Nicole Darmon , Nutrition Research Unit UMR NORT INRA, INSERM, AMU, Marseille , France

1. Food price policies improve diet quality while increasing socioeconomic inequalities in nutrition An illustration withexperimentaleconomics • Nicole Darmon, Nutrition Research Unit • UMR NORT INRA, INSERM, AMU, Marseille, France • with A. Lacroix, L. Muller, B. Ruffieux, Experimental Economy Laboratory • UMR GAEL INRA, Grenoble, France

2. Introduction: Social inequalities in diets and health, and costconstraints, in France Prevalence of adult obesity, by income, France (Obepi survey, 2012) • Strong social gradient in obesity in France • Link with food budget constraints? 1/20

3. INTRODUCTION • Budget for food, by income, France (National budget survey, 2000) % of incomespent on food Absoluteexpenditureon food (€/d) Householdincomedecile • Double constraint: low amount of money weights heavily on total budget • Impact on foodchoices? 2/20

4. INTRODUCTION Starchy food 387g Fruit & Vegetables 351g Mixed dishes, including soups 336g Dairy products 320g 275g Meat/Fish/Poultry Food consumption (g/d), by food sufficiency and income, France (INCA2 survey, 2008) * g/d Means are adjusted on age, gender, and energy intakes * * Sweet products F. Insecure (12%) FS1 FS2 FS3 FS4 Food secure, income quartiles Bocquier PHN2015 • Social gradient in diet quality • Link withdietcost? 3/20

5. INTRODUCTION Diet cost (€/d), by quintiles of food group consumption, France €/d Q1 Q2 Q3 Q4 Q5 Fruit and Vegetables Q1 Q2 Q3 Q4 Q5 Fats and sugar Drewnowski & Darmon AJPH 2004 • Social gradient in diet quality • Prices important determinants of food choices • Link withfoodprices? 4/20

6. INTRODUCTION 0.7 0.6 0.5 0.4 Energy Cost, €/100 kcal 0.3 0.2 0.1 0.0 Fruit & Vegetables Meat & Fish Prepareddishes & Snacks Dairy Sugar/Salt products Added fats Cereals & Starches Cost of 100kcal fromdifferentfood groups Darmon, NutrRev, 2015 0.66 € 0.58 € 0.18 € 0.06 € • Healthy food groups are more expensive than unhealthyones • Unhealthyfood groups are lessexpensive and more convenient • (easy to transport, stock, prepare) 5/20

7. INTRODUCTION Nutritionalquality and price of individualfood * *SAIN :meanadequacy for 15 nutrients N =687 food items log Darmon, NutrRev, 2015 • Healthy foods are more expensive than unhealthyones • The structure of food prices doesn’t favor healthy eating, • possibly explaining: • the socioeconomic gradient in diet quality, • the higher prevalence of obesity in low-income populations 6/20

8. Hypothesis and Aim • Hypothesis • Food price policies (subsidies and taxes): • may orient food choices towards more healthy options • may help fighting against social inequalities in nutrition • Aim • Use experimental economics • To simulate the impact of 2 policies: • - subsidies • - subsidies and taxes • On the food choices of 2 populations: • - medium-income women • - low-incomewomen ? 7/20

9. Methods Two policies 1. ‘Fruits & Vegetables (FV) policy’: 30% price reduction for fruit and vegetables (i.e. subsidies only) SAIN F&V + otherHealthy Intermediate 2. ’Nutrient Profile (NP) policy’, 30% price reduction for healthy products 30% price increase for unhealthy products (i.e. both subsidies and taxes) Healthy and unhealthy products defined with the SAIN,LIM nutrient profile system: (Darmon N, Am J ClinNutr 2009) Neutral Unhealthy LIM 8/20

10. Methods Two populations 1. Low-income group: 95 women below the poverty line, 18.5% were obese 2. Medium-income group: 33 women near the French median income 6.3% were obese. Prevalence of adult obesity, by income 9/20

11. Methods Experimental economics 1. Subjects were asked to select (on a computer) daily food baskets that THEY WOULD LIKE TO BUY 2. They were told that THEY WOULD HAVE TO BUY one of the baskets (randomly selected) 3. At the end of the experiment, THEY REALLY BOUGHT one of the baskets they selected Incentive mechanism used to reveal ‘true’ preferences Limits the social desirability associated with purely declarative statements 10/20

12. Methods Experimental design - Description of one’s session task • Nutritional scores: • MeanAdequacy Ratio (MAR), % adequacy/basket • EnergyDensity (ED), in kcal/100g • Free Sugars, % energy 11/20

13. Results Daily food baskets selected at baseline by the 2 populations Quantities, in g/d Expenditure, in €/d * Medium income Lowincome * * * * * => Low income: more unhealthy products, less fruit&veg, less other healthy products, => Low income: also lower MAR, higher energy density, higher % energy from free sugars (not shown) Fruit & Veg Fruit & Veg Otherhealthy Otherhealthy Unhealthy Unhealthy Neutral Neutral At baseline, low-income women had less healthy diets 12/20

14. Results * Dietary changes (g/d) induced by the 2 prices policies in the 2 populations 1. Fruit & Vegpolicy 2. Nutrient Profile policy * * Medium income Lowincome * * * * * * * * * * 1 • => F&V purchases increased in both populations, but the magnitude was lower for the low-income • => Medium- but not low-income women also increased other healthy products • => F&V purchases increased and unhealthy products decreased in both populations • => Medium- but not low-income women strongly increased other healthy products Fruit & Veg Fruit & Veg Otherhealthy Otherhealthy Unhealthy Unhealthy Neutral Neutral

15. Results * Dietary changes (g/d) induced by the 2 prices policies in the 2 populations 1. Fruit & Vegpolicy 2. Nutrient Profile policy * * Medium income Lowincome * * * * * * * * * * 1 Food policies had a favorable impact on food choices, but the magnitude of the effect was lower for the low income women Fruit & Veg Fruit & Veg Otherhealthy Otherhealthy Unhealthy Unhealthy Neutral Neutral 14/20

16. Results Nutritional quality at baseline and under the Fruit & Veg policy 3. Free sugars, % kcal 2. Energy Density, kcal/100g 1. MAR, %adequacy Medium income Lowincome Baseline F&V policy Baseline F&V policy Baseline F&V policy F&V policy improved nutritional quality in both populations, BUT the magnitude was lower in the low-income group Unwanted effects in the low-income group: free sugars increased

17. Results Nutritional quality at baseline and under the Nutrient Profile policy 3. Free sugars, % kcal 2. Energy Density, kcal/100g 1. MAR, %adequacy Medium income Lowincome Baseline NP Policy Baseline NP Policy Baseline NP Policy The NP policy improved nutritional quality in both populations BUT the policy did not decrease nutritional inequalities (the low income group still had a lower nutritional quality than the medium income one) 16/20

18. Summary of results Fruit and Vegetables policy Fruit & Veg increased ------------------------- Other healthy foods increased------------- Nutritional quality improved----------------- Nutrient Profile policy Fruit & Veg increased-------------------------- Other healthy foods strongly increased Unhealthy products decreased------------ Nutritional quality improved----------------- But lower magnitude for the low-income But in the medium-income group only But unwanted effects for the low income But lower magnitude for the low-income But in the medium-income group only In both populations But lower magnitude for the low income Food price policies improved dietary quality BUT low income women benefited less than medium income women 17/20

19. Concludingremarks • LIMITATIONS • Small sample • Experimental study • Large (+/- 30%) variations in prices (unrealistic, politically unacceptable • CONCLUSION • Food price policies (subsidies and taxes): • may orient food choices towards more healthy options • but they may increase existing social inequalities in nutrition • it is already known that policies directed at the whole population benefit more to the high income ones • Study published International Journal of Behavorial Nutrition and Physical Activity, 2014 18/20

20. Concludingremarks Importance of targeting food policies at low income groups For instance: • Facilitating the access to producemarkets • Developurbancommunitygardens • in poorneighborhoods 19/20

21. Many thanks for you attention

22. Additionalresults Increase of Social Disparities in purchasing power • The purchasing power was improved for both groups by both policies, but inequalities increased between groups. • The purchasing power of richer women was, relatively to the low incomes, improved because: • - their initial consumption pattern generated more subsidies and fewer taxes • they better adapted the new price structure by opting for wished substitutions Suppl