How much does it cost to eat a decent meal?

The incredible Alex Honnold, also a vegan… Copyright: The great Jimmy Chin for National Geographic

The answer to that question turns out to be a lot for some people. There are have been some recent projects and papers as a result aimed at trying to understand whether or not people can afford the kind of diets recommended in national food-based dietary guidelines, the EAT Lancet, and other publications. Many have pontificated that these healthy, higher quality diets — promoted in such guidelines and Commissions made up elitist scientists — are unaffordable for most of the world. Some argue the recommendations are just downright dangerous (beef industry responding to the EAT Lancet) or unfair. GAIN argued that meat is important for child growth, and athletes. I don’t think they meant it is an absolute essential for athletes, as Alex Honnold is a vegan and that dude climbed El Capitan with nothing but sheer muscle strength, stamina and maybe an insanely lack of feeling of fear. If you have not seen the documentary Free Solo, I highly recommend it. What a human feat, and with no meat! Yes, I wax poetic.

This debate is not new, and there has been a lot of science articulated the cost. And there are more papers to come. But a few new papers are looking beyond just a specific country, a specific national dietary database or a specific population, and looking at the costs of foods and diets around the world from low- to high-income countries, whether they fulfill nutritional needs, and if not, what disease outcomes are they associated with.

IFPRI’s Derek Headey and Harold Alderman, two pretty stellar researchers in nutrition, published a fantastic piece in the Journal of Nutrition. They tested relative caloric prices (RCPs) for different food categories across 176 countries. One will have to read the methods in some detail to understand how they come up with this calculation but one key piece is how they calculate the RCP. They measure the ratio of the price of 1 calorie of a given food (the edible portion) to the price of 1 calorie of a representative basket of starchy staple food in each country. As the authors articulated: an RCP of 5 for eggs implies that it is 5 times as expensive to obtain a calorie from eggs as it is to obtain a calorie from starchy staples. Easy yes?

While the authors find that there is a lot of variety in the food prices nationally, in high-income countries, most non-cereal foods were relatively cheap, including sugar- and fat-rich foods. In contrast, in low-income countries, healthy foods were expensive, especially most animal-sourced foods and fortified infant cereals. Oils/fats were notably very cheap in all regions as were unprocessed red meat, which was moderately cheap in all regions. As the authors wrote in a recent blog:

“As countries develop, their food systems get better at providing healthier foods cheaply, but they also get better at providing unhealthier foods cheaply. Hence the problem in less developed countries is that poor people also live in poor food systems: Nutrient-dense foods like eggs, milk, fruits and vegetables can be very expensive in these countries, making it much harder to diversify away from nutrient-sparse staple foods like rice, corn and bread. The problem in more developed countries is rather different: Unhealthy calories have simply become a very affordable option. In the U.S., for example, calories from soft drinks are just 1.9 times as expensive as staple food calories and require no preparation time.”

The authors then looked at the association of these prices with nutrition outcomes, controlling for confounders like education, urbanization and income. Higher milk and fortified infant product prices were positively associated with childhood stunting. They also found that little children consume less of these important foods when expensive. An increase in soft drink prices was associated with a reduction on overweight prevalence.

Headey and Alderman show the association of milk prices with childhood stunting. Copyright: IFPRI

A few years ago Adam Drewnowski and Nicole Darmon published a study, using very different methodology and from French databases, showing that foods of lower nutritional value and lower-quality diets generally cost less per calorie and tended to be selected by groups of lower socioeconomic status. A number of nutrient-dense foods were available at low cost but were not always palatable or culturally acceptable to the low-income consumer. Acceptable healthier diets were uniformly associated with higher costs. They argue three things:

  1. Energy-dense foods composed of refined grains, added sugars, or fats are cheaper per calorie than are the recommended nutrient-dense foods.

  2. Lower-quality diets, with a higher content of added sugars and fats, were generally less expensive on a per-calorie basis.

  3. Cheaper and more energy-dense diets, often devoid of vegetables and fruit, tend to be selected across different countries by lower-income groups.

Another paper coming out in the Lancet by IFPRI (including Headey) and Tufts colleagues including the great Will Masters, examined retail prices of foods and identified the most affordable foods to meet EAT-Lancet targets. They compared the total cost per day of these foods to each country's gross national income to see if the MOST affordable EAT-Lancet diet exceeded household incomes.

Here is what they found: Examining 744 items across 159 countries, revealing that the most affordable EAT-Lancet diets cost a global average of $2.89 per day ($2.44 per day for low-income countries and $2.77 for high-income countries). The largest share was the diet cost was fruits and vegetables (31.2%), followed by legumes and nuts (18.7%), meat, eggs and fish (15.2%) and dairy (13.2%). While this is a pretty cheap diet in high-income countries, it is not affordable for 1.56 billion of the poorest households in the world where this diet would cost households 70% of their daily income (national averages)! Where is this diet unaffordable? Mostly in sub-Saharan Africa and South Asia.

On the left side is the cost of the EAT-Lancet diet by country income levels and major regions. On the right side, is the cost of the EAT-Lancet diet as a percentage of Gross National Income per capita. Copyright: Lancet.

They also concluded that the EAT-Lancet diet would cost 64% more than achieving minimally adequate levels of essential nutrients and is currently unaffordable in low-income countries, because “it requires larger quantities of higher-cost food groups such as dairy, eggs, meat, fish, fruits and vegetables than the near-subsistence diets that are currently consumed by very low-income people.” The authors argue that:

“Our findings indicate that a widespread global shift to the EAT-Lancet diet recommendation is feasible only through some combination of higher earnings, more favorable market prices and nutrition assistance for low-income people, in addition to changes in local and global food systems that drive food choice among more affluent populations. Meeting EAT-Lancet targets in low-income areas will require higher farm productivity and improved access to markets, plus greater non-farm earnings and social safety nets, allowing people to shift consumption away from starchy staples and increase their intake of more nutritious but currently unaffordable animal-sourced and vegetal foods.”

Sam Bloch tested out the EAT-Lancet diet in early 2019 and wrote up a great piece in the New Food Economy (love this site). He found it hard to follow and it was more expensive. And he is probably a high-income consumer (living in New York City) and his wife is a chef!

A group at World Food Programme is doing a “Fill the Nutrient Gap” (FNG), which aims to “support identification of strategies to increase availability, access, and choice of nutritious foods, to ultimately improve nutrient intake.” This approach looks at the nutrient intake of different target groups, and then uses linear programming to look at the barriers to nutrient intake including the availability, cost and affordability of nutritious diets for households and target groups with higher nutritional needs. They then model potential interventions to improve them. I have heard they have done at least 25 countries. So they are taking it further as compared to these other studies. They are not only looking at the cost of diets, but why they are expensive and what households can do about it.

In last year’s Global Nutrition Report, we showed some preliminary data on the range of non-affordability of a nutritious diet across areas in different countries. The data shows a range of non-affordability depending on the region in each country – for example, across different regions of El Salvador, 9% to 44% of households cannot afford a nutritious diet, whereas the range is much greater in Lao People’s Democratic Republic (17% to 95%).

The range of “non-affordability” of the typical diet in select countries. Copyright: GNR 2018

There are others working on the cost of a diet. Marco Springmann will also test out the cost of the EAT-Lancet diet, as an EAT-Lancet Commissioner. I think his study will look more at the cost of dietary patterns - vegetarian, pescetarian, omnivorous etc. So keep your eye out on that publication!

Food Bytes: July 8 - July 20

Food Bytes is a weekly blog post of “nibbles” of information on all things food and nutrition science, policy and culture.

Food environments seem to be on the tip of the tongue for everyone these days. Food environments are the “collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people’s food choices and nutritional status.” Or to put it more simply, it is the place where consumers go to buy or order food - a market, a restaurant, a cafeteria.

The UN Standing Committee on Nutrition, also known as UNSCN, has just published a collection of papers on the food environment. It splits up the food environment into two entry points - the food supply shaping these environments and the consumer demand side - and what it would take to make change, also known as the enabling environment. The publication is chock-full of case studies from all over the world. I like the ones on Mexico, the private sector last mile, the flathead reservation, cash transfers, and the digital influence.

Food Environment Framework showing supply and demand. Source: Marshall et al 2019 UNSCN report

In South Africa’s Soweto hood, women struggle to be healthy. Food environments are pretty dismal (fries, fries and more fries), and exercising outside can be dangerous. It is not just about supply and demand of healthy foods, which the UNSCN publication focused on, but the whole built environment, the way women are treated in our society and urban safety. At the same time, its seems many South Africans are taking food security into their own hands. One study found that 2.2 million households have recently constructed food gardens at their homes in order to avert food insecurity.

While we are on the lovely UN, the UN Committee on Food Security is rolling out a series of regional consultations on what is known as the Voluntary Guidelines on Food Systems and Nutrition. This stems from the High Level Panel of Experts on Nutrition and Food Systems report which called for these guidelines to be developed by governments collectively and collaboratively. These voluntary guidelines are meant to create a global norm of reference in the governance of food systems and nutrition/diets. The guidelines outline principles and practices that governments can refer to when making laws and administering food systems. These guidelines should be seen as an internationally negotiated soft law or a set of guidelines in which all governments have reached a common ground. So, they can be important, and quite powerful. Anyone can comment on the zero draft - far from its final - here. The regional consultations started in Africa, Ethiopia. Then, Asia, Bangkok. Then Central and South America, Panama, North Africa, Egypt, Europe, Budapest and last but not least, North America. I had the pleasure of being at the Ethiopia meeting and it was quite fantastic to have so many African countries in one room talking about African food systems. Amazing stuff.

Source and Copyright: Johnny Miller, NYT 2019

Speaking of Africa, the diversity of cuisines and culture is what makes the continent so amazing. Take Nigeria. Reading Yewande Komolafe’s recipes made me want to jump on a plane to Lagos and eat my way through it.

But it is not always a rosy picture for Africa. The continent is still struggling with food insecurity, while at the same time, obesity is creeping up, up and up. The FAO State of Food Insecurity (SOFI) 2019 report just came out, two months early. It was reasoned that it came out to line up with the High Level Political Forum. Yeah sure. I think it was timed to be released right before the Director General, José Graziano da Silva stepped down to celebrate his 8 years as the leader of FAO. However, the report is nothing to celebrate. I digress…The major findings of the SOFI were the following:

  • More than a quarter of the world’s population now struggles to eat safe, nutritious and sufficient food.

  • Hunger is on the rise in most of Africa, in parts of the Middle East and in Latin America and the Caribbean. The situation is most alarming in Africa, where since 2015 undernourishment has steadily increased in almost all subregions. In Asia, undernourishment has been decreasing in most regions, reaching 11.4 percent in 2017. In Latin America and the Caribbean, rates of undernourishment have increased in recent years, largely as a consequence of the situation in South America.

  • Economic shocks are contributing to prolonging and worsening the severity of food crises caused primarily by conflict and climate shocks.

  • No region is exempt from the rising trends of overweight and “obesity rates are higher in those countries where moderate food insecurity is also higher.”

We see this in the United States too. I just wrote a piece for Bloomberg Opinion (I didn’t choose the photo.) showing that food insecure adults in the U.S. are 32% more likely than others to be obese — especially if they are women. Poverty and unemployment have driven the dual rise in food insecurity and obesity since the 1960s, especially in rural America. But many city dwellers subsisting with inadequate social services and support structures are also susceptible. Every time I write a piece in Bloomberg Opinion, I always get lots of interesting email comments. For this piece, most commenters feel that if you are fat, it is your fault. If healthy foods are available, affordable and easy to access, “these people” will always make the wrong choice. My reaction? WOW. It is so hard to eat healthy in our perverse food environments. Blaming and shaming is not going to make things better. But it seems, consumers are catching on in the U.S. - diet quality is improving.

But what does the latest evidence suggest for those who are overweight and want to lose weight? I will soon dedicate a longer blog to this issue because the literature is confusing. Is it a keto diet? Is it intermittent fasting? Is it low-carb? Is it putting a teaspoon of oil in your coffee every morning? New evidence suggests that cutting 300 calories per day, from any food, can lead to substantial weight loss in adults (7.5 kilos over two years) compared to the control group. Tamar Haspel of the Washington Post, argues that eating ultra-processed foods comes down to increased calorie consumption. We consume more of those foods, and they are calorically dense. She wrote:

“In a nutshell: The root of obesity is palatability and calorie density, combined with ubiquity and convenience. Satiety hormones and other metabolic machinations have much less to do with it. We’re responding to cues from without, not from within. One new study doesn’t prove it, of course, but it’s the hypothesis that best fits the preponderance of the evidence.”

I really appreciate this article that “Being Fat is Not a Moral Failure.” Damn straight. This Scientific American article argues “Individual behavior change is ineffective in the face of social and structural barriers that constrain individual choice. These barriers are uniquely relevant among racial and ethnic minorities and impoverished adults who are more likely to be obese.”

A bunch of scientific papers and media articles came out this week on diets, nutrition, and food systems. Here are some highlights.

Kathmandu food stall - healthy and unhealthy foods. Source and Copyright: Jess Fanzo

  • “Ultra-processed” foods or what I call, junk food, are in the news again. This article outlines four dangers with food reformulation - redesigning an existing processed food product with the objective of making it healthier. This article argues that reformulation just tinkers around the edges, and isn’t really fixing the root problems of the food system, and what the authors say is food and beverage industries.

  • Case in point? Nearly 10,000 cases of heart disease and stroke and 1,500 cases of cancer could have been avoided in England if the government had not switched to a voluntary deal (as opposed to mandatory) with the food industry to cut salt in food. England is doing so much good stuff in the food space right now, but man, there are potential setbacks with Brexit and political shifts. This BMJ post by Annie Purdie and colleagues is concerned about Boris Johnson’s recent decision to look at “sin taxes” and creating a nanny state. The authors argue that the public health community needs to “move beyond debating the cost-effectiveness of interventions, and engage with the underlying political nature of the issue.” We need to pay more attention to the language (sin, nanny, liberties etc) used to highlight the problem and the proposed solutions like taxes on soda and regulating the levels of salt and sugar in foods. As Bob Marley sang, “don’t let ‘em fool ya.”

  • There is more and more coming out that nutritional sciences is “broken.” In this article, they use the “eggs are again bad for you” study that came out in JAMA. Waah. Is it? I disagree! Of course, when we focus on specific foods and nutrients, the data is not clear, but dietary patterns show basically the same thing. Give it a rest dudes.

  • While these researchers argue that more evidence is needed, they did find that snack foods and sugar‐sweetened beverages are providing a substantial proportion of energy intakes (ranges from 13 to 38%!) among children below 2 years of age in Latin American and South‐east Asian low and middle income countries.

  • A study in the capitol of Nepal, Kathmandu, showed just that consumption of unhealthy snack foods and beverages contributed 47% of total energy intake among the wealthiest consumers, compared with 5% among the poorest. This pattern of junk food consumption among young children was associated with inadequate micronutrient intakes. The reason that mom’s give these foods to their children? Convenience - they are easy to prepare and easy to feed. Makes sense. Looks like even among very poor countries, we are seeing the nutrition transition play out in real time. Ever try making dal bhat from scratch? Not easy and incredibly time consuming…

  • I love that the Lancet is calling on oral health researchers to review the evidence and conflicts of interest of the impacts of what we eat on our dental health and the caries that come with sugar consumption. The lead scientist argues, and this goes back to the infant studies: “A particular concern is the high levels of sugar in processed commercial baby foods and drinks which encourage babies and toddlers to develop a preference for sweetness in early life. We need tighter regulation and legislation to restrict the marketing and promotion of sugary foods and drinks if we are to tackle the root causes of oral conditions.”

  • New microbiome research shows that a specialized food made up of chickpeas, soy, peanuts, bananas and a blend of oils and micronutrients substantially boost microbiome health in severely malnourished children. Yummy.

  • Do cookbooks need nutrition labels? Great question but sort of takes the fun out of cookbooks no?

Some things have improved for food security and nutrition. Source: Byerlee and Fanzo, 2019 GFS Journal

Derek Byerlee and I wrote a piece looking back 75 years on commitment to hunger when the first international commitment to ending hunger was made at the UN Conference on Food and Agriculture, at Hot Springs, Virginia, USA in 1943. That conference set the goal of ‘freedom from want of food, suitable and adequate for the health and strength of all peoples’ that should be achieved ‘in all lands within the shortest possible time’ (US Department of State, 1943). It is sobering and shameful that 75 years after this clarion call, as well as the dozens of similar global declarations since 1943 for ending hunger, some 800 million persons are estimated to be undernourished and over 2 billion adults and children suffer from other forms of malnutrition be it obesity or micronutrient deficiencies. We remind readers of the significance of the Hot Springs conference and briefly trace the long road that has led us back to the original vision of ending hunger that recognized the several dimensions of nutrition, from undernourishment to micronutrient deficiencies. While there has been progress, this reflection over 75 years helps appreciate the fact that today for the first time, the links of agriculture, health and nutrition outlined in 1943 are again at center stage in the global hunger challenge as embraced in SDG2. Accordingly, SDG2 offers a better foundation for accelerating progress in reducing malnutrition in its several dimensions, although we recognize major gaps in knowledge, financing, and implementation capacity for realizing SDG2 targets.

Someone else is realizing the importance of agriculture. It seems Bill Gates has woken up to the fact that the CGIAR exists. His article is titled “You’ve probably never heard of CGIAR, but they are essential to feeding our future.” Hate to spoil it Billie Boy, but we have heard of the CGIAR…and I don’t confuse it with the word “cigar,” cigarillos, ciggies, or ziggie stardust.

Country ratios of fruit and vegetable availability to WHO age-specific recommendations. Source: Mason-D’Croz et al 2019

Country ratios of fruit and vegetable availability to WHO age-specific recommendations. Source: Mason-D’Croz et al 2019

On the environmental and climate change front, lots going on. The World Resources Institute released a mother of a report - 564 pages - on Creating A Sustainable Food Future. You may have seen the abbreviated version released 6 months ago. But this one goes into great detail a 22-item “menu” which is divided into five “courses” that together could close the food, land and greenhouse gas gaps: (1) reduce growth in demand for food and agricultural products; (2) increase food production without expanding agricultural land; (3) protect and restore natural ecosystems; (4) increase fish supply (through improved wild fisheries management and aquaculture); and (5) reduce GHG emissions from agricultural production. Richard Waite and Janet Ranganathan are seriously my heroes in creating these action oriented solutions. Well done.

Following on the heals of that report, two Lancet Planetary Health papers came out. One paper shows that even under optimistic socioeconomic scenarios future supply of fruits and vegetables, central components of a healthy diet, will be insufficient to achieve recommended levels in many countries. Consequently, systematic public policy targeting the constraints to producing and consuming fruits and vegetables will be needed. The second paper shows climate change and increased atmospheric CO2 will impact the availability of protein, zinc and iron availability. The many countries that currently have high levels of nutrient deficiency would continue to be disproportionately affected.

This expose by the Guardian shows that Brazil’s huge beef sector, and the appetite for beef, continues to threaten health of world’s largest rainforest, the Amazon. This is just downright sad.

And while those of us in nutrition don’t really get to the larger social determinants of food insecurity and malnutrition, it is important to do so. This article in NPR’s Goats and Soda delve into the practice of trading sex for fish in Lake Chilwa in Malawi. This is driven by poverty and food insecurity and the impacts are catastrophic in this southern African country - HIV, violence and stigma - for these women.