title: Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis.
abstract: OBJECTIVE
  To conduct a systematic review and meta-analysis of prices of healthier versus less healthy foods/diet patterns while accounting for key sources of heterogeneity.
  
  
  METHODS
  MEDLINE (2000-2011), supplemented with expert consultations and hand reviews of reference lists and related citations.
  
  
  METHODS
  Studies reviewed independently and in duplicate were included if reporting mean retail price of foods or diet patterns stratified by healthfulness. We extracted, in duplicate, mean prices and their uncertainties of healthier and less healthy foods/diet patterns and rated the intensity of health differences for each comparison (range 1-10). Prices were adjusted for inflation and the World Bank purchasing power parity, and standardised to the international dollar (defined as US$1) in 2011. Using random effects models, we quantified price differences of healthier versus less healthy options for specific food types, diet patterns and units of price (serving, day and calorie). Statistical heterogeneity was quantified using I(2) statistics.
  
  
  RESULTS
  27 studies from 10 countries met the inclusion criteria. Among food groups, meats/protein had largest price differences: healthier options cost $0.29/serving (95% CI $0.19 to $0.40) and $0.47/200 kcal ($0.42 to $0.53) more than less healthy options. Price differences per serving for healthier versus less healthy foods were smaller among grains ($0.03), dairy (-$0.004), snacks/sweets ($0.12) and fats/oils ($0.02; p<0.05 each) and not significant for soda/juice ($0.11, p=0.64). Comparing extremes (top vs bottom quantile) of food-based diet patterns, healthier diets cost $1.48/day ($1.01 to $1.95) and $1.54/2000 kcal ($1.15 to $1.94) more. Comparing nutrient-based patterns, price per day was not significantly different (top vs bottom quantile: $0.04; p=0.916), whereas price per 2000 kcal was $1.56 ($0.61 to $2.51) more. Adjustment for intensity of differences in healthfulness yielded similar results.
  
  
  CONCLUSIONS
  This meta-analysis provides the best evidence until today of price differences of healthier vs less healthy foods/diet patterns, highlighting the challenges and opportunities for reducing financial barriers to healthy eating.
authors.affiliation: The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
authors.forename: Mayuree
authors.initials: M
authors.lastname: Rao
authors.forename: Ashkan
authors.initials: A
authors.lastname: Afshin
authors.forename: Gitanjali
authors.initials: G
authors.lastname: Singh
authors.forename: Dariush
authors.initials: D
authors.lastname: Mozaffarian
keywords: HEALTH ECONOMICS; PREVENTIVE MEDICINE; PUBLIC HEALTH; SOCIAL MEDICINE