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Nutrient-Dense Food Groups Have High Energy Costs: An Econometric Approach to Nutrient Profiling


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Consumers wishing to replace some of the foods in their diets with more nutrient-dense options need to be able to identify such foods on the basis of nutrient profiling. The present study used nutrient profiling to rank 7 major food groups and 25 subgroups in terms of their contribution to dietary energy, diet quality, and diet cost for 1332 adult participants in the French National INCA1 Study. Nutrient profiles were based on the presence of 23 qualifying nutrients, expressed as the percentage of nutrient adequacy per 8 MJ, and 3 negative or disqualifying nutrients, expressed as the percentage of the maximal recommended values for saturated fatty acids, added sugar, and sodium per 1.4 kg. Calculated cost of energy (euro/8 MJ) was based on the mean retail price of 619 foods in the nutrient composition database. The meat and the fruit and vegetables food groups had the highest nutritional quality but were associated with highest energy costs. Sweets and salted snacks had the lowest nutritional quality but were also one of the least expensive sources of dietary energy. Starches and grains were unique because they were low in disqualifying nutrients yet provided low-cost dietary energy. Within each major food group, some subgroups had a higher nutritient-to-price ratio than others. However, the fact that food groups with the more favorable nutrient profiles were also associated with higher energy costs suggests that the present structure of food prices may be a barrier to the adoption of food-based dietary guidelines, at least by low-income households.
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The Journal of Nutrition
Nutritional Epidemiology
Nutrient-Dense Food Groups Have High Energy
Costs: An Econometric Approach
to Nutrient Profiling
Matthieu Maillot,
Nicole Darmon,
* Michel Darmon,
Lionel Lafay
and Adam Drewnowski
INSERM, U476 ‘Nutrition Humaine et Lipides’’, Marseille, F-13385 France;
INRA, UMR1260, Marseille, F-13385 France;
e Aix-Marseille 2, Faculte
de Me
decine, IPHM, Marseille, F-13385 France;
University of Bordeaux-2, Biochemistry and
Molecular Biology Laboratory, 33076 Bordeaux, F-33076 France;
Agence Francxaise de Se
Sanitaire des Aliments (AFSSA),
Maisons-Alfort, F-94700 France; and
Nutritional Sciences Program, School of Public Health and Community Medicine,
University of Washington, Seattle, WA 98195-3410
Consumers wishing to replace some of the foods in their diets with more nutrient-dense options need to be able to identify
such foods on the basis of nutrient profiling. The present study used nutrient profiling to rank 7 major food groups and 25
subgroups in terms of their contribution to dietary energy, diet quality, and diet cost for 1332 adult participants in the
French National INCA1 Study. Nutrient profiles were based on the presence of 23 qualifying nutrients, expressed as the
percentage of nutrient adequacy per 8 MJ, and 3 negative or disqualifying nutrients, expressed as the percentage of the
maximal recommended values for saturated fatty acids, added sugar, and sodium per 1.4 kg. Calculated cost of energy (V/8
MJ) was based on the mean retail price of 619 foods in the nutrient composition database. The meat and the fruit and
vegetables food groups had the highest nutritional quality but were associated with highest energy costs. Sweets and
salted snacks had the lowest nutritional quality but were also one of the least expensive sources of dietary energy.
Starches and grains were unique because they were low in disqualifying nutrients yet provided low-cost dietary energy.
Within each major food group, some subgroups had a higher nutritient-to-price ratio than others. However, the fact that
food groups with the more favorable nutrient profiles were also associated with higher energy costs suggests that the
present structure of food prices may be a barrier to the adoption of food-based dietary guidelines, at least by low-income
households. J. Nutr. 137: 1815–1820, 2007.
Food prices and diet costs may be one factor limiting the
adoption of healthier diets, especially by the low-income
consumer. That food prices affect food purchases and food
consumption has been repeatedly shown by studies in economics
(1,2), marketing (3), consumer behavior (4,5), and nutritional
epidemiology (6).
If nutrient-poor diets cost less, then economic factors could
help explain the high prevalence of nutrient deficiencies and
nutrition-related diseases, particularly obesity, among the more
disadvantaged populations (7–9). If healthier diets cost more,
then economic barriers may help explain the low consumption
of fruits, vegetables (10,11), and fish (12) among the lower-
income groups. Diet modeling studies using linear programming
suggest that food budget constraints preferentially orient food
choices toward energy-dense diets that are low in essential
nutrients (13,14). In addition, there is accumulating evidence
that the recommended healthier, balanced, or more prudent diets
are associated with higher costs than are the ‘unhealthy’ diets
(15–17). In particular, the consumption of higher amounts of
fruit and vegetables (18) and essential micronutrients (19) has
been associated with higher diet costs, adjusted for energy.
Conversely, high dietary energy density (amount of energy in
100 g of food) has been associated with lower diet costs (20).
A science-based nutrient profiling system, based on the nutri-
tional characteristics of individual foods or food groups, is
currently under consideration by the European Commission
(21). Intended for consumer protection, the system will deter-
mine which foods or categories of foods will be allowed or
disqualified from certain nutritional or health claims (21). Al-
though diverse nutrient profiling schemes are available (22,23),
few have considered the issue of food costs and nutrient-to-price
ratios. The present study tested the hypothesis that the inverse
relationship between nutrient density and energy cost holds not
only between but also within food groups. In both cases, the more
nutrient-dense foods and food categories would be associated
Supported by the French National Research Agency’s 2005–2008 Nutritional
Policies project, the French National Institute for Health Prevention and
Education (INPES), and by the USDA Cooperative State Research, Education,
and Extension Service (CSREES), grant 2004-35215-14441.
Author disclosures: M. Maillot, N. Darmon, M. Darmon, L. Lafay, and A.
Drewnowski, no conflicts of interest.
* To whom correspondence should be addressed. E-mail: nicole.darmon@
0022-3166/07 $8.00 ª 2007 American Society for Nutrition.
Manuscript received 13 December 2006. Initial review completed 31 January 2007. Revision accepted 11 May 2007.
by guest on June 12, 2013jn.nutrition.orgDownloaded from
with higher costs, whereas the least nutrient-dense foods and
categories would be associated with lower costs. The relationship
between the qualifying (beneficial) and the disqualifying (neg-
ative) nutrients and energy cost was a topic of particular interest
to us. We used an across-the-board nutrient profiling system to
estimate the nutritional quality of food groups, based on 23
qualifying nutrients and 3 disqualifying nutrients, saturated
fatty acids (SFA),
added sugars, and sodium. Nutrient profiling
of foods has been recently described as a powerful tool to rank
foodstuffs according to their contribution to a balanced diet (22).
Materials and Methods
Food consumption data. The national INCA dietary survey, con-
ducted in 1999 by the French National Agency for Food Safety, provided
the food consumption data used in this study. This survey was based on a
nationally representative sample of 1985 French adults, aged 15–92 y,
who were selected using the quota method of sampling (24). All
participants completed a 7-d food record, which was aided by a
photographic manual of portion sizes. Subjects who under- or over-
reported their energy intakes (284 men and 312 women) according to the
method of Black (25) were removed from the sample. The physical
activity level assumed in the calculation of the threshold was 1.55,
corresponding to seated work with low walking and leisure activity. The
final sample of 1332 included 596 men (age range of 15 to 92 y) and 736
women (age range of 15 to 90 y).
Drinking water, diet beverages, tea, and coffee were excluded from
all analyses. The nutritional composition of the remaining 619 foods was
computed from the INCA food composition database (26), the Suvimax
food composition database (27), and other databases (28–30) including
the USDA food composition data for zinc, copper, iodine, and selenium
(31). The French mean national 1997 retail prices, mainly obtained from
marketing research (SECODIP), were also added to the analysis. All
prices were adjusted for preparation and waste using conversion factors.
Food groups. The foods were aggregated into 7 major food groups and
25 food subgroups (Table 1) according to the classification system used
to develop the French food-based dietary guidelines (32). The starches
and grains group included grains, starchy vegetables, dry beans, and
peas. The fruit subgroup included fruit juice and other processed fruits;
the vegetables subgroup included frozen and canned vegetables as well as
soups. The sweets subgroup included sweets, chocolate, pastries,
cookies, ice-creams, and desserts; the salted subgroup included chips,
savory snacks, and salted nuts. The mixed dishes subgroup included
foods like couscous-based dishes, paella, and cassoulet (french equiva-
lent of a bean dish with meat); and a snacks subgroup included foods like
pizzas, quiches, and sandwiches.
Contribution of food groups to diet energy and diet cost. Daily
energy intakes (in MJ/d) and daily diet costs (in V/d) were calculated for
each participant. The percentage of contributions of each food group to
total energy intakes and to the estimated diet costs were determined. The
cost of energy was calculated separately for each food group and
subgroup and was expressed in V/8 MJ (i.e., V/1913 kcal). We chose the
8 MJ value because it is close to the recommended energy intakes for the
studied population of French adults: 9.2 MJ (2200 kcal) for inactive men
and 7.5 MJ (1800 kcal) for inactive women.
Nutrient profiling of food groups. Nutrient profiling of the 7 food
groups and 25 subgroups was based on 2 indicators. An expanded and
modified version of a previously used nutrient density score (NDS) (33)
assessed the presence of qualifying nutrients thought to have a beneficial
effect on health. The score, based on 23 nutrients (Table 2), was the
mean of percentages of the French 2001 recommended dietary allow-
ances (RDA) (34) for each nutrient based on 8 MJ (1913 kcal) of the food
group consumed. The NDS algorithm was as follows:
Þ=23Þ 3 100 3 8=EI
where Nutrient
is the daily content (g, mg, or mg) of nutrient p
provided by group (or subgroup) k to a subject i, and RDA
is the French
RDA for nutrient p. EI
is the energy content (in MJ) provided by group
k to a subject i. A NDS of 100% indicates that the consumption of 8 MJ
(i.e., 1913 kcal) of any one food group or subgroup covers a mean of
100% of the RDA for 23 nutrients (34) (Table 2). Only those nutrients
naturally present in foods were included in the calculation of the NDS.
We developed a second indicator of limited nutrients (LIM) specif-
ically for this study. The LIM used 3 negative or disqualifying nutrients,
TABLE 1 Food groups, subgroups and number of foods
per group
Groups n Subgroups
Meat 166 Shellfish, fatty fish, lean fish, poultry, red meat,
organ meats, deli meats, eggs
Fruit and vegetables 114 Vegetables, fruit, dried fruit, nuts
Mixed dishes and snacks 70 Mixed dishes, snacks
Dairy 87 Yogurts, cheese, milk
Starches and grains 37 Legumes, whole grains, refined grains, potatoes
Sweets and salted snacks 107 Sweets, salted snacks
Added fats 39 Animal fats, vegetable fats
Abbreviations used: LIM, limited nutrient score; MRV, maximal recommended
value; NDS, nutrient density score; RDA, recommended dietary allowances;
SFA, saturated fatty acids.
TABLE 2 Recommended dietary allowances and maximal
recommended values used to calculate the nutrient
density and the limited nutrient scores
Men Women
Nutrients RDA RDA
Proteins, g/d 70 50
Fiber, g/d 30 30
Linoleic acid, g/d 10 8
Linolenic acid, g/d 21.6
Docosahexaenoic, g/d 0.12 0,10
Vitamin A, mg/d 800 600
Thiamin, mg/d 1.3 1.1
Riboflavin, mg/d 1.6 1.5
Niacin, mg/d 14 11
Vitamin B-6, mg/d 1.8 1.5
Folates, mg/d 330 300
Vitamin B-12, mg/d 2.4 2.4
Ascorbic acid, mg/d 110 110
Vitamin E, mg/d 12 12
Vitamin D, mg/d 55
Calcium, mg/d 900 900
Potassium, mg/d 3100 3100
Iron, mg/d 916
Magnesium, mg/d 420 360
Zinc, mg/d 12 10
Copper, mg/d 2.0 1.5
Iodine, mg/d 150 150
Selenium, mg/d 60 50
Limited nutrients MRV MRV
Saturated fat acids, g/d 25 20
Added sugars, g/d 55 45
Sodium, mg/d 2365 2365
1816 Maillot et al.
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which, when present in a food, could disqualify it from bearing a
nutritional or health claim. Unlike the NDS, the LIM was calculated for
a given quantity, not a given energy content, to avoid favoring energy-
dense foods. We chose a quantity of 1.4 kg, which approximated the
daily intake of foods (excluding alcohol and nonenergetic beverages) in
this population of French adults (1523 g for men and 1302 g for women).
The LIM was calculated as follows:
Þ=3Þ 3 100 3 1400=Q
where L
is the daily amount (in g or mg) of LIM t provided by group
(or subgroup) k to a subject i. MRV
is the maximal recommended value
for limited nutrient t (34). Q
is the quantity of foods (in g) from group k
consumed by subject i. The 3 limited nutrients were sodium, simple
added sugars, and SFA. The MRV for SFA and added sugars corre-
sponded to 10% of the recommended energy intake, i.e., 9.2 MJ (2200
kcal) for inactive men and 7.5 MJ (1800 kcal) for inactive women (35).
The MRV for sodium corresponds to a daily intake of 6 g NaCl.
A LIM of 100% would indicate that the consumption of 1.4 kg of
any one food group or subgroup would provide a mean of 100% of the
MRV for sodium, added sugars, and SFA.
Statistical analyses. Differences between means were tested using
ANOVA. Food groups were sorted by decreasing cost of energy, and
decreasing and increasing trends of mean NDS and LIM were respec-
tively tested. All models were adjusted for within-subject effect. Statis-
tical significance was determined at a ¼ 0.05. All analyses were
performed using SAS software, version 9.1 (SAS Institute).
Mean energy intakes were 9.9 MJ/d (2368 kcal/d) for men and
7.8 MJ/d (1866 kcal/d) for women. The daily cost of the
participants’ diets was estimated at 5.26 V/d (i.e., $6.89/d) for
men and 4.26 V/d (i.e., $5.59/d) for women. The mean cost of
the standard daily energy ration of 8 MJ was therefore 4.25 V
(i.e., $2.90/1000 kcal) for men and 4.37 V (i.e., $2.28/1000
kcal) for women.
Contribution of food groups to diet energy and diet cost.
We calculated the contribution of each of the 7 major food
groups to the total energy content and total cost of diets
consumed by the INCA participants as well as the cost of dietary
energy (in V/8 MJ) for each food group (Fig. 1A). Food groups
that contributed the most energy to the population diet were not
those that contributed the most to diet cost. In this population
sample, fruit and vegetables contributed only 8% of the total
dietary energy, but accounted for 17% of total diet cost. The
meat group contributed 18% of total energy intakes but 35% of
diet costs, whereas mixed dishes and snacks contributed 10%
energy and 13% of diet cost. Conversely, starches and grains,
sweets and salty snacks, and added fats contributed much more
dietary energy in relation to cost. Starches and grains accounted
for 23% of dietary energy but only 9% of the daily diet cost,
whereas added fats provided 10% of dietary energy and 2% of
diet cost. Dairy products were well balanced with respect to
dietary energy and diet cost, contributing ;11% to each. This
energy-to-cost relation by food group was illustrated by ranking
the food groups according to their decreasing order of energy
cost (Fig. 1A).
Nutrient profiling and cost of energy of food groups. The
relationship between mean NDS and cost of energy for each of the
7 major food groups is indicated in Figure 1B. The fruit and
vegetables group had the highest mean NDS, covering 210% of
the RDA. For the same quantity of energy (8 MJ), the meat group
covered a mean of 174% of the RDA, whereas the milk group
covered 112%. The remaining food groups all had NDS below
100%, with sweets and salted snacks scoring the lowest (38%).
The relationship between mean limited nutrient score and
cost of energy among the 7 major food groups is shown in Figure
1C. The fruit and vegetables group had the lowest mean LIM,
with 1.4 kg providing only 21% of MRV. For the same quantity,
the starches and grains group covered a mean of 76%. The
remaining food groups all had LIM .100%, with added fats
and sweets and salted snacks scoring the highest (816% and
387%, respectively).
The lower energy cost was paralleled by a lower NDS (P for
trend ¼ 0.01) and by a higher LIM (P for trend ¼ 0.01) (Fig. 1B,
C). These data confirm the hypothesis that higher energy costs
FIGURE 1 Energy and cost contributions (%) to the total energy
content and total cost of diets (A), NDS (B), LIM (C), and dietary energy
cost (A, B, C) of each of the 7 food groups consumed by INCA
participants. P for decreasing and increasing trend of NDS ,0.01 and of
LIM ,0.01, respectively.
Econometric approach to nutrient profiling 1817
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were associated with higher nutritional quality, whereas lower
energy costs were associated with lower nutritional quality. The
mixed dishes, snacks, and dairy products, which had interme-
diate costs of energy, were also intermediate in terms of
nutritional quality: they had relatively high NDS (close to
100%) as well as high LIM (.150%). However, this nutritional
quality-to-price hierarchy among food groups was not absolute.
Starches and grains were unique because they provided dietary
energy at a low cost (2.0 V /8 MJ or $1.37/1000 kcal), without
containing important amounts of disqualifying nutrients. Dairy
products had a better nutritional quality (both a higher NDS and
a lower LIM) than mixed dishes and snacks, although they were
less expensive sources of energy. Sweets and salted snacks were
relatively expensive sources of energy (3.5 V/8 MJ or $2.40/
1000 kcal), given their low NDS (38%) and their high LIM
Nutrient profiling and cost of energy for food subgroups.
The NDS and LIM for each of the 25 food subgroups were
ranked according to decreasing cost of energy within each food
group (Table 3). Among the meat group, organ meats had the
highest NDS (754%) and were associated with a low cost of
energy. In contrast, fish and shellfish had NDS that were almost
as high but were also the most expensive in terms of energy cost.
Deli meats had the lowest NDS (120%) and the highest LIM
(454%) in the meat group. Eggs had a good nutritional quality-
to-price ratio insofar as they had the lowest energy cost in this
group for intermediate values of both NDS and LIM.
Vegetables and fruit had NDS .100% and LIM ,100%.
Dried fruits were less expensive as source of energy than fruit
and vegetables, but their nutrient densities were also lower. Nuts
were the least expensive source of energy in this group, but they
also had the highest LIM.
In the dairy group, milk had higher nutritional quality-to-
price ratio than either cheese or yogurt, in that it was the least
expensive source of energy and had both the highest NDS and
the lowest LIM. In the starches and grains group, all subgroups
had low LIM. Legumes also had high NDS (156%). The nutri-
tional quality of sweets and salted snacks was low (low NDS and
high LIM). Within the added fats group, vegetable fats had a
higher nutritional quality-to-price ratio than animal fats: they
had both higher NDS and lower LIM for a lower cost of energy.
The data show that food groups and subgroups differ widely in
terms of nutritional quality and in terms of cost per MJ. The
meat and the fruit and vegetables groups that offered the highest
NDS overall were also the most expensive in terms of cost per
MJ. Conversely, added fats provided dietary energy at a very low
cost and had both a low NDS and a high content of negative or
disqualifying nutrients. Mixed dishes, snacks, and dairy pro-
ducts were intermediate in rank, both in terms of nutritional
quality and in terms of cost of energy. Sweets and salted snacks
had a lower nutritional quality than would be expected from
their relatively high cost of energy.
Both fish and vegetables and fruit had good nutrient profiles,
as indicated by very high NDS and by low LIM. However, they
were also associated with higher costs per MJ and therefore with
higher diet costs. On the other hand, as our previous studies
showed (33), vegetables and fruit provided an affordable package
of nutrients (as opposed to energy) per unit cost.
Overall, starches and grains had very favorable nutritional
quality-to-price ratio. These foods appear to be a good choice,
particularly whole or unrefined staples, which provide adequate
nutrition at a moderate cost. Whole-grain cereals generally provided
twice the amount of nutrients than refined cereal products, but at
twice the price. It will be interesting to determine whether the food
choices made by lower income and food insecure persons, high in
grains and starches and low in vegetables and fruit (7), is a rational
behavior in response to economic constraints, or whether tradition
and education are mainly involved in these choices.
Although a clear ranking of nutrient-to-price ratios was
found among food groups, food subgroups showed more
diversity. Although several food subgroups had a high nutri-
tional quality, they were not the most expensive ones within
their group. These subgroups, particularly milk, organ meats,
and eggs, had a very good nutritional quality-to-price ratio.
Vegetable fats, dried fruit, and nuts also showed good nutri-
tional quality-to-price ratios. Interestingly, diets obtained using
a computer to attain the whole set of nutritional recommenda-
tions at the lowest cost preferentially contained foods belonging
to the groups and subgroups identified in the present study as
having good nutritional quality-to-price ratios (36). This does
TABLE 3 Nutrient density score, limited nutrient score, and
cost of energy of food subgroups consumed by
INCA participants
Groups and
subgroups n
NDS %/8 MJ LIM %/1.4 kg
Cost of energy
V/8 MJ
Shellfish 370 643 6 373 64 6 28 33.2 6 20.4
Lean fish 921 375 6 92 60 6 32 15.8 6 8.8
Fatty fish 454 622 6 188 130 6 100 14.4 6 8.1
Red meat 1297 147 6 30 138 6 42 10.3 6 3.1
Poultry 1051 168 6 62 63 6 30 8.8 6 2.6
Organ meats 262 754 6 551 83 6 42 7.4 6 3.4
Deli meats 1102 120 6 75 454 6 103 4.8 6 2.0
Eggs 889 212 6 20 139 6 32 3.2 6 0.3
Fruit and vegetables
Vegetables 1318 352 6 172 27 6 14 15.1 6 8.1
Fruit 1220 134 6 50 13 6 22 7.7 6 3.2
Dried fruit 63 85 6 32 4.7 6 1.9 3.9 6 0.9
Nuts 173 120 6 23 145 6 40 1.7 6 0.9
Mixed dishes and snacks
Mixed dishes 967 106 6 40 155 6 50 6.7 6 4.6
Snacks 1027 80 6 18
229 6 77 5.4 6 2.6
Yogurts 1040 119 6 31 65 6 43 4.7 6 1.0
Cheese 1238 101 6 15 478 6 66 4.7 6 1.4
Milk 913 138 6 8.7 29 6 5.9 2.1 6 0.2
Starches and grains
Legumes 405 156 6 24 24 6 23 3.6 6 0.9
Whole grains 146 83 6 10 98 6 24 3.5 6 0.9
Potatoes 1243 75 6 12 58 6 38 1.6 6 0.6
Refined grains 1326 40 6 2.8 77 6 21 1.5 6 0.3
Sweets and salted snacks
Salted snacks 493 80 6 99 422 6 150 6.2 6 14
Sweets 1326 37 6 15 388 6 167 2.8 6 1.1
Added fats
Animal fats 1330 25 6 2.9 1040 6 185 1.2 6 0.1
Vegetable fats 1325 80 6 13 360 6 52 0.6 6 0.1
Values are means 6 SD.
For each subgroup, n indicates the number of participants consuming foods from this
1818 Maillot et al.
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not mean that low-income consumers should select only grains
and starches and stay away from fruit, vegetables, and fish. On
the contrary, the good quality-to-price ratio of grains and
starches leaves a substantial amount of the budget for high-cost,
nutrient-dense foods such as fruit, vegetables, and fish. Model-
ing studies using both cost and nutritional constraints showed
that including important amounts of unrefined starches in the
diet actually made it possible to fulfill all nutritional require-
ments for people on a moderate food budget (36). Interestingly,
such modeled diets also included important amounts of fruit,
vegetables, and fish.
The analysis of the link between diet cost and nutritional
quality has been hampered for a long time by methodological
limitations. Economists, who typically analyze household bud-
gets surveys, lack information about individual consumption
and about the nutritional composition of purchased foods.
Conversely, nutritional epidemiologists lack information on the
price of foods actually consumed by individuals. Associating a
mean price to foods in food consumption surveys (as well as the
mean nutritional composition associated with them) has allowed
investigators to solve this methodological issue and to estimate
the daily cost of each individual diet (15). Although this
approach only roughly estimates individual expenditures, it
seemed valid, in our study, to evaluate mean expenditures for
food consumed at home, insofar as the mean daily cost estimated
from the present data (4.7 V/d or $6.20/d) was very close to that
from the last French household budget survey (37). The price of
a given food varies according to stores, season, brand, size,
packaging, and according to whether it is prepared at home or
bought ready to eat. The use of a mean price partially hid this
variability; although frequently consumed foods weighted
higher in the mean price calculation. For instance, the mean
price of green beans was closer to the price of the processed items
rather than to that of the fresh ones. Likewise, the mean price of
a given fruit was closer to the price in full season rather than to
the price out of season.
Price variability within a single category of food may alter the
nutritional quality-to-price ratio of foods considered individu-
ally. Actually, a British study showed that branded foods
generally cost 2.5 times the price of economy-line foods, but
do not contain more nutrients, so that the quantity of nutrients
bought for one shilling of food was always clearly higher with
economy-line products (38). We considered that this intrafood
cost variability would not alter the nutritional quality-to-price
hierarchy among main food groups, but this requires further
investigation. Another possible drawback was the evolving
nature of the indicators used to estimate the nutritional quality
of food groups. The present NDS was based on 23 nutrients with
a known RDA. Although only some of these nutrients are
implicated in public health problems, the European Commission
takes into account those nutrients that are scientifically recog-
nized as having an effect on health. That list is still not finalized,
especially insofar as nutritional problems are not the same in all
countries because of different food habits, availability, and
different enrichments and supplementation practices. We there-
fore preferred a more universal score than a country-specific
score. On the other hand, one could also argue that our score
does not consider enough different nutrients. Actually, several
bioactive compounds, including polyphenols and some trace
elements, were not included in the NDS, either because the
nutrient composition database was not available or because the
nutritional requirement was not yet defined. Furthermore, we
calculated only those nutrients naturally present in foods and
not those introduced by enrichment. This was done to avoid
direct comparisons between a fortified food and a nonfortified
food with a similar nutrient content.
The nutritional quality-to-price hierarchy presently found
between food groups probably explains the positive association
observed between the nutritional quality of the diet and its cost
(15,18–20). Notwithstanding, the wide disparity of nutritional
quality and prices observed within food groups is compatible
with the fact that improving diet quality is not necessarily
associated with increased diet costs in intervention studies
implicating nutrition education (39–41). Our results suggest
that, by preferentially selecting subgroups that have the highest
nutritional quality-to-price ratio, healthy diets can be obtained
at a moderate cost. However, such low-cost nutritionally
adequate diets (39–41) deviated considerably from the typical
food habits of the population (36). Although nutrition education
could make such diets more attractive, they may not be palatable
enough or socially acceptable. In addition, there is a threshold
cost under which it is impossible to obtain a nutritionally
adequate diet, estimated at ;3.5 V/d per adult in France (36)
and at $116/wk for a 4-person family in the U.S. (42). Many
studies have emphasized that food budgets of the poor are often
under this threshold (16,17,36,43). The fact that food groups
with the more favorable nutrient profile were also the more
expensive sources of energy suggests that the present structure of
food prices does not favor the adoption of food-based dietary
guidelines, at least by low-income people.
Although nutritionally balanced diets can be obtained at
limited cost (36,39–41), often they are neither palatable nor
convenient. It is a major challenge for public health nutrition to
link public health imperatives with economic realities of life in
ensuring that nutritionally adequate and socially acceptable
foods are affordable and available to all. A refinement of food
and agriculture policies and food assistance programs is one
potential strategy for change (44–46, and unpublished data by
Z. Rambeloson, N. Darmon, and E. L. Ferguson). Effective
dietary guidance must take into account both the nutrient profile
of foods and their nutrient and energy costs. These consider-
ations will allow consumers to identify and select optimal diets
at an affordable cost.
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... This is probably because oils, fats, spices, and condiments are used culturally in their food preparation [38]. These food groups are likely to be more accessible but less nutrient-dense than others like legumes and nuts, meat, poultry, organ meat, eggs, milk, or fish [39]. ...
... Consumption of other vegetables (e.g., tomato and pepper) was significantly higher in the COG. However, other vegetables (e.g., tomato and pepper) tend to be less nutrient-dense than foods like spinach, peas, meats, or dairy products [39]. The higher consumption of these food groups could be due to the good dietary behaviour of the participants as a result of their fairly high literacy and educational levels [40], as most of our participants have up to secondary and tertiary school levels of education [8]. ...
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Background To maintain an optimal nutritional status and immunological function in PLHIV, a diet with adequate nutrients is of utmost importance. This is a major challenge among poor populations in developing worlds like Nigeria, where malnutrition and food insecurity are endemic. This study aimed to assess the type of regular diet consumed and assess the impact of supplementation of the diet with Moringa oleifera Lam. leaves on the nutritional status and CD4 cell counts of PLHIV that are on ART in Nigeria. Method A double-blind, randomized trial was conducted. Two hundred consented patients were randomly allocated to either the Moringa oleifera Lam. group (MOG) or the control group (COG). The FAO individual dietary diversity questionnaire was used. The regular diets of participants at baseline and six months were monitored. The measurements of weight, BMI, MUAC, and CD4 cell counts were obtained from baseline to six months of Moringa oleifera Lam. leaves supplementation. Results One hundred and seventy-seven patients completed the six-month follow-up (89 MOG versus 88 COG). At both baseline and sixth month, the foods most commonly consumed by the participants in both MOG and COG were cereals, spices and condiments, oils, fats and palm oil, and dark green vegetables. At baseline, significantly higher consumption of legumes, nuts & seeds (p= 0.001) was observed in the MOG and higher consumption of other vegetables (p= 0.024) in COG. Consumption of cereals, roots, and tubers was significantly higher (p= 0.024; 0.045) in the COG in the sixth month. In both groups, participants were in the medium or low dietary diversity tercile. Throughout the study period, all the nutritional status variables observed were not significantly different between the two study groups [(p > 0.0001); weight; p=0.5556; BMI; p=0.5145; MUAC; p=0.6456]. Over the study period, the treatment by time interaction shows a significant difference in CD4 counts by treatment group (p<0.0001) and an estimate of fixed effects 10.33 folds greater in the MOG than COG. All tests were conducted at 95CI. Conclusion This study revealed a poor dietary diversity amongst PLHIV. Supplementation of regular diet with Moringa oleifera Lam. leaves did not affect the nutritional status but could improve the immune response of HIV-positive adults attending the antiretroviral treatment centre in the present study area.
... Nevertheless, plant-based products have been criticized for being overly processed (12). While it is undoubtedly true that many UPFs are not nutrient dense (170,171), it is important not to assume that "ultraprocessed" equals poor nutritional quality, since quality does not depend solely on the intensity or complexity of processing but on the final composition of the food itself (172). ...
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In many non-Asian countries, soy is consumed via soy-based meat and dairy alternatives, in addition to the traditional Asian soyfoods, such as tofu and miso. Meat alternatives are typically made using concentrated sources of soy protein, such as soy protein isolate (SPI) and soy protein concentrate (SPC). Therefore, these products are classified as ultra-processed foods (UPFs, Group 4) according to NOVA (not an acronym), an increasingly widely used food classification system that classifies all foods into one of four groups according to the processing they undergo. Furthermore, most soymilks, even those made from whole soybeans, are also classified as UPFs because of the addition of sugars and emulsifiers. Increasingly, recommendations are being made to restrict the consumption of UPFs because their intake is associated with a variety of adverse health outcomes. Critics of UPFs argue these foods are unhealthful for a wide assortment of reasons. Explanations for the proposed adverse effects of UPFs include their high energy density, high glycemic index (GI), hyper-palatability, and low satiety potential. Claims have also been made that UPFs are not sustainably produced. However, this perspective argues that none of the criticisms of UPFs apply to soy-based meat and dairy alternatives when compared to their animal-based counterparts, beef and cow's milk, which are classified as unprocessed or minimally processed foods (group 1). Classifying soy-based meat and dairy alternatives as UPFs may hinder their public acceptance, which could detrimentally affect personal and planetary health. In conclusion, the NOVA classification system is simplistic and does not adequately evaluate the nutritional attributes of meat and dairy alternatives based on soy.
... 8 Where vegetables are available, they are unaffordable for many, with three billion people unable to afford healthy diets. 9 Fruits and vegetables, along with animalsource foods, are the most expensive element of a healthy diet by many metrics 10,11 comprising around 40% of the cost of a healthy diet. 9 Even if vegetables are available and affordable, most people still do not consume large enough quantities, 12 particularly if they are not considered as an acceptable or desirable food choice, for instance due to food safety or contamination concerns, taste preferences, or cultural appropriateness. ...
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Background Vegetables are an essential element in healthy diets, but intakes are low around the world and there is a lack of systematic knowledge on how to improve diets through food system approaches. Methods This scoping review assessed how studies of food systems for healthy diets have addressed the role of vegetables in low- and middle-income countries. We apply the PRISMA guidelines for scoping reviews to narratively map the literature to an accepted food systems framework and identify research gaps. Results We found 1383 relevant articles, with increasing numbers over 20 years. Only 6% of articles looked at low-income countries, and 93% looked at single-country contexts. Over half of articles assessed vegetables as a food group, without looking at diversity within the food group. 15% looked at traditional vegetables. Issues of physical access to food were among the least studied food system topics in our review (7% of articles). Only 15% of articles used a comprehensive food system lens across multiple dimensions. There is also a research gap on the impacts of different policy and practice interventions (13% of articles) to enable greater vegetable consumption. Conclusions Food system studies necessarily drew on multiple disciplines, methods and metrics to describe, analyze, and diagnose parts of the system. More work is needed across disciplines, across contexts, and across the food system, including understanding interventions and trade-offs, and impacts and change for diets particularly of marginalized population groups. Filling these gaps in knowledge is necessary in order to work toward healthy vegetable-rich diets for everyone everywhere.
... 13,24 These high energy-dense foods are less expensive and more resistant to inflation than low energy-dense food such as fruits and vegetables, thus more likely to be purchased by food-insecure adults. 25,26 Access to healthy foods is also an issue, since low-income neighbourhoods frequently have challenging access to affordable nutritious food, and low income adults may prefer to purchase easily accessible low cost food, primarily high sugar and high energy-dense food items. 27 ...
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Introduction The Supplemental Nutrition Assistance Program (SNAP) is a federal program aims to alleviate hunger and improve food insecurity. The impact of SNAP participation on overall health has been studied. However, little is known about the effects of SNAP participation on oral health. We aimed to investigate the association between participating in SNAP and dental caries and to explore the role of food insecurity as a moderator in this relationship. Methods We obtained data from the National Health and Nutrition Examination Survey (NHANES) cycles 2011-2012 and 2013-2014.The primary outcome was untreated dental caries (none vs. one or more). Self-reported SNAP participation status in the past 12 months was the predictor and food security was the moderator. Food security was measured as overall food security status (full food secure/ food insecure) and household-level food security (full, marginal, low, and very low). Bivariate and multiple logistic regression analyses were conducted to evaluate the relationship between SNAP and dental caries, and whether food insecurity moderates this relationship. Statistical analysis was carried out in September 2020. Results Our results suggested that after adjusting for potential confounders, SNAP participants were more likely to have untreated dental caries than non-SNAP participants (odds ratio:1.6; 95% CI:1.2-2.0). Food security status didn’t alter the relationship between SNAP participation and untreated dental caries. Conclusions Food security status didn’t alter the relationship between SNAP participation and untreated dental caries. SNAP participation was associated with untreated dental caries among U.S. adults, and this was not affected by their food security status.
... The products on the shelf varied according to size and number of portions included per package, so we used the energy density of the product chosen (kcal/100 g of product) as our key dependent variable, which meant we could control for differences in the size of the products displayed on the shelf. Moreover, diets with high energy density tend to have lower nutrient content than diets with low energy density Ledikwe et al. 2006;Maillot et al. 2007), and energy density is an important criterion for weight management (De Oliveira, Sichieri, and Mozzer 2008;Pérez-Escamilla et al. 2012). We also computed an index of nutritional quality for each product using the previously used FSA score; the FSA scores of the products displayed varied from −4 to 29. ...
The adoption of front-of-package (FoP) nutrition labels to promote healthier food choices is increasing worldwide, yet it remains unclear which types of nutrition labels are superior from a public policy perspective. This research compares two common forms of evaluative FoP nutrition labels that vary in the number of colors and corresponding letters they display (three colors, A—C [3C] vs. five colors, A—E [5C]). Four studies, including a field study with vending machines and a study in an experimental supermarket using eye-tracking, show that compared with the 3C label and no label (control) conditions, the 5C label enhances purchase intentions and choices of healthy alternatives. In particular, the 5C nutrition label is superior because it provides more information that helps consumers discriminate the products’ healthiness. This ability to discriminate healthiness modifies consumers’ perceived healthiness of products and influences both their purchase intentions and choice of healthy food options.
... Pocock et al. (2010) stated that preventing overweight and/or obesity by parents in families is complex and are influenced by many factors. For example, food prices may be a barrier for parents to obtain healthy food (Maillot et al., 2007), and the home environment influences the development of children's healthy lifestyle (Bates et al., 2018;Tinsley, 2003). Parents are role models for both healthy and unhealthy behaviour factors related to child's weight (Golan & Crow, 2004;Hardy et al., 2004;Rodenburg et al., 2012). ...
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Purpose: This study aimed at gaining insight into parents' perceptions towards health behaviour in parenting and the impact of the school environment. Healthcare professionals experience barriers to discuss health behaviour in families where levels of overweight and obesity are elevated. There is a need to understand parents' perception and perceived significance of health behaviour. Design and methods: Sixty-three semi-structured interviews were conducted with parents of children from three primary schools located in two different neighbourhoods in Zwolle, the Netherlands. Parents were asked to formulate their top three priority goals in parenting, additionally supplemented with 15 predetermined goals, including a health behaviour related goal. Parents ranked the goals in order of importance and gave an explanation. Finally, parents shared their opinions regarding the school environment in promoting health behaviour, according to the EnrG framework. Results: In 8 out of 63 interviews, health was reported in the top three self-formulated goals. Other goals considered important were happiness and being respectful to others. When health was ranked as less important in parenting, routine of health behaviour, own beliefs and religion were given as explanations. The physical school environment and teachers were mentioned as important factors in promoting health behaviour. Conclusions: Parents indicate health behaviour as a key-element in parenting, even when health behaviour is not considered as the most important priority. Practice implications: Since school is perceived as a logical and powerful environment, healthcare professionals should collaborate with school staff to empower their own, teachers' and parents' roles to address health promotion.
... A photographic manual of food portion sizes (7 sizes per food item) assisted in portion size estimations (17). A foodcomposition database composed of all the foods that have been declared as consumed by the INCA participants in their 7-d food records was specifically developed for this survey (18). Alcoholic beverages, tea, coffee, and drinking water were excluded from the present analyses because their consumption is often not well reported in dietary surveys. ...
Healthy diet is an effort to reduce the risk of non-communicable diseases (NCDs). The use of scientific terms on nutrition information panels (NIP) is complicated and difficult to understand, so that it becomes an obstacle in delivering accurate nutritional information for consumers. Nutrients-Rich Foods (NRFn,3) Index provides an alternative to simplify NIP. In general, nutrient-rich foods are asso-ciated with high-priced products. This study aimed to analyze correlation between NRFn,3 index with nutrients fulfillment and price of products. NIP of dairy products and their analogues were used as research samples. The NRFn,3 index was determined using two calculation bases, 100 kcal and 100 g of ready-to-consume products. NRF12,3 index score in ready-to-drink (RTD) milk and instant powdered milk positively correlated with the fulfillment of 11 nutrients to encourage. The average NRF12,3 index score per 100 g of instant powdered milk was 91, higher than RTD milk which was only 76. As nutrient-dense foods, they had an index score of NRF12,3 per 100 kcal that was higher per 100 g. Products with higher NRF12,3 index scores tended to be marketed at higher price than that of lower ones.
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Unhealthy diets are recognized as a major risk factor for many diseases. The decrease in costs of industrialized products, as well as the possible misinformation about a healthy diet, has led to new behaviors in the dietary patterns of the pediatric population. The costs of dietary patterns have not been estimated in our population, so the objective of this study was to determine the cost associated with dietary patterns in Mexican children and adolescents, hypothesizing that a healthy diet is not necessarily more economically expensive. This study analyzed data from a population-based cross-sectional study of healthy children and adolescents in Mexico City. Data were collected from a food frequency questionnaire and the meal cost of habitual food shopping. Eating patterns were obtained by using principal component analysis. A micro-costing technique was performed to obtain the direct costs of each pattern. When comparing the healthy pattern with the transition and non-healthy patterns, it was observed that there were no statistically significant differences between the dietary patterns (p = 0.8293). The cost of the healthy pattern only takes up 16.6% of the total biweekly income of a salaried Mexican. In this study, no differences were observed between the costs of a healthy and a less healthy diet.
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Purpose The goal of this work is to analyse the environmental impacts across the productive continuum of market gardening in southern Benin, to determine whether significant differences exist amongst the types of production, and to highlight their hotpots suitable to improvement. Moreover, the relative nutritional quality of products from different production system types were compared to determine whether there were differences and to assess them in relation to the associated environmental impacts. Methods LCA and laboratory analyses were performed on a representative sample of systems and products (carrot, cucumber, tomato, lettuce, watermelon). The resulting scores (single scores for LCA and Nutrient Rich Food scores for nutritional quality) were statistically treated to identify the representativeness of their differences across production sites and production types (featuring distinctive production strategies: Conventional — synthetic fertilisers and pesticides, Organic — organic fertilisers and pesticides and “Lean” — limited inputs). Results and discussion Statistically significant differences across environmental scores were found amongst production sites (for carrot, lettuce and all crops) and types (for carrot and all crops). For tomato, produced on all sites, under all production types, the natural and management-driven variability is large enough that no significant differences were found. Impacts are dominated by direct emissions from (over-)fertilisation and by fuel consumption for water pumping. Despite the absence of significant differences amongst production system types regarding the contents of both β-carotene and polyphenols, the nutritional indices suggest at least marginal differences across types regarding the overall nutritional value of carrot and tomato across types. Based on the limited data available, it cannot be stated that such differences are statistically significant. For carrot, there seems to be a correlation between nutritional quality and environmental impacts, with higher nutritional scores associated with lower environmental impacts. For tomato, it does not seem to exist a correlation. Conclusions Significant differences in environmental scores exist amongst the types of production, with the larger impact associated with organic production, whilst that no statistically significant differences on nutritional quality can be demonstrated across types. Overall improvement of these systems would be achieved by less energy-intensive irrigation, organic waste processing platforms to reduce volatilisation losses, knowledge on the fertilising value of organic waste, and agricultural extension services or technical guides on good agricultural practices to reduce over-fertilisation and other negative environmental impacts.
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Highest rates of obesity and diabetes in the United States are found among the lower-income groups. The observed links between obesity and socioeconomic position may be related to dietary energy density and energy cost. Refined grains, added sugars, and added fats are among the lowest-cost sources of dietary energy. They are inexpensive, good tasting, and convenient. In contrast, the more nutrient-dense lean meats, fish, fresh vegetables, and fruit generally cost more. An inverse relationship between energy density of foods (kilojoules per gram) and their energy cost (dollars per megajoule) means that the more energy-dense diets are associated with lower daily food consumption costs and may be an effective way to save money. However, economic decisions affecting food choice may have physiologic consequences. Laboratory studies suggest that energy-dense foods and energy-dense diets have a lower satiating power and may result in passive overeating and therefore weight gain. Epidemiologic analyses suggest that the low-cost energy-dense diets also tend to be nutrient poor. If the rise in obesity rates is related to the growing price disparity between healthy and unhealthy foods, then the current strategies for obesity prevention may need to be revised. Encouraging low-income families to consume healthier but more costly foods to prevent future disease can be construed as an elitist approach to public health. Limiting access to inexpensive foods through taxes on frowned upon fats and sweets is a regressive measure. The broader problem may lie with growing disparities in incomes and wealth, declining value of the minimum wage, food imports, tariffs, and trade. Evidence is emerging that obesity in America is a largely economic issue.
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The current European legislation in matter of labelling forbids the attribution of properties capable to prevent, treat or cure a human disease or to mention properties as such. In the past the States members of the European Union applied various interpretations of the legislation in matter of labelling because a regulation in this field was missing. In the meanwhile, in Europe (and in Italy) man y alimentary products have been giving uncontrolled nutritional information for years. Nowadays it is widely shared that healthy information must be properly formulated in order to protect the consumer, to encourage commerce and to support research and innovation in the alimentary industry. The Regulation (EC) 1924/2006, that establishes general principles applicable to the indications given on alimentary products, has been emanated to give rules to nutritional information that, as a matter of fact, is already widely used by alimentary firms. This work questions some aspects regulated by the current European and national legislation concerning nutritional and healthy information.
La pauvreté, qu'elle soit appréhendée à partir de critères monétaires ou non monétaires, a une répercussion sur l'alimentation des ménages. L'alimentation occupe, en effet, une position spécifique chez les ménages défavorisés par son importance dans le budget total. L'analyse du statut nutritionnel permet de mettre en évidence des inégalités d'ordre socio-économique, mais aussi au sein d'une même famille. La relation forte entre éducation ou revenu et consommation alimentaire se retrouve dans l'approche sociologique de l'alimentation des populations défavorisées. Ainsi, l'obésité touche davantage les catégories les moins favorisées de la population. Et l'étude des pratiques du régime alimentaire fait émerger la singularité de l'alimentation et de ses significations en milieu défavorisé.
La pauvreté, qu'elle soit appréhendée à partir de critères monétaires ou non monétaires, a une répercussion sur l'alimentation des ménages. L'alimentation occupe, en effet, une position spécifique chez les ménages défavorisés par son importance dans le budget total. L'analyse du statut nutritionnel permet de mettre en évidence des inégalités d'ordre socio-économique, mais aussi au sein d'une même famille. La relation forte entre éducation ou revenu et consommation alimentaire se retrouve dans l'approche sociologique de l'alimentation des populations défavorisées. Ainsi, l'obésité touche davantage les catégories les moins favorisées de la population. Et l'étude des pratiques du régime alimentaire fait émerger la singularité de l'alimentation et de ses significations en milieu défavorisé
The American diet is said to be increasingly energy-rich but nutrient-poor. To help improve the nutrient-to-energy ratio, the 2005 Dietary Guidelines for Americans recommend that consumers replace some foods in their diets with more nutrient-dense options. Such dietary guidance presupposes the existence of a nutrient density standard. However, a review of the literature shows that the concept of a nutritious food is not based on any consistent standards or criteria. In many cases, healthful foods are defined by the absence of problematic ingredients-fat, sugar, and sodium-rather than by the presence of any beneficial nutrients they might contain. Past attempts to quantify the nutrient density of foods have been based on a variety of calories-to-nutrient scores, nutrients-per-calorie indexes, and nutrient-to-nutrient ratios. The naturally nutrient rich (NNR) score, which is based on mean percentage daily values (DVs) for 14 nutrients in 2000 kcal food, can be used to assign nutrient density values to foods within and across food groups. Use of the NNR score allows consumers to identify and select nutrient-dense foods while permitting some flexibility where the discretionary calories are concerned. This approach has implications for food labeling, nutritional policy making, and consumer education. The Food and Drug Administration has considered approving nutrient claims based on the ratio of a beneficial nutrient to the food's energy content, as opposed to a specified minimum amount of a nutrient per serving size. Given the current dietary trends, the nutrient density approach can be a valuable toot for nutrition education and dietary guidance.
Economic constraints, by inducing the selection of low cost energy dense diets, could indirectly be responsible for the high prevalence of obesity in low socio-economic status groups. Diet optimisation by linear programming was used to test this hypothesis, by examining the relationship between the cost and the energy density (ED) of modelled diets. Models were developed that minimized the departure from the mean adult French diet estimated from a cross-sectional dietary survey. Palatability constraints were introduced into all models. The impacts of cost on ED and of ED on cost were explored by introducing and strengthening first a constraint on cost and then a constraint on ED. Forcing the cost of the linear programming diets to decrease induced a strong increase in their EDs. In contrast, forcing the ED to increase induced only a moderate decrease in diet costs. These results suggest that, although an energy dense diet can be selected at a relatively high cost, when cost is not influencing food choices, an energy dense diet will be preferentially selected to maintain habitual French dietary patterns when the budget for food is low. This supports the hypothesis that economic constraints play a role in the high prevalence of obesity in low-income people.
Background—Half a century of research has provided consensual evidence of major personal requisites of adult health in nutrition, physical activity and psychosocial relations. Their minimal money costs, together with those of a home and other basic necessities, indicate disposable income that is now essential for health. Methods—In a first application we identified such representative minimal costs for healthy, single, working men aged 18‐30, in the UK. Costs were derived from ad hoc survey, relevant figures in the national Family Expenditure Survey, and by pragmatic decision for the few minor items where survey data were not available. Results—Minimum costs were assessed at £131.86 per week (UK April 1999 prices). Component costs, especially those of housing (which represents around 40% of this total), depend on region and on several assumptions. By varying these a range of totals from £106.47 to £163.86 per week was detailed. These figures compare, 1999, with the new UK national minimum wage, after statutory deductions, of £105.84 at 18‐21 years and £121.12 at 22+ years for a 38 hour working week. Corresponding basic social security rates are £40.70‐£51.40 per week. Interpretation—Accumulating science means that absolute standards of living, “poverty”, minimal oYcial incomes and the like, can now be assessed by objective measurement of the personal capacity to meet the costs of major requisites of healthy living. A realistic assessment of these costs is presented as an impetus to public discussion. It is a historical role of public health as social medicine to lead in public advocacy of such a national agenda. (J Epidemiol Community Health 2000;54:885‐889)
he average American dietary style at the beginning of the 21st century resembles an hour glass rather than the Federal Gov- ernment's Food Guide Pyramid. We gobble huge amounts of added fats and sugars from the top tier of the Pyramid (marked "Use sparingly") and heaping plates of pasta and other refined grains from the bot- tom tier, but we are sorely lacking in the vegetables, fruits, low-fat milk products, and other nutritious foods in the middle of the Pyramid. A big jump in average calorie intake between 1985 and 2000 without a corresponding increase in the level of physical activity (calorie expenditure) is the prime factor behind America's soaring rates of obesity and Type 2 dia- betes. ERS's loss-adjusted annual per capita food supply series (ad- justed for spoilage, cooking losses, plate waste, and other food losses accumulated throughout the mar- keting system and the home) sug- gests that average daily calorie consumption in 2000 was 12 per-