The real cost of obesity: Disparities in diet quality and health

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Community Medicine University of Washington Fruit and vegetables and the prevention of obesity and its associated diseases.

1 The real cost of obesity: Disparities in diet quality and health Adam Drewnowski, PhD Director, Center for Public Health Nutrition Director, NIH Roadmap Center for Obesity Research Professor of Epidemiology and Medicine School of Public Health and Community Medicine University of Washington Fruit and vegetables and the prevention of obesity and its associated diseases. EGEA International Conference, April 27, Brussels, Belgium Disparities in obesity rates can be seen at local level All politics is local

2 Disparities by county in the US A necessary question: Is obesity an economic issue?

Taste Obesity Grains, Time/Convenience Sugar/fat Health

3 How do people make food choices Grains, Cost Sugar/fat Grains, Energy density Sugar/fat Food choices Sugar/fat Taste Obesity Grains, Time/Convenience Sugar/fat Health Variety A disconnect between the ideal diet.. The Harvard SPH Food Pyramid

4 and reality for most consumers First question Do energy-dense foods cost less? Energy density defined as kcal/1g Energy cost defined as /1 kcal, edible portion Added s and fats cost less The recommended healthier foods cost more (note log scale)

5 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 1 8 butter Energy density (kcal/1g) 6 4 spreads Log scale! Energy cost (Euros/1kcal) 1 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 8 butter Energy density (kcal/1g) 6 4 desserts 2 soft drinks Energy cost (Euros/1kcal)

6 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 1 8 butter Energy density (kcal/1g) 6 4 grains bread desserts 2 pasta soft drinks Energy cost (Euros/1kcal) 1 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 8 butter Energy density (kcal/1g) 6 4 grains cheese desserts 2 pasta yogurt milk Energy cost (Euros/1kcal)

7 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 1 8 butter Energy density (kcal/1g) 6 4 grains cheese 2 desserts pasta meat milk Energy cost (Euros/1kcal) 1 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 8 butter Energy density (kcal/1g) 6 4 grains cheese foie gras 2 desserts pasta meat fish/shellfish milk Energy cost (Euros/1kcal)

8 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 1 8 butter Energy density (kcal/1g) 6 4 grains cheese 2 desserts pasta meat fish/shellfish milk vegetables Energy cost (Euros/1kcal) 1 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 8 butter Energy density (kcal/1g) 6 4 grains desserts nuts cheese fruit 2 pasta fish/shellfish milk vegetables Energy cost (Euros/1kcal)

9 Energy density (kcal/1g) and energy cost (Euros/1kcal) INCA study 1 8 butter Energy density (kcal/1g) 6 4 grains desserts nuts cheese fruit Wine/alcohol 2 pasta fish/shellfish milk vegetables Energy cost (Euros/1kcal) Energy density (kcal/1g) and energy cost ($/1kcal) Seattle 26 Supermarket prices 1 8 butter Energy density (kcal/1g) 6 4 grains desserts nuts cheese fruit 2 pasta fish/shellfish milk vegetables Energy cost ($/1kcal)

10 A comment about rising prices Seattle food prices collected in 24 and 26 Same supermarkets, same foods, same packages The foods were split by energy density Fruits and vegetables Price Inflation (%) ] ] ] Quintiles of Energy Density ] Fats and sweets ] Second question Are energy-dense foods nutrient-poor? Energy-dense taste better and cost less But are they lacking in key nutrients? We need nutrient profiling and a nutrient density score Then we can look at nutrients per calorie and nutrients per unit cost

11 Examples of nutrient profiling: Creating a nutrient density score for foods Nutrient Density Score is the ratio between the amount of nutrients in a food and the energy that the food provides NDS = (NAS/ED) * 1 Nutrient Adequacy Score is based on percent DVs for N key nutrients as provided by 1 g of food NAS = (Σ (Nutrient i /DV i ) * 1)/N Nutrient-to-price ratio NPR = NAS/price per 1g Maillot et al. 27 (submitted for publication) Fruit and vegetables have low energy density and high nutrient density 9 8 Fats/s Energy Density (kcal/1g) beverages F+V Nutrient Density Score/1 kcal Darmon, Darmon, Maillot, Drewnowski JADA 25

12 Higher nutrient-density (per 1g) usually means higher cost (also per 1g) 1 Nutrient Adequacy Score/1g All foods F+V Price (Euros/1g) Darmon, Darmon, Maillot, Drewnowski JADA 25 Third question Do energy-dense diets cost less? INCA I is a nationally representative study of 1,985 French adults, based on 7-day diet records. Mean national food prices for >65 foods supplied by the French government (INSEE); by market research agencies (SECODIP), and by industry websites Diet costs estimated by multiplying unit price for each item by portion size and summing over all foods consumed by that person That is the estimated cost of the diet assuming that all foods are purchased and prepared at home

13 At each intake quintile, higher energy density = lower cost ( /wk) 1 9 Diet cost (Euros/week) EI Drewnowski et al. 27 Energy density (KJ/g) At each intake quintile, higher energy density = lower cost ( /wk) 1 9 Diet cost (Euros/week) EI 2 EI Drewnowski et al. 27 Energy density (KJ/g)

14 At each intake quintile, higher energy density = lower cost ( /wk) 1 9 Diet cost (Euros/week) EI 3 EI 2 EI Drewnowski et al. 27 Energy density (KJ/g) At each intake quintile, higher energy density = lower cost ( /wk) 1 9 Diet cost (Euros/week) EI 4 EI 3 EI 2 EI Drewnowski et al. 27 Energy density (KJ/g)

15 At each intake quintile, higher energy density = lower cost ( /wk) 1 9 Diet cost (Euros/week) EI 5 EI 4 EI 3 EI 2 EI Drewnowski et al. 27 Energy density (KJ/g) 1 9 As dietary ED increases so do total energy intakes Energy density (KJ/g) INCA data Energy intake (MJ/week)

16 Last question: What happens when you stratify diets by energy cost? Food expenditures can be a proxy for SES Low-cost diets: more energy, fewer nutrients % of Q Referent diet Q1 Q2 Q3 Q4 4.9 /1MJ 4.5 /d 5.9 /1MJ 5.3 /d 6.9 /1MJ 6. /d 9. /1MJ 7.4 /d Vitamin C Vitamin D ß Carotene Folates Vit E Energy Intake Energy Density

incomes 1937 Share of income spent on food in the US keeps declining 3 25 2 Total food

17 What do we know about food, health, and income? Engel s Law (1867) 4% 33% 25% As incomes rise, food costs account for lower share of incomes 1937 Share of income spent on food in the US keeps declining Total food Food at home Food away from home Boyd Orr: UK 1937 USDA s Economic Research Service Food Review, 23, 2

Consumption by income: Boyd Orr 1937 Fruit

Sugar What can you get for $1/week for a family of

zucchini squash Energy density (MJ/kg) 3 2 1

eggs cheese ground beef green peppers lettuce

18 Consumption by income: Boyd Orr 1937 Fruit Vegetables Bread Potatoes Fish Meat Lard, suet Sugar What can you get for $1/week for a family of 4. The USDA Thrifty Food Plan: shortening zucchini squash Energy density (MJ/kg) margarine mayonnaise crackers white bread beans eggs cheese ground beef green peppers lettuce fresh tomatoes potatoes milk koolaid Energy cost (log cents/1mj)

expensive More expensive If a meal of grilled chicken, broccoli and fresh fruit costs more and is less

19 Access to healthy foods Affordability Energy-dense foods are cheaper Accessibiity Energy-dense foods are closer Convenience Fast foods take less time to prepare A challenge for public health nutrition Less expensive More expensive If a meal of grilled chicken, broccoli and fresh fruit costs more and is less convenient than a burger and fries, the battle against obesity will be lost Editorial, The Lancet January 31, 24

Drewnowski & Specter, Am J Clin Nutr 24;79:6-16 The Energy Density curve Drewnowski and Specter AJCN 24:79:6-16

20 2 5 Spend less = Eat more Are obesity and poverty linked by the low cost of energy- dense foods that are both palatable and convenient? Drewnowski & Specter, Am J Clin Nutr 24;79:6-16 The Energy Density curve Drewnowski and Specter AJCN 24:79:6-16 Sugar fat Low quality High quality Energy density Food energy requirement Food energy Food costs (log) The paradox it is possible to spend less and get more But the calories will be refined grains, added and fat

21 Conclusions: The real cost of obesity lies in the current hierarchy of food prices and the promotion of low cost energy-dense foods Obesity is an economic issue

Nutrition economics: The cost of eating well

Nutrition economics: The cost of eating well Adam Drewnowski, PhD Director, UW Center for Obesity Research Director, Center for Public Health Nutrition Director, Nutritional Sciences Program Professor