High monetary costs of dietary patterns associated with lower body mass index: a population-based study

The Relationship between Diet Costs and Dietary Adequacy: A Scoping Review of Measures and Methods with a Focus on Cost Estimation using Food Supply Data

BACKGROUND

"Diet cost" refers to a methodological approach developed by Drewnowski et al. to estimate individual daily diet costs, where cost vectors are derived by matching prices from food supply data to the food sources of reported intakes from dietary assessment tools. The dietary assessment method and food price collection approach have been found to vary diet cost estimates. There is a need to better understand how food supply prices might be better standardized and attached to price individuals' diets.

OBJECTIVES

To conduct a scoping review to examine Drewnowski's diet cost method, with a focus on a detailed description and charting of cost estimation measures and methods used to price individuals' consumed diets.

METHODS

Five databases were searched from the inception of each database to March 2023. Included articles comprised analyses of individual-level dietary assessment data matched to food prices to assign estimates of individual daily diet costs.

RESULTS

A total of 55 articles were included, published between 1999 and 2022 from 17 countries. In all studies, cost estimates were intended to be representative of price exposures among individual respondents' dietary assessment data. All studies derived cost estimates from separately collected food prices. 34 (62%) of included articles collected food prices from retail (supermarket) audits. A minority of studies (19, 35%) reported the number of food prices used to cost diets, and those varied widely, ranging from 57 to nearly 4600 distinct food prices per study.

CONCLUSIONS

In the absence of a standardized approach to study the relationship between diet costs and dietary adequacy, this scoping review has described methodological concepts and parameters used to price individuals' consumed diets. Our review shows that despite common arithmetic to calculate cost vectors, there is substantial variation in the methods used to select and attach prices from the food supply to self-reported dietary intake assessments.

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.

Cost of a Healthy Diet: A Population-Representative Comparison of 3 Diet Cost Methods in Canada

BACKGROUND

Different food price sources and dietary assessment tools may impact the estimation of diet costs and hamper our understanding of the relationship between diet costs and dietary intakes.

OBJECTIVES

We aimed to investigate the effect of 3 diet cost derivation methods, with increasing numbers of food prices and geographic specificity, holding consistent the dietary assessment tool, on the estimation of diet costs overall and by food group.

METHODS

We matched 24-h dietary recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS-N) to food price data from 3 Canadian Consumer Price Index (CPI) food price lists; national short list, national long list, and provincial long list. We compared the daily ($/day) and energy-adjusted ($/2000 kcal) diet costs overall and by food groups for the overall population (4+), children (4-18), and adults (19+).

RESULTS

The proportion of dietary intakes (grams) that were covered by CPI prices significantly increased from the national short list to the national long list but did not significantly differ from the national long list to the provincial long list. The national short list resulted in the highest daily and energy-adjusted diet costs overall. No difference in diet costs was noted between the national and provincial long lists. Diet costs for 4 food groups-additions, sweets, fruits, and vegetables, which were poorly covered by the national short list-significantly differed using the national and provincial long lists. All 3 diet cost methods were significantly correlated with energy intakes; however, a strong/very strong correlation was detected for children, and a weak/moderate correlation for adults.

CONCLUSIONS

The choice of food price data may introduce bias in the diet cost estimate, as well as limiting our understanding of how individuals allocate their diet costs. Refinement of diet cost estimation methodology and measures can strengthen future studies of how consumers allocate their purchases to their diets.

Association of monetary diet cost of foods and diet quality in Spanish older adults

BACKGROUND

A major barrier to a healthy diet may be the higher price of healthy foods compared to low-quality foods.

OBJECTIVES

This study aimed to assess the association between the monetary cost of food and diet quality in Spanish older adults at high risk of cardiovascular disease.

METHODS

Cross-sectional analysis was carried out in Spanish older adults (n = 6,838; 48.6% female). A validated food frequency questionnaire was used to assess dietary intake. Metabolic syndrome severity, adherence to the Mediterranean diet (MedDiet), adherence to a provegetarian dietary pattern, and dietary inflammatory index were assessed. The economic cost of the foods was obtained from the Spanish Ministry of Agriculture Fisheries and Food database (2015-2017, the period of time when the participants were recruited). The total cost of diet adjusted per 1,000 kcal was computed.

RESULTS

The healthier dietary pattern was associated with a higher cost of the diet. Higher adherence to the MedDiet, anti-inflammatory diet, and the healthy version of the provegetarian dietary pattern were related to higher costs of the diet.

CONCLUSION

Higher diet quality was associated with a higher dietary cost of the diet per 1,000 kcal/day. Food prices can be an important component of interventions and policies aimed at improving people's diets and preventing diet-related chronic diseases.

CLINICAL TRIAL REGISTRY NUMBER

The trial was registered in 2014 at the International Standard Randomized Controlled Trial (ISRCT; http://www.isrctn.com/ISRCTN89898870) with the number 89898870.

The joint association of serum vitamin D status and cardiorespiratory fitness with obesity and metabolic syndrome in Tehranian adults

We aimed to assess the individual and joint association of serum vitamin D and cardiorespiratory fitness (CRF) with obesity and metabolic syndrome (MetSyn). In this cross-sectional study 270 adults with an age range of 18 years and older were recruited from health centers from five districts in Tehran, Iran. CRF was assessed with Bruce protocol. MetSyn was defined based on International Diabetes Federation 2009. The odds ratio (OR) and 95 % confidence interval (CI) of obesity and MetSyn across tertiles of serum vitamin D and CRF were estimated with control for confounders. The results indicated that neither 25(OH)D nor 1,25(OH)D was associated with obesity and MetSyn. There was a strong inverse association between CRF and general (P_-trend < 0.001) and abdominal adiposity (P_-trend: 0.001). The joint association of vitamin D and CRF indicated that the inverse association of CRF with obesity was stronger in those with high serum vitamin D than those with low serum vitamin D and this joint association remained after considering age and diet quality. There was a significant inverse association for those with low serum 25(OH)D and high CRF (OR: 0.12, 95 % CI: 0.04-0.81; P = 0.02) compared to those with low serum 25(OH)D and low CRF in the crude model. Also, the OR of general obesity was 0.17 (95 % CI: 0.02-0.79; P = 0.03) for those with high CRF and low serum 1,25(OH)D compare with the reference group. Our findings indicated a strong inverse association between CRF and obesity, especially in those with high serum vitamin D.

Application of Mediterranean Diet in Cardiovascular Diseases and Type 2 Diabetes Mellitus: Motivations and Challenges

Objective: Cardiovascular disease (CVD) is the leading cause of disability and death in many countries. Together with CVD, Type 2 diabetes mellitus (T2DM) accounts for more than 80% of all premature non-communicable disease deaths. The protective effect of the Mediterranean diet (MedDiet) on CVD and its risk factors, including T2DM, has been a constant topic of interest. Notwithstanding, despite the large body of evidence, scientists are concerned about the challenges and difficulties of the application of MedDiet. This review aims to explore the motivations and challenges for using MedDiet in patients with CVD and T2DM. Design: An electronic search was conducted for articles about MedDiet published in PubMed, ScienceDirect, Scopus, and Web of Science up to December 2021, particularly on CVD and T2DM patients. From a total of 1536 studies, the final eligible set of 108 studies was selected. Study selection involved three iterations of filtering. Results: Motivation to apply MedDiet was driven by the importance of studying the entire food pattern rather than just one nutrient, the health benefits, and the distinct characteristics of MedDiet. Challenges of the application of MedDiet include lacking universal definition and scoring of MedDiet. Influences of nutritional transition that promote shifting of traditional diets to Westernized diets further complicate the adherence of MedDiet. The challenges also cover the research aspects, including ambiguous and inconsistent findings, the inexistence of positive results, limited evidence, and generalization in previous studies. The review revealed that most of the studies recommended that future studies are needed in terms of health benefits, describing the potential benefits of MedDiet, identifying the barriers, and mainly discussing the effect of MedDiet in different populations. Conclusions: In general, there is consistent and strong evidence that MedDiet is associated inversely with CVD risk factors and directly with glycemic control. MedDiet is the subject of active and diverse research despite the existing challenges. This review informs the health benefits conferred by this centuries-old dietary pattern and highlights MedDiet could possibly be revolutionary, practical, and non-invasive approach for the prevention and treatment CVD and T2DM.

Sustainability Dimensions of the Mediterranean Diet: A Systematic Review of the Indicators Used and Its Results

The concern about sustainability is growing and the Mediterranean diet has been extensively identified as a promising model, with benefits for human and environmental health. This systematic review aims to identify and describe the indicators that have been used to evaluate the sustainability of the Mediterranean diet and the results from their application. A methodology using PRISMA guidelines was followed, and searches were performed in Web of Science, PubMed, Scopus, and GreenFile. A total of 32 studies assessing the sustainability of the Mediterranean diet were identified. Twenty-five of these studies quantified the environmental impact, 7 studies evaluated the nutritional quality, and 12 studies assessed the daily cost of this dietary pattern. A total of 33 distinct indicators were identified, of which 10 were used to assess the environmental dimension (mainly, carbon, water, and ecological footprint), 8 were used to assess the nutritional dimension (mainly Health score and Nutrient Rich Food Index), 1 was used to assess the economic dimension (dietary cost), and 8 used combined indicators. The remaining 6 indicators for the assessment of sociocultural dimension were only identified in 1 study but were not measured. The Mediterranean diet had a lower environmental impact than Western diets and showed a carbon footprint between 0.9 and 6.88 kg CO2/d per capita, a water footprint between 600 and 5280 m3/d per capita, and an ecological footprint between 2.8 and 53.42 m2/d per capita. With regard to the nutritional dimension, the Mediterranean diet had a high nutritional quality and obtained 122 points on the Health score and ranged between 12.95 and 90.6 points on the Nutrient Rich Food Index. The cost of the Mediterranean diet is similar to other diets and varied between 3.33 and 14.42€/d per capita. These findings show that no uniformity in assessing the MDiet's sustainability exists.

Low Adherence to the Mediterranean Diet Is Associated with Poor Socioeconomic Status and Younger Age: A Cross-Sectional Analysis of the EpiDoC Cohort

The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns as it has been consistently associated with several beneficial health outcomes. Adherence to the MD pattern has been decreasing in southern European countries for the last decades, especially among low socioeconomic groups. The aim of this study was to assess the adherence to the MD in Portugal, to evaluate regional differences, and explore associated factors (sociodemographic, economic, and lifestyles behaviors). This study used the third data collection wave of the Epidemiology of Chronic Diseases Cohort Study (EpiDoC 3). MD adherence was assessed using the Portuguese-validated MD adherence score (MEDAS) questionnaire. Non-adjusted and adjusted logistic regression models were used to assess the risk factors for low MD adherence and individual MEDAS items. In this cross-sectional evaluation of the EpiDoC 3 cohort study (n = 5647), 28.8% of the Portuguese population had low adherence to a MD. Azores and Madeira had lower adherence to the MD than the rest of the country. Younger individuals in lower income categories (e.g., OR_{finding it very difficult} = 1.48; 95% CI 1.16-1.91) and with a lower educational level (e.g., OR_{0-4 years} = 2.63; 95% CI 2.09-3.32) had higher odds of having a lower adherence to the MD. Portuguese adults have a high prevalence of low adherence to the MD, especially among those who are younger and have lower socioeconomic status. Public health policies to promote adherence to the MD should pay special attention to these groups.

Feasibility and measurement error in using food supply data to estimate diet costs in Canada

OBJECTIVE

The cost of food is a key influence on diet. The majority of diet cost studies match intake data from population-based surveys to a single source of food supply prices. Our aim was to examine the methodological significance of using food supply data to price dietary intakes.

METHODS

Nationally representative 24-hour dietary recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS-N) was matched to the 2015 Canadian Consumer Price Index (CPI) food price list. Proportions and means of reported intakes covered by the 2015 CPI price list were used to compare reported intakes of food groups and food components of interest and concern overall, and by quartile of CPI coverage.

SETTING

Canada.

PARTICIPANTS

20,487 Canadians ages one and older.

RESULTS

The CPI covered on average 76.3% of total dietary intake (g) without water. Staple food groups that were more commonly consumed had better CPI price coverage than those less commonly consumed. Yet some food groups (vegetables, additions, sweets) that were also commonly consumed by Canadians were not well covered by price data. Individuals in the poorest CPI coverage quartile reported consuming significantly greater fibre (g), gram weight (g), dietary fibre (g), and energy (kcal) as compared to those with the best coverage.

CONCLUSIONS

Differential CPI price coverage exists among food components and commonly consumed food groups; additionally dietary intake differs significantly in the population by CPI coverage. Methodological refinements are needed to better account for error when using prices from food supply data to estimate diet costs.

Assessment of the Cost of the Mediterranean Diet in a Low-Income Region: Adherence and Relationship with Available Incomes

Background

The Mediterranean Diet (MD) is recognized as heart-healthy, but the economic cost associated with this type of diet has scarcely been studied.

The objective of the present study is to explore the cost and adherence of a low-income region population to the MD and its relationship with income.

Methods

A population-based study was carried out on 2,833 subjects between 25 and 79 years of age, 54% women, selected at random from the municipalities of Vegas Altas, La Siberia and La Serena in the province of Badajoz, Extremadura (Spain).

Average monthly cost of each product included in the MD was computed and related to adherence to the MD using the Panagiotakos Index and average disposable income.

Results

The monthly median cost was 203.6€ (IQR: 154.04-265.37). Food-related expenditure was higher for men (p<0.001), age cohort between 45 and 54 years (p<0.013) and those living in urban areas (p<0.001). A positive correlation between food-related expenditure and the MD adherence was found. Monthly median cost represents 15% of average disposable income, ranging between 11% for the group with low MD adherence and 17% for the group with high MD adherence.

Conclusions

The monthly cost of the MD was positively correlated with the degree of adherence to this dietary pattern. Given that the estimated monthly cost is similar to that of other Spanish regions with a higher income level, the economic effort required to be able to afford the Mediterranean diet is higher. This may represent a barrier to access, which should be analyzed in detail by public decision-makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12433-w.

The cost of diets according to diet quality and sociodemographic characteristics in children and adolescents in Belgium

This study aims to estimate cost variations according to diet quality and sociodemographic characteristics in children. Data (n = 1,596; 5-17 y) from the Belgian National Food Consumption Survey were used. The "Kidmed index" and dietary patterns (DP) identified through principal component analysis were used to assess diet quality. Daily diet cost was estimated after linking the consumed foods with the GfK ConsumerScan panel food prices. The mean diet cost was 4.68€/day (SEM: 0.05). Adjusted for covariates and energy intake, the mean diet cost was 9.1% higher in the highest Kidmed adherence (vs. the lowest) and 6.2% higher in the tercile T3 (vs. T1) of the "Healthy" DP score. It was 4.8% lower in the T3 (vs. T1) for the "Junk food" DP score. Diet cost was higher in 12-17 year-olds (vs. 5-11 years) and in medium and high educated household (vs. the lowest). These findings support policies to make healthy diets more affordable.

Dietary changes and food habits: social and clinical determinants in a cohort of women diagnosed with breast cancer in Barcelona (DAMA cohort)

OBJECTIVE

The aim of this study was to analyze the influence of social determinants on changes in dietary habits before and after diagnosis of breast cancer in women (Barcelona, 2003-2013).

METHODS

We performed a cohort study with 2,235 women diagnosed with breast cancer. The information was obtained from an ad hoc questionnaire based on recommendations from the Spanish Society of Community Nutrition. We conducted a descriptive bivariate analysis and fit logistic regression models. The dependent variable was the change in dietary habits (food groups) and the independent variables were a selection of social and clinical variables (age, social class, cohabitation, years since diagnosis, history of replaces, and treatment with chemotherapy).

RESULTS

While 5.8% of women followed a healthy diet (consumption of vegetables, fruits, farinaceous, lean meat, and seafood) before diagnosis, 9.5% did so after diagnosis. We observed statistically significant changes in consumption of all food groups (p < 0.001) after diagnosis. The greatest change in consumption patterns was observed in women aged < 50 years and those from non-manual classes (high classes) [e.g., legume consumption: OR_{<50 years/>65 years} = 2.9 (95% CI 1.78-4.81); OR_{non-manual/manual} = 2.5 (95% CI 1.38-4.36)]. The occurrence of relapses and chemotherapy was associated with greater changes in dietary habits.

CONCLUSION

Women with breast cancer change their eating habits after diagnosis, and these changes are conditioned by social and clinical determinants.

Affordability of Different Isocaloric Healthy Diets in Germany-An Assessment of Food Prices for Seven Distinct Food Patterns

Affordability of different isocaloric healthy diets in Germany—an assessment of food prices for seven distinct food patterns Background: For decades, low-fat diets were recommended as the ideal food pattern to prevent obesity, type 2 diabetes and their long-term complications. Nowadays, several alternatives considering sources and quantity of protein, fat and carbohydrates have arisen and clinical evidence supports all of them for at least some metabolic outcomes. Given this variety in diets and the lack of a single ideal diet, one must evaluate if patients at risk, many of which having a lower income, can actually afford these diets. Aim: We modelled four-week food plans for a typical family of two adults and two school children based on seven different dietary patterns: highly processed standard omnivore diet (HPSD), freshly cooked standard omnivore diet (FCSD), both with German average dietary composition, low-protein vegan diet (VeganD), low-fat vegetarian diet (VegetD), low-fat omnivore diet (LFD), Mediterranean diet (MedD) and high-fat moderate-carb diet (MCD). The isocaloric diets were designed with typical menu variation for all meal times. We then assessed the lowest possible prices for all necessary grocery items in 12 different supermarket chains, avoiding organic foods, special offers, advertised exotic super foods and luxury articles. Prices for dietary patterns were compared in total, stratified by meal time and by food groups. Results: Among all seven dietary patterns, price dispersion by supermarket chains was 12–16%. Lowest average costs were calculated for the VegetD and the FCSD, followed by HPSD, LFD, VeganD, MedD and—on top—MCD. VeganD, MedD and MCD were about 16%, 23% and 67% more expensive compared to the FCSD. Major food groups determining prices for all diets are vegetables, salads and animal-derived products. Calculations for social welfare severely underestimate expenses for any kind of diet. Conclusions: Food prices are a relevant factor for healthy food choices. Food purchasing is financially challenging for persons with very low income in Germany. Fresh-cooked plant-based diets are less pricy than the unhealthy HPSD. Diets with reduced carbohydrate content are considerably more expensive, limiting their use for people with low income. Minimum wage and financial support for long-term unemployed people in Germany are insufficient to assure a healthy lifestyle.

Adhering to a Mediterranean diet in a Mediterranean country: an excess cost for families?

BACKGROUND

Adherence to the Mediterranean diet has been decreasing in southern Europe, which could be linked to several cultural or educational factors. Our aim is to evaluate the extent to which economic aspects may also play a role, exploring the relationship between food prices in Portugal and adherence to the Mediterranean diet.

METHODS

We evaluated data from the Portuguese National Food, Nutrition, and Physical Activity Survey (IAN-AF 2015-2016) (n=3,591). Diet expenditures were estimated by attributing a retail price to each food group and the diet was transposed into the Mediterranean Diet Score used in the literature. Prices were gathered from five supermarket chains (65% of the Portuguese market share). Linear regression models were used to assess the association between different adherence levels to the MD levels and dietary costs.

RESULTS

Greater adherence to the MD was associated with a 21.2% (p< 0.05) rise in total dietary cost, which accounts for more 0.59€ in mean daily costs when compared with low adherence. High adherence individuals (vs. low adherence) had higher absolute mean daily costs with fish (0.62€/+285.8%; p< 0.05), fruits (0.26€/+115.8%; p< 0.05), and vegetables (0.10€/+100.9%; p< 0.05). The analysis stratified by education and income level showed significantly higher mean daily diet cost only amongst higher income groups.

CONCLUSIONS

Our findings suggest that greater adherence to the MD was positively and significantly associated with higher total dietary cost. Policies to improve population's diet should take into consideration the cost of healthy foods, especially for large low- and middle-income families.

The Cost of Diets According to Nutritional Quality and Sociodemographic Characteristics: A Population-Based Assessment in Belgium

BACKGROUND

Prices of foods can influence purchase and, therefore, overall quality of diet. However, a limited number of studies have analyzed the cost of diets according to the overall quality of diets taking into account sociodemographic characteristics.

OBJECTIVE

Our aim was to estimate cost variations according to diet quality and to identify sociodemographic characteristics associated with such cost differences in adults' diets in Belgium.

DESIGN

This cross-sectional study used nationally representative data from Belgium.

PARTICIPANTS/SETTINGS

Participants were adults (aged 18 to 64 years; n = 1,158) included in the 2014-2015 Belgian National Food Consumption Survey.

MAIN OUTCOME MEASURES

Dietary assessment was based on two 24-hour dietary recalls and a food frequency questionnaire. The Mediterranean Diet Score and the Healthy Diet Indicator were used to assess diet quality. Daily diet cost was estimated after linking the consumed foods with the 2014 GfK ConsumerScan Panel food price data.

STATISTICAL ANALYSES PERFORMED

Associations were estimated using linear regressions.

RESULTS

The mean daily diet cost was US$6.51 (standard error of mean [SEM] US$0.08; €5.79 [€0.07]). Adjusted for covariates and energy intake, mean (SEM) daily diet cost was significantly higher in the highest tercile (T3) of both diet quality scores than in the T1 (Mediterranean Diet Score: T1 = US$6.29 [US$0.10]; €5.60 [€0.09] vs T3 = US$6.78 [US$0.11]; €6.03 [€0.10]; Healthy Diet Indicator: T1 = US$6.09 [US$0.10]; €5.42 [€0.09] vs T3 = US$7.13 [US$0.11]; €6.34 [€0.10]). Both diet quality and cost were higher in 35- to 64-year-old respondents (vs 18- to 34-year-olds), workers (vs students), and those with higher education levels (vs the lowest). The association between quality and cost of diets was weaker in men and among individuals with higher education levels.

CONCLUSIONS

In Belgium, a high-quality diet was more expensive than a low-quality diet. These findings can be used to inform public health policies.

Measuring cost and affordability of current vs. healthy diets in Argentina: an application of linear programming and the INFORMAS protocol

BACKGROUND

Food cost and affordability is one of the main barriers to improve the nutritional quality of diets of the population. However, in Argentina, where over 60% of adults and 40% of children and adolescents are overweight or obese, little is known about the difference in cost and affordability of healthier diets compared to ordinary, less healthy ones.

METHODS

We implemented the "optimal approach" proposed by the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS). We modelled the current diet and two types of healthy diets, one equal in energy with the current diet and one 6.3% lower in energy by linear programming. Cost estimations were performed by collecting food product prices and running a Monte Carlo simulation (10,000 iterations) to obtain a range of costs for each model diet. Affordability was measured as the percentage contribution of diet cost vs. average household income in average, poor and extremely poor households and by income deciles.

RESULTS

On average, households must spend 32% more money on food to ensure equal energy intake from a healthy diet than from a current model diet. When the energy intake target was reduced by 6.3%, the difference in cost was 22%. There are no reasonably likely situations in which any of these healthy diets could cost less or the same than the current unhealthier one. Over 50% of households would be unable to afford the modelled healthy diets, while 40% could not afford the current diet.

CONCLUSIONS

Differential cost and affordability of healthy vs. unhealthy diets are germane to the design of effective public policies to reduce obesity and NCDs in Argentina. It is necessary to implement urgent measures to transform the obesogenic environment, making healthier products more affordable, available and desirable, and discouraging consumption of nutrient-poor, energy-rich foods.

The Economic Cost of Diet and Its Association with Adherence to the Mediterranean Diet in a Cohort of Spanish Primary Schoolchildren

Background: Adoption of a certain dietary pattern is determined by different factors such as taste, cost, convenience, and nutritional value of food. Objective: To assess the association between the daily cost of a diet and its overall quality in a cohort of 6-12-year-old Spanish schoolchildren. Methods: A cross-sectional survey was conducted on a cohort (n = 130; 47% female) of 6-12-year-old children schooled in primary education in the central region of Spain. Three-day 24 h records were administered, and the nutritional quality of the diet was also determined by means of Mediterranean Adequacy Index (MAI). A questionnaire on sociodemographic data, frequency of eating in fast-food restaurants, and supplement intake were also recorded. The person responsible for the child's diet and the schooler himself completed the questionnaires, and homemade measures were used to estimate the size of the portions. Food prices were obtained from the Household Consumption Database of the Spanish Ministry of Agriculture, Fisheries and Food. The economic cost of the diet was calculated by multiplying the amount in grams of the food consumed by each child by the corresponding price in grams and adding up the total amount for each participant. The total economic cost of the diet was calculated in €/day and in €/1000 kcal/day. Results: The area under the curve (AUC) for €/day and €/1000 kcal/day represent 62.6% and 65.6%, respectively. According to AUC values, adherence to Mediterranean diet (MD) is a moderate predictor of the monetary cost of the diet. A direct relationship between the cost of the diet and the adherence to MD was observed [OR (€/1000 kcal/day) = 3.012; CI (95%): 1.291; 7.026; p = 0.011]. Conclusions: In a cohort of Spanish schoolchildren with low adherence to the MD, a higher cost of the diet standardized to 1000 kcal was associated with above-average MAI values.

Mediterranean Lifestyle to Promote Physical, Mental, and Environmental Health: The Case of Chile

Chile is currently experiencing a progressive epidemiological transition towards chronic diseases. In this country, >50% of annual deaths are attributed to cardiovascular disease and cancer. Moreover, health surveys have shown high prevalence of obesity, diabetes, hypertension, and elevated cardiovascular disease risk. In addition, mental health issues are also frequent among Chilean adults. On the other hand, the agri-food system contributes to 21-37% of greenhouse gases emissions worldwide. Overall, current health and food chain situation calls out for design and implementation of evidence-based feasible and effective nutritional interventions needed to promote physical and mental health along with addressing food sustainability in Chile. Nowadays, the Mediterranean diet is recognized as one of the healthiest dietary patterns based on observational and interventional studies linked to a wide variety of health outcomes. However, a Mediterranean lifestyle goes well beyond food intake: it includes promotion of psychosocial resources, community life as well as cultural traditions. Indeed, Mediterranean lifestyle is a true modus vivendi that integrally promotes physical, mental, and social well-being. In addition, the Mediterranean diet stands out for its environmental sustainability because it is characterized mainly as a plant-based dietary pattern with low carbon and water footprints. Remarkably, Central Chile has a Mediterranean-like setting with plant and animal food production and availability patterns comparable to those present in countries located around the Mediterranean Sea. Therefore, this article reviews how promotion of Mediterranean lifestyle adherence in Chile offers great potential for management of the ongoing epidemiological transition to chronic diseases as well to promote psychological well-being within a unique food system and dietary sustainability vision for this Latin American country.

Monetary diet cost is positively associated with diet quality and obesity: an analysis of school-aged children in Southwest China

BACKGROUND

Little is known about the relationships between diet cost, dietary intake and obesity in Chinese populations. This study explored how diet cost was related to diet quality and obesity among school-aged children in Southwest China.

METHODS

Data from a cross-sectional study was analysed. Diet cost was estimated based on dietary intake assessed with 24-h dietary recalls and retail food prices. Diet quality was measured using the Chinese Children Dietary Index. Body height, weight, waist circumference and skinfold thicknesses were measured, and their body mass index standard deviation score (BMISDS), waist-to-height ratio (WHtR), fat mass index (FMI) and fat-free mass index (FFMI) were calculated. Multivariate regression models were used to explore the relevance of diet cost to diet quality and obesity.

RESULTS

After adjustment for potential confounders, a positive association was observed between diet quality and energy-adjusted diet cost (β = 0.143, 95% confidence interval, CI: 0.014-0.285, Pfor-trend = 0.0006). Energy-adjusted diet cost also showed a positive association with FMI (β = 0.0354, 95% CI: 0.0001-0.0709, Pfor-trend = 0.01), BMISDS (β = 0.0200, 95% CI: 0.0006-0.0394, Pfor-trend = 0.002) and WHtR (β = 0.0010, 95% CI: 0.0003-0.0017, Pfor-trend = 0.02).

CONCLUSIONS

Energy-adjusted diet cost was independently and positively associated with diet quality and obesity among Chinese school-aged children.

The association between the cost and quality of diets of children in Canada

OBJECTIVES

To examine the association between the cost and quality of diets of grade 5 children in Alberta, Canada.

METHODS

We used survey data of 2731 grade 5 students (10-11 years of age), collected between March and June 2014. This survey included the Harvard Youth Adolescent Food Frequency Questionnaire which captures information on intake of 147 food items. On the basis of these food items, we calculated the diet quality, using the Diet Quality Index-International (DQI) and Canada's Food Guide, and costs by accessing prices from four Canadian grocery retailers. We applied linear regression to determine the association of diet quality with costs.

RESULTS

We estimated the cost of a child's diet to be CAD $13.19 per day. For the 12% of children with a low diet quality, these costs were $12.12 and for the 66% of children with moderate and 22% with high diet quality, these costs were $13.27 and $13.51, respectively. For every one-unit increase in DQI, the cost of the diet increased by seven cents per day. Diets that met the recommendations for vegetables and fruit and for meat and alternatives were respectively 53 cents and $1.39 higher relative to diets not meeting these recommendations. Costs for unessential food items constituted $1.39 per day.

CONCLUSION

We observed a gradient whereby diets of better quality are costlier. For low-income households, this may lead to a genuine barrier to healthy eating. Initiatives that target unhealthy unessential foods may create the financial space for households to purchase pricier healthier options. Such initiatives may also alleviate future health care costs.

Obesity and the Mediterranean Diet: A Review of Evidence of the Role and Sustainability of the Mediterranean Diet

Several different socio-economic factors have caused a large portion of the population to adopt unhealthy eating habits that can undermine healthcare systems, unless current trends are inverted towards more sustainable lifestyle models. Even though a dietary plan inspired by the principles of the Mediterranean Diet is associated with numerous health benefits and has been demonstrated to exert a preventive effect towards numerous pathologies, including obesity, its use is decreasing and it is now being supplanted by different nutritional models that are often generated by cultural and social changes. Directing governments' political actions towards spreading adherence to the Mediterranean Diet's principles as much as possible among the population could help to tackle the obesity epidemic, especially in childhood. This document intends to reiterate the importance of acting in certain age groups to stop the spread of obesity and proceeds with a critical review of the regulatory instruments used so far, bearing in mind the importance of the scientific evidence that led to the consideration of the Mediterranean Diet as not just a food model, but also as the most appropriate regime for disease prevention, a sort of complete lifestyle plan for the pursuit of healthcare sustainability.

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.

Dietary cost associated with adherence to the Mediterranean diet, and its variation by socio-economic factors in the UK Fenland Study

High cost of healthy foods could be a barrier to healthy eating. We aimed to examine the association between dietary cost and adherence to the Mediterranean diet in a non-Mediterranean country. We evaluated cross-sectional data from 12 417 adults in the UK Fenland Study. Responses to 130-item FFQ were used to calculate a Mediterranean diet score (MDS). Dietary cost was estimated by matching food consumption data with retail prices of five major supermarkets. Using multivariable-adjusted linear regression, we examined the association of MDS and individual foods with dietary cost in absolute and relative scales. Subsequently, we assessed how much the association was explained by education, income, marital status and occupation, by conducting mediation analysis and testing interaction by these variables. High compared with low MDS (top to bottom third) was associated with marginally higher cost by 5·4 % (95 % CI 4·4, 6·4) or £0·20/d (95 % CI 0·16, 0·25). Participants with high adherence had higher cost associated with the healthier components (e.g. vegetables, fruits and fish), and lower cost associated with the unhealthy components (e.g. red meat, processed meat and sweets) (P for trend<0·001 each). In total, 20·7 % (95 % CI 14·3, 27·0) of the MDS-cost association was explained by the selected socio-economic factors, and the MDS-cost association was of greater magnitude in lower socio-economic groups (P interaction<0·005). Overall, greater adherence to the Mediterranean diet was associated with marginally higher dietary cost, partly modified and explained by socio-economic status, but the potential economic barriers of high adherence might be offset by cost saving from reducing unhealthy food consumption.

Contribution of Dietary Supplements to Nutritional Adequacy by Socioeconomic Subgroups in Adults of the United States

Many Americans have inadequate intakes of several nutrients, and the Dietary Guidelines for Americans 2015–2020 identified vitamins A, C, D, and E, in addition to calcium, magnesium, iron, potassium, choline, and fiber as “underconsumed nutrients”. Based on nationally representative data on 10,698 adults from National Health and Nutrition Examination Surveys (NHANES), 2009–2012, assessments were made of socioeconomic differences, based on the Poverty Income Ratio (PIR), in terms of the association of dietary supplement use on nutrient intake and nutrient inadequacies. Compared to food alone, the use of any dietary supplement plus food was associated with significantly (p < 0.01) higher intakes of 15–16 of 19 nutrients examined in all socioeconomic groups; and significantly reduced rates of inadequacy for 10/17 nutrients in the subgroup PIR > 1.85 (not poor), but only 4–5/17 nutrients (calcium and vitamins A, C, D, E) for the poor and nearly poor subgroups (PIR < 1.35 and PIR 1.35 to ≤1.85, respectively). An increased prevalence of intakes above the Tolerable Upper Intake Level (UL) was seen for 3–9/13 nutrients, but all were less than 5% in the PIR subgroups. In conclusion, dietary supplement use was associated with an increased micronutrient intake, decreased inadequacies, and a slight increase in the prevalence of intakes above the UL, with greater benefits seen in the PIR > 1.85 subgroup.

Neighborhood Prices of Healthier and Unhealthier Foods and Associations with Diet Quality: Evidence from the Multi-Ethnic Study of Atherosclerosis

It is known that the price of food influences the purchasing and consumption decisions of individuals; however, little work has examined if the price of healthier food relative to unhealthier food in an individual’s neighborhood is associated with overall dietary quality while using data from multiple regions in the United States. Cross-sectional person-level data came from The Multi-Ethnic Study of Atherosclerosis (exam 5, 2010–2012, n = 2765); a food frequency questionnaire assessed diet. Supermarket food/beverage prices came from Information Resources Inc. (n = 794 supermarkets). For each individual, the average price of select indicators of healthier foods (vegetables, fruits, dairy) and unhealthier foods (soda, sweets, salty snacks), as well as their ratio, was computed for supermarkets within three miles of the person’s residential address. Logistic regression estimated odds ratios of a high-quality diet (top quintile of Healthy Eating Index 2010) associated with healthy-to-unhealthy price ratio, adjusted for individual and neighborhood characteristics. Sensitivity analyses used an instrumental variable (IV) approach. Healthier foods cost nearly twice as much as unhealthier foods per serving on average (mean healthy-to-unhealthy ratio = 1.97 [SD 0.14]). A larger healthy-to-unhealthy price ratio was associated with lower odds of a high-quality diet (OR = 0.76 per SD increase in the ratio, 95% CI = [0.64–0.9]). IV analyses largely confirmed these findings although—as expected with IV adjustment—confidence intervals were wide (OR = 0.82 [0.57–1.19]). Policies to address the large price differences between healthier and unhealthy foods may help improve diet quality in the United States.

Nutritional correlates of monetary diet cost in young, middle-aged and older Japanese women

Studies in many Western countries have consistently shown that monetary diet cost is positively associated with diet quality, but this may not necessarily be the case in Japan. This cross-sectional study examined the nutritional correlates of monetary diet cost among 3963 young (all 18 years old), 3800 middle-aged (mean age 48 years) and 2211 older (mean age 74 years) Japanese women. Dietary intakes were assessed using a comprehensive self-administered diet history questionnaire for young and middle-aged women and a brief self-administered diet history questionnaire for older women. Monetary diet cost was estimated using retail food prices. Total vegetables, fish and shellfish, green and black tea, white rice, meat, fruit and alcoholic beverages contributed most (79–89 %) to inter-individual variation in monetary diet cost. Multiple regression analyses showed that monetary diet cost was negatively associated with carbohydrate intake, but positively with intakes of all other nutrients examined (including not only dietary fibre and key vitamins and minerals but also saturated fat and Na) in all generations. For food group intakes, irrespective of age, monetary diet cost was associated inversely with white rice and bread but positively with pulses, potatoes, fruit, total vegetables, fruit and vegetable juice, green and black tea, fish and shellfish, and meat. In conclusion, in all three generations of Japanese women and contrary to Western populations, monetary diet cost was positively associated with not only healthy dietary components (including fruits, vegetables, fish and shellfish, dietary fibre, and key vitamins and minerals), but also less healthy components (including saturated fat and Na).

A systematic review of diet quality indices in relation to obesity

Tools, called ‘diet/dietary quality indices’, evaluate the level of adherence to a specified pattern or a set of recommendations in populations. Yet, there are no review studies providing unanimous comprehensive results of dietary indices on obesity. We reviewed observational studies, focusing on the association of diet quality indices with general obesity or abdominal obesity in adults. We systematically conducted a search in all English language publications available on MEDLINE, ISI Web of Science and Embase between January 1990 and January 2016. Among the wide variety of indices and weight-derived variables, studies with dietary-guideline-based indices and mean changes for weight gain or OR for general obesity and abdominal obesity were selected. From a total of 479 articles, thirty-four studies were selected for the current review, ten of which had prospective designs and twenty-six had cross-sectional designs. Associations of weight status with the original Healthy Eating Index (HEI) and other versions of the HEI including alternative HEI, HEI-2005 and HEI-05 were examined in thirteen studies, with ten studies revealing significant associations. The HEI was a better general obesity predictor in men than in women. Diet scores lacked efficacy in assessing overall diet quality and demonstrated no significant findings in developing countries, in comparison with US populations. In addition, indices based on dietary diversity scores were directly associated with weight gain. Despite the insufficient evidence to draw definitive conclusions about the relation between dietary indices and obesity, HEI was found to be inversely associated with obesity and diversity-based indices were positively associated with obesity.

Cooking at Home: A Strategy to Comply With U.S. Dietary Guidelines at No Extra Cost

INTRODUCTION

Cooking at home is associated with better diet quality. This study examined the frequency of home-cooked dinners versus eating out in relation to the Healthy Eating Index (HEI), and food expenditures.

METHODS

The Seattle Obesity Study used a stratified random sample of 437 King County adults. In-person computer-assisted interviews collected sociodemographic and behavioral data during 2011-2013. HEI-2010 and 2005 were computed using Food Frequency Questionnaires. Multivariable regression analyses, conducted in 2015, examined associations among HEI scores, food expenditures, and frequency of cooking at home versus eating out variables.

RESULTS

Frequent home-cooked dinners were associated with being married, unemployed, larger households, presence of children aged <12 years, and lower frequency of eating out, but unrelated to education or income. In adjusted models, frequent at-home cooking was associated with higher HEI-2010 (β=7.4, p<0.001), whereas frequent eating out was associated with lower HEI-2010 (β= -6.6, p<0.001). Frequent home cooking was linked with reduced per capita food expenditures overall ($330/month among low vs $273/month among high cooking group, p<0.001), and reduced away-from-home expenditures ($133 and $65, respectively), without any significant increase in at-home food expenditures. However, frequent eating out was associated with significantly higher per capita food expenditures overall ($261 in low vs $364 among high eating out group, p=0.001), and higher away-from-home expenditures.

CONCLUSIONS

Home-cooked dinners were associated with greater dietary guideline compliance, without significant increase in food expenditures. By contrast, frequent eating out was associated with higher expenditures and lower compliance. Home cooking may be a component of nutrition resilience.

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.

Challenges to the Mediterranean diet at a time of economic crisis

AIMS

The traditional Mediterranean diet (MD) is reportedly associated with lower risk of major chronic diseases and long considered to contribute to the reduced rates of cardiovascular and cerebrovascular events and to the highest life expectancy in adults who lived near the Mediterranean Sea. But despite its widely documented health benefits, adherence to this dietary pattern has been rapidly declining over the last decades due to a clear socioeconomic influence. The present review provides an overview of the evidence on the current major determinants of adherence to the Mediterranean diet, with a particular emphasis on Mediterranean Countries at a time of economic crisis; second it explores emerging socioeconomic inequalities in other domains of healthy dietary behaviours such as dietary variety, access to organic foods and food purchasing behaviour.

DATA SYNTHESIS

According to ecological evidence, the Mediterranean Countries that used to have the highest adherence to the Mediterranean pattern in the Sixties, more recently experienced the greatest decrease, while Countries in Northern Europe and some other Countries around the world are currently embracing a Mediterranean-like dietary pattern. A potential cause of this downward trend could be the increasing prices of some food items of the Mediterranean diet pyramid. Recent evidence has shown a possible involvement of the economic crisis, material resources becoming strong determinants of the adherence to the MD just after the recession started in 2007-2008. Beyond intake, the MD also encourages increasing dietary diversity, while international dietary recommendations suggest replacing regular foods with healthier ones.

CONCLUSIONS

Socioeconomic factors appear to be major determinants of the adherence to MD and disparities also hold for other indices of diet quality closely related to this dietary pattern.

[Feasibility and results of the short Diet Quality Screener in Primary Care: EMAP study]

OBJECTIVE

To study the feasibility and results of the self-reported short diet quality screener (sDQS) in Primary Care. The variables associated with difficulty and inadequate diet are also determined.

METHOD

Cross-sectional descriptive study conducted with 196 participants aged >18 years with diabetes mellitus, hypertension, or hypercholesterolaemia, consecutively included from 4 Primary Health Care Centres in Barcelona. The main variables collected were, age, sex, educational level, cardiovascular risk factors, body mass index, time to complete the sDQS, degree of difficulty, and diet score: inadequate diet ≤18, adequate in some aspects 19-27, adequate >27.

RESULTS

The mean age was 48.8 years (52% males). The analysis of the variables showed that the prevalence of having higher than a primary education level, hypertension, diabetes, hypercholesterolemia, and obesity was 50%, 54.6%, 23.5%, 56.6%, and 27.5%, respectively. The mean time to complete the questionnaire was 2.3min. More than 80% considered it easy or very easy. An inadequate diet was reported by 21.4%, adequate in some aspects by 76.5%, and an adequate diet only by 2%. To be older than 49 years and a low diet quality increased the risk of needing ≥2min to complete the sDQS (OR 2.0, 95% CI; 1.0-4.3, and OR 2.3, 95% CI; 1.1-5.1, respectively). Not following a low cholesterol diet and age less than 49 years increased the risk of a low diet quality (OR 2.2; 95% CI: 1.1-4.5, and OR 2.9; 95% CI: 1.2-6.8, respectively).

CONCLUSIONS

The completion of the sDQS is easy and was not a significant time-burden in Primary Care. A significant proportion of participants with cardiovascular risk reported a low diet quality.

Monetary Diet Cost, Diet Quality, and Parental Socioeconomic Status in Spanish Youth

BACKGROUND

Using a food-based analysis, healthy dietary patterns in adults are more expensive than less healthy ones; studies are needed in youth. Therefore, the objective of the present study was to determine relationships between monetary daily diet cost, diet quality, and parental socioeconomic status.

DESIGN AND METHODS

Data were obtained from a representative national sample of 3534 children and young people in Spain, aged 2 to 24 years. Dietary assessment was performed with a 24-hour recall. Mediterranean diet adherence was measured by the KIDMED questionnaire. Average food cost was calculated from official Spanish government data. Monetary daily diet cost was expressed as euros per day (€/d) and euros per day standardized to a 1000kcal diet (€/1000kcal/d).

RESULTS

Mean monetary daily diet cost was 3.16±1.57€/d (1.56±0.72€/1000kcal/d). Socioeconomic status was positively associated with monetary daily diet cost and diet quality measured by the KIDMED index (€/d and €/1000kcal/d, p<0.019). High Mediterranean diet adherence (KIDMED score 8-12) was 0.71 €/d (0.28€/1000kcal/d) more expensive than low compliance (KIDMED score 0-3). Analysis for nonlinear association between the KIDMED index and monetary daily diet cost per1000kcal showed no further cost increases beyond a KIDMED score of 8 (linear p<0.001; nonlinear p = 0.010).

CONCLUSION

Higher monetary daily diet cost is associated with healthy eating in Spanish youth. Higher socioeconomic status is a determinant for higher monetary daily diet cost and quality.

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.

Monetary value of self-reported diets and associations with sociodemographic characteristics and dietary intake among Japanese adults: analysis of nationally representative surveys

OBJECTIVE

To examine the relationships of monetary value of diets with sociodemographic and lifestyle characteristics and dietary intake among Japanese adults.

DESIGN

Cross-sectional study based on two nationally representative surveys: the Comprehensive Survey of Living Conditions and the National Health and Nutrition Survey, 2013. Dietary intake was assessed by a 1 d semi-weighed household dietary record with information on individual proportion of intakes. Diet cost was estimated by linking dietary data with retail food prices. A wide variety of sociodemographic and lifestyle variables were obtained from the two surveys.

SETTING

A random sample of nationally representative households in Japan.

SUBJECTS

Japanese adults aged 20 years or older (n 4658).

RESULTS

Lower energy-adjusted diet cost (Japanese yen/4184 kJ) was significantly associated with being younger, having a lower education, less equivalent monthly household expenditure, large household size, less physical activity and living in rented houses. Lower diet cost was associated with a lower intake of pulses, vegetables, fruits, fish, meat and dairy products, and a higher intake of grain, eggs, and fats and oils. At the nutrient level, lower diet cost was associated with a lower intake of protein, alcohol, dietary fibre, cholesterol and all vitamins and minerals examined, and a higher intake of carbohydrate. Diet cost was inversely associated with dietary energy density.

CONCLUSION

These data suggest that certain low socio-economic subgroups in Japan consume diets of lower monetary value, resulting in a lower quality of food and nutrient intake pattern except for lower sodium, cholesterol and alcohol consumption.

Food-choice motives of adolescents in Jakarta, Indonesia: the roles of gender and family income

Objective

The aims of the present study were to assess the reliability and validity of the Food Choice Questionnaire (FCQ) and to determine the factors associated with food-choice motives in public junior-high-school students in Jakarta, Indonesia.

Design

Cross-sectional study with self-administered questionnaires. Trained research assistants measured height and weight of the participants on the day of the data collection.

Settings

Fourteen randomly selected public junior-high schools in East Jakarta, Indonesia.

Subjects

Public junior-high-school students (n681) in grades 7 and 8, aged 13–14 years (377 girls and 304 boys).

Results

Three food-choice motives (subscales) were obtained from factor analysis and reliability testing: (i) comfort; (ii) convenience and price; and (iii) health. The subscale with the greatest mean value was health. Family affluence was inversely associated with the convenience and price subscale (β=−0·05,P=0·01) and with the health subscale (β=−0·04;P=0·02). Females were less likely than males to consider health when choosing foods (β=−0·16;P=0·03).

Conclusions

While its factor structure differed from those found in previous studies of adults, the FCQ can provide reliable measures of food-choice motives among these adolescents. Students from less affluent families placed more importance on food’s convenience and price, but more affluent students did not necessarily make healthier choices. Compared with females, males were more likely to choose healthy foods. Future interventions should be tailored based on the socio-economic status of the target group.

Monetary Value of Diet Is Associated with Dietary Quality and Nutrient Adequacy among Urban Adults, Differentially by Sex, Race and Poverty Status

OBJECTIVE

The association between monetary value of the diet (MVD, $/day) with dietary quality was examined using a large sample of urban US adults, differentially by socio-demographic factors.

METHODS

This was a cross-sectional study of 2,111 participants, aged 30-64y, using data from the Healthy Aging in Neighborhoods of Diversity across the Life Span Study. Dietary quality indices included Healthy Eating Index-2010 (HEI-2010) and Mean Adequacy Ratio (MAR), (two 24-hr recalls). A national food price database was used to estimate MVD. Multiple linear/logistic regression analyses were conducted stratifying separately by sex, race and poverty status.

RESULTS

Women had significantly higher HEI-2010 scores than men (43.35 vs 41.57 out of 100, respectively), whereas MAR scores were higher for men (76.8 vs 69.9, out of 100), reflecting energy intake gender differentials. Importantly, a $3/day higher MVD (IQR: $3.70/d (Q1) to $6.62/d (Q4)) was associated with a 4.98±0.35 higher total HEI-2010 and a 3.88±0.37 higher MAR score, after energy-adjustment and control for key confounders. For HEI-2010 and MAR, stronger associations were observed among participants above poverty and among women, whilethe MVD vs. HEI-2010 association was additionally stronger among Whites. Sex and poverty status differentials were observed for many MAR and some HEI-2010 components.

CONCLUSIONS

Despite positive associations between measures of dietary quality and MVD, particularly above poverty and among women, approaching compliance with the Dietary Guidelines (80 or more for HEI-2010) requires a substantially higher MVD. Thus, nutrition education may further improve people's decision-making regarding food venues and dietary choices.

Sociodemographic and Behavioural Determinants of a Healthy Diet in Switzerland

Background/Aims: The determinants of a healthy diet have not been studied in Switzerland. This study aimed at assessing the individual and behavioural factors associated with a healthy diet in a Swiss city. Methods: Cross-sectional, population-based study conducted between 2009 and 2013 (n = 4,439, 2,383 women, mean age 57.5 ± 10.3 years) in Lausanne. Food consumption was assessed using a validated food frequency questionnaire. Two Mediterranean diet scores (classic score and specific for Switzerland) and the Harvard School of Public Health alternate healthy eating index were computed. Results: For all three dietary scores considered, living in couple or having a high education were associated with a healthier diet. An unhealthy lifestyle (smoking, sedentary behaviour) or a high body mass index were associated with an unhealthier diet. Participants born in Italy, Portugal and Spain had healthier diets than participants born in France or Switzerland. Women and elderly participants had healthier diets than men and young participants according to 2 scores, while no differences were found for the Swiss-specific Mediterranean score. Conclusions: In Switzerland, healthy eating is associated with high education, a healthy lifestyle, marital status and country of origin. The associations with gender and age depend on the dietary score considered.

Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis

CONTEXT

It is well established in the literature that healthier diets cost more than unhealthy diets.

OBJECTIVE

The aim of this review was to examine the contribution of food prices and diet cost to socioeconomic inequalities in diet quality.

DATA SOURCES

A systematic literature search of the PubMed, Google Scholar, and Web of Science databases was performed.

STUDY SELECTION

Publications linking food prices, dietary quality, and socioeconomic status were selected.

DATA EXTRACTION

Where possible, review conclusions were illustrated using a French national database of commonly consumed foods and their mean retail prices.

DATA SYNTHESIS

Foods of lower nutritional value and lower-quality diets generally cost less per calorie and tended to be selected by groups of lower socioeconomic status. A number of nutrient-dense foods were available at low cost but were not always palatable or culturally acceptable to the low-income consumer. Acceptable healthier diets were uniformly associated with higher costs. Food budgets in poverty were insufficient to ensure optimum diets.

CONCLUSIONS

Socioeconomic disparities in diet quality may be explained by the higher cost of healthy diets. Identifying food patterns that are nutrient rich, affordable, and appealing should be a priority to fight social inequalities in nutrition and health.

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 carbohydrate-fat problem: can we construct a healthy diet based on dietary guidelines?

The inclusion of nutrition economics in dietary guidance would help ensure that the Dietary Guidelines for Americans benefit equally all segments of the US population. The present review outlines some novel metrics of food affordability that assess nutrient density of foods and beverages in relation to cost. Socioeconomic disparities in diet quality in the United States are readily apparent. In general, groups of lower socioeconomic status consume cheaper, lower-quality diets and suffer from higher rates of noncommunicable diseases. Nutrient profiling models, initially developed to assess the nutrient density of foods, can be turned into econometric models that assess both calories and nutrients per reference amount and per unit cost. These novel metrics have been used to identify individual foods that were affordable, palatable, culturally acceptable, and nutrient rich. Not all nutrient-rich foods were expensive. In dietary surveys, both local and national, some high-quality diets were associated with relatively low cost. Those population subgroups that successfully adopted dietary guidelines at an unexpectedly low monetary cost were identified as "positive deviants." Constructing a healthy diet based on dietary guidelines can be done, provided that nutrient density of foods, their affordability, as well as taste and social norms are all taken into account.

Novel insights on nutrient management of sarcopenia in elderly

Sarcopenia is defined as a syndrome characterized by progressive and generalized loss of muscle mass and strength. The more rationale approach to delay the progression of sarcopenia is based on the combination of proper nutrition, possibly associated with the use of dietary supplements and a regular exercise program. We performed a narrative literature review to evaluate the till-now evidence regarding (1) the metabolic and nutritional correlates of sarcopenia; (2) the optimum diet therapy for the treatment of these abnormalities. This review included 67 eligible studies. In addition to the well recognized link between adequate intake of proteins/amino acids and sarcopenia, the recent literature underlines that in sarcopenic elderly subjects there is an unbalance in vitamin D synthesis and in omega-6/omega-3 PUFA ratio. Given the detrimental effect of these metabolic abnormalities, a change in the lifestyle must be the cornerstone in the treatment of sarcopenia. The optimum diet therapy for the sarcopenia treatment must aim at achieving specific metabolic goals, which must be reached through accession of the elderly to specific personalized dietary program aimed at achieving and/or maintaining muscle mass; increasing their intake of fish (4 times/week) or taking omega-3 PUFA supplements; taking vitamin D supplementation, if there are low serum levels.

Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis

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.

DATA SOURCES

MEDLINE (2000-2011), supplemented with expert consultations and hand reviews of reference lists and related citations.

DESIGN

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.

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.

Cost and cost-effectiveness of the Mediterranean diet: results of a systematic review

The growing impact of chronic degenerative pathologies (such as cardiovascular disease, type 2 diabetes and Alzheimer’s disease) requires and pushes towards the development of new preventive strategies to reduce the incidence and prevalence of these diseases. Lifestyle changes, especially related to the Mediterranean diet, have the potential to modify disease outcomes and ultimately costs related to their management. The objective of the study was to perform a systematic review of the scientific literature, to gauge the economic performance and the cost-effectiveness of the adherence to the Mediterranean diet as a prevention strategy against degenerative pathologies. We investigated the monetary costs of adopting Mediterranean dietary patterns by determining cost differences between low and high adherence. Research was conducted using the PubMed and Scopus databases. Eight articles met the pre-determined inclusion criteria and were reviewed. Quality assessment and data extraction was performed. The adherence to the Mediterranean diet has been extensively reported to be associated with a favorable health outcome and a better quality of life. The implementation of a Mediterranean dietary pattern may lead to the prevention of degenerative pathologies and to an improvement in life expectancy, a net gain in health and a reduction in total lifetime costs.

Dietary standards for school catering in France: serving moderate quantities to improve dietary quality without increasing the food-related cost of meals

OBJECTIVE

To assess the impact on food-related cost of meals to fulfill the new compulsory dietary standards for primary schools in France.

DESIGN

A descriptive study assessed the relationship between the level of compliance with the standards of observed school meals and their food-related cost. An analytical study assessed the cost of series of meals published in professional journals, and complying or not with new dietary standards. The costs were based on prices actually paid for food used to prepare school meals.

MAIN OUTCOME MEASURE

Food-related cost of meals.

ANALYSIS

Parametric and nonparametric tests from a total of 42 and 120 series of 20 meals in the analytical and descriptive studies, respectively.

RESULTS

The descriptive study indicated that meeting the standards was not related to cost. The analytical study showed that fulfilling the frequency guidelines increased the cost, whereas fulfilling the portion sizes criteria decreased it. Series of meals fully respecting the standards (ie, frequency and portion sizes) cost significantly less (-0.10 €/meal) than series not fulfilling them, because the standards recommend smaller portion sizes.

CONCLUSIONS AND IMPLICATIONS

Introducing portion sizes rules in dietary standards for school catering may help increase dietary quality without increasing the food cost of meals.

The monetary value of diets consumed by British adults: an exploration into sociodemographic differences in individual-level diet costs

OBJECTIVE

To describe the diet costs of adults in the National Diet and Nutrition Study (NDNS) and explore patterns in costs according to sociodemographic indicators.

DESIGN

Cross-sectional diet diary information was matched to a database of food prices to assign a cost to each food or non-alcoholic beverage consumed. Daily diet costs were calculated, as well as costs per 10 MJ to improve comparability across differing energy requirements. Costs were compared between categories of sociodemographic variables and health behaviours. Multivariable regression assessed the effects of each variable on diet costs after adjustment.

SETTING

The NDNS is a rolling dietary survey, recruiting a representative UK sample each year. The study features data from 2008-2010.

SUBJECTS

Adults aged 19 years or over were included. The sample consisted of 1014 participants.

RESULTS

The geometric mean daily diet cost was £2·89 (95 % CI £2·81, £2·96). Energy intake and daily diet cost were strongly associated. The mean energy-adjusted cost was £4·09 (95 % CI £4·01, £4·18) per 10 MJ. Energy-adjusted costs differed significantly between many subgroups, including by sex and household income. Multivariable regression found significant effects of sex, qualifications and occupation (costs per 10 MJ only), as well as equivalized household income, BMI and fruit and vegetable consumption on diet costs.

CONCLUSIONS

This is the first time that monetary costs have been applied to the diets of NDNS adults. The findings suggest that certain subgroups in the UK - for example those on lower incomes - consume diets of lower monetary value. Observed differences were mostly in the directions anticipated.

Monitoring the price and affordability of foods and diets globally

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation.

Measuring diet cost at the individual level: a comparison of three methods

Background/objectives:

Household-level food spending data are not suitable for population-based studies of the economics of nutrition. This study compared three methods of deriving diet cost at the individual level.

Subjects/methods:

Adult men and women (n=164) completed 4-day diet diaries and a food frequency questionnaire (FFQ). Food expenditures over 4 weeks and supermarket prices for 384 foods were obtained. Diet costs (US$/day) were estimated using: (1) diet diaries and expenditures; (2) diet diaries and supermarket prices; and (3) FFQs and supermarket prices. Agreement between the three methods was assessed on the basis of Pearson correlations and limits of agreement. Income-related differences in diet costs were estimated using general linear models.

Results:

Diet diaries yielded mean (s.d.) diet costs of $10.04 (4.27) based on Method 1 and $8.28 (2.32) based on Method 2. FFQs yielded mean diet costs of $7.66 (2.72) based on Method 3. Correlations between energy intakes and costs were highest for Method 3 (r²=0.66), lower for Method 2 (r²=0.24) and lowest for Method 1 (r²=0.06). Cost estimates were significantly associated with household incomes.

Conclusion:

The weak association between food expenditures and food intake using Method 1 makes it least suitable for diet and health research. However, merging supermarket food prices with standard dietary assessment tools can provide estimates of individual diet cost that are more closely associated with food consumed. The derivation of individual diet cost can provide insights into some of the economic determinants of food choice, diet quality and health.