Pakistan, 58 percent of the population spends less on food than CoRD. It is highest in Balochistan province (82 percent) and lowest in KPK (47 percent).<sup>29</sup>

# **6 Conclusion**

We find that the cost of food can be particularly prohibitive when considering a recommended healthy and nutritious diet. We further find that prices of the most nutrient-dense foods are rising faster, and are more seasonally and spatially variable, than those of energy-dense, lowmicronutrient foods. The main factor behind this trend is shifting prices for vegetables. Changes in vegetable prices also account for the differences in the cost of a nutritious diet across geographic locations.

The most energy-dense foods (cereals, oils and fats, sugars) generally had the most stable prices, showing the least inflation, seasonality, and regional variation, except for in Afghanistan where the price of cereals is regionally variable. Energy-dense foods generally have a longer shelf life for storage and transportation than nutrient-dense foods, which tend to be highly perishable. Food security and agriculture policies have emphasized energy-dense foods for the last several decades. The findings of our paper suggest that food security and agriculture policies need to focus more on nutrient-dense foods, which are relatively unaffordable throughout the year but particularly during price spikes in certain seasons and regions. In particular, policymakers can reduce the cost and price volatility of nutritious diets by taking steps to reduce vegetable prices and their sensitivity to seasonal factors, and by improving the integration of markets particularly for vegetables and other perishable, nutrient-dense foods.

The most nutrient-dense foods are missing from a majority of diets around the world (Micha, Kalantarian, and Wirojratana 2012). This has high costs to human health and productivity. Malnutrition and dietary risks are the top two factors in the global burden of disease (GDB 2016 Risk Factor Collaborators 2017). Our results suggest that there may be strong economic reasons why consumers consume little of the most nutrient-dense foods: They simply cannot afford it. If policymakers want to improve diet quality and nutrition in South Asia, they must implement more policies and take more action to improve affordability of vegetables, legumes, fruits, and animalsource foods.

A strength of our analytical approach is that countries can track the cost of nutritious diets quite easily using existing food price monitoring systems of national statistics organizations. Spatial trends and price inflation can be monitored by calculating CoRD and NPI. CoRD in particular is important for policy coherence, providing a means to monitor the price of diet patterns that meet national guidelines. However, to estimate CoRD we are limited to the foods contained in the Consumer Price Index food list, which may not include the most nutritionally important foods or the cheapest foods. Comparison with household expenditure survey prices suggest that indeed, there may be cheaper sources of nutritious foods available than those contained in the CPI list. Using the median-cost food items in a longer list of foods, rather than the lowest-cost food items

> 29 An alternative calculation would be to calculate CoRD for each province and compare this to nominal per individual food expenses (not spatially adjusted). Results of this alternative method are presented in Appendix Figure A2. Using this method, the proportion of individuals who spend less on food than CoRD increases; in Sri Lanka 56 percent of individuals spend less on food than CoRD and in Pakistan 65 percent of individuals spend less on food than CoRD.

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