A cost-analysis of adopting a healthful diet in a family-based obesity treatment program

Low energy density, high nutrient adequacy and high nutrient density are each associated with higher diet costs in Chinese adults from Henan Province

OBJECTIVES

Food price is a determining factor in food choice which affect diet quality accordingly. However, the association between food price and diet quality has not been thoroughly discussed among Chinese adults. This study aimed to analyze the association of daily energy-adjusted dietary costs (CNY/2000 kcal) and diet quality among Chinese adults.

METHODS

A total of 680 Chinese adults aged above 25 years from Henan province were investigated in 2020. Three indices were adopted for evaluating diet quality: the nutrient-rich foods 9.2 (NRF 9.2) index for evaluating nutrient density, the mean adequacy ratio (MAR) for evaluating nutrient adequacy, energy density (ED) based on solid foods only for evaluating energy density. The daily energy-adjusted diet cost was calculated by dividing the estimated daily diet costs (CNY/day) by the energy intake per day (kcal/day) and multiplying the result by 2000.

RESULTS

Subjects who closely adhered to the NRF9.2, MAR, and ED paid ¥8.92, ¥13.17, and ¥14.34 more for daily food consumption, respectively, than those who weakly adhered to these dietary patterns did. Furthermore, multiple linear regression analysis adjusted covariance revealed that an increase in ¥1 of the energy-adjusted diet cost per day was associated with changes of 0.494 units (P < 0.001), 0.003 units (P < 0.001), and - 0.018 units (P < 0.001) in the NRF9.2, MAR, and ED, respectively.

CONCLUSION

Higher energy-adjusted diet cost was associated with higher quality diets. This might be important for public health policies to develop strategies to promote healthy diets by regulating food supply and its costs.

Childhood Transitions Between Weight Status Categories: Evidence from the UK Millennium Cohort Study

BACKGROUND

Assessing the cost-effectiveness of interventions targeting childhood excess weight requires estimates of the hazards of transitioning between weight status categories. Current estimates are based on studies characterized by insufficient sample sizes, a lack of national representativeness, and untested assumptions.

OBJECTIVES

We sought to (1) estimate transition probabilities and hazard ratios for transitioning between childhood weight status categories, (2) test the validity of the underlying assumption in the literature that transitions between childhood bodyweight categories are time-homogeneous, (3) account for complex sampling procedures when deriving nationally representative transition estimates, and (4) explore the impact of child, maternal, and sociodemographic characteristics.

METHODS

We applied a multistate transition modeling approach accounting for complex survey design to UK Millennium Cohort Study (MCS) data to predict transition probabilities and hazard ratios for weight status movements for children aged 3-17. Surveys were conducted at ages 3 (wave 2 in 2004), 5 (wave 3 in 2006), 7 (wave 4 in 2008), 11 (wave 5 in 2012), 14 (wave 6 in 2015), and 17 (wave 7 in 2018) years. We derived datasets that included repeated body mass index measurements across waves after excluding multiple births and children with missing or implausible bodyweight records. To account for the stratified cluster sample design of the MCS, we incorporated survey weights and jackknife replicates of survey weights. Using a validation dataset from the MCS, we tested the validity of our models. Finally, we estimated the relationships between state transitions and child, maternal, and sociodemographic factors.

RESULTS

The datasets for our primary analysis consisted of 10,399 children for waves 2-3, 10,729 for waves 3-4, 9685 for waves 4-5, 8593 for waves 5-6, and 7085 for waves 6-7. All datasets consisted of roughly equal splits of boys and girls. Under the assumption of time-heterogeneous transition rates (our base-case model), younger children (ages 3-5 and 5-7 years) had significantly higher annual transition probabilities of moving from healthy weight to overweight (0.033, 95% confidence interval [CI] 0.026-0.041, and 0.027, 95% CI 0.021-0.033, respectively) compared to older children (0.015, 95% CI 0.012-0.018, at ages 7-11; 0.018, 95% CI 0.013-0.023, at ages 11-14; and 0.018, 95% CI 0.013-0.025 at ages 14-17 years). However, the resolution of unhealthy weight was more strongly age-dependent than transitions from healthy weight to non-healthy weight states. Transition hazards differed by child, maternal, and sociodemographic factors.

CONCLUSIONS

Our models generated estimates of bodyweight status transitions in a representative UK childhood population. Compared to our scenario models (i.e., time-homogeneous transition rates), our base-case model fits the observed data best, indicating a non-time-homogeneous pattern in transitions between bodyweight categories during childhood. Transition hazards varied significantly by age and across subpopulations, suggesting that conducting subgroup-specific cost-effectiveness analyses of childhood weight management interventions will optimize decision-making.

Post hoc analysis of food costs associated with Dietary Approaches to Stop Hypertension diet, whole food, plant-based diet, and typical baseline diet of individuals with insulin-treated type 2 diabetes mellitus in a nonrandomized crossover trial with meals provided

BACKGROUND

Americans consume diets that fall short of dietary recommendations, and the cost of healthier diets is often cited as a barrier to dietary change. We conducted a nonrandomized crossover trial with meals provided utilizing 2 diets: Dietary Approaches to Stop Hypertension (DASH) and whole food, plant-based (WFPB), and thus had intake data from baseline and both intervention diets.

OBJECTIVES

Using actual diet records, describe food costs of baseline diets of individuals with type 2 diabetes (T2DM) as well as therapeutic DASH and WFPB diets.

METHODS

Three-day food records were collected and analyzed for each 7-d diet phase: baseline, DASH, and WFPB. Nutrient content was analyzed using the Nutrient Data System for Research and cost was determined using Fillet, an application to manage menu pricing. Food costs were calculated for each diet as consumed and adjusted to a standardized 1800 kcal/d. Ingredient-only costs of food away from home (FAFH) were approximated and analyzed. Costs were analyzed using linear mixed-effect models as a function of diet.

RESULTS

Fifteen subjects enrolled; 12 completed all dietary phases. The baseline, DASH, and WFPB diets, as consumed, cost $15.72/d (95% CI; $13.91, $17.53), $12.74/d ($11.23, $14.25), and $9.78/d ($7.97, $11.59), respectively. When adjusted to an 1800 kcal/d intake, the baseline, DASH, and WFPB diets cost $15.69/d ($13.87, $17.52), $14.92/d ($13.59, $16.26), and $11.96/d ($10.14, $13.78), respectively. When approximated ingredient-only costs of FAFH were analyzed, as consumed baseline [$11.01 ($9.53, $12.49)] and DASH diets [$11.81 ($10.44, $13.18)] had similar costs; WFPB diet [$8.83 ($7.35, $10.31)] cost the least.

CONCLUSIONS

In this short-term study with meals provided, the food costs of plant-predominant diets offering substantial metabolic health benefits were less than or similar to baseline food costs of adults with insulin-treated T2DM. Longer-term data without meal provision are needed for more generalizable results. This trial was registered at clinicaltrials.gov as NCT04048642.

Understanding Time Series Patterns of Weight and Meal History Reports in Mobile Weight Loss Intervention Programs: Data-Driven Analysis

Background

Mobile apps for weight loss provide users with convenient features for recording lifestyle and health indicators; they have been widely used for weight loss recently. Previous studies in this field generally focused on the relationship between the cumulative nature of self-reported data and the results in weight loss at the end of the diet period. Therefore, we conducted an in-depth study to explore the relationships between adherence to self-reporting and weight loss outcomes during the weight reduction process.

Objective

We explored the relationship between adherence to self-reporting and weight loss outcomes during the time series weight reduction process with the following 3 research questions: “How does adherence to self-reporting of body weight and meal history change over time?”, “How do weight loss outcomes depend on weight changes over time?”, and “How does adherence to the weight loss intervention change over time by gender?”

Methods

We analyzed self-reported data collected weekly for 16 weeks (January 2017 to March 2018) from 684 Korean men and women who participated in a mobile weight loss intervention program provided by a mobile diet app called Noom. Analysis of variance (ANOVA) and chi-squared tests were employed to determine whether the baseline characteristics among the groups of weight loss results were different. Based on the ANOVA results and slope analysis of the trend indicating participant behavior along the time axis, we explored the relationship between adherence to self-reporting and weight loss results.

Results

Adherence to self-reporting levels decreased over time, as previous studies have found. BMI change patterns (ie, absolute BMI values and change in BMI values within a week) changed over time and were characterized in 3 time series periods. The relationships between the weight loss outcome and both meal history and self-reporting patterns were gender-dependent. There was no statistical association between adherence to self-reporting and weight loss outcomes in the male participants.

Conclusions

Although mobile technology has increased the convenience of self-reporting when dieting, it should be noted that technology itself is not the essence of weight loss. The in-depth understanding of the relationship between adherence to self-reporting and weight loss outcome found in this study may contribute to the development of better weight loss interventions in mobile environments.

Is healthy eating too expensive?: How low-income parents evaluate the cost of food

Debates about whether a healthy diet is affordable often overlook how low-income consumers themselves evaluate food cost. This question is relevant to explaining food choices and measuring food prices. Drawing on interviews with 49 low-income primary caregivers and grocery-shopping observations with 34 of these interviewees, I find that respondents judge food cost in two ways: 1) absolute judgments, or assessments of whether a food covers a family's needs with scarce resources and 2) relative judgments, or interpretations of price relative to another food that frames an item as affordable or pricey by contrast. Absolute judgments reflect actual expenditures, including not just the sticker price, but also four underappreciated monetary costs. These underappreciated costs stem from food waste; packages containing more than is needed; food that is consumed too quickly; and unsatiating foods. When monetary costs go unmeasured and when consumers interpret prices in relative terms, researchers' views of food cost diverge from the experiences of low-income people. Divergent views have two results: food-cost estimates overstate the affordability of a healthy diet and observers may misconstrue purchases as financially imprudent. These findings can inform policy, programming, and public discourse.

Diet Quality and Total Daily Price of Foods Consumed among Iranian Diabetic Patients

Background:

The aim is to investigate the association between diet quality and daily price of foods consumed among Iranian diabetic patients.

Methods:

This cross-sectional study was conducted among 200 patients with type 2 diabetes mellitus (T2DM) aged 30–70 years. General information, socioeconomic status, anthropometric and biochemical characteristics, and food prices were collected by pretested questionnaires. Dietary intakes were assessed using a semi-quantitative reliable and valid food frequency questionnaire. Modified nutritionist IV and SPSS software were used for analyses.

Results:

The results of the present study indicated a direct relationship between total daily price of diet and nutrient adequacy ratio of Vitamin D, Vitamin B1, selenium, zinc, magnesium, potassium, and mean adequacy ratio of 11 micronutrients (Vitamin C, Vitamin E, Vitamin D, Vitamin B1, Vitamin B6, Vitamin B12, selenium, zinc, calcium, magnesium, and potassium) (P < 0.05). Furthermore, the total daily price of diet had a positive association with dietary intakes of protein, Vitamin D, Vitamin B1, selenium, zinc, magnesium and potassium among type 2 diabetic patients (P < 0.05). However, no significant relationship was observed between the total daily price of diet and anthropometric indices, biochemical characteristics, and socioeconomic status of participants in the present study (P > 0.05).

Conclusions:

This study showed that dietary quality and dietary intakes of energy, protein, and micronutrients were directly associated with the total daily price of foods among Iranian patients with type 2 diabetes.

WITHDRAWN: Interventions for treating obesity in children

BACKGROUND

Child and adolescent obesity is increasingly prevalent, and can be associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the efficacy of lifestyle, drug and surgical interventions for treating obesity in childhood.

SEARCH METHODS

We searched CENTRAL on The Cochrane Library Issue 2 2008, MEDLINE, EMBASE, CINAHL, PsycINFO, ISI Web of Science, DARE and NHS EED. Searches were undertaken from 1985 to May 2008. References were checked. No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of lifestyle (i.e. dietary, physical activity and/or behavioural therapy), drug and surgical interventions for treating obesity in children (mean age under 18 years) with or without the support of family members, with a minimum of six months follow up (three months for actual drug therapy). Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data following the Cochrane Handbook. Where necessary authors were contacted for additional information.

MAIN RESULTS

We included 64 RCTs (5230 participants). Lifestyle interventions focused on physical activity and sedentary behaviour in 12 studies, diet in 6 studies, and 36 concentrated on behaviorally orientated treatment programs. Three types of drug interventions (metformin, orlistat and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies included varied greatly in intervention design, outcome measurements and methodological quality.Meta-analyses indicated a reduction in overweight at 6 and 12 months follow up in: i) lifestyle interventions involving children; and ii) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.

AUTHORS' CONCLUSIONS

While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Episodic future thinking and grocery shopping online

Grocery shopping shapes the home food environment, which can contribute to the development of obesity. Episodic future thinking (EFT) helps adults make healthier decisions by initiating prospective thinking, which guides one to forego smaller immediate rewards in favor of larger delayed rewards. EFT could help parents improve grocery purchases thereby improving the home food environment and family eating behaviors. The effect of EFT on food shopping was evaluated in two studies with mothers who were overweight/obese and primary household shoppers. In Study 1, 24 mothers were randomized to goal-directed process EFT versus a money saving control. In Study 2, 33 mothers were randomized to goal-directed process EFT, general EFT, or an episodic recent thinking (ERT) control. Following cue generation, participants completed a task where they purchased one week of groceries from an online store. Food purchases were analyzed for calories purchased per family member. In Study 1 the goal-directed process EFT group purchased fewer calories per person (F(1, 23) = 25.16, p < .001; ηp2 = 0.522). In Study 2 the goal-directed process EFT purchased fewer calories (F(1, 30) = 5.98, p = .02; ηp2 = 0.166) than the ERT control as did the EFT general group (F(1, 30) = 4.61, p = .04; ηp2 = 0.133). The two EFT groups did not differ from each other (F(1, 30) = 0.16, p = .69; ηp2 = 0.005). EFT may be an effective intervention for reducing the energy intake of foods purchased while grocery shopping.

Perceived Barriers to Adherence to Hemodialysis Dietary Recommendations

Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

BACKGROUND

Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages.

OBJECTIVES

To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials.

AUTHORS' CONCLUSIONS

Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.

How expensive is a cardioprotective diet? Analysis from the CRESSIDA study

OBJECTIVE

To determine whether a cardioprotective dietary intervention based on UK dietary guidelines was more expensive than a conventional UK diet.

DESIGN

Cost analysis of food records collected at baseline and after a 12-week dietary intervention of a cardioprotective diet v. conventional UK diet.

SETTING

A randomized controlled dietary intervention study (CRESSIDA; ISRCTN 92382106) investigating the impact of following a diet consistent with UK dietary guidelines on CVD risk.

SUBJECTS

Participants were healthy UK residents aged 40-70 years. A sub-sample of participants was randomly selected from those who completed the cardioprotective dietary intervention (n 20) or the conventional UK dietary intervention (n 20).

RESULTS

Baseline diet costs did not differ between groups; mean daily food cost for all participants was £6·12 (sd £1·83). The intervention diets were not more expensive: at end point the mean daily cost of the cardioprotective diet was £6·43 (sd £2·05) v. the control diet which was £6·53 (sd £1·53; P=0·86).

CONCLUSIONS

There was no evidence that consumption of a cardioprotective diet was more expensive than a conventional dietary pattern. Despite the perception that healthier foods are less affordable, these results suggest that cost may not be a barrier when modifying habitual intake and under tightly controlled trial conditions. The identification of specific food groups that may be a cost concern for individuals may be useful for tailoring interventions for CVD prevention for individuals and populations.

Can Families Eat Better Without Spending More? Improving Diet Quality Does Not Increase Diet Cost in a Randomized Clinical Trial among Youth with Type 1 Diabetes and Their Parents

BACKGROUND

Although cost is a frequently cited barrier to healthful eating, limited prospective data exist.

OBJECTIVE

To examine the association of diet cost with diet quality change.

DESIGN

An 18-month randomized clinical trial evaluated a dietary intervention.

PARTICIPANTS AND SETTING

Youth with type 1 diabetes duration ≥1 year, age 8.0 to 16.9 years, receiving care at an outpatient tertiary diabetes center in Boston, MA, participated along with a parent from 2010 to 2013 (N=136). Eighty-two percent of participants were from middle- to upper-income households.

INTERVENTION

The family-based behavioral intervention targeted intake of whole plant foods.

MAIN OUTCOME MEASURES

Diet quality as indicated by the Healthy Eating Index 2005 (HEI-2005) (which measures conformance to the 2005 Dietary Guidelines for Americans) and whole plant food density (cup or ounce equivalents per 1,000 kcal target food groups) were calculated from 3-day food records of youth and parent dietary intake at six and four time points, respectively. Food prices were obtained from two online supermarkets common to the study location. Daily diet cost was calculated by summing prices of reported foods.

STATISTICAL ANALYSES PERFORMED

Random effects models estimated treatment group differences in time-varying diet cost. Separate models for youth and parent adjusted for covariates examined associations of time-varying change in diet quality with change in diet cost.

RESULTS

There was no treatment effect on time-varying diet cost for either youth (β -.49, 95% CI -1.07 to 0.08; P=0.10) or parents (β .24, 95% CI -1.61 to 2.08; P=0.80). In addition, time-varying change in diet quality indicators was not associated with time-varying change in diet cost for youth. Among parents, a 1-cup or 1-oz equivalent increase in whole plant food density was associated with a $0.63/day lower diet cost (β -.63, 95% CI -1.20 to -0.05; P=0.03).

CONCLUSIONS

Improved diet quality was not accompanied by greater cost for youth with type 1 diabetes and their parents participating in a randomized clinical trial. Findings challenge the prevailing assumption that improving diet quality necessitates greater cost.

Association between energy density and diet cost in children

Highlights

The average of the energy-adjusted diet cost in 6-12 years-old children was 2.17€/1000Kcal (SD + 0.49).Energy-density diets (EDs - Kcal/g) were calculated by three distinct methods: (1) with food and all beverages (ED1), (2) with food and caloric beverages (ED2), and (3) only with food (ED3).The distributions of the three EDs were statistically different, being higher the ED3 - calculated excluding all beverages (1.15Kcal (SD + 0.28) vs. ED2: 1.10Kcal/g; SD + 0.24 vs. ED1: 0.99Kcal/g; SD + 0.22).Lower energy-density diets (EDs) were associated with higher diet cost in a sample of school children from a Mediterranean country, regardless the differences between the EDs calculated by three distinct methods.

Background

Lower energy density diets tend to cost more, but data using different ways to calculate the dietary energy density, is scarce.

Objectives

To estimate the dietary energy density, and to assess how it is associated with the diet cost in children.

Methods

Data were obtained from a community-based survey from public elementary schools in Portugal. Dietary intake of 464 children (6-12 years) was assessed by a 24 h recall in 2007/2008. Dietary energy density (kcal/g) was calculated as following: (1) with food and all beverages (ED1), (2) with food and caloric beverages (ED2), and (3) only with food (ED3). Energy-adjusted diet cost (€/1000 kcal) was calculated based on the collection of food prices from a national leader supermarket. Anthropometric measures were taken and socio-demographic data were obtained from parents. Logistic regression was used to estimate the association between diet cost and energy density.

Results

For boys, the energy-adjusted diet cost of the highest third of energy density was lower, between 81% in the ED3 (p for trend <0.001) and 87% in the ED1 (p for trend <0.001), compared to the lowest third. Girls showed similar, but weaker associations.

Conclusions

Higher dietary energy density was associated with lower dietary cost among children.

Adolescents' non-core food intake: a description of what, where and with whom adolescents consume non-core foods

OBJECTIVE

Little is known about adolescents' non-core food intake in the UK and the eating context in which they consume non-core foods. The present study aimed to describe types of non-core foods consumed by British adolescents in total and across different eating contexts.

DESIGN

A descriptive analysis, using cross-sectional data from food diaries. Non-core foods were classified based on cut-off points of fat and sugar from the Australian Guide to Healthy Eating. Eating context was defined as 'where' and 'with whom' adolescents consumed each food. Percentages of non-core energy were calculated for each food group in total and across eating contexts. A combined ranking was then created to account for each food's contribution to non-core energy intake and its popularity of consumption (percentage of consumers).

SETTING

The UK National Diet and Nutrition Survey 2008-2011.

SUBJECTS

Adolescents across the UK aged 11-18 years (n 666).

RESULTS

Non-core food comprised 39·5 % of total energy intake and was mostly 'Regular soft drinks', 'Crisps & savoury snacks', 'Chips & potato products', 'Chocolate' and 'Biscuits'. Adolescents ate 57·0 % and 51·3 % of non-core food at 'Eateries' or with 'Friends', compared with 33·2 % and 32·1 % at 'Home' or with 'Parents'. Persistent foods consumed across eating contexts were 'Regular soft drinks' and 'Chips & potato products'.

CONCLUSIONS

Regular soft drinks contribute the most energy and are the most popular non-core food consumed by adolescents regardless of context, and represent a good target for interventions to reduce non-core food consumption.

The Brazilian Cardioprotective Nutritional Program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol (The BALANCE Program Trial)

This article reports the rationale for the Brazilian Cardioprotective Nutritional Program (BALANCE Program) Trial. This pragmatic, multicenter, nationwide, randomized, concealed, controlled trial was designed to investigate the effects of the BALANCE Program in reducing cardiovascular events. The BALANCE Program consists of a prescribed diet guided by nutritional content recommendations from Brazilian national guidelines using a unique nutritional education strategy, which includes suggestions of affordable foods. In addition, the Program focuses on intensive follow-up through one-on-one visits, group sessions, and phone calls. In this trial, participants 45 years or older with any evidence of established cardiovascular disease will be randomized to the BALANCE or control groups. Those in the BALANCE group will receive the afore mentioned program interventions, while controls will be given generic advice on how to follow a low-fat, low-energy, low-sodium, and low-cholesterol diet, with a view to achieving Brazilian nutritional guideline recommendations. The primary outcome is a composite of death (any cause), cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, or hospitalization for unstable angina. A total of 2468 patients will be enrolled in 34 sites and followed up for up to 48 months. If the BALANCE Program is found to decrease cardiovascular events and reduce risk factors, this may represent an advance in the care of patients with cardiovascular disease.

Diet inequality prevails among consumers interested and knowledgeable in nutrition

Background

Previous studies have demonstrated a correlation between diet cost and adherence to nutritional recommendations among consumers in general. This has adverse effects on diet and health inequality. It could be hypothesized that consumers knowledgeable in nutrition escape this correlation.

Objective

Investigate whether the previously observed relationship between diet cost and nutritional quality prevails among consumers with an above-average interest in and knowledge of nutrition.

Design

Full open diet registrations of 330 students taking a basic university-level course in nutrition over a total of 780 days.

Results

The consumers with the highest daily average diet cost differ from the lowest cost quartile: The diets had higher micronutrient density, more fruits and vegetables, and lower energy density. The highest cost daily diet quartile had a significantly higher energy adjusted intake of the micronutrients that were on average consumed below the recommendation (vitamin D, folate, and iron for women). On the other hand, alcohol intake was significantly higher among the high diet cost group. The highest diet cost respondents consumed more fish, meat, coffee, and spreads, whereas the lowest diet cost respondents had a higher consumption of cereals, bread, jam, sausage, and milk.

Conclusions

Dietary differences prevail even in the above-average interested and knowledgeable group. The respondents did not use their higher level of knowledge to break this commonly observed relationship. This suggests that an increased minimum level of knowledge in nutrition may not by itself eliminate dietary inequality.

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.

Little variation in diet cost across wide ranges of overall dietary quality among youth with type 1 diabetes

We examined the association of diet quality with diet cost in a sample of youth with type 1 diabetes, for whom diet is an important component of medical management. Differences in food group spending by diet quality were also examined to identify potential budgetary reallocation to improve overall diet quality. Families of 252 youth with type 1 diabetes aged 8 to 18 years completed 3-day youth diet records. Cost of each food reported was calculated based on the average price obtained from two online grocery stores. Diet cost was estimated as average daily cost of foods consumed. The Healthy Eating Index 2005 (HEI2005), Nutrient Rich Foods Index version 9.3, and Whole Plant Food Density scores were evaluated. Differences in mean daily diet cost across tertiles of HEI2005, Nutrient Rich Foods Index version 9.3, and Whole Plant Food Density were modest, with none reaching statistical significance. Those in the upper tertile of HEI2005 spent more on whole fruit, whole grains, lean meat, and low-fat dairy, and less on high-fat meat and high-fat dairy compared with those in the lower tertiles. Higher-quality diets can be obtained at comparable costs to lesser-quality diets, suggesting that cost need not be an insurmountable barrier to more healthful eating. Reallocation of spending may increase overall quality without substantially increasing overall spending. Findings suggest potential strategies for assisting families of youth with type 1 diabetes in identifying cost-effective ways to achieve a more healthful diet.

Nutrieconomic model can facilitate healthy and low-cost food choices

Objective

Promotion of healthy eating can no longer be postponed as a priority, given the alarming growth rate of chronic degenerative diseases in Western countries. We elaborated a nutrieconomic model to assess and identify the most nutritious and affordable food choices.

Design

Seventy-one food items representing the main food categories were included and their nationally representative prices monitored. Food composition was determined using CRA-NUT (Centro di Ricerca per gli Alimenti e la Nutrizione) and IEO (Istituto Europeo di Oncologia) databases. To define food nutritional quality, the mean adequacy ratio and mean excess ratio were combined. Both prices and nutritional quality were normalised for the edible food content and for the recommended serving sizes for the Italian adult population.

Setting

Stores located in different provinces throughout Italy.

Subjects

Not applicable.

Results

Cereals and legumes presented very similar nutritional qualities and prices per serving. Seasonal fruits and vegetables presented differentiated nutritional qualities and almost equal prices. Products of animal origin showed similar nutritional qualities and varied prices: the best nutrieconomic choices were milk, oily fish and poultry for the dairy products, fish and meat groups, respectively.

Conclusions

Analysing two balanced weekly menus, our nutrieconomic model was able to note a significant decrease in cost of approximately 30 % by varying animal-protein sources without affecting nutritional quality. Healthy eating does not necessarily imply spending large amounts of money but rather being able to make nutritionally optimal choices. The nutrieconomic model is an innovative and practical way to help consumers make correct food choices and nutritionists increase the compliance of their patients.

Cost-effectiveness of family-based group treatment for child and parental obesity

BACKGROUND

Obesity runs in families, and family-based behavioral treatment (FBT) is associated with weight loss in overweight/obese children and their overweight/obese parents. This study was designed to estimate the costs and cost-effectiveness of FBT compared to separate group treatments of the overweight/obese parent and child (PC).

METHODS

Fifty overweight/obese 8- to 12-year-old children with overweight/obese parents were randomly assigned to 12 months of either FBT or PC treatment program. Assessment of societal costs (payer plus opportunity costs) were completed based on two assumptions: (1) programs for parent and child were available on separate days (PC-1) or (2) interventions for parent and child were available in the same location at sequential times on the same day (PC-2). Cost-effectiveness was calculated based on societal cost per unit of change using percent overBMI for children and weight for parents.

RESULTS

The average societal cost per family was $1,448 for FBT and $2,260 for PC-1 (p < 0.001) and $2,124 for PC-2 (p < 0.001). Child cost-effectiveness for FBT was $209.17/percent overBMI, compared to $1,036.50/percent overBMI for PC-1 and $973.98/percent overBMI for PC-2. Parent cost-effectiveness was $132.97/pound (lb) for FBT and $373.53/lb (PC-1) or $351.00/lb (PC-2).

CONCLUSIONS

For families with overweight/obese children and parents, FBT presents a lower cost per unit of weight loss for parents and children than treating the parent and child separately. Given the high rates of pediatric and adult obesity, FBT may provide a unique cost-effective platform for obesity intervention that alters weight in overweight/obese parents and their overweight/obese children.

Examining the economic costs related to lifestyle and pharmacological interventions in youth with Type 2 diabetes

The best treatment option for children with Type 2 diabetes has not yet been established. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study is currently testing the efficacy of three therapies: metformin, metformin plus rosiglitazone and metformin plus an intensive lifestyle intervention. The relative cost-effectiveness of these therapies is also being examined. This review discusses the rationale for the design and methods applied in the economic analysis. The design of the economic analysis in the TODAY study was influenced by the existing literature and two primary study parameters: the nature of the interventions and the participants' age. The lifestyle intervention is an intensive behavioral intervention comprising diet and physical activity. Since economic factors influence both diet and physical activity, the analytical plan includes measurement of food and exercise-related purchases. Due to the young age of the participants, the impact of the intervention on adult caregivers is also included in the analysis. This analysis focuses on the time spent by the caregivers in both medical treatment and nutrition- and activity-related activities, and the value of this time relative to usual activities. Important methodological questions include how and when to collect information, not only on medical costs, but also on the impact of caregiver time, travel, food and equipment purchases. In the TODAY study, these latter resources are being measured by regularly administered surveys completed by the caregivers. The approach to the cost-effectiveness assessment undertaken by the TODAY study is one of the first in diabetes research to focus on youth and to include a societal perspective, regular and prospective assessment of clinician and caregiver time, and a comprehensive assessment of the costs associated with lifestyle behaviors. It can serve as a model for future studies of diabetes treatments.

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.

The quality of dietary intake methodology and reporting in child and adolescent obesity intervention trials: a systematic review

Assessing dietary intake is important in evaluating childhood obesity intervention effectiveness. The purpose of this review was to evaluate the dietary intake methods and reporting in intervention studies that included a dietary component to treat overweight or obese children. A systematic review of studies published in the English language, between 1985 and August 2010 in health databases. The search identified 2,295 papers, of which 335 were retrieved and 31 met the inclusion criteria. Twenty-three studies reported energy intake as an outcome measure, 20 reported macronutrient intakes and 10 studies reported food intake outcomes. The most common dietary method employed was the food diary (n = 13), followed by 24-h recall (n = 5), food frequency questionnaire (FFQ) (n = 4) and dietary questionnaire (n = 4). The quality of the dietary intake methods reporting was rated as 'poor' in 15 studies (52%) and only 3 were rated as 'excellent'. The reporting quality of FFQs tended to be higher than food diaries/recalls. Deficiencies in the quality of dietary intake methods reporting in child obesity studies were identified. Use of a dietary intake methods reporting checklist is recommended. This will enable the quality of dietary intake results to be evaluated, and an increased ability to replicate study methodology by other researchers.

Does a low glycaemic index (GI) diet cost more during pregnancy?

&#160;The aim of this study was to examine the monetary cost of dietary change among pregnant women before and after receiving low glycaemic index (GI) dietary advice. The pregnant women in this study were a subgroup of participants in the Pregnancy and Glycaemic Index Outcomes (PREGGIO) study. Twenty women from the low GI dietary advice group, who had completed their pregnancies, were randomly chosen. All these women had completed three day food records at 12&#8211;16 weeks and again around 36 weeks of gestation. Consumer food prices were applied to recorded dietary intake data. The mean &#177; SD GI of the diet reduced from 55.1 &#177; 4.3 to 51.6 &#177; 3.9 (p = 0.003). The daily cost of the diet (AUD) was 9.1 &#177; 2.7 at enrolment and 9.5 &#177; 2.1 prior to delivery was not significantly different (p = 0.52). There were also no significant differences in the daily energy intake (p = 0.2) or the daily cost per MJ (p = 0.16). Women were able to follow low GI dietary advice during pregnancy with no significant increase in the daily costs.

Is healthy eating for obese children necessarily more costly for families?

BACKGROUND

During consultations on weight management in childhood obesity clinics, the additional costs incurred by healthy eating are often cited, as an economic barrier to achieving a better nutritional balance.

AIM

To examine whether adopting an improved theoretical, balanced diet compared to current dietary habits in children incurs additional cost.

DESIGN AND SETTING

Children aged 5-16 years (body mass index [BMI] ≥98th percentile) recruited to a randomised trial comparing a hospital-based and primary care childhood obesity clinics provided data for this study.

METHOD

Three-day dietary diaries collected at baseline were analysed for energy and fat intake and then compared to a theoretical, adjusted healthy-eating diet based on the Food Standards Agency, 'Eatwell plate'. Both were priced contemporaneously using the appropriate portion size, at a neighbourhood, mid-range supermarket, at a budget supermarket, and on the local high street.

RESULTS

The existing diet purchased at a budget supermarket was cheapest (£2.48/day). The healthier, alternative menu at the same shop cost an additional 33 pence/day (£2.81). The same exercise in a mid-range supermarket, incurred an additional cost of 4 pence per day (£3.40 versus £3.44). Switching from an unhealthy mid-range supermarket menu to the healthier, budget-outlet alternative saved 59 pence per day. The healthier, alternative menu was cheaper than the existing diet if purchased on the high street (£3.58 versus £3.75), although for both menus this was most expensive.

CONCLUSION

For many obese children, eating healthily would not necessarily incur prohibitive, additional financial cost, although a poor diet at a budget supermarket remains the cheapest of all options. Cost is a possible barrier to healthy eating for the most economically disadvantaged.

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.

Risk factors for obesity and high blood pressure in Chinese American children: maternal acculturation and children's food choices

The objective of this study is to explore risk factors associated with overweight and high blood pressure in Chinese American children. Students and their parents were recruited from Chinese language schools in the San Francisco Bay Area. Data were collected on 67 children and their mothers, and included children’s weight, height, waist and hip circumferences, blood pressure, level of physical activity, dietary intake, usual food choice, knowledge about nutrition and physical activity, and self-efficacy regarding diet and physical activity. Mothers completed questionnaires on demographic data and acculturation. About 46% of children had a body mass index exceeding the 85th percentile. Lower level of maternal acculturation is a risk factor for overweight and higher waist to hip ratio. Children’s unhealthy food choices were predictive of high body mass index and high systolic blood pressure, whereas older age and less physical activity in children were predictors of high diastolic blood pressure. Developing culturally sensitive and developmentally appropriate interventions to reduce overweight and high blood pressure is critical to reduce health disparities among minority children.

Can low-income Americans afford to satisfy MyPyramid fruit and vegetable guidelines?

OBJECTIVE

To estimate the costs of satisfying MyPyramid fruit and vegetable guidelines, with a focus on whether low-income households can bear these costs.

DESIGN

Descriptive analysis of the 2008 National Consumer Panel with information on the food purchases of 64,440 households across the contiguous United States was used to analyze the cost of fruits and vegetables. Costs per MyPyramid cup-equivalents were calculated by accounting for cooking yields and the portion of a food item's retail weight that is inedible.

VARIABLES MEASURED

Costs per cup-equivalent for less expensive fruits and vegetables by MyPyramid subgroup including whole and cut fruit, fruit juice, dark green vegetables, orange vegetables, starchy vegetables, other vegetables, and legumes.

RESULTS

In 2008, a variety of fruits and vegetables was available for an average cost of $0.40 to $0.50 per cup-equivalent. MyPyramid fruit and vegetable recommendations could be satisfied at this cost level.

CONCLUSIONS AND IMPLICATIONS

Low-income Americans facing national average food prices can satisfy MyPyramid fruit and vegetable guidelines with a budget equal to the Thrifty Food Plan allocation to fruits and vegetables. However, many low-income households spend too much money on food that is low in fruit and vegetable content. Some money should be reallocated to fruits and vegetables.

A cost comparison of more and less nutritious food choices in US supermarkets

OBJECTIVE

The present study directly compared prices of more and less nutritious foods within given categories in US supermarkets.

DESIGN

Foods selected from six supermarkets in Jackson County were categorized using the five criteria of the Nutrition Detectives™ (ND) programme and an item-to-item cost comparison was made using posted prices. The nutritional quality of foods was distinguished using the clues of the ND nutrition education programme for elementary-school children and validated using the Overall Nutritional Quality Index.

SETTING

Supermarkets in Jackson County, MO, USA.

SUBJECTS

Not applicable.

RESULTS

The average price of the item for more nutritious foods did not differ significantly from that of less nutritious foods overall ($US 2·89 (sd $US 0·74) v. $US 2·85 (sd $0·68), P = 0·76). More nutritious breads cost more than less nutritious breads ($US 3·36 (sd $ US 0·28) v. $US 2·56 (sd $US 0·80, P = 0·03), whereas more nutritious cereals ($US 2·46 (sd $US 0·69) v. $US 3·50 (sd $US 0·30), P < 0·01) and cookies ($US 2·76 (sd $US 0·50) v. $US 3·40 (sd $US0·28), P < 0·01) cost less.

CONCLUSIONS

Our findings indicate that it is possible to choose more nutritious foods within many common categories without spending more money and suggest that making small improvements in dietary choices does not invariably cost more.

Diet cost, diet quality and socio-economic position: how are they related and what contributes to differences in diet costs?

OBJECTIVE

To examine diet costs in relation to dietary quality and socio-economic position, and to investigate underlying reasons for differences in diet costs.

DESIGN

Dietary intake was assessed by a 4 d food diary and evaluated using the 2005 Healthy Eating Index (HEI). National consumer food prices collected by Statistics Sweden and from two online stores/supermarkets were used to estimate diet costs.

SETTING

Sweden.

SUBJECTS

A nationally representative sample of 2160 children aged 4, 8 or 11 years.

RESULTS

Higher scores on the HEI resulted in higher diet costs and, conversely, higher diet costs were linked to increased total HEI scores. Children who consumed the most healthy and/or expensive diets ate a more energy-dilute and varied diet compared with those who ate the least healthy and/or least expensive diets. They also consumed more fish, ready meals and fruit. Regression analysis also linked increased food costs to these food groups. There was a positive, but weak, relationship between HEI score and diet cost, parental education and parental occupation respectively.

CONCLUSIONS

Healthy eating is associated with higher diet cost in Swedish children, in part because of price differences between healthy and less-healthy foods. The cheapest and most unhealthy diets were found among those children whose parents were the least educated and had manual, low-skill occupations. Our results pose several challenges for public health policy makers, as well as for nutrition professionals, when forming dietary strategies and providing advice for macro- and microlevels in society.

Motivational interviewing for screening and feedback and encouraging lifestyle changes to reduce relative weight in 4-8 year old children: design of the MInT study

Background

Because parental recognition of overweight in young children is poor, we need to determine how best to inform parents that their child is overweight in a way that enhances their acceptance and supports motivation for positive change. This study will assess 1) whether weight feedback delivered using motivational interviewing increases parental acceptance of their child's weight status and enhances motivation for behaviour change, and 2) whether a family-based individualised lifestyle intervention, delivered primarily by a MInT mentor with limited support from "expert" consultants in psychology, nutrition and physical activity, can improve weight outcomes after 12 and 24 months in young overweight children, compared with usual care.

Methods/Design

1500 children aged 4-8 years will be screened for overweight (height, weight, waist, blood pressure, body composition). Parents will complete questionnaires on feeding practices, physical activity, diet, parenting, motivation for healthy lifestyles, and demographics. Parents of children classified as overweight (BMI ≥ CDC 85^th) will receive feedback about the results using Motivational interviewing or Usual care. Parental responses to feedback will be assessed two weeks later and participants will be invited into the intervention. Additional baseline measurements (accelerometry, diet, quality of life, child behaviour) will be collected and families will be randomised to Tailored package or Usual care. Parents in the Usual care condition will meet once with an advisor who will offer general advice regarding healthy eating and activity. Parents in the Tailored package condition will attend a single session with an "expert team" (MInT mentor, dietitian, physical activity advisor, clinical psychologist) to identify current challenges for the family, develop tailored goals for change, and plan behavioural strategies that best suit each family. The mentor will continue to provide support to the family via telephone and in-person consultations, decreasing in frequency over the two-year intervention. Outcome measures will be obtained at baseline, 12 and 24 months.

Discussion

This trial offers a unique opportunity to identify effective ways of providing feedback to parents about their child's weight status and to assess the efficacy of a supportive, individualised early intervention to improve weight outcomes in young children.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12609000749202

Childhood nutrition: perceptions of caretakers in a low-income urban setting

The incidence of overweight and obese children, especially those from low-income and minority backgrounds, continues to rise. Multiple factors contribute to the rising rates. In order to gain an understanding of factors contributing to obesity in low-income families, a qualitative study was conducted with the purpose of gaining knowledge of low-income urban caretakers' understanding and attitudes regarding children's nutrition. A focused ethnography was used as a means of understanding behavior within the context of a person's cultural environment. The sample was 17 caretakers of children in the 1st-3rd grades. Four focus groups were conducted. Two themes emerged from caretakers' perceptions: knowing the right things children should eat and balancing healthy nutrition with unhealthy choices. Four categories emerged regarding influences on food choices: tradition, finances, time constraints, and role models. Lastly, five barriers and three facilitating factors emerged. Implications of the study findings for school nurses include the need, when implementing healthy eating programs for school children, to gain information from caretakers about their perceptions of childhood nutrition.

Are the lowest-cost healthful food plans culturally and socially acceptable?

OBJECTIVE

Nutritious yet inexpensive foods do exist. However, many such foods are rejected by the low-income consumer. Is it because their use violates unspoken social norms? The present study was designed to assess the variety and cost of the lowest-cost market basket of foods that simultaneously met required dietary standards and progressively stricter consumption constraints.

DESIGN

A mathematical optimisation model was used to develop the lowest-cost food plans to meet three levels of nutritional requirements and seven levels of consumption constraints.

SUBJECTS

The nationally representative INCA (National Individual Survey of Food Consumption) dietary survey study of 1332 adults provided population estimates of food consumption patterns in France. Food plan costs were based on retail food prices.

RESULTS

The lowest-cost food plans that provided 9204 kJ/d (2200 kcal/d) for men and 7531 kJ/d (1800 kcal/d) for women and met specified dietary standards could be obtained for <1.50 euro/d. The progressive imposition of consumption constraints designed to create more mainstream French diets sharply increased food plan costs, without improving nutritional value.

CONCLUSIONS

Minimising diet costs, while meeting nutrition standards only, led to food plans that provided little variety and deviated substantially from social norms. Aligning the food plan with mainstream consumption led to higher costs. Food plans designed for low-income groups need to be socially acceptable as well as affordable and nutritious.

Mapping the availability and accessibility of healthy food in rural and urban New Zealand--Te Wai o Rona: Diabetes Prevention Strategy

OBJECTIVE

Uptake of advice for lifestyle change for obesity and diabetes prevention requires access to affordable 'healthy' foods (high in fibre/low in sugar and fat). The present study aimed to examine the availability and accessibility of 'healthy' foods in rural and urban New Zealand.

DESIGN

We identified and visited ('mapped') 1230 food outlets (473 urban, 757 rural) across the Waikato/Lakes areas (162 census areas within twelve regions) in New Zealand, where the Te Wai O Rona: Diabetes Prevention Strategy was underway. At each site, we assessed the availability of 'healthy' foods (e.g. wholemeal bread) and compared their cost with those of comparable 'regular' foods (e.g. white bread).

RESULTS

Healthy foods were generally more available in urban than rural areas. In both urban and rural areas, 'healthy' foods were more expensive than 'regular' foods after adjusting for the population and income level of each area. For instance, there was an increasing price difference across bread, meat, poultry, with the highest difference for sugar substitutes. The weekly family cost of a 'healthy' food basket (without sugar) was 29.1% more expensive than the 'regular' basket ($NZ 176.72 v. $NZ 136.84). The difference between the 'healthy' and 'regular' basket was greater in urban ($NZ 49.18) than rural areas ($NZ 36.27) in adjusted analysis.

CONCLUSIONS

'Healthy' foods were more expensive than 'regular' choices in both urban and rural areas. Although urban areas had higher availability of 'healthy' foods, the cost of changing to a healthy diet in urban areas was also greater. Improvement in the food environment is needed to support people in adopting healthy food choices.

Monetary cost of self-reported diet in relation to biomarker-based estimates of nutrient intake in young Japanese women

Objective

All previous studies on monetary diet cost have examined the relationship of monetary cost of self-reported diet to self-reported, rather than biomarker-based, estimates of dietary intake. The present cross-sectional study examined the association between monetary costs of self-reported diet and biomarker-based estimates of nutrient intake.

Design

Monetary diet cost (Japanese yen/1000 kJ) was calculated based on dietary intake information from a self-administered, comprehensive diet history questionnaire using retail food prices. Biomarker-based estimates of nutrient intake (percentage of energy for protein and mg/1000 kJ for K and Na) were estimated based on 24 h urinary excretion and estimated energy expenditure.

Setting

A total of fifteen universities and colleges in Japan.

Subjects

A total of 1046 female Japanese dietetic students aged 18–22 years.

Results

Total monetary diet cost showed a significant positive association with biomarker-based estimates of protein, K and Na. Vegetables and fish were not only the main contributors to total monetary diet cost (16·4 % and 15·5 %, respectively) but also were relatively strongly correlated with total monetary diet cost (Pearson’s correlation coefficient: 0·70 and 0·68, respectively). Monetary cost of vegetables was significantly positively associated with all three nutrients, while that of fish showed a significant and positive association only with protein.

Conclusions

Total monetary cost of self-reported diet was positively associated with biomarker-based estimates of protein, K and Na intake in young Japanese women, and appeared mainly to be explained by the monetary costs of vegetables and fish.

A holistic food labelling strategy for preventing obesity and dental caries

Obesity and dental caries in childhood are among the major public health concerns described as a global pandemic because of their global distribution and severe consequences. A consensus has developed as to a recently emerging and alarming common risk factor that leads to the double burden of dental caries and obesity; energy-dense foods (sugar-coated cereals, high-sugar yogurt, soft drinks) are becoming very popular among children because of their dense marketing, cheaper price, increased supply and variety. Implementation of health-promoting and -supporting marketing strategies for healthy food can be one initial cornerstone for successful application of the common risk factor approach in prevention of obesity and dental caries, as also suggested by World Health Organization. Labelling healthy food with a 'health-friendly' logo, illustrating that the teeth and the heart are both parts of the whole body (standing side by side supporting each other as close friends), both happy and protected because of consumption of healthy food for the whole body, can promote the foods that are friendly to health of the whole body, implementing the common risk factor approach under a single theme. Labelling healthy food as 'health-friendly' based on an international consensus will provide a clear and uniform picture of what is healthy to eat and result in an international integrated programme for prevention of obesity and caries.

Less-energy-dense diets of low-income women in California are associated with higher energy-adjusted diet costs

BACKGROUND

US-based studies are needed to estimate the relation, if any, between diet quality and estimated diet costs.

OBJECTIVE

We hypothesized that lower cost diets among low-income women in California would be energy dense but nutrient poor.

DESIGN

Energy and nutrient intakes for 112 women aged 18-45 y living in California were obtained with a food-frequency instrument. Dietary energy density (in MJ/kg or kcal/g) and energy-adjusted diet costs (in $/10 MJ or $/2000 kcal) were calculated with local food prices. Tertile splits of energy density and energy cost were analyzed with one-factor analysis of variance.

RESULTS

Mean daily energy intake excluding all beverages was 7.1 MJ (1699 kcal), and mean dietary energy density was 6.5 kJ/kg (1.54 kcal/g). Lower dietary energy density was associated with significantly higher intakes of dietary fiber (P = 0.004), vitamin A (P < 0.001), and vitamin C (P < 0.001) and with significantly lower intakes of total fat (P = 0.003) and saturated fat (P < 0.001). Higher diet cost was associated with significantly lower dietary energy density (P < 0.001), total fat (P = 0.024), and saturated fat (P = 0.025) and with significantly higher intakes of vitamins A (P = 0.003) and C (P < 0.001). Each additional dollar in estimated diet costs was associated with a drop in energy density of 0.94 MJ/kg (0.225 kcal/g).

CONCLUSIONS

The finding that higher quality diets were more costly for these low-income women has implications for the food assistance and education programs of the US Department of Agriculture. Policy interventions may be required to allow low-income families in the United States to improve the quality of their diets given their food budget constraints.

Interventions for treating obesity in children

BACKGROUND

Child and adolescent obesity is increasingly prevalent, and can be associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the efficacy of lifestyle, drug and surgical interventions for treating obesity in childhood.

SEARCH STRATEGY

We searched CENTRAL on The Cochrane Library Issue 2 2008, MEDLINE, EMBASE, CINAHL, PsycINFO, ISI Web of Science, DARE and NHS EED. Searches were undertaken from 1985 to May 2008. References were checked. No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of lifestyle (i.e. dietary, physical activity and/or behavioural therapy), drug and surgical interventions for treating obesity in children (mean age under 18 years) with or without the support of family members, with a minimum of six months follow up (three months for actual drug therapy). Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data following the Cochrane Handbook. Where necessary authors were contacted for additional information.

MAIN RESULTS

We included 64 RCTs (5230 participants). Lifestyle interventions focused on physical activity and sedentary behaviour in 12 studies, diet in 6 studies, and 36 concentrated on behaviorally orientated treatment programs. Three types of drug interventions (metformin, orlistat and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies included varied greatly in intervention design, outcome measurements and methodological quality.Meta-analyses indicated a reduction in overweight at 6 and 12 months follow up in: i) lifestyle interventions involving children; and ii) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.

AUTHORS' CONCLUSIONS

While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Comparability of weighed dietary records and a self-administered diet history questionnaire for estimating monetary cost of dietary energy

An increasing number of studies have estimated monetary diet cost using various dietary assessment methods, based on databases on retail food prices, for investigating its association with dietary intake and health outcomes. However, information regarding the comparability of monetary diet cost across dietary assessment methods is absolutely lacking. This study compared monetary cost of dietary energy estimated from weighed dietary records (DRs) with that estimated from a self-administered diet history questionnaire (DHQ). The subjects were 92 Japanese women aged 31-69 years and 92 Japanese men aged 32-76 years. The DHQ (assessing diet during the preceding month) and 4-day DRs (one weekend day and three weekdays) were completed in each season over a 1-year period (DHQs1-4 and DRs1-4, respectively). An additional DHQ was completed at one year after completing DHQ1 (DHQ5). Monetary cost of dietary energy (Japanese yen/4184 kJ) was calculated using food intake information derived from each dietary assessment method, based on retail food prices. Pearson correlation between the mean of DRs1-4 and mean of DHQs1-4 was 0.64 for women and 0.69 for men. Pearson correlation between the mean of DRs1-4 and DHQ1 was 0.60 for women and 0.52 for men, while intraclass correlation between DHQ1 and DHQ5 was 0.64 for women and 0.51 for men. These data indicate reasonable comparability of monetary cost of dietary energy across DR and a DHQ as well as usefulness of a single administration of the DHQ for estimating monetary cost of dietary energy.

Nutrient profiling can help identify foods of good nutritional quality for their price: a validation study with linear programming

Nutrient profiling ranks foods based on their nutrient content. They may help identify foods with a good nutritional quality for their price. This hypothesis was tested using diet modeling with linear programming. Analyses were undertaken using food intake data from the nationally representative French INCA (enquête Individuelle et Nationale sur les Consommations Alimentaires) survey and its associated food composition and price database. For each food, a nutrient profile score was defined as the ratio between the previously published nutrient density score (NDS) and the limited nutrient score (LIM); a nutritional quality for price indicator was developed and calculated from the relationship between its NDS:LIM and energy cost (in euro/100 kcal). We developed linear programming models to design diets that fulfilled increasing levels of nutritional constraints at a minimal cost. The median NDS:LIM values of foods selected in modeled diets increased as the levels of nutritional constraints increased (P = 0.005). In addition, the proportion of foods with a good nutritional quality for price indicator was higher (P < 0.0001) among foods selected (81%) than among foods not selected (39%) in modeled diets. This agreement between the linear programming and the nutrient profiling approaches indicates that nutrient profiling can help identify foods of good nutritional quality for their price. Linear programming is a useful tool for testing nutrient profiling systems and validating the concept of nutrient profiling.