# **1 Introduction**

Around the world, the cost of nutritious foods, such as fruits, vegetables, and animal-source foods, is typically higher than the cost of less nutritious foods, such as oil and sugar. In some parts of the world, this gap in price has been increasing over time. Moreover, the cost of nutritious foods is more variable across geographic locations. Many nutritious foods are highly perishable and less tradable. As such, their prices are largely determined by local productivity and value chain efficiency (Headey 2017; Monsivais, Mclain, and Drewnowski 2010).

The relatively high cost of nutritious foods can affect nutrition outcomes. While price elasticities differ across countries and foods, higher relative prices can generally result in reduced consumption of nutritious foods (Miller, Yusaf, and Chow 2016; Andreyeva, Long, and Brownell 2010; Green et al. 2013). The cost of nutritious diets has also been linked to the quality of overall diets and to nutrition outcomes, such as stunting and obesity (Beydoun, Powell, Chen, and Wang 2011; Grossman, Tekin, and Wada 2013; Headey 2017). Importantly, the poor are more likely affected by the higher cost of nutritious foods. They are more sensitive to prices, and as such are likely to choose cheaper, energy-dense diets (Miller, Yusaf, and Chow 2016; Green et al. 2013; Darmon and Drewnowski 2015). While the cost of healthy and unhealthy foods is not the only factor determining diets and nutrition outcomes, it is an important one and likely more binding for the poor than the non-poor.

Our study focuses on understanding the cost of nutritious diets in South Asia, a region highly affected by malnutrition in all its forms.<sup>1</sup> The region has among the highest burdens of child undernutrition in the world, with 36 percent stunted and 16 percent wasted (UNICEF, WHO, and World Bank 2017).<sup>2</sup> Stunting rates are not only high, but they are also highest among the poor. While there are multiple causes of malnutrition, the coexistence of undernutrition, micronutrient deficiencies, and markers of diet-related disease signal that poor diets are widespread.<sup>3</sup> It is likely that cost plays a significant role in access to nutritious diets.

We adapt policy-coherent and easily tractable methods to measure the trends and spatial variation in the cost of nutritious diets. Developed as part of the Indicators of Affordability of Nutritious Diets in Africa (IANDA) project, the adapted methods use existing price-monitoring and nutrition data from government statistical agencies. The first method, calculating the Cost of a Recommended Diet (CoRD), estimates the cost of meeting food-based dietary guidelines (FBDGs) using food prices and national FBDGs.<sup>4</sup> The second measure, the Nutritious Food Price Index (NPI), tracks changes in the price of nutritious foods by reweighting the standard food Consumer

> 1 Looking at micronutrient deficiencies in South Asia, 42 percent of children under age five are vitamin A deficient and 49 percent of women are anemic; the figures are greater in India and Pakistan. Looking at overconsumption and diet-related noncommunicable disease, 24 percent of women are overweight, more than 25 percent of adults have raised blood pressure, and the region has one of the highest rates of raised blood glucose (9–10 percent) (Development Initatives 2017).

> 2 Stunting is a measure of low height for age, an indicator of chronic undernutrition; wasting is a measure of low weight for height, an indicator of acute malnutrition.

> 3 In South Asia, 13 percent of people experience severe food insecurity (FAO, 2017). Many more lack access to adequate diets. Only 23 percent of young children aged 6–23 months receive minimum dietary diversity (at least four of seven food groups), with 15 percent in Bhutan, 22 percent in India and Pakistan, 28 percent in Bangladesh and, 37 percent in Nepal (Development Initatives 2017).

> 4 Food-based dietary guidelines are based on expert opinion and policy dialogue in country.

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