1. Health Economics and Nutrition Pablo Monsivais, University of Cambridge Marc Suhrcke, University of East Anglia Institute of Public Health

2. Nutrition Economics: “The discipline dedicated to researching and characterising health and economic outcomes in nutrition for the benefit of society.” One way to combine health economics and nutrition:

3. Beyond Cost Effectiveness, DALYs and QALYs: (This is not NICE) Can health economics help us understand the determinants of dietary behaviors?

4. Food Prices

5. Outline Economics in nutrition Data needs and research questions to be resolved Opportunities for new research

6. Definitions Economic factors: Food prices Incomes, wages, wealth, social class Area level, built environments

7. Economics in Nutrition Merging health economics with nutrition can help… explain patterns of diet, obesity and chronic disease identify mechanisms of dietary behavior and diet quality suggest optimal solutions for poor diet, obesity and chronic disease

8. Patterns of diet 1.Secular trends in dietary intake, obesity 2.Social patterning of food consumption and diet quality

9. Secular trends in dietary intake Women Men Energy IntakeMix of foods dietary data, NHANESBased on USDA food disappearance

10. Secular trends in weight & health Increasing overweight and chronic disease % obese % overweight/obese % with diagnosed diabetes The National Health and Nutrition Examination Survey

11. Secular trends in affordability of food Food has become more affordable Food expenditures as a percentage of income, 1929-2009

12. Secular trends in relative food prices Inflation-adjusted price index Fresh fruits & vegetables Food at Home Carbonated sweetened soft drinks Year Bureau of Labor Statistics, 2010 US consumer price index for selected foods and beverages 1983-2009 (1982-83=1)

13. Social patterning of food consumption and diet quality

14. Britain, 1935 Boyd-Orr, 1937

15. Britain, 1990s Social patterning of food consumption and diet quality Income Classes servings/d from James et al, 1997, UK Nat’l Food Survey Diet Quality Classes from Cade et al, 1995, UK Women's Cohort Study % with degree Food Intake by Income Education by Diet Quality

16. Social patterning of food consumption and diet quality from Rehm, Monsivais, Drewnowski, 2011Monsivais, in preparation USA, 2001-2004 Diet Quality by Education Level Healthy Eating Index-2005 Years of Education Completed DASH diet adherence Years of Education Completed HEI-2005 score DASH score

17. Contextual economic correlates Relate individual dietary or health data to national, or regional economic conditions, food prices or concurrent trends Study Designs Individual economic correlates Link individual dietary intake data to individual food price data to compute the monetary cost of the foods consumed Compute expenditures at the individual level Observational

18. Dietary intake and health Data Sources? Food prices, food expenditure, economic environment Individual level household level macroeconomic indicators

19. Dietary intake and health attach food prices to standard dietary assessment (US national food prices merged with NHANES) Quintiles of DASH diet adherence Diet Cost ($) Monsivais, in preparation Years of Education Completed DASH score Individual

20. Contextual Rising cost of F/V leads to increasing child BMI (USA) Powell, Bao, Econ Hum Biol, 2009 Food prices, diet and health Use food price index as a predictor for diet and body weight outcomes Geographic and temporal covariation in F/V prices and child BMI (USA) Sturm, Datar, Publ Health, 2005, 2008 Temporal variation in relative prices of foods changes is reflected in food consumption (Russia) Dellava, Bullik, Popkin, 2010

21. Questions to be Resolved To what extent do differences in food budgets account for social patterning of food choice? How do absolute and relative food prices modify food choice? How are food prices perceived by different population groups? To what extent are unhealthful diet patterns modifiable via economic measures? Social norms? Time, money and food choice? Scientific:

23. Research Opportunities Observational: existing data Experimental: new projects with retail and marketing partnerships.

24. Observational Studies Merging economic variables with existing datasets of diet and health to systematically explore linkages between diet cost and diet quality among different population groups – EPIC – SPEEDY – ALSPAC – BIOBANK

25. Experimental Studies To examine the modifiability of consumer food choice in relation to price and nutrition information