Relation of food cost to healthfulness of diet among US women

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.

The damaging duo: Obesity and excess dietary salt contribute to hypertension and cardiovascular disease

Hypertension is a primary risk factor for cardiovascular disease. Cardiovascular disease is the leading cause of death among adults worldwide. In this review, we focus on two of the most critical public health challenges that contribute to hypertension-obesity and excess dietary sodium from salt (i.e., sodium chloride). While the independent effects of these factors have been studied extensively, the interplay of obesity and excess salt overconsumption is not well understood. Here, we discuss both the independent and combined effects of excess obesity and dietary salt given their contributions to vascular dysfunction, autonomic cardiovascular dysregulation, kidney dysfunction, and insulin resistance. We discuss the role of ultra-processed foods-accounting for nearly 60% of energy intake in America-as a major contributor to both obesity and salt overconsumption. We highlight the influence of obesity on elevated blood pressure in the presence of a high-salt diet (i.e., salt sensitivity). Throughout the review, we highlight critical gaps in knowledge that should be filled to inform us of the prevention, management, treatment, and mitigation strategies for addressing these public health challenges.

Qualitative Research on the Perceptions of Factors Influencing Diet and Eating Behaviors among Primarily Latinx Seventh-Grade Students

BACKGROUND

Latinx youth are a population of concern, at elevated risk for chronic diseases and with poor adherence to dietary recommendations.

OBJECTIVES

To examine Latinx seventh-grade students' perceptions of the factors that influence their diet and eating behaviors.

DESIGN

This qualitative research used focus groups and an inductive content analysis approach.

PARTICIPANTS/SETTING

Five sex-stratified focus groups (three groups with females) with 35 primarily Latinx seventh-grade students were conducted at two local Title 1 public middle schools in a large metropolitan area of the Southwestern United States.

MAIN OUTCOME MEASURES

The discussion protocol included questions about participants' food choices, the role of their parents in their diet, and healthy body-related concerns among their peers.

ANALYSES

Verbatim transcripts were coded in NVivo 12 on the basis of specificity, extensiveness, and frequency. Themes emerged from group dialogue, detailed conversations, and predominant topics of discussion, and aligned with ecological systems theory.

RESULTS

Participants referred to factors influencing Latinx seventh-grade students' eating behaviors at the individual, family, household, and school levels. At the individual level, participants described their eating as unhealthy and perceived it as determined by taste, convenience, ease of preparation, and home availability. Participants expressed concerns about diabetes because of their body weight and family history, and identified those concerns as reasons for acceptance of healthy foods and the desire for parents to model healthy eating behaviors. Family-level factors perceived as influencing dietary behaviors included the role of parents as providers of food and models of unhealthy eating, budget constraints, and availability (or lack thereof) of healthy foods at home. Similarly, the identified school-level factors aligned with availability and quality of foods in that environment.

CONCLUSIONS

Family- and household-related factors emerged as important influences on seventh-grade students' dietary behaviors. Future diet interventions should incorporate strategies targeting these multiple-level factors that influence dietary intake for Latinx youth and that address the concerns related to disease risk.

Adhering to Canada's Food Guide Recommendations on Healthy Food Choices Increases the Daily Diet Cost: Insights from the PREDISE Study

The aim of this study was to assess the association between daily diet costs and the Healthy Eating Food Index (HEFI)-2019, an index that reflects the alignment of dietary patterns to recommendations on healthy food choices in the 2019 Canada’s Food Guide (CFG). Dietary intake data from 24 h recalls, completed between 2015 and 2017, of 1147 French-speaking participants of the web-based multicenter cross-sectional PRÉDicteurs Individuels, Sociaux et Environnementaux (PREDISE) study in Quebec were used. Diet costs were calculated from dietary recall data using a Quebec-specific 2015–2016 Nielsen food price database. Usual dietary intakes and diet costs were estimated using the National Cancer Institute’s multivariate method. Linear regression models were used to evaluate associations between diet costs and HEFI-2019 scores. When standardized for energy intake, a higher HEFI-2019 score (75th vs. 25th percentiles) was associated with a 1.09 $CAD higher daily diet cost (95% CI, 0.73 to 1.45). This positive association was consistent among different sociodemographic subgroups based on sex, age, education, household income, and administrative region of residence. A higher daily diet cost was associated with a higher HEFI-2019 score for the Vegetables and fruits, Beverage, Grain foods ratio, Fatty acids ratio, Saturated fats, and Free sugars components, but with a lower score for the Sodium component. These results suggest that for a given amount of calories, a greater adherence to the 2019 CFG recommendations on healthy food choices is associated with an increased daily diet cost. This highlights the challenge of conciliating affordability and healthfulness when developing national dietary guidelines in the context of diet sustainability.

Diet cost and quality using the Healthy Eating Index-2015 in adults from urban and rural areas of Mexico

OBJECTIVE

To assess the association between diet cost and quality by place of residence.

DESIGN

We analysed cross-sectional data of the National Health and Nutrition Survey-2012. Diet cost was estimated by linking dietary data, obtained from a 7-d SFFQ, with municipality food prices, which were derived from a national expenditure survey. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). Association between quintiles of diet cost and HEI-2015 was assessed using linear regression analysis.

SETTINGS

Mexico.

PARTICIPANTS

2438 adults (18-59 years).

RESULTS

Diet cost was positively associated with diet quality (HEI-2015) in urban but not in rural areas. Compared with quintile (Q1) of cost, the increment in diet quality score was 1·17 (95 % CI -0·06, 4·33) for Q2, 2·14 (95 % CI -0·06, 4·33) for Q3, 4·70 (95 % CI 2·62, 6·79) for Q4 and 6·34 (95 % CI 4·20, 8·49) for Q5 (P-trend < 0·001). Individuals in rural v. urban areas on average have higher quality diets at lower cost with higher intakes of whole grains and beans and lower intakes of Na, added sugars and saturated fats. Living in the South, being indigenous and having low socio-economic status were also associated with higher quality diets.

CONCLUSIONS

Diet cost was positively associated with diet quality, but only in urban areas. Further studies are needed to understand the relation between diet cost and quality in rural areas. To improve overall diet quality in Mexico, strategies that aim to reduce the cost of high-quality diets should consider the heterogeneity by place of residence.

Study protocol for CELLAR (COVID-related Eating Limitations and Latent dietary effects in the Atlantic Region): population-based observational study to monitor dietary intakes and purchasing during COVID-19 in four Atlantic Canadian provinces

INTRODUCTION

Poor diet is a leading preventable risk for the global burden of non-communicable disease. Robust measurement is needed to determine the effect of COVID-19 on dietary intakes and consumer purchasing, given the widespread changes to consumer food environments and economic precarity. The research objectives are as follows: (1) describe dietary intakes of foods, beverages and nutrients of concern during the COVID-19 pandemic; (2) quantify change in diet during COVID-19 as compared with prepandemic, previously captured in the provincial samples of the population-representative 2015 Canadian Community Health Survey-Nutrition and (3) examine how household purchasing practices predict dietary intakes during COVID-19.

METHODS AND ANALYSES

Observational study of diet, using a population-based stratified probability sampling strategy allocated via dual-frame (landline and cellphone) calls to random-digit dialled numbers, followed by age-sex group quotas. The base population comprises the four provinces of the Atlantic region of Canada, jurisdictions with an excess burden of pre-existing dietary risk, compared with the rest of Canada. Our aim is n=1000 to obtain reliable estimates at a regional level to describe intakes and compare with prepandemic baseline. Data collection entails 12 weeks participation: (1) enrolment with sociodemographics (key dietary risk predictors such as age, sex, gender, pre-COVID-19 income, employment, household composition, receipt of economic relief, rural residence); (2) two 24hour diet recalls using the online ASA-24 Canada 2018 tool; and (3) online uploads of household food purchase receipts over the 12 weeks enrolled. Participation incentives will be offered.

ETHICS AND DISSEMINATION

This research protocol received funding from the Canadian Institutes of Health Research (FRN VR5 172691) and ethics review approval from the Dalhousie University Research Ethics Board. Study protocol and instruments and a de-identified dataset will be made publicly available. We will submit the findings to peer-reviewed journals, as well as conferences geared towards scientific and decision-maker audiences.

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.

Cost-effective options for increasing consumption of under-consumed food groups and nutrients in the USA

OBJECTIVE

To identify the most cost-effective options/contributors of under-consumed food groups and nutrients in the USA.

DESIGN

Twenty-four-hour dietary recall data were used for the dietary sources of under-consumed food groups and nutrients. Costs were estimated using USDA National Food Price Database 2001-2004 after adjustments for inflation using Consumer Price Index.

SETTING

National Health and Nutrition Examination Survey, 2013-2016.

PARTICIPANTS

A total of 10 112 adults aged 19+ years.

RESULTS

Top five cost-effective options for food groups were apple and citrus juice, bananas, apples, and melons for fruit; baked/boiled white potatoes, mixtures of mashed potatoes, lettuce, carrots and string beans for vegetables; oatmeal, popcorn, rice, yeast breads and pasta/noodles/cooked grains for whole grain; and reduced-fat, low-fat milk, flavoured milk and cheese for dairy. Top five cost-effective sources of under-consumed nutrients were rice, tortillas, pasta/noodles/cooked grains, rolls and buns, and peanut butter-jelly sandwiches for Mg; grits/cooked cereals, low- and high-sugar ready-to-eat (RTE) cereal, rolls and buns, and rice for Fe; low- and high-sugar RTE cereals, rice, protein and nutritional powders, and rolls and buns for Zn; carrots, margarine, other red and orange vegetables, liver and organ meats, butter and animal fats for vitamin A; and citrus juice, other fruit juice, vegetable juice, mustard and other condiments, and apple juice for vitamin C.

CONCLUSIONS

Apple/citrus juice, white potatoes/carrots, oatmeal, RTE cereals and milk were the most cost-effective food sources of multiple under-consumed food groups and nutrients and can help promote healthy eating habits at minimal cost.

Assessing the Cost of Healthy and Unhealthy Diets: A Systematic Review of Methods

PURPOSE OF REVIEW

Poor diets are a leading risk factor for chronic disease globally. Research suggests healthy foods are often harder to access, more expensive, and of a lower quality in rural/remote or low-income/high minority areas. Food pricing studies are frequently undertaken to explore food affordability. We aimed to capture and summarise food environment costing methodologies used in both urban and rural settings.

RECENT FINDINGS

Our systematic review of high-income countries between 2006 and 2021 found 100 relevant food pricing studies. Most were conducted in the USA (n = 47) and Australia (n = 24), predominantly in urban areas (n = 74) and cross-sectional in design (n = 76). All described a data collection methodology, with just over half (n = 57) using a named instrument. The main purpose for studies was to monitor food pricing, predominantly using the 'food basket', followed by the Nutrition Environment Measures Survey for Stores (NEMS-S). Comparatively, the Healthy Diets Australian Standardised Affordability and Price (ASAP) instrument supplied data on relative affordability to household incomes. Future research would benefit from a universal instrument reflecting geographic and socio-cultural context and collecting longitudinal data to inform and evaluate initiatives targeting food affordability, availability, and accessibility.

Higher-diet quality is associated with higher diet costs when eating at home and away from home: National Health and Nutrition Examination Survey, 2005-2016

OBJECTIVES

To evaluate the association between diet quality and cost for foods purchased for consumption at home and away from home.

DESIGN

Cross-sectional analysis. Multivariable linear regression models evaluated the association between diet quality and cost for all food, food at home (FAH) and food away from home (FAFH).

SETTING

Daily food intake data from the National Health and Nutrition Examination Survey (2005-2016). Food prices were derived using data from multiple, publicly available databases. Diet quality was assessed using the Healthy Eating Index-2015 and the Alternative Healthy Eating Index-2010.

PARTICIPANTS

30 564 individuals ≥20 years with complete and reliable dietary data.

RESULTS

Mean per capita daily diet cost was $14·19 (95 % CI (13·91, 14·48)), including $6·92 (95 % CI (6·73, 7·10)) for FAH and $7·28 (95 % CI (7·05, 7·50)) for FAFH. Diet quality was higher for FAH compared to FAFH (P < 0·001). Higher diet quality was associated with higher food costs overall, FAH and FAFH (P < 0·001 for all comparisons).

CONCLUSIONS

These findings demonstrate that higher diet quality is associated with higher costs for all food, FAH and FAFH. This research provides policymakers, public health professionals and clinicians with information needed to support healthy eating habits. These findings are particularly relevant to contemporary health and economic concerns that have worsened because of the COVID-19 pandemic.

Data Integration for Diet Sustainability Analyses

Diet sustainability analyses are stronger when they incorporate multiple food systems domains, disciplines, scales, and time/space dimensions into a common modeling framework. Few analyses do this well: there are large gaps in food systems data in many regions, accessing private and some public data can be difficult, and there are analytical challenges, such as creating linkages across datasets and using complex analytical methods. This article summarizes key data sources across multiple domains of food system sustainability (nutrition, economic, environment) and describes methods and tools for integrating them into a common analytic framework. Our focus is the United States because of the large number of publicly available and highly disaggregated datasets. Thematically, we focus on linkages that exist between environmental and economic datasets to nutrition, which can be used to estimate the cost and agricultural resource use of food waste, interrelationships between healthy eating and climate impacts, diets optimized for cost, nutrition, and environmental impacts, and others. The limitations of these approaches and data sources are described next. By enhancing data integration across these fields, researchers can be better equipped to promote policy for sustainable diets.

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.

Association of Healthy Eating Index and the Alternative Healthy Eating Index with the cell blood count indices

OBJECTIVES

There is an association between diet quality and markers of inflammation. We aimed to investigate the relationship between diet quality with cell blood count (CBC) and inflammatory indices such as red cell distribution width (RDW) and white blood cell count (WBC).

STUDY DESIGN

A total of 367 male subjects aged 20-69 yrs, who were employees of Shahid Hasheminejad Gas Processing Company (SGPC) completed the study.

METHODS

All participants completed a questionnaire that contained questions about demography. Standard protocols were used for measuring anthropometric indices in all subjects. Blood samples were collected after a 12 hrs fast from all participants. Biochemical parameters were determined in all participants using an auto-analyzer (Eppendorf, Germany). Systolic and diastolic blood pressure were measured using a standard mercury sphygmomanometer. CBC was measured using the Sysmex auto analyser system (KX-21 N). The HEI/AHEI scores extracted from a validated food frequency questionnaire (FFQ) to evaluate the diet quality. Data analyses were performed using SPSS 16 (SPSS Inc., IL, and USA).

RESULTS

A total of 674 men (aged 43.68±9.09 yrs) completed the study. The CBC indices were not significantly different between the HEI/AHEI classifications among the Iranian men (p-value >0.05 for all variables). Moreover, there was no association between HEI/ AHEI with the CBC indices in our population (p-value >0.05 for all variables).

CONCLUSIONS

In summary, there was no association between the diet quality with the cell blood count parameters among Iranian men.

Improvements in Neighborhood Socioeconomic Conditions May Improve Resident Diet

Neighborhood socioeconomic conditions (NSECs) are associated with resident diet, but most research has been cross-sectional. We capitalized on a natural experiment in Pittsburgh, Pennsylvania, in which 1 neighborhood experienced substantial investments and a sociodemographically similar neighborhood that did not, to examine pathways from neighborhood investments to changed NSECs and changed dietary behavior. We examined differences between renters and homeowners. Data were from a random sample of households (n = 831) in each of these low-income Pittsburgh neighborhoods that were surveyed in 2011 and 2014. Structural equation modeling tested direct and indirect pathways from neighborhood to resident dietary quality, adjusting for individual-level sociodemographics, with multigroup testing by homeowners versus renters. Neighborhood investments were directly associated with improved dietary quality for renters (β = 0.27, 95% confidence interval (CI): 0.05, 0.50) and homeowners (β = 0.51, 95% CI: 0.10, 0.92). Among renters, investments also were associated with dietary quality through a positive association with commercial prices (β = 0.34, 95% CI: 0.15, 0.54) and a negative association with residential prices (β = -0.30, 95% CI: -0.59, -0.004). Among homeowners, we did not observe any indirect pathways from investments to dietary quality through tested mediators. Investing in neighborhoods may support resident diet through improvements in neighborhood commercial environments for renters, but mechanisms appear to differ for homeowners.

Diet Quality and Sociodemographic, Lifestyle, and Health-Related Determinants among People with Depression in Spain: New Evidence from a Cross-Sectional Population-Based Study (2011-2017)

The role of diet quality in depression is an emerging research area and it appears that diet quality could be an important modifying factor. The aims of this study were to report the prevalence of diet quality among individuals with and without a self-reported diagnosis of depression aged from 16 to 64 years old in Spain, to analyze the time trends of the frequency of food consumption and diet quality from 2011 to 2017 in individuals with a self-reported diagnosis of depression, and to explore the associations between poor/improvable diet quality and sociodemographic, lifestyle, and health-related factors. A nationwide cross-sectional study was conducted in 42,280 participants with and without a self-reported diagnosis of depression who had participated in the 2011/2012 and 2017 Spanish National Health Surveys and the 2014 European Health Survey in Spain. A logistic regression analysis was performed to identify the variables associated with diet quality. The overall prevalence of diet quality among depressive and non-depressive individuals revealed 65.71% and 70.27% were in need of improvement, respectively. Moreover, having a poor or improvable diet quality is associated with male gender, people aged 16-24 years old and 25-44 years old, separated or divorced, and also in smokers.

Identification of Barriers to Adherence to a Weight Loss Diet in Women Using the Nominal Group Technique

Background: At any given time, a majority of women are engaged in some type of weight loss diet; however, these efforts are difficult to sustain for long-term weight control. Because women are more likely to develop obesity and suffer a greater severity of obesity-related health and economic consequences, we sought to identify the key factors that make adhering to a weight loss diet difficult for overweight/obese women. Methods: Ten nominal group technique (NGT) sessions aimed at identifying perceived barriers to adherence to a weight loss diet were conducted as part of a weight loss study for overweight/obese women (n = 33) during the controlled feeding weight loss phase. Results: Individual-level barriers to emerge from the sessions included knowing when to stop eating, being able to control cravings and emotional eating, and sustaining healthier dietary habits. Environmental-level barriers included family/social events that bring people together, especially those centered around food and drink, eating out, cost, and busy schedules. Conclusions: These findings offer a deeper understanding of barriers women find most salient to adhering to a weight loss diet, providing direction for the clinical application of weight loss programs.

Nutrient density, but not cost of diet, is associated with anemia and iron deficiency in school-age children in South Africa

OBJECTIVES

This study aimed to investigate the relationship of nutrient density and diet cost with anemia and iron deficiency (ID) in children.

METHODS

Dietary intake data of 5- to 12-y-old children (n = 578) from three independent studies in low-income communities were pooled. Nutrient densities were calculated using the Nutrient Rich Foods index and Nutrient Rich Diet index, with higher scores indicating more nutrient-dense foods and diets. Food prices and food intake data were used to calculate ratios of nutrient density to price for foods and diets. Descriptive and correlation analyses examined associations of nutrient density and diet cost with anemia and ID.

RESULTS

Most children (>50%) consumed starchy staples (100%), vegetables that are not vitamin A rich (63.9%), and legumes (58.1%), with mean NRF9.3 scores ranging from 31.9 to 56.3. Cheese, eggs, organ meat, fish, dark-green leafy vegetables, and vitamin A-rich vegetables and fruits had mean NRF9.3 scores ranging from 112.6 to 184.7, but each was consumed by less than a third of the children. Children with anemia or ID had lower NRD9.3 scores than children without (P < 0.001 and P = 0.039, respectively). Diet cost did not differ according to anemia and iron status, but nutrient-density-to-price ratio was lower in children with anemia than without (P = 0.001).

CONCLUSIONS

Careful selection of nutrient-dense foods as substitutes for foods with lower nutrient density could make it possible for children to consume a diet richer in specific nutrients and help prevent anemia and ID without affecting diet cost.

Healthy diets can create environmental trade-offs, depending on how diet quality is measured

Background

There is an urgent need to assess the linkages between diet patterns and environmental sustainability in order to meet global targets for reducing premature mortality and improving sustainable management of natural resources. This study fills an important research gap by evaluating the relationship between incremental differences in diet quality and multiple environmental burdens, while also accounting for the separate contributions of retail losses, inedible portions, and consumer waste.

Methods

Cross sectional, nationally-representative data on food intake in the United States were acquired from the National Health and Nutrition Examination Survey (2005–2016), and were linked with nationally-representative data on food loss and waste from published literature. Survey-weighted procedures estimated daily per capita food retail loss, food waste, inedible portions, and consumed food, and were summed to represent Total Food Demand. Diet quality was measured using the Healthy Eating Index-2015 and the Alternative Healthy Eating Index-2010. Data on food intake, loss, and waste were inputted into the US Foodprint Model to estimate the amount of agricultural land, fertilizer nutrients, pesticides, and irrigation water used to produce food.

Results

This study included dietary data from 50,014 individuals aged ≥2 y. Higher diet quality (HEI-2015 and AHEI-2010) was associated with greater per capita Total Food Demand, as well as greater retail loss, inedible portions, consumer waste, and consumed food (P < 0.001 for all comparisons). Consumed food accounted for 56–74% of agricultural resource use (land, fertilizer nutrients, pesticides, and irrigation water), retail loss accounted for 4–6%, inedible portions accounted for 2–15%, and consumer waste accounted for 20–23%. Higher diet quality was associated with lower use of agricultural land, but the relationship to other agricultural resources was dependent on the tool used to measure diet quality (HEI-2015 vs. AHEI-2010).

Conclusions

Over one-quarter of the agricultural inputs used to produce Total Food Demand were attributable to edible food that was not consumed. Importantly, this study also demonstrates that the relationship between diet quality and environmental sustainability depends on how diet quality is measured. These findings have implications for the development of sustainable dietary guidelines, which requires balancing population-level nutritional needs with the environmental impacts of food choices.

Using the COM-B model to identify barriers and facilitators towards adoption of a diet associated with cognitive function (MIND diet)

OBJECTIVE

The aim of the study was to identify components of the COM-B (capability, opportunity, motivation and behaviour) model that influences behaviour to modify dietary patterns in 40-55-year-olds living in the UK, in order to influence the risk of cognitive decline in later life.

DESIGN

This is a qualitative study using the COM-B model and theoretical domains framework (TDF) to explore beliefs to adopting the Mediterranean-DASH Intervention for Neurodegenerative delay (MIND) diet.

SETTING

Northern Ireland.

PARTICIPANTS

Twenty-five participants were recruited onto the study to take part in either a focus group or an interview. Participants were men and women aged between 40 and 55 years. Participants were recruited via email, Facebook and face to face.

RESULTS

Content analysis revealed that the main perceived barriers to the adoption of the MIND diet were time, work environment, taste preference and convenience. The main perceived facilitators reported were improved health, memory, planning and organisation, and access to good quality food.

CONCLUSIONS

This study provides insight into the personal, social and environmental factors that participants report as barriers and facilitators to the adoption of the MIND diet among middle-aged adults living in the UK. More barriers to healthy dietary change were found than facilitators. Future interventions that increase capability, opportunity and motivation may be beneficial. The results from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.

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.

Associations of socio-demographic factors with adiposity among immigrants in Norway: a secondary data analysis

BACKGROUND

Obesity is becoming an important public health challenge, especially among immigrants coming from low and middle income to high-income countries. In this study we examined the relationship between overweight/obesity and various socio-demographic indicators among different immigrant groups in Norway.

METHODS

We used data from the Living Conditions Survey among Immigrants 2016, conducted by Statistics Norway. Our study sample included 4194 immigrants from 12 different countries. Participants were asked about a number of topics including health, weight, height, demographic factors, length of residence and employment. We ran logistic regression analysis to determine the odds ratio (OR) of the associations between socio-demographic factors with adiposity among immigrants.

RESULTS

Approximately 53% of the sample was overweight/obese. There was a significant difference in overweight/obesity by gender, age, country of origin and marital status. Overall immigrant men were almost 52% more likely to be overweight/obese than women. Women from Somalia had the highest odds (13.1; CI: 7.4-23.1) of being overweight/obese, followed by Iraq (8.6; CI: 4.9-14.9), Pakistan (7.5; CI: 4.2-13.4), Kosovo (7.0; CI: 4.1-12.1), and Turkey (6.8; CI: 4.0-11.6) as compared to the women from Vietnam (reference). Whereas men from Turkey had the highest odds (5.2; CI: (3.2-8.3)) of being overweight/obese, followed by Poland (4.2; CI: 2.7-6.1), Bosnia (4.1; CI: (2.6-6.5) and Kosovo (3.9; CI: 2.5-6.1). The odds for obesity increased with age and odds were highest in the eldest group 45-66 years (4.3; CI: 3.2-5.8) as compared to reference group16-24 years. The odds of being overweight/obese was higher among married (1.6; CI: 1.3-1.9) and divorced/separated/widowed (1.5; CI: 1.1-2.0) as compared to singles. Education, employment status, physical activity and length of residence were not associated with the odds of being overweight/obese.

CONCLUSION

The findings of this study call attention to the importance of a greater understanding of the processes leading to obesity among certain immigrant groups in Norway. Moreover, there is a need for culturally adapted prevention strategies targeting immigrant men and women with high rates of overweight/obesity.

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.

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.

The role of food parcel use on dietary intake: perception of Dutch food bank recipients - a focus group study

OBJECTIVE

To gain insight in Dutch food bank recipients' perception on the content of the food parcels, their dietary intake and how the parcels contribute to their overall dietary intake.

DESIGN

Eleven semi-structured focus group discussions were conducted. Focus group topics were based on Andersons food insecurity definition: the lack of availability of nutritionally adequate foods and the assured ability to acquire foods in socially acceptable ways. Data were coded and analysed with Atlas.ti 7.0 software, using the framework approach.

SETTING

Seven food banks throughout the Netherlands.

PARTICIPANTS

A total of 44 Dutch food bank recipients.

RESULTS

Food bank recipients were not always satisfied with the amount, quality, variation and type of foods in the food parcel. For the participants who could afford to, supplementing the food parcel was reported as main reason for buying foods, and price was the most important aspect in selecting these foods. Participants were not satisfied with their dietary intake; they mainly reported not having enough to eat. The content of the food parcel importantly influenced participants' overall dietary intake. Finally, participants reported struggling with their feelings of dissatisfaction, while also being grateful for the foods they receive.

CONCLUSIONS

This study suggests that, despite their best efforts, food banks are not meeting food bank recipients' needs. Our results provide valuable directions for improving the content of the food parcels by increasing the quantity, quality and variation in the foods supplied. Whether this also improves the dietary intake of recipients needs to be determined.

Cardiometabolic disease costs associated with suboptimal diet in the United States: A cost analysis based on a microsimulation model

BACKGROUND

Poor diet is a leading risk factor for cardiometabolic disease (CMD) in the United States, but its economic costs are unknown. We sought to estimate the cost associated with suboptimal diet in the US.

METHODS AND FINDINGS

A validated microsimulation model (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends [CVD PREDICT]) was used to estimate annual cardiovascular disease (fatal and nonfatal myocardial infarction, angina, and stroke) and type 2 diabetes costs associated with suboptimal intake of 10 food groups (fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, sodium). A representative US population sample of individuals aged 35-85 years was created using weighted sampling from National Health And Nutrition Examination Surveys (NHANES) 2009-2012 cycles. Estimates were stratified by cost type (acute, chronic, drug), sex, age, race, education, BMI, and health insurance. Annual diet-related CMD costs were $301/person (95% CI $287-$316). This translates to $50.4 billion in CMD costs (18.2% of total) for the whole population, of which 84.3% are attributed to acute care ($42.6 billion). The largest annual per capita costs are attributed to low consumption of nuts/seeds ($81; 95% CI $74-$86) and seafood omega-3 fats ($76; 95% CI $70-$83), and the lowest are attributed to high consumption of red meat ($3; 95% CI $2.8-$3.5) and polyunsaturated fats ($20; 95% CI $19-$22). Individual costs are highest for men ($380), those aged ≥65 years ($408), blacks ($320), the less educated ($392), and those with Medicare ($481) or dual-eligible ($536) insurance coverage. A limitation of our study is that dietary intake data were assessed from 24-hour dietary recall, which may not fully capture a diet over a person's life span and is subject to measurement errors.

CONCLUSIONS

Suboptimal diet of 10 dietary factors accounts for 18.2% of all ischemic heart disease, stroke, and type 2 diabetes costs in the US, highlighting that timely implementation of diet policies could address these health and economic burdens.

Longitudinal Associations between Monetary Value of the Diet, DASH Diet Score and the Allostatic Load among Middle-Aged Urban Adults

Lower cost can lead to poorer-quality diets, potentially worsening metabolic profiles. We explored these pathways among urban adults. Longitudinal data were extracted from 1224-1479 participants in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. DASH_(mean) (Dietary Approaches to Stop Hypertension) score was computed using four 24 h recalls (v1/v2: 2004-2013) linked with a national food price database to estimate monetary value of the diet [MVD_(mean)]. Allostatic load (AL) was measured at visits 2 (v2) and 3 (v3) in 2009-2018. Mixed-effects regression and structural equation modeling (SEM) were conducted, linking MVD_(mean)/DASH_(mean) to AL [v2 and annual change(v3-v2)] and exploring mediating pathways between MVD_(mean) and AL_(v3) through DASH_(mean), stratifying by sex, race and poverty status. MVD_(mean) tertiles were linearly associated with contemporaneous DASH_(mean), after energy adjustment. In mixed-effects regression models, DASH_(mean) was consistently linked to lower AL_(v2). DASH_(mean) and MVD_(mean) were positively associated with higher serum albumin_(v2). In SEM, MVD_(mean) was linked to AL_(v3) through DASH_(mean), mainly among Whites and specifically for the cholesterol and Waist-Hip-Ratio AL components. In summary, energy and other covariate-adjusted increase in MVD may have a sizeable impact on DASH which can reduce follow-up AL among urban White middle-aged adults. More studies are needed to replicate findings in comparable samples of urban adults.

Plant- and animal-protein diets in relation to sociodemographic drivers, quality, and cost: findings from the Seattle Obesity Study

BACKGROUND

Promoting plant-based proteins is at the forefront of many initiatives in public health nutrition.

OBJECTIVES

The aim of this study was to characterize the sociodemographic drivers of plant-based protein diet consumption, and to study these in relation to diet quality and cost.

METHODS

The Seattle Obesity Study series (SOS I and II) yielded the study sample (n = 1636). Sociodemographic data were obtained by survey self-report. Diet quality and cost came from the Fred Hutchinson Cancer Research Center Food-Frequency Questionnaire linked to retail food prices. The Healthy Eating Index 2010 (HEI-2010) and mean adequacy ratio (MAR) served as measures of diet quality. Linear regressions with robust standard errors examined associations.

RESULTS

Total proteins contributed 16.8% of daily dietary energy. The breakdown by animal and plant proteins was 10.9% and 5.9%, respectively. The sociodemographic factors associated with plant-protein consumption were a positive attitude towards healthy eating and higher education but not income. Plant-protein diets were characterized by severalfold increases in nuts and seeds, soy and legumes, but much less meat, poultry, dairy, solid fats, and added sugars. Higher quartiles of plant-based diets were associated with significantly higher HEI-2010 (β: 13.0 from quartile 1 to quartile 4; 95% CI: 11.8, 14.3) and higher MAR (β: 6.0; 95% CI: 3.5, 8.5) with minimal impact on diet costs (β: 0.35; 95% CI: 0.04, 0.67). In contrast, higher quartiles of animal-protein diets were associated with higher diet costs (β: 1.07; 95% CI: 0.77, 1.36) but lower HEI-2010 (β: -3.2; 95% CI: -4.5, -1.9). Each additional 3% of energy from plant proteins was associated with an 8.4-unit increase in HEI-2010 (95% CI: 7.6, 9.1) and with a 4.1-unit increase in MAR (95% CI: 2.7, 5.5) with a minimal increase in diet cost (β: 0.28; 95% CI: 0.06, 0.50).

CONCLUSION

Plant-based protein diets may be a cost-effective way to improve diet quality at all levels of income. Future research needs to evaluate the quality of plant-based protein in relation to amino acids and health.

Healthy eating index versus alternate healthy index in relation to diabetes status and health markers in U.S. adults: NHANES 2007-2010

BACKGROUND

It remains to be determined whether the Alternate Healthy Eating Index 2010 (AHEI-2010) or the Healthy Eating Index 2010 (HEI-2010) is preferably recommended as means to assess dietary quality in people with type 2 diabetes (T2DM).

METHODS

The purpose of this study was to determine whether the AHEI-2010 provides a more accurate assessment of dietary quality than the HEI-2010 in relation to diabetes status, while controlling for health markers, sociodemographic and lifestyle factors. The 2007-2010 National Health and Nutrition Examination Survey (NHANES) was used as a representative sample of U.S. adults age 20+ years (n = 4097). HEI-2010 and the AHEI-2010 scores were used as measures of dietary quality and were calculated using data from the first 24-h dietary recall. Health markers evaluated include anthropometrics, blood pressure, lipid and inflammatory markers, and presence of co-morbid diseases. Least Squares Means were computed to determine differences across diabetes status (nondiabetes, prediabetes, T2DM) for total and sub-component HEI-2010 and AHEI-2010 scores, and to determine differences across total HEI-2010 and AHEI-2010 quartiles for health markers. Covariate-adjusted logistic regression was used to examine the association between total HEI-2010 and AHEI-2010 scores and diabetes status.

RESULTS

Adults with T2DM showed higher HEI-2010 and AHEI-2010 scores compared to adults with prediabetes and nondiabetes but did not have better health markers. For HEI-2010 component scores, adults with T2DM had highest consumption (highest score) of total protein foods and lowest consumption (highest score) for empty calories (p < 0.01). For AHEI-2010 component scores, adults with T2DM had the lowest consumption (highest score) for sugar-sweetened beverages and fruit juice, sodium, and alcohol (lowest score). In addition, adults with T2DM had the highest consumption (lowest score) for red and/or processed meats (p < 0.01). However, neither total HEI-2010 nor AHEI-2010 scores were significantly associated with diabetes status (p > 0.05). Results suggest that neither index was clearly superior to the other in terms of its predictive ability in relation to T2DM.

CONCLUSION

Neither total HEI-2010 nor AHEI-2010 scores performed better in terms of their relationship with diabetes status. However, the significant relationships between 1) diabetes status and health markers and 2) between HEI-2010 and AHEI-2010 scores and health markers suggest that diet has some influence on T2DM.

An Economic Gap Between the Recommended Healthy Food Patterns and Existing Diets of Minority Groups in the US National Health and Nutrition Examination Survey 2013-14

The US Department of Agriculture (USDA) has identified three Healthy Food Patterns as ways to implement the 2015–2020 Dietary Guidelines for Americans. We estimated the daily cost of the Healthy Vegetarian, US-Style, and Mediterranean Food Patterns (at 2,000 kcal/d) using national food prices adjusted for inflation. We also estimated the cost of existing dietary intakes in $/2,000 kcal/d for persons ≥2 years in the National Health and Nutrition Examination Survey (NHANES 2013–2014) using the same national food prices. The Nutrient Rich Food index (NRF9.3) was used as a measure of diet quality. Compared to existing diets, the USDA Healthy Food Patterns were higher in protein, fiber, vitamins, and minerals; were lower in solid fats, sugars, and sodium, and had higher diet quality scores. However, they also cost more. The cost of existing diets in NHANES was $5.47/d for Hispanics, $5.48/d for African-Americans, $5.94/d for Whites and $6.57/d for Asians. By contrast, the recommended US-Style Pattern cost $8.27/d, the Vegetarian Pattern cost $5.90/d, and the Mediterranean Pattern cost $8.73/d. Further, the Healthy Food Patterns featured some of the recommended food groups in unrealistic amounts. To ensure that the US Dietary Guidelines are both feasible and relevant to minority health, economic modeling studies should accompany government-issued dietary advice.

Performance Nutrition Dining Facility Intervention Improves Special Operations Soldiers' Diet Quality and Meal Satisfaction

OBJECTIVE

To assess the impact of the Special Operations Forces Human Performance Program dining facility (DFAC) intervention on patron diet quality and meal satisfaction.

DESIGN

Nonrandomized, controlled time series study using digital food photography and surveys pre-post intervention (0, 4, 8, and 12 months).

SETTING

Two Fort Bragg, NC military installation DFACs.

PARTICIPANTS

Volunteers (n = 688 total; n = 573 complete dataset) were US Army active duty soldiers.

INTERVENTION

The DFAC intervention included food choice architecture, new performance-optimizing food recipes to increase nutrient density, revised menus to offer more performance foods daily, and nutrition labeling to influence food choice.

MAIN OUTCOME MEASURES

Daily DFAC nutrient intake and Healthy Eating Index (HEI) 2010 scores.

ANALYSIS

Descriptive and ANOVA statistical analyses were performed between control and intervention groups and from baseline to 4, 8, and 12 months postintervention (α = .05; 80% power).

RESULTS

The intervention resulted in a higher posttest HEI score (60.1 ± 8.8 points; +3.4%; P = .005) and DFAC satisfaction compared with control (49.0 ± 10.4 points; P > .05). Improved intervention HEI scores were attributed to changes in citrus and melon fruit (+46%), red and orange vegetables (+35%), whole grains (+181%), legumes (65%), yogurt (+45%), oils (-26%), and solid fat (-18%) consumption (all P < .05).

CONCLUSIONS AND IMPLICATIONS

These data illustrate that the Special Operations Forces Human Performance Program military DFAC nutrition intervention was feasible to implement and was associated with diet quality improvements. Access to high-quality ingredients and recipes may improve soldier meal quality and acceptance in other settings and warrants further investigation.

Longitudinal change in the diet's monetary value is associated with its change in quality and micronutrient adequacy among urban adults

Background

Reducing diet costs may lead to the selection of energy-dense foods, such as refined grains or foods high in added sugars and/or fats, which can lower overall dietary quality. We examined the longitudinal association between the monetary value of the diet (MVD) and the overall dietary quality across sex, race and income groups.

Methods and findings

Longitudinal data from 1,466 adult urban participants from Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used. Healthy Eating Index–2010 (HEI–2010) and Mean Adequacy Ratio (MAR) were computed and a national food price database was used to estimate MVD. Multiple linear regression analyses were conducted linking annual rates of change (Δ) in MVD to ΔHEI-2010 and ΔMAR, stratifying by sex, race and income groups. Among key findings, ΔHEI-2010 was comparable across socio-demographic groups, while ΔMAR was higher among women and individuals above poverty. Adjusting for key covariates, ΔMVD was positively associated with both ΔHEI-2010 and ΔMAR, and with a consistently stronger association among individuals above poverty, specifically for the total proteins and empty calories components of HEI-2010 and several nutrient adequacy ratios (NARs: vitamins C, E, B-6 and Zinc). ΔMVD-ΔMAR association was stronger in women, mainly influenced by ΔMVD’s positive associations with B-vitamins, copper, calcium, magnesium and phosphorus NARs. ΔMVD-Δvitamin D NAR’s positive relationship was stronger among Whites, while ΔMVD-Δvitamin B-12 NAR’s association was stronger among African-Americans.

Conclusions

In sum, a potential increase in MVD may have a stronger impact on dietary quality among urban adult women and above-poverty individuals.

Cardiovascular Disease Prevention by Diet Modification: JACC Health Promotion Series

Reduction in excess calories and improvement in dietary composition may prevent many primary and secondary cardiovascular events. Current guidelines recommend diets high in fruits, vegetables, whole grains, nuts, and legumes; moderate in low-fat dairy and seafood; and low in processed meats, sugar-sweetened beverages, refined grains, and sodium. Supplementation can be useful for some people but cannot replace a good diet. Factors that influence individuals to consume a low-quality diet are myriad and include lack of knowledge, lack of availability, high cost, time scarcity, social and cultural norms, marketing of poor-quality foods, and palatability. Governments should focus on cardiovascular disease as a global threat and enact policies that will reach all levels of society and create a food environment wherein healthy foods are accessible, affordable, and desirable. Health professionals should be proficient in basic nutritional knowledge to promote a sustainable pattern of healthful eating for cardiovascular disease prevention for both healthy individuals and those at higher risk.

Higher Dietary Cost Is Associated with Higher Diet Quality: A Cross-Sectional Study among Selected Malaysian Adults

Food price is a determining factor of food choices; however its relationship with diet quality is unclear in Malaysia. This study aimed to examine socio-economic characteristics and daily dietary cost (DDC) in relation to diet quality in the state of Selangor, Malaysia. Dietary intake was assessed using a Food Frequency Questionnaire (FFQ) and diet quality was estimated using a Malaysian Healthy Eating Index (M-HEI). DDC in Malaysian Ringgit (RM) was calculated from dietary intake and national food prices. Linear regression models were fitted to determine associations between DDC and M-HEI scores and predictors of diet quality. The mean M-HEI score of respondents was 61.31 ± 10.88 and energy adjusted DDC was RM10.71/2000 kcal (USD 2.49). The highest quintile of adjusted DDC had higher M-HEI scores for all respondents (Q1: 57.14 ± 10.07 versus Q5: 63.26 ± 11.54, p = 0.001). There were also positive associations between DDC and M-HEI scores for fruits (p < 0.001) and vegetables (p = 0.017) for all respondents. Predictors of diet quality included carbohydrate (β = 0290; p < 0.001) and fat intakes (β = −0.242; p < 0.001) and energy adjusted DDC (β= 0.196; p < 0.001). Higher dietary cost is associated with healthy eating among Malaysian adults.

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).

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.

Community Priorities for Healthy Eating in Older Adults

Community planners such as policymakers and health care and nutrition service providers can create an "age-friendly" environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n = 30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers' markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents' ability to achieve optimal nutritional health.

Dietary changes needed to reach nutritional adequacy without increasing diet cost according to income: An analysis among French adults

OBJECTIVE

To explore the dietary changes needed to achieve nutritional adequacy across income levels at constant energy and diet cost.

MATERIALS AND METHODS

Individual diet modelling was used to design iso-caloric, nutritionally adequate optimised diets for each observed diet in a sample of adult normo-reporters aged ≥20 years (n = 1,719) from the Individual and National Dietary Survey (INCA2), 2006-2007. Diet cost was estimated from mean national food prices (2006-2007). A first set of free-cost models explored the impact of optimisation on the variation of diet cost. A second set of iso-cost models explored the dietary changes induced by the optimisation with cost set equal to the observed one. Analyses of dietary changes were conducted by income quintiles, adjusting for energy intake, sociodemographic and socioeconomic variables, and smoking status.

RESULTS

The cost of observed diets increased with increasing income quintiles. In free-cost models, the optimisation increased diet cost on average (+0.22 ± 1.03 euros/d) and within each income quintile, with no significant difference between quintiles, but with systematic increases for observed costs lower than 3.85 euros/d. In iso-cost models, it was possible to design nutritionally adequate diets whatever the initial observed cost. On average, the optimisation at iso-cost increased fruits and vegetables (+171 g/day), starchy foods (+121 g/d), water and beverages (+91 g/d), and dairy products (+20 g/d), and decreased the other food groups (e.g. mixed dishes and salted snacks), leading to increased total diet weight (+300 g/d). Those changes were mostly similar across income quintiles, but lower-income individuals needed to introduce significantly more fruit and vegetables than higher-income ones.

CONCLUSIONS

In France, the dietary changes needed to reach nutritional adequacy without increasing cost are similar regardless of income, but may be more difficult to implement when the budget for food is lower than 3.85 euros/d.

Tobacco cessation and household spending on non-tobacco goods: results from the US Consumer Expenditure Surveys

Objectives

To estimate the impact of tobacco cessation on household spending on non-tobacco goods in the USA.

Methods

Using 2006–2015 Consumer Expenditure Survey data, 9130 tobacco-consuming households were followed for four quarters. Households were categorised during the fourth quarter as having: (1) recent tobacco cessation, (2) long-term cessation, (3) relapsed cessation or (4) no cessation. Generalised linear models were used to compare fourth quarter expenditures on alcohol, food at home, food away from home, housing, healthcare, transportation, entertainment and other goods between the no-cessation households and those with recent, long-term or relapsed cessation. The full sample was analysed, and then analysed by income quartile.

Results

In the full sample, households with long-term and recent cessation had lower spending on alcohol, food, entertainment and transportation (p<0.001). Recent cessation was further associated with reduced spending on food at home (p<0.001), whereas relapsed cessation was associated with higher spending on healthcare and food away from home (p<0.001). In the highest income quartile, long-term and recent cessations were associated with reduced alcohol spending only (p<0.001), whereas in the lowest income quartile, long-term and recent cessations were associated with lower spending on alcohol, food at home, transportation and entertainment (p<0.001).

Conclusions

Households that quit tobacco spend less in areas that enable or complement their tobacco cessation, most of which may be motivated by financial strain. The most robust association between tobacco cessation and spending was the significantly lower spending on alcohol.

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.

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.

Socioeconomic inequalities in the healthiness of food choices: Exploring the contributions of food expenditures

Investigations of the contribution of food costs to socioeconomic inequalities in diet quality may have been limited by the use of estimated (vs. actual) food expenditures, not accounting for where individuals shop, and possible reverse mediation between food expenditures and healthiness of food choices. This study aimed to explore the extent to which food expenditure mediates socioeconomic inequalities in the healthiness of household food choices. Observational panel data on take-home food and beverage purchases, including expenditure, throughout 2010 were obtained for 24,879 UK households stratified by occupational social class. Purchases of (1) fruit and vegetables and (2) less-healthy foods/beverages indicated healthiness of choices. Supermarket choice was determined by whether households ever visited market-defined high-price and/or low-price supermarkets. Results showed that higher occupational social class was significantly associated with greater food expenditure, which was in turn associated with healthier purchasing. In mediation analyses, 63% of the socioeconomic differences in choices of less-healthy foods/beverages were mediated by expenditure, and 36% for fruit and vegetables, but these figures were reduced to 53% and 31% respectively when controlling for supermarket choice. However, reverse mediation analyses were also significant, suggesting that 10% of socioeconomic inequalities in expenditure were mediated by healthiness of choices. Findings suggest that lower food expenditure is likely to be a key contributor to less-healthy food choices among lower socioeconomic groups. However, the potential influence of cost may have been overestimated previously if studies did not account for supermarket choice or explore possible reverse mediation between expenditure and healthiness of choices.

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.

New perspectives on dietary-derived treatments and food safety-antinomy in a new era

Despite the advances in science and technology and wide use of chemical drugs, dietary intervention (or food therapy) remains useful in preventing or treating many human diseases. A huge body of evidence shows that the dietary pattern or habit is also an important contributing factor to the development of chronic diseases such as hypertension, type 2 diabetes, hyperlipidemia, and cancers. In recent years, over-the-counter health foods, nutraceuticals, and plant-derived medicinal products have been gaining popularity all over the world, particularly in developed countries. Unfortunately, owing to the contamination with various harmful substances in foods and the presence of toxic food components, food-borne diseases have also become increasingly problematic. Incidents of food poisonings or tainted food have been increasing worldwide, particularly in China and other developing countries. Therefore, the government should put in a greater effort in enforcing food safety by improving the surveillance mechanism and exerting highest standards of quality control for foods.

Economic constraints on taste formation and the true cost of healthy eating

This article shows how an interaction between economic constraints and children's taste preferences shapes low-income families' food decisions. According to studies of eating behavior, children often refuse unfamiliar foods 8 to 15 times before accepting them. Using 80 interviews and 41 grocery-shopping observations with 73 primary caregivers in the Boston area in 2013-2015, I find that many low-income respondents minimize the risk of food waste by purchasing what their children like--often calorie-dense, nutrient-poor foods. High-income study participants, who have greater resources to withstand the cost of uneaten food, are more likely to repeatedly introduce foods that their children initially refuse. Several conditions moderate the relationship between children's taste aversion and respondents' risk aversion, including household-level food preferences, respondents' conceptions of adult authority, and children's experiences outside of the home. Low-income participants' risk aversion may affect children's taste acquisition and eating habits, with implications for socioeconomic disparities in diet quality. This article proposes that the cost of providing children a healthy diet may include the possible cost of foods that children waste as they acquire new tastes.

Global growth of "big box" stores and the potential impact on human health and nutrition

Despite a large body of literature on the food environment, little is known about the role of supercenters in human nutrition and health. The objectives of this review are to examine what is currently known about the association between supercenters, nutrition, and obesity, to identify how supercenters may affect disparities in food access and nutritional quality of food purchases, and to document the rapid rise of supercenters as a source of food purchases in the United States. A case study of Wal-Mart, the largest food retailer in the United States, is presented that demonstrates the major and increasing role of supercenters as a source of packaged food purchases in the United States, particularly among low-income households, as well as the role of supercenters in supplying key nutrients. Taken together, this review and case study highlight the dominant role of supercenters in the US diet and the need to better understand how supercenters can be leveraged to improve the nutritional quality of what consumers buy and eat.