Consumer preferences for attributes in sweet beverages and market impacts of beverage innovation.

Consumption of sugar-sweetened beverages (SSB) is considered as an important risk factor for the development of overweight and obesity in populations worldwide, with a particular focus on the risks in the younger parts of the population - children and adolescents. Together with fiscal measures and information tools, innovation-based approaches such as the development of sugar-free or sugar-reduced versions of established beverages and development of new beverage products have been used to reduce this challenge, but the effects of product innovation on sugar intake are not well understood from the literature, as previous studies have largely ignored substitution effects of product innovation in the beverage domain. The objective of the present study was to investigate the potential effectiveness of product innovation as a strategy to affect consumers' intake of energy from sweetened non-alcoholic beverages. Using household panel shopping data from approximately 3000 Danish households over the years 2006-2014, we developed a hedonic pricing approach to estimate the influence of product attributes on consumers' utility, based on observed data for Danish households' purchases of sweet drinks. Overall, the study found that beverages' degree of sweetness positively affected the satiation effect of beverage consumption and in turn made the demand for these beverages less sensitive to e.g. price changes or introduction of competing products, whereas the energy density of the beverages positively affected the demand sensitivity to market changes. Findings like these can be useful for assessing market effects as well as environmental and public health impacts of changes to the market environment.

Health and Economic Burden of Seven Foodborne Diseases in Denmark, 2019.

We ranked seven foodborne pathogens in Denmark on the basis of their health and economic impact on society in 2019. We estimated burden of disease of infections with Campylobacter spp., Salmonella spp., Shiga toxin-producing Escherichia coli (STEC), Yersinia enterocolitica, Listeria monocytogenes, norovirus, and hepatitis A virus in terms of incidence, mortality, disability-adjusted life years (DALY), and economic burden in terms of direct and indirect health costs. These seven pathogens accounted for 268,372 cases, 98 deaths, and 3121 DALYs, and led to a total expenditure of 434 million Euro in 1 year in a country with 5.8 million citizens. Foodborne infections by Campylobacter, Salmonella, and norovirus caused the most DALYs, whereas Campylobacter, and norovirus and STEC had the higher costs. A combination of disease burden and cost of illness estimates is useful to inform policymaking and establish food safety priorities at the national level.

Consumer preferences for reduced antibiotic use in Danish pig production.

Denmark has a large and intensive pig production sector which accounts for around half of the total use of antimicrobials in Demark. The economic feasibility of alternative strategies involving reduced use of antibiotics depends not only on their effects on productivity but also on consumers' demand, and willingness-to-pay (WTP), for pork from pigs with no or lower antibiotic treatment. This study investigates the various concerns that consumers might have about the use of antibiotics in pig production, and how they affect demand and WTP. We used data from an online questionnaire survey of approximately 1000 Danish consumers. WTP estimates were obtained using payment card data analysed in an ordered probit regression. We found that 41 % of the respondents wanted antibiotic use to be reduced substantially, and that they linked reduced use of antibiotics in pig production primarily with reduced risk of antibiotic residues in pork and a lowered risk of resistant bacteria developing. A considerable share of the consumers we sampled also linked reduced antibiotic use with improved animal welfare, and with price increases for pork. Two thirds of the consumers stated a positive WTP for reduced use of antibiotics, but only one in five were willing to pay more than 10 % for pork produced using antibiotics 20 % less than average. The WTP estimates differed with socio-demographic variables (education, geography, gender and age). In addition, the respondents' perceptions of the effects of reducing antibiotic use and of externalities associated with the pig industry, and the frequency of their pork consumption, were found to affect their WTP for pork produced with lower antibiotic use. As the vast majority of the Danish pork is exported, future studies should examine consumer perceptions of antibiotic use in pig production in importing countries.

The case for developing a cohesive systems approach to research across unhealthy commodity industries.

OBJECTIVES: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. METHODS: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. RESULTS: There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. CONCLUSION: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.

Health economic benefits from optimized meal services to older adults-a literature-based synthesis.

Malnutrition among older adults causes health problems and economic costs. Prevention of malnutrition through meal service can reduce such costs. This study estimates potential health economic benefits to be generated through meal service to home-dwelling older adults. The study contains three components: (1) systems analysis describing the relationship between meal service, nutritional status, health risk, and health-related costs, focusing on older adults, (2) a series of literature reviews to quantify the identified elements in each stage-subject combination: (i) meal service impact on nutrition status of older adults, (ii) associations between nutrition status and health risks, (iii) health care resource needs associated with these health risks, and (3) a model synthesis of literature findings to estimate the expected economic benefit of improved health status derived from meal service enrollment, using Denmark as an example. Expected economic benefits in terms of saved direct and indirect health care costs and improved quality-of-life was estimated at an amount of €307 per year per individual enrolled, of which direct health care cost savings constituted €75, while value of improved quality-of-life and reduced mortality constituted the rest. The average health economic benefit from enrolling older adults into meal service is likely to decrease with the number of subscribers. Findings like these are important to take into consideration, when making policy decisions regarding size of the meal service capacity, although it should be noted that the presented estimates are based on a number of assumptions of which some are subject to uncertainty.

Including aesthetic and recreational values in cost-effectiveness analyses of land use change based nitrogen abatement measures in Denmark.

In recent years there has been an increased focus on including aspects such as greenhouse gas emissions and biodiversity in cost-effectiveness analyses of nitrogen (N) abatement measures. Side-effects such as aesthetic and recreational benefits generated by the land use changes implied by some N abatement measures, such as afforestation and constructed wetlands, are included in ecosystem service approaches, but seldom explicitly in cost-effectiveness analyses. While several studies have estimated these values for e.g. forests and wetlands, per se, few have studied how these effects are valued by the general population when generated through the implementation of land use changes driven by measures aimed at reducing the loss of nitrogen from agriculture. The land use changes implied by the N abatement measures have different characteristics to that of the evaluations of forests for recreation or larger wetlands created or maintained for biodiversity, mainly because the area affected varies considerably in size and shape. In this paper, we estimate the welfare economic impacts of some of the potential side-effects, such as recreational and aesthetic effects, of three N abatement measures related to agricultural land use change: afforestation, constructed wetlands or energy crops. We incorporate the value of these side-effects in a standard cost-effectiveness analysis and discuss the policy implications. This allows us to evaluate to what extent the inclusion of these side-effects change the ranking of the measures and the cost levels used. We thereby provide a more holistic approach to the cost-effectiveness analysis of land use change based N abatement measures, and discuss the challenges relating to the spatial aspects that arise when accounting for the value of the analyzed side-effects. The analysis shows that public access to the area largely determine whether the selected measures are perceived as positive or negative. The impact of the analyzed side-effects on the cost-effectiveness analysis critically depends on the size of the affected population, as the value of the side-effects are measured per household.

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

How to Obtain Forty Percent Less Environmental Impact by Healthy, Protein-Optimized Snacks for Older Adults.

It is well known that meals containing less meat are more sustainable, but little is known about snack-meals, which typically do not contain meat. This study investigates the diversity in environmental impacts associated with snack production based on 20 common recipes optimized for protein content, energy content and sensory aspects for older adults. The purpose is to improve sustainability of public procurement by serving more sustainable snack-meals. Public procurement serves Danish older adults over millions of snack-meals every year, and millions more are served in countries with a similar social service. The environmental impact of snack production was estimated by consequential life cycle assessment. The average impact of producing the 10 least environmentally harmful snacks was 40% less than the average impact of producing the 10 most harmful snacks. This is true whether the functional unit was mass, energy, or protein content, and whether the environmental impact was measured as global warming potential or the monetized value of 16 impact categories. We conclude that large-scale public procurement of snack-meals by private and municipal kitchens can be reduced by up to 40% if the kitchens evaluate the environmental impact of all their snacks and serve the better half more frequently.

Reducing calorie sales from supermarkets - 'silent' reformulation of retailer-brand food products.

BACKGROUND: Food product reformulation is seen as one among several tools to promote healthier eating. Reformulating the recipe for a processed food, e.g. reducing the fat, sugar or salt content of the foods, or increasing the content of whole-grains, can help the consumers to pursue a healthier life style. In this study, we evaluate the effects on calorie sales of a 'silent' reformulation strategy, where a retail chain's private-label brands are reformulated to a lower energy density without making specific claims on the product. METHODS: Using an ecological study design, we analyse 52 weeks' sales data - enriched with data on products' energy density - from a Danish retail chain. Sales of eight product categories were studied. Within each of these categories, specific products had been reformulated during the 52 weeks data period. Using econometric methods, we decompose the changes in calorie turnover and sales value into direct and indirect effects of product reformulation. RESULTS: For all considered products, the direct effect of product reformulation was a reduction in the sale of calories from the respective product categories - between 0.5 and 8.2%. In several cases, the reformulation led to indirect substitution effects that were counterproductive with regard to reducing calorie turnover. However, except in two insignificant cases, these indirect substitution effects were dominated by the direct effect of the reformulation, leading to net reductions in calorie sales between -3.1 and 7.5%. For all considered product reformulations, the reformulation had either positive, zero or very moderate negative effects on the sales value of the product category to which the reformulated product belonged. CONCLUSIONS: Based on these findings, 'silent' reformulation of retailer's private brands towards lower energy density seems to contribute to lowering the calorie intake in the population (although to a moderate extent) with moderate losses in retailer's sales revenues.

A real options approach to biotechnology investment policy-the case of developing a Campylobacter vaccine to poultry.

The aim of the article is to identify and analyse public-private incentives for the development and marketing of new animal vaccines within a real options methodological framework, and to investigate how real options methodology can be utilized to support economic incentives for vaccine development in a cost-effective way. The development of a vaccine against Campylobacter jejuni in poultry is applied as a case study. Employing the real options methodology, the net present value of the vaccine R&D project becomes larger than a purely probabilistic expected present value throughout the different stages of the project - and the net present value becomes larger, when more types of real options are taken into consideration. The insight from the real options analysis reveals opportunities for new policies to promote the development of animal vaccines. One such approach might be to develop schemes combining stage-by-stage optimized subsidies in the individual development stages, with proper account taken of investors'/developers' economic incentives to proceed, sell or cancel the project in the respective stages. Another way of using the real options approach to support the development of desirable animal vaccines could be to issue put options for the vaccine candidate, enabling vaccine developers to hedge against the economic risk from market volatility.

Cost-Effectiveness of a New Nordic Diet as a Strategy for Health Promotion.

Inappropriate diets constitute an important health risk and an increasing environmental burden. Healthy regional diets may contribute to meeting this dual challenge. A palatable, healthy and sustainable New Nordic diet (NND) based on organic products from the Nordic region has been developed. This study assesses whether a large-scale introduction of NND is a cost-effective health promotion strategy by combining an economic model for estimating the utility-maximizing composition of NND, a life cycle assessment model to assess environmental effects of the dietary change, and a health impact model to assess impacts on the disease burden. Consumer expenditure for food and beverages in the NND is about 16% higher than currently, with the largest relative difference in low-income households. Environmental loads from food consumption are 15%-25% lower, and more than 18,000 disability-adjusted life years (DALY) will be saved per year in Denmark. NND exhibits a cost-effectiveness ratio of about €73,000-94,000 per DALY saved. This cost-effectiveness improves considerably, if the NND's emphasis on organic and Nordic-origin products is relaxed.

The new nordic diet--consumer expenditures and economic incentives estimated from a controlled intervention.

BACKGROUND: Several studies suggest that a healthy diet with high emphasis on nutritious, low-energy components such as fruits, vegetables, and seafood tends to be more costly for consumers. Derived from the ideas from the New Nordic Cuisine--and inspired by the Mediterranean diet, the New Nordic Diet (NND) has been developed as a palatable, healthy and sustainable diet based on products from the Nordic region. The objective of the study is to investigate economic consequences for the consumers of the NND, compared with an Average Danish Diet (ADD). METHODS: Combine quantity data from a randomized controlled ad libitum dietary 6 month intervention for central obese adults (18-65 years) and market retail price data of the products consumed in the intervention. Adjust consumed quantities to market price incentives using econometrically estimated price elasticities. RESULTS: Average daily food expenditure of the ADD as represented in the unadjusted intervention (ADD-i) amounted to 36.02 DKK for the participants. The daily food expenditure in the unadjusted New Nordic Diet (NND-i) costs 44.80 DKK per day per head, and is hence about 25% more expensive than the Average Danish Diet (or about 17% when adjusting for energy content of the diet). Adjusting for price incentives in a real market setting, the estimated cost of the Average Danish Diet is reduced by 2.50 DKK (ADD-m), compared to the unadjusted ADD-i diet, whereas the adjusted cost of the New Nordic Diet (NND-m) is reduced by about 3.50 DKK, compared to the unadjusted NND-i. The distribution of food cost is however much more heterogeneous among consumers within the NND than within the ADD. CONCLUSION: On average, the New Nordic Diet is 24-25 per cent more expensive than an Average Danish Diet at the current market prices in Denmark (and 16-17 per cent, when adjusting for energy content). The relatively large heterogeneity in food costs in the NND suggests that it is possible to compose an NND where the cost exceeds that of ADD by less than the 24-25 per cent.

Micro-level economic factors and incentives in Children's energy balance related behaviours - findings from the ENERGY European cross-section questionnaire survey.

BACKGROUND: To date, most research on obesogenic environments facing school children has focused on physical and socio-cultural environments. The role of economic factors has been investigated to a much lesser extent. Our objective was to explore the association of micro-level economic factors and incentives with sports activities and intake of soft drinks and fruit juice in 10-12 year-old school children across Europe, and to explore price sensitivity in children's soft drink consumption and correlates of this price sensitivity. METHODS: Data for the study originate from a cross-sectional survey undertaken in seven European countries (Belgium, Greece, Hungary, Netherlands, Norway, Slovenia and Spain) in 2010 among 10-12 year-old school children and their parents. In total, 7234 child questionnaires and 6002 parent questionnaires were completed. The child questionnaire included questions addressing self-reported weekly intake of soft drinks and fruit juices and time spent on sports activities, perception of parental support for sports activities, use of pocket money for soft drinks and perceived price responsiveness. Parent questionnaires included questions addressing the role of budget and price considerations in decisions regarding children's sports activities, soft drink consumption, home practices and rules and socio-demographic background variables. Data were analysed using multiple linear regression and discrete-choice (ordered probit) modelling. RESULTS: Economic factors were found to be associated with children's sports participation and sugary drink consumption, explaining 27% of the variation in time for sports activities, and 27% and 12% of the variation in the children's soft drink and juice consumption, respectively. Parents' financial support was found to be an important correlate (Beta =0.419) of children's sports activities. Children's pocket money was a strong correlate (Beta =21.034) of soft drink consumption. The majority of the responding children reported to expect that significantly higher prices of soft drinks would lead them to buy less soft drinks with their own pocket money, but a majority of parents did not expect higher soft drink prices to reduce their children's soft drink consumption. CONCLUSIONS: We conclude that economic factors, especially parents' financial support and amount of pocket money, appear to be of importance for children's sports participation and soft drink consumption, respectively.

Economic incentives and nutritional behavior of children in the school setting: a systematic review.

The aim of the present review was to examine the existing literature on the effectiveness of economic incentives for producing sound nutritional behavior in schools. Studies published in the English-language literature that included baseline and/or outcome data regarding food and beverage intake of schoolchildren were eligible for inclusion. A systematic search of the literature was conducted to identify relevant primary studies and relevant systematic reviews of primary studies. Altogether, 3,472 research publications were identified in the systematic search, of which 50 papers were retrieved. Of these, 30 publications representing 28 studies fulfilled the criteria for inclusion. The studies addressing price incentives suggest that such incentives are effective for altering consumption in the school setting. Other types of economic incentives have been included in combined intervention schemes, but the inclusion of other intervention elements makes it difficult to draw conclusions about the effectiveness of the economic incentive instruments per se in these studies.

Can worksite nutritional interventions improve productivity and firm profitability? A literature review.

AIMS: This paper investigates whether and how worksite nutrition policies can improve employee productivity. METHODS: The questions are pursued through a literature review, including a systematic search of literature--combined with literature identified from backward references--on randomized controlled or quasi-experimental worksite intervention trials and observational cross-sectional studies. Studies were selected on the basis of topic relevance, according to publication title and subsequently according to abstract content. A quality appraisal of the studies was based on study design and clarity in definition of interventions, as well as environmental and outcome variables. RESULTS: The search identified 2,358 publications, 30 of which were found suitable for the review. Several of the reviewed studies suggest that diet-related worksite interventions have positive impacts on employees' nutritional knowledge, food intake and health and on the firm's profitability, mainly in terms of reduced absenteeism and presenteeism. CONCLUSIONS: Well-targeted and efficiently implemented diet-related worksite health promotion interventions may improve labour productivity by 1%-2%. On larger worksites, such productivity gains are likely to more than offset the costs of implementing such interventions. These conclusions are subject to some uncertainty due to the relatively limited amount of literature in the field.