Increasing Fruit and Vegetable Consumption: A Cost-Efficiency Analysis of Public Policies

A L I M E N T A T I O N A G R I C U L T U R E

E N V I R O N N E M E N T

Increasing Fruit and Vegetable Consumption:A Cost-Efficiency Analysis of Public Policies

Mobilizing the food chain for health OECD, PARIS,

October 25-26 2012

J. Dallongeville1, L. Dauchet1, O. de Mouzon2, V. Requillart2, L.G. Soler3

1Institut Pasteur, Lille2TSE (INRA-GREMAQ), Toulouse3INRA-ALISS UR 1303, Ivry sur Seine



MOTIVATIONS

• Food and non communicable diseases (cancers, cardiovascular diseases ….)

• Public health actions to reach the recommended intake of 400g of fruit and vegetables (F&V) per day– Education and information campaigns – Economic instruments (consumption subsidies, ‘F&V’ stamps...)

• Many studies based on local experiments

• Very few studies integrating economic and health parameters



Important challenges for policy makers :

-Targeted versus non targeted policies

-Economic instruments versus information

-Public (and private) costs / Heath benefits

- Efficiency versus Equity



OBJECTIVES

• Evaluation of policy scenarios aiming at increasing F&V consumption in France

• Policies– P1: decrease in VAT – P2: F&V stamps for ‘poor’ consumers– P3 : Generic information campaign

• Cost-Efficiency analysis : cost per Life Year Saved



OVERVIEW ON THE METHOD• An economic model of the F&V market (Equilibrium Displacement

Model) Policy Changes in F&V consumption

• A health model

Changes in F&V consumption Number of Life Years Saved (LYS) using “Relative Risks” associated to an increase in F&V consumption

• Cost-effectivenessImplementation cost of the policy / LYS

• Simulations to take into account the uncertainties on the model inputs



POLICIES

• P1: Reduction of VAT– Decrease consumer price (less than the VAT reduction)– Increase consumption– Effects at equilibrium depend on price elasticity of demand,

price elasticity of supply

• P2: F&V stamps to low income consumers (LIC)– Equivalent to an increase in income– Increase consumption of LIC– Increase consumer price– Decrease consumption of other consumers



POLICIES• P3: General Information campaigns

– Increase ‘stock’ of information of consumers– Increase demand and mean consumption– Increase price – Consumption of some consumers might decrease if less

responsive to information

• Simulations

- Decrease in VAT : 3%- Budget for F&V stamps : 300M euros- Targeted consumers : 1 to 10% of the population- F&V stamp per person : 50 to 350 euros per year



Relative Risks associated to the consumption of one additional portion (80g/day)

Whole population

First decileof income Men Women

CancerMouth, pharynx and larynx 0.92 [0.81 - 1.06] 5 536 1 013 18.5 20.4Esophagus 0.92 [0.85 - 1.00] 3 837 696 16.1 15.8Stomach 0.97 [0.93 - 1.01] 4 763 820 13.7 13.7Pancreas 0.97 [0.90 - 1.04] 8 263 1 369 14.5 13.9Lung 0.94 [0.92 - 0.97] 28 347 5 088 16.0 20.0Colon and rectum 0.99 [0.94 - 1.04] 16 426 2 733 12.4 12.6Ovary 0.84 [0.62 - 1.13] 3 342 463 17.1

Cardiovascular diseaseCoronary heart disease 0.97 [0.94 - 0.99] 38 806 7 497 11.6 8.4Stroke 0.96 [0.94 - 0.98] 32 652 6 335 10.2 8.8

Disease Number of deaths Expected number of

years of li fe lostRR for one aditional portion of fruit and vegetable:

Mean [CI 95%]



0 1 2 3 4 5 6 7 8 9 100

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5x 10

5

Targeted population (in income percentiles)

Cost

by

Life

Year

Sav

ed (€

)

Line width meaning:median2.5 & 97.5 percentiles



Conclusion

LIMITS

• Only F&V sector • Uncertainty on the values of some parameters (information

responsiveness in particular) • Decreased morbidity not taken into account• We assumed that people use the FV stamps they get

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• Generally speaking, modest impacts on consumption and health

• ...but cost/LYS often compatible with acceptable thresholds

• Information policies are cost-effective... because they are not very expensive. However they might increase (slightly) the health disparities among the population (different from the result of another study in the UK).

• Price policy dominates F&V stamp policy....

.... except if the F&V stamp policy is focused on a “small” part of the population (greater amount of individual stamps but for less people)

=“optimal” size of the targeted population (which depends on the total budget used for the implementation of the policy)

• Challenge : to determine the “best” policy mix



Thank you for your attention



Median 2.5%ile 97.5%ile Median 2.5%ile 97.5%ile Median 2.5%ile 97.5%ile

Value of the F&V stamp (€/year for each targeted person) 126 314

Consumer price variation (%) - 1.23 - 1.65 - 0.78 0.20 0.13 0.31 0.49 0.32 0.73

Individual consumption variation (g/day)

Targeted LIC 3.1 2.0 4.7 26.9 25.5 32.0 167.0 164.3 176.8 Non-targted LIC 3.1 2.0 4.7 - 0.5 - 0.8 - 0.3 - 1.3 - 1.8 - 0.7 Non-targeted SIC 3.8 2.4 5.7 - 0.6 - 1.0 - 0.4 - 1.6 - 2.3 - 0.9 Whole population 3.7 2.4 5.6 0.8 0.5 1.1 1.9 1.2 2.5

Number of deaths avoided (DA)

Targeted LIC 9 5 16 202 132 279 481 318 641 Non-targted LIC 34 19 57 - 3 - 6 - 2 - 14 - 23 - 7 Non-targeted SIC 235 128 401 - 40 - 67 - 20 - 97 - 161 - 50 Whole population 279 152 474 157 101 223 366 237 505

Cancer 165 75 301 84 44 129 188 96 281 Cardio-Vascular 112 52 204 73 37 115 178 92 272

Number of life-years saved (LYS)



Mean cost per DA (M€) 1.08 0.63 1.97 1.91 1.34 2.97 0.82 0.59 1.26

Mean cost per LYS (k€) 78 45 145 144 101 226 62 45 97

0.001 0.000 0.002 - 0.016 - 0.023 - 0.011 - 0.038 - 0.051 - 0.025

Policy comparisonVAT reduction by 3.06 points Targeted LIC = 5% Targeted LIC = 2%

Health disparity index:odds-ratio (LIC vs. SIC) variation












Mean cost per DA (M€) 1.08 0.63 1.97 1.91 1.34 2.97 0.82 0.59 1.26


0.001 0.000 0.002 - 0.016 - 0.023 - 0.011 - 0.038 - 0.051 - 0.025














Mean cost per DA (M€) 1.08 0.63 1.97 1.91 1.34 2.97 0.82 0.59 1.26


0.001 0.000 0.002 - 0.016 - 0.023 - 0.011 - 0.038 - 0.051 - 0.025



Median 2.5% ile 97.5%il e Median 2.5% ile 97.5%ile Median 2.5% ile 97.5% ile



Individual consumpti on variation (g/day)

Targeted LIC 3.1 2.0 4.7 26.9 25.5 32.0 167.0 164.3 176.8 Non- targted LIC 3.1 2.0 4.7 - 0.5 - 0.8 - 0.3 - 1.3 - 1.8 - 0.7 Non- targeted SIC 3.8 2.4 5.7 - 0.6 - 1.0 - 0.4 - 1.6 - 2.3 - 0.9 Whole population 3.7 2.4 5.6 0.8 0.5 1.1 1.9 1.2 2.5


Targeted LIC 9 5 16 202 132 279 481 318 641 Non- targted LIC 34 19 57 - 3 - 6 - 2 - 14 - 23 - 7 Non- targeted SIC 235 128 401 - 40 - 67 - 20 - 97 - 161 - 50 Whole population 279 152 474 157 101 223 366 237 505



Targeted LIC 126 69 214 2706 1745 3766 6401 4174 8522 Non- targted LIC 456 249 777 - 47 - 79 - 24 - 188 - 312 - 97 Non- targeted SIC 3267 1742 5618 - 553 - 946 - 277 - 1344 - 2265 - 678 Whole population 3850 2063 6606 2084 1327 2982 4804 3086 6625


Mean cost per DA (M €) 1.08 0.63 1.97 1.91 1.34 2.97 0.82 0.59 1.26

Mean cost per LYS ( k€) 78 45 145 144 101 226 62 45 97

0.001 0.000 0.002 - 0.016 - 0.023 - 0.011 - 0.038 - 0.051 - 0.025

Policy comparisonV AT reduction by 3.06 points Targeted LIC = 5% Targeted LIC = 2%

Health disparity index:odds-ratio (LIC vs. S IC) variati on



Related Literature

• Unhealthy food taxation, healthy food subsidizing : Chouinard et al (2007), Mytton (2007), Allais et al. (2010), Bonnet et al. (2007), ...

• Cost-efficiency analysis: Cash et al (2005)• Food stamps: Alston et al. (2009), Meyerhoefer et Pylipchuk (2008),

Chen et al. (2005)• Information campaign : Pomerleau et al (2005)• ........

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Increasing Fruit and Vegetable Consumption: A Cost-Efficiency Analysis of Public Policies

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