Planning dietary improvements without additional costs for low-income individuals in Brazil: linear programming optimization as a tool for public policy in nutrition and health

Avoidable diet-related deaths and cost-of-illness with culturally optimized modifications in diet: The case of Brazil

BACKGROUND

Dietary risk factors have an important impact on premature deaths and disabilities due to non-communicable diseases. In this study, we perform diet optimization to design different dietary scenarios taking into account food prices and preferences and evaluate the number of deaths that would be prevented as well as the economic burden and costs from the health system that would be saved in Brazil.

METHODS

We used dietary intake and food prices data from the nationwide Household Budget Survey (HBS) and the National Dietary Survey (NDS) 2017-2018. Linear programming models were performed to design five scenarios which different sets of key diet modifications at the least deviation from the baseline consumption. Comparative risk assessment models were used to estimate the health impacts of optimized dietary changes on mortality and the economic impacts on morbidity (hospitalizations) and premature deaths.

RESULTS

The optimized diets were, on average, more expensive than the baseline diets, varying from Int$ (international dollar) 0.02/day to 0.52/day/adult. The number of deaths prevented or postponed varied from 12,750 (10,178-15,225) to 57,341 (48,573-66,298) according to the different scenarios. The diet modifications would save from 50 to 219 million in hospitalizations and from 239 to 804 million yearly in productivity losses with the reduction of premature deaths.

CONCLUSION

A substantial number of deaths and costs due to hospitalization and productivity losses would be avoidable even with small changes in diets. However, even the cheapest intervention might be prohibitive for deprived families, yet subsidies and social policies could contribute to improving diets.

Optimized menu formulation to enhance nutritional goals: design of a mixed integer programming model for the workers' food program in Brazil

BACKGROUND

In Brazil, institutional foodservices are required to meet the recommendations of the Workers? Food Program (WFP), a national public policy used to plan collective menus. The current study aimed to propose a mathematical model to generate a one-month menu that meets the nutritional recommendations of the WFP, with low cost and good quality.

METHODS

We considered aspects related to the eating habits of the Brazilian population, spacing of repetitions between the dishes, texture combination, and monotonicity of colors of the dishes served. A mixed integer programming model was built to formulate daily menus for an institutional foodservice for one month. The menu consisted of a base dish, a base dish option, salads (2 options), a protein dish, a protein dish option, a side dish, and a dessert.

RESULTS

The model ensured compliance with the recommendations proposed by the WFP and the provision of healthy and nutritionally balanced meals. The menu generated met the recommendations of the WFP, with an average of 716.97 kcal/meal, including on average 58.28% carbohydrates, 17.89% proteins, and 24.88% total fats/meal.

CONCLUSION

The model used can help in the menu elaboration dynamics of institutional foodservices, optimizing the work of the nutritionist in charge.

Differences in Cost-Effectiveness of Adherence to Nutritional Recommendations: Why, Where, and What?

Cost-effectiveness analysis of diets may comprise an important tool to promote food security; however, studies show divergent evidence regarding the relationship between diet quality and cost in diverse populations. Thus, this study assesses differences in cost-effectiveness ratios regarding adherence to nutritional recommendations using data representative of the population level in Sao Paulo municipality, Brazil. Information from adolescents and adult individuals (n = 1742) was used to estimate diet quality and cost in 2015. Differences in cost-effectiveness ratios were investigated through application of two diet quality indexes and exploration of individuals' personal and contextual characteristics. Results indicated that higher diet cost was associated with higher adherence to nutritional recommendations at the national level and inversely associated with adherence to international recommendations. Purchasing foods in street markets was linked to healthier diets at lower costs, and protein consumption was associated with higher diet cost regardless of diet quality; however, diet quality was linked to type of protein consumed by individuals. Differences in cost-effectiveness ratios were attributable to methodological choices in measuring dietary quality (why); individuals' personal and contextual characteristics, in particular, access to retail equipment (where); and certain food choices (what). Therefore, cost-effectiveness analyses should be tailored to policy goals and local environments to ensure proper assessment of nutrition programs and to foster improvements in nutritional diet quality at lower cost.

Meeting nutritional adequacy in the Brazilian population increases pesticide intake without exceeding chronic safe levels

Achieving nutritional adequacy requires an increase in fresh foods consumption, which may increase pesticide intakes. This study aimed to identify required dietary modifications to achieve nutritional adequacy without exceeding the acceptable daily intake (ADI) for pesticides. Data from the National Dietary Survey 2017-2018 were linked to the pesticide database from the Program on Pesticide Residue Analysis in Food. We performed linear programming models to design nutritionally adequate diets constrained by food preferences for different constraints on pesticide intake at the least cost increment. Nutritional adequacy led to an increase in pesticide intakes without exceeding their ADI. Modifications in diets varied according to the model, but, in general, consisted in an increase in fruits and vegetables, dairy, and seafood, and a reduction in rice, red meat, and sugar-sweetened beverages quantities. In conclusion, meeting nutritional adequacy increases pesticide intake compared to the observed diets, without representing a health concern to consumers.

How to Estimate Food Prices and Diet Costs in Population-Based Studies?

Health and nutrition surveys usually comprise detailed information on health characteristics and food consumption of certain population groups; however, the lack of data collection on the food prices may pose challenges for the estimation of the diet costs for the comprehensive analysis of food demand. The Household Budget Survey (HBS) represents an opportunity to obtain the data on the food prices for the nutrition surveys in the diverse countries worldwide. Although the HBS and the health and nutrition surveys may correspond to different periods, the application of the appropriate Consumer Price Index (CPI) allows to address the changes in the relative prices to perform the linkage between the data of food consumption with information on the food prices. Therefore, the aim of this study was to present the methods for the extraction and linkage of the food prices data from the Brazilian HBS (2002–2003 and 2008–2009) by using the pairing features related to the household characteristics to match the Health Survey of São Paulo [Inquérito de Saúde de São Paulo (ISA-Capital)] conducted in 2003, 2008, and 2015. Data referring to the household characteristics and food prices acquired by the household members living in São Paulo municipality were selected from the HBS datasets for integration with the ISA-Capital dataset. Specific deflators referring to the food items surveyed in São Paulo were obtained from the datasets of the Brazilian Broad Consumer Price Index (BCPI). Therefore, the pairing criteria referring to time, location, and household characteristics were adopted to allow linking foods consumed by the individuals in the ISA-Capital with the prices from the foods acquired by household members interviewed in the HBS. Matching data on the key pairing criteria (location/year/household income per capita/number of residents/family profile) resulted in the linkage of 94.4% (2003), 92.6% (2008), and 81.2% of the cases (2015). Following the data linkage, it was possible to estimate diet costs per gram and per calorie including application of cooking and conversion factors. Data were presented in the International Monetary Unit under the purchasing power parity (PPP) to allow the comparison at the international level. The mean diet costs identified in the population of São Paulo municipality were $8.45 (dp = 0.38) per capita per day in 2003, $8.72 (dp = 0.24) per capita per day in 2008, and $9.62 (dp = 0.23) per capita per day in 2015. Thus, it was possible to estimate the diet costs based on the prices of food items through pairing linkage of information from the household surveys, such as the Brazilian HBS, with the health and nutrition surveys lacking information on the expenditures or prices such as the ISA-Capital. Similar procedures may be used in the diverse countries with availability of the datasets of the household expenditures and health and nutrition surveys, allowing the researchers worldwide to associate the diet quality with food demand.

Reducing ultra-processed foods and increasing diet quality in affordable and culturally acceptable diets: a study case from Brazil using linear programming

The aim was to design culturally acceptable and healthy diets with reduced energetic share of ultra-processed foods (UPF%) at no cost increment and to evaluate the impact of the change in the UPF% on diet quality. Food consumption and price data were obtained from the Household Budget Survey (n 55 970 households) and National Dietary Survey (n 32 749 individuals). Linear programming models were performed to design diets in which the mean population UPF% was reduced up to 5 % with no cost increment relative to the observed costs. The models were isoenergetic or allowed the energy content to vary according to the UPF%, and they were not constrained to nutritional goals (nutrient-free models) or maximised the compliance with dietary recommendations (nutrient-constrained models). Constraints regarding food preference were introduced in the models to obtain culturally acceptable diets. The mean population UPF% was 23·8 %. The lowest UPF% attained was approximately 10 %. The optimised diet cost was up to 20 % cheaper than the observed cost, depending on the model and the income level. In the optimised diets, the reduction in the UPF% was followed by an increase in fruits, vegetables, beans, tubers, dairy products, nuts, fibre, K, Mg, vitamin A and vitamin C in the nutrient-constrained models, compared with the observed consumption in the population. There was little variation in most nutrients across the UPF% reduction. The UPF% reduction in the nutrient-free models impacted only trans-fat and added sugar content. UPF% reduction and increase in diet quality are possible at no cost increment.

Assessment of dietary intake of bioactive food compounds according to income level in the Brazilian population

There is an inverse association between bioactive compounds intake and disease risk. The knowledge of its consumption according to socio-economic strata is important, which allows identification of potential intervention targets. Thus, we aimed to investigate bioactive compounds intake according to income level in Brazilian population. Data were obtained from the Brazilian Household Budget Survey, a cross-sectional survey which included data on individual food intake of 34,003 subjects aged 10 years and over collected using two 24-h dietary records. Polyphenol and carotenoid content of foods was identified using published databases. Total polyphenol and carotenoid intake were determined according to per capita income, as well as main food sources. Total polyphenols and flavonoids intake increased with income level, and subjects with lower income showed higher phenolic acids intake than individuals in highest income (p = 0.0001). Total carotenoids and classes intake (with exception to β-cryptoxanthin and zeaxanthin) were higher among subjects in highest income quartile, compared to the lowest quartile (p = 0.0001). Coffee was major source to total polyphenols and phenolic acids intake, and orange juice was main flavonoid provider in individuals from all income levels. In the upper income quartile, total carotenoid was supplied mainly by tomato and kale, and fruits had important contribution to carotenoid intake in the lowest income quartile. There is important influence of income level on diet quality regarding intake of foods with bioactive compounds, and individuals with lower income may experience lower quality diets due to less availability of foods with bioactive compounds.

Measuring cost and affordability of current vs. healthy diets in Argentina: an application of linear programming and the INFORMAS protocol

BACKGROUND

Food cost and affordability is one of the main barriers to improve the nutritional quality of diets of the population. However, in Argentina, where over 60% of adults and 40% of children and adolescents are overweight or obese, little is known about the difference in cost and affordability of healthier diets compared to ordinary, less healthy ones.

METHODS

We implemented the "optimal approach" proposed by the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS). We modelled the current diet and two types of healthy diets, one equal in energy with the current diet and one 6.3% lower in energy by linear programming. Cost estimations were performed by collecting food product prices and running a Monte Carlo simulation (10,000 iterations) to obtain a range of costs for each model diet. Affordability was measured as the percentage contribution of diet cost vs. average household income in average, poor and extremely poor households and by income deciles.

RESULTS

On average, households must spend 32% more money on food to ensure equal energy intake from a healthy diet than from a current model diet. When the energy intake target was reduced by 6.3%, the difference in cost was 22%. There are no reasonably likely situations in which any of these healthy diets could cost less or the same than the current unhealthier one. Over 50% of households would be unable to afford the modelled healthy diets, while 40% could not afford the current diet.

CONCLUSIONS

Differential cost and affordability of healthy vs. unhealthy diets are germane to the design of effective public policies to reduce obesity and NCDs in Argentina. It is necessary to implement urgent measures to transform the obesogenic environment, making healthier products more affordable, available and desirable, and discouraging consumption of nutrient-poor, energy-rich foods.

The cost of eating more sustainable diets: A nutritional and environmental diet optimisation study

We aim to identify the dietary changes to improve nutrition and reduce diet-related greenhouse gas emission (GHGE) simultaneously in Brazil, taking into account the heterogeneity in food habits and prices across the country. Food consumption and prices were obtained from two nationwide surveys (n = 55,970 households and 34,003 individuals). Linear programming models were performed to design optimised diets most resembling the observed diets, and meeting different sets of constraints: (i) nutritional, for preventing chronic diseases and meeting nutrient adequacy; (ii) socio-cultural: by respecting food preferences; and (iii) environmental: by reducing GHGE by steps of 10%. Moving toward a diet that meets nutritional recommendations led to a 14% to 24% cost increase and 10% to 27% GHGE reduction, depending on the stringency of the acceptability constraints. Stronger GHGE reductions were achievable (up to about 70%), with greater departure from the current diet, but not achieving calcium and potassium goals. Diet cost increment tended to be mitigated with GHGE reduction in most models, along with reductions in red meat, chicken, eggs, rice, and high-fat sugar sodium foods.

Multi-Objective Optimization of Nutritional, Environmental and Economic Aspects of Diets Applied to the Spanish Context

Current food consumption patterns must be revised in order to improve their sustainability. The nutritional, environmental, and economic consequences of these dietary patterns must be taken into consideration when diet guidelines are proposed. This study applied a systematic optimization methodology to define sustainable dietary patterns complying with nutritional, environmental, and economic issues. The methodology was based on a multi-objective optimization model that considered a distance-to-target approach. Although the three simultaneous objectives (maximal nutritional contribution, minimal greenhouse gas emissions, and minimal costs) could be divergent, the proposed model identified the optimal intake of each food product to achieve the maximal level of nutritional, environmental, and economic diets. This model was applied to six different eating patterns within the Spanish context: one based on current food consumption and five alternative diets. The results revealed that dietary patterns with improved nutritional profiles and reduced environmental impacts could be defined without additional costs just by increasing the consumption of vegetables, fruits, and legumes, while reducing the intake of meat and fish.

Nutrient density and affordability of foods in Brazil by food group and degree of processing

OBJECTIVE

Affordable nutrition refers to the relation between nutrient density of foods and their monetary cost. There are limited data on affordable nutrition in low- and middle-income countries. The present study aimed to develop a nutrient density score and nutrient affordability metrics for 377 most consumed foods in Brazil.

DESIGN

The foods were aggregated into seven major food groups and four NOVA food categories. Nutrient composition data were obtained from the Brazilian Institute of Geography and Statistics. Food prices were obtained from retailer websites and were converted to prices per 100 g and 418 kJ. The Nutrient Rich Food (NRF8.2) score was based on protein, fiber, vitamins A, C and E, Ca, Fe and K. Nutrients to limit were sugar and Na. Affordability was measured as kcal/R$ and nutrients/R$.

RESULTS

Grains, fats and sweets were more energy dense and had lower NRF8.2 scores than dairy, vegetables and fruits. Grains, fats and sweets were the lowest cost sources of energy. Vegetables and fruits, beans, nuts and seeds and eggs and dairy were the lowest cost sources of multiple nutrients. Ultra-processed foods (48 % of total) had higher energy density and lower NRF8.2 scores than did unprocessed foods. In Brazil, fruits, vegetables and dairy products offered the most nutrients per real.

CONCLUSIONS

Analysis of the relationship between nutrient density of foods and their cost can help identify locally available foods that are nutrient rich, affordable and culturally acceptable. Achieving high nutrient density at an affordable cost should be the goal of Brazil's food systems.

[Quality of diet and daily spending on food by adults with cardiovascular disease in Brazil]

Adherence to a healthy diet depends on factors such as food prices, while studies in developed countries have identified higher costs of more nutritional foods. The current study aimed to assess the direct food expenditures by adults with cardiovascular disease in Brazil, investigating the relationship between cost and quality of diet. The study used data from a randomized clinical trial, the BALANCE Program. The current study is a cross-sectional baseline analysis of participants with high adherence to the trial, conducted in 35 sites in all five major geographic regions of Brazil. Food consumption by 1,160 individuals was collected with a 24-hour dietary recall (24HR), quality of diet was measured with the Diet Quality Index Revised (DQI-R), and direct food costs were estimated from market prices. No significant differences were observed between tertiles of adherence in the direct costs of food or individual characteristics. When all the 24HR were analyzed, there was no correlation between cost and quality of diet (r = 0.38; p = 0.17), while analysis by tertiles showed a weak correlation in the lowest tertile of adherence (r = -0.112; p = 0.03). The study showed absence of differences between direct costs of healthy versus unhealthy foods, a finding that can serve as an incentive for adherence to food recommendations in Brazil, thereby minimizing barriers to the adoption of healthy lifestyles.

Reaching culturally acceptable and adequate diets at the lowest cost increment according to income level in Brazilian households

Objective

To identify food choices allowing the fulfillment of nutritionally adequate diets resembling actual food patterns at the lowest cost achievable for the Brazilian population, stratified by income level.

Methods

Food consumption and prices were obtained from the Household Budget Survey (n = 55,970 households) and National Dietary Survey (n = 32,749 individuals). The sample was stratified into capitals of the states and further by income levels according to the official minimum wage (totaling 108 geographic-economic strata, or GES). Linear programming models were performed for each GES in order to find the lowest cost of diets that meet a set of nutritional constraints. In order to find realistic diets, constraints referring to preferences were introduced in the models allowing optimized food quantities to depart progressively from the current intake for each food and food group. The impact of meeting each target nutrient was assessed by performing models removing each nutrient at the time.

Results

The observed and optimized diet costs were US$2.16 and US$2.58 per capita/day. The highest cost increment and the greatest food shifts were observed in the lowest income level. The nutrient adequacy was reached by mainly increasing fruits and vegetables, beans, fish and seafood, dairy, nuts, and eggs; and reducing red and processed meat, chicken, margarine and butter, cookies, cakes, sugar-sweetened beverages, and sauces. As the departure from the current intakes increase, the optimized healthy diet cost reduced. In the lowest income, the lowest cost increment was about US$ 0.10; in the higher income levels, it tended to be cheaper than the observed cost. Calcium was the most expensive nutrient to meet adequacy.

Conclusion

Nutritionally adequate diets are possible but costlier than the observed.