the popular dssemnaton of these recpes n top-sellng recpe books, n magaznes, n electronc meda, etc. efforts that have been able to beneft from recent years above-mentoned nternatonal success of the New Nordc Cusne n Dansh gourmet restaurants and the publcty around ths success [3]. Nevertheless, the scenaro of a full-scale mplementaton of the NND s stll consdered to face serous challenges. One partcular challenge n relaton to the NND prncple of at least 95% of the ngredents beng of Nordc orgn s the relatvely low avalablty of some products (especally wthn fruts and vegetables) durng a perod of the year. The recpe materal addresses ths challenge by takng nto account the seasonalty n the avalablty of Nordc-orgn food products. Furthermore, as noted n the results secton, the modelled NND ncludes some consumpton of mported fruts, whch may compensate for low avalablty of local fruts n the wnter and sprng seasons. In the modellng of NND s health effects, we assumed shfts n mean values of statstcal dstrbutons of dfferent detary ntakes (fruts, vegetables, seafood, etc.), whle keepng the standard devatons and correlatons of the ndvdual ntake components unchanged, due to lack of estmates of these parameters. Ths assumpton ntroduces uncertanty to the calculated health effects. For example, the study by Jensen and Poulsen [57] suggested a larger varaton n calculated food expendture wthn the NND than the ADD, but the reverse pattern could also be magned, and ntake dstrbutons may have dfferent skewness propertes and correlaton patterns n the two dets. Moreover, t should be noted that the quanttatve health mpact assessment only ncludes sx dseases, suggestng that these health mpact estmates should be consdered as lower-end estmates of the total health benefts. Furthermore, the assumpton of a constant relatonshp between DALY and number of deaths for these sx dseases from 2004 to 2010 also adds uncertanty to the health mpact estmates. In the food expendture calculaton, we have assumed that current market prces wll preval after a detary swtch, and hence that there are no constrants on the avalablty and accessblty of the ngredents n the NND. A full-scale swtch may however mpose radcal changes n the demand-supply balance on the markets for some products wthn the NND (e.g., fresh fruts, berres, vegetables, seafood and wld herbs) as well as n the ADD (e.g., meat or processed foods). For nternatonally traded commodtes, ths s not supposed to affect prces sgnfcantly, but for commodtes that are traded n more solated (e.g., local) markets, a larger demand may lead to a prce ncrease, whereas lower demand can lead to reduced prces. As the NND has hgh emphass on locally produced, fresh and organc products traded n relatvely small markets, the shft may mply an upward prce push of these commodtes at least n the short-to-medum term, suggestng that the estmated ncrease n consumer expendture may represent a lower-end estmate n the short run, but may be realstc n a long-run perspectve.

15 Int. J. Envron. Res. Publc Health 2015, The am of ths study has been to assess the cost-effectveness propertes of a full-scale mplementaton of a New Nordc Det n Denmark and thereby estmate the full potental of a change n det composton, rather than to gude an mplementaton of the det. Hence, n the analyses, the New Nordc Det scenaro s assumed mplemented wthout consderng potental polcy vehcles to obtan ths detary change. The economc model analyss yelded mplct prces n the NND and ther devatons from current market prces, and these devatons provde some ndcaton of the ncentve barrers that should be overcome n order to realze the NND scenaro. Some of these barrers could be changed by modfyng food prces va taxes or subsdes, although Denmark s membershp of the European Unon etc. may pose lmts to the extent to whch consumers access to mported food commodtes can be governed by such publc regulaton tools. Other ways to reduce the barrers for extendng the NND to broader groups could be an mproved performance of the markets for these foods and/or ncreased retaler focus on NND components n ther marketng and promoton actvtes, but changes n consumers preferences wll probably also be necessary, f the NND scenaro should become realty. The present study s based on a combnaton of emprcally based smulaton models from dfferent scentfc dscplnes. Naturally, ths combned analyss nherts exstng weaknesses from the dfferent components of the model framework, ncludng e.g., uncertanty on the parameters of the respectve model tools (such as prce elastctes, RR estmates, envronmental mpact coeffcents and monetzaton of the envronmental mpacts). The model approach descrbes changes for average households wthn dfferent ncome groups but dsregards the heterogenety n e.g., food consumpton patterns wthn these ncome groups, and ths may add some uncertanty to the quanttatve results not least wth regard to the estmaton of health mpacts. Despte such weaknesses and uncertantes, the above analyss s consdered to yeld new and mportant quanttatve nsghts nto the potental health economc prospects of major detary changes, such as a naton-wde mplementaton of the New Nordc Det. 5. Conclusons The present study fnds that on an aggregate level, the New Nordc Det s on average about 16% more expensve for the consumers than the current Average Dansh Det at the current market prces. The cost dfference s relatvely larger n low-ncome households, whch s n lne wth results of prevous cost studes comparng healthy wth less healthy dets. However, takng nto account postve envronmental effects (whch could be consdered as a socetal beneft), the cost ncrement s reduced to 9% 12%. The shft s found to reduce the aggregate dsease burden of sx chronc dseases (cardovascular dsease, stroke, dabetes melltus, colorectal cancer, breast cancer and lung cancer) by about 14%, yeldng a calculated cost-effectveness rato of about 73,000 94,000 per DALY saved. As both health mpacts and cost dfferences tend to be relatvely larger n low-ncome households, there s no clear soco-economc pattern n the cost-effectveness propertes. If the assumptons of 75% organc products and 95% products of Nordc orgn are relaxed, the cost-effect ratos would be substantally lower. Hence, mplementaton of the New Nordc Det could be an economcally relevant strategy for promoton of publc health, provded moderate transacton costs assocated wth such mplementaton.

16 Int. J. Envron. Res. Publc Health 2015, Supplementary Materal Table S1. Overvew of the average daly content of the detary components n the New Nordc Det (NND) n relaton to the average daly content n the Average Dansh Det (ADD) (energy-adjusted ntake per 10 MJ of all persons aged 4 75 years). Detary Component Average Content n the NND (g/day) Average Content n the Dansh Populaton s Det 2010 (g/day) Ingredents, g/10 MJ Frut >300 ( ) 240 Vegetables >400 ( ) 181 Includng - berres (50 100) 5 - cabbages >29 (25 35) 9 - root vegetables > legumes >30 7 Fresh herbs As much as possble ( 1) Potatoes >140 ( ) 106 Plants and mushrooms from the wld countrysde 5 (3 7) <1 Whole grans >75 36 Nuts >30 1 Fsh and shellfsh >43 (40 50) 22 Seaweed 5 (3 7) <1 Free-range lvestock (90 110) 143 Includng - game >4 (2 6) <1 Macronutrents etc. Proten (E%) 18 (15 23) 15 Total carbohydrate (ncl. fbres), E% 52 (48 56) 50 Added sugar (E%) <10 Total fat (E%) 30 (25 35) 35 Saturated fat (E%) <10 15 Nordc produce (%) 95 Organc (%) 75 Italcs: Lmts mpled by the NND. E%: Energy per cent. Source: [4].

17 Int. J. Envron. Res. Publc Health 2015, Table S2. Monetzed envronmental effects (2010 prce level). Unt COI/COD Approach, Based on Adjusted US GDP/Capta COI/COD Approach, Based on Unadjusted US GDP/Capta Human toxcty, carcnogens /kg C 2 H 3 Cl-eq Human toxcty, non-carcnogens /kg C 2 H 3 Cl-eq Respratory norgancs /kg PM 2.5 -eq Ozone layer depleton /kg CFC-11-eq Ecotoxcty, aquatc /kg TEG-eq w Ecotoxcty, terrestral /kg TEG-eq w Nature occupaton /m 2 agr.land Global warmng /kg CO 2 -eq Acdfcaton /m 2 UES Eutrophcaton, aquatc /kg NO 3 -eq Eutrophcaton, terrestral /m 2 UES Respratory organcs /pers ppm h Photochemcal ozone vegetaton /m 2 ppm hours Source: [17]; onzng radaton and non-renewable energy were not monetzed. Table S3. Relatve det-related health rsks. Cardo- Vascular Dsease Stroke Dabetes Stomach Cancer Lung Cancer Breast Cancer Fruts and vegetables exposure, 200 g/day g/day g/day g/day g/day Fsh, exposure, 10 g/day g/day g/day g/day Red meat exposure +100 g/day Processed meat exposure +50 g/day Sugared drnks exposure, 10 g/day g/day g/day g/day Whole gran exposure +10 g/day Total fat exposure, +5 E% Saturated fat exposure, +5 E% Monounsaturated fat exposure, +5 E% Polyunsaturated fat exposure +5 E% Sources: [20 53].

18 Int. J. Envron. Res. Publc Health 2015, Acknowledgments Ths research has been conducted as part of the OPUS project. Source of Fundng: OPUS s an acronym of the project Optmal well-beng, development and health for Dansh chldren through a healthy New Nordc Det and s supported by a grant from the Nordea Foundaton. Author Contrbutons Jørgen Dejgård Jensen conducted the economc analyss, drafted the manuscrpt and coordnated the work, Henrk Saxe conducted LCA to quantfy envronmental mpacts, and Sgrd Denver conducted the modellng of publc health mpacts. Conflcts of Interest The authors declare no conflct of nterest. Lst of Abbrevatons OPUS: NND: ADD: Acronym for the project Optmal well-beng, development and health for Dansh chldren through a healthy New Nordc Det New Nordc Det Average Dansh Det References 1. Lm, S.S.; Vos, T.; Flaxman, A.D.; Danae, G.; Shbuya, K.; Adar-Rohan, A.; AlMazroa, M.A.; Amann, M.; Anderson, H.R.; Andrews, K.G.; et al. A comparatve rsk assessment of burden of dsease and njury attrbutable to 67 rsk factors and rsk factor clusters n 21 regons, : A systematc analyss for the Global Burden of Dsease Study Lancet 2012, 380, Trchopoulou, A.; Costacou, T.; Bama, C.; Trchopoulos, D. Adherence to a Medterranean det and survval n a Greek populaton. N. Engl. J. Med. 2003, 348, Bocuse d Or. The Bocuse d Or Wnners Academy Avalable onlne: (accessed on 9 January 2013). 4. Mthrl, C.; Dragsted, L.O.; Meyer, C.; Tetens, I.; Bltoft-Jensen, A.; Astrup, A. Detary composton and nutrent content of the New Nordc Det. Publ. Health Nutr. 2012, do: /s Drewnowsk, A.; Darmon, N. The economcs of obesty: Detary energy densty and energy cost, Am. J. Cln. Nutr. 2005, 82, Drewnowsk, A.; Darmon, N. Food choces and det costs: An economc analyss. J. Nutr. 2005, 135, Darmon, N.; Drewnowsk, A. Does socal class predct det qualty? Am. J. Cln. Nutr. 2008, 87, Schröder, H.; Marrugat, J.; Covas, M.I. Hgh monetary costs of detary patterns assocated wth lower body mass ndex: A populaton-based study. Int. J. Obes. 2006, 30,

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