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SPECIAL ARTICLES |
1 From the Center for Public Health Nutrition, Departments of Epidemiology and Medicine, University of Washington, Seattle (AD), and the US Department of Agriculture Western Human Nutrition Research Center, University of California, Davis (SES)
2 Address reprint requests to A Drewnowski, Nutritional Sciences Program, 305 Raitt Hall, Box 353410, University of Washington, Seattle, WA 98195–3410. E-mail: adamdrew{at}u.washington.edu.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Key Words: Poverty • food insecurity • obesity • education • income • energy density • food costs • added sugar • added fat • palatability • socioeconomic status
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Public health policies for the prevention of obesity increasingly call for taxes and levies on fats and sweets, both to discourage their consumption and to help promote alternative and healthier food choices (15, 16). Past studies on dietary antecedents of obesity have addressed taste preferences for sugar and fat as well as preferences for energy-dense foods (17-19). In contrast, the relation between fat and sugar consumption, dietary energy density (MJ/kg), and energy costs ($/MJ) has not been explored. Establishing associative links between obesity, dietary energy density, and energy costs is the chief focus of this report
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POVERTY AND OBESITY |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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20 y were classified as overweight and 30% were classified as obese. Overweight is defined as a body mass index (BMI; in kg/m2) > 25, whereas obesity is defined as a BMI > 30 (20). A sharp increase in the number of massively obese people (BMI > 35) has been observed in certain population subgroups (23).
There is no question that the rates of obesity and type 2 diabetes in the United States follow a socioeconomic gradient, such that the burden of disease falls disproportionately on people with limited resources, racial-ethnic minorities, and the poor (20). Among women, higher obesity rates tend to be associated with low incomes and low education levels (21, 23-25). The association of obesity with low socioeconomic status (SES) has been less consistent among men (21, 25). Minority populations (except for Asian Americans) have higher rates of obesity and overweight than do US whites (21). Analyses of data for 68 556 US adults in the National Health Interview Survey by the Centers for Disease Control and Prevention showed that the highest obesity rates were associated with the lowest incomes and low educational levels (22). The relation between obesity and education and income, based on charts published by the Centers for Disease Control and Prevention (22), is shown separately for men and women in Figure 1
. Although obesity rates have continued to increase steadily in both sexes, at all ages, in all races, and at all educational levels (26), the highest rates occur among the most disadvantaged groups.
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In the 1995 US Department of Agriculture (USDA) Current Population Survey, food insecurity was defined as "limited or uncertain availability of nutritionally acceptable or safe foods" (30, 31). The 1995 Current Population Survey judged 11.9% of all US households to be food insecure (30). However, not all food-insecure households showed evidence of hunger, and the relation between poverty, food insecurity, and hunger was a complex one (32, 33). There was no one-to-one correspondence between income-based measures of poverty and food insecurity, and only 13.1% of those in poverty were affected by hunger (34). Of the food-insecure households, 65% (7.8% of total) showed no evidence of hunger, 28% (3.3%) reported moderate hunger, and 6.9% (0.8%) reported severe hunger (30). There was also a positive association between food insecurity and participation in the Food Stamp Program (27), because food-insecure persons were more likely to seek food assistance.
In the third National Health and Nutrition Examination Survey (NHANES III), 1988–1994, food insufficiency was defined as "sometimes" or "often" not having enough to eat (27). The prevalence of food insufficiency was 4% in the total sample but as high as 14% among low-income respondents. According to the USDA Economic Research Service, 10.1% (10.5 million) of American households reported some level of food insecurity in 1999, including 9.5% of adults and 16.9% of children aged < 18 y. Households with children were twice as likely to report food insecurity (35). Among low-income families, food insufficiency was associated with single-parent families, not having health insurance, and having a family head with < 12 y of education.
Among women, food insecurity without hunger appears to be associated with overweight. Analyses of NHANES III data (28) showed that women, but not men, in food-insufficient households were more likely to be overweight than were food-sufficient women (58% compared with 47%). In another study, food-insecure women were > 10 lb (4540 g) heavier on average than was the comparison group (36). Whereas links between food insecurity and lower diet quality might be expected, the association between food insecurity and overweight was something of a paradox (28). Given that low-income families are the chief beneficiaries of food-assistance programs, exploration of the causal connections between food insecurity and obesity has major implications for food and nutrition policies in the United States (28).
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ENERGY-DENSITY COST FRAMEWORK |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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(28, 37). Food restriction at home first occurs in adults because parents typically turn over their own food to children when resources are scarce (38).
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. As food costs diminish further, dietary energy density rises, and total energy intakes may actually increase. Some of the evidence linking dietary energy density with higher energy intakes is outlined below.
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ENERGY DENSITY INFLUENCES ENERGY INTAKES |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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The energy density of foods is a function of their water content (17). Whereas energy-dilute foods are heavily hydrated, energy-dense foods are dry and may also contain fat, sugar, or starch (17, 39). Potato chips (23 kJ/g), chocolate (22 kJ/g), and doughnuts (18 kJ/g) are energy-dense foods. Dairy products vary in energy density, from dry cheeses (17.0 kJ/g) to yogurt (4.2 kJ/g) to fluid low-fat milk (1.6 kJ/g) (17). Because of their high water content, the energy density of raw vegetables and fruit is low (
0.4–2.0 kJ/g). Beverages with different nutrient compositions may have the same energy density; for example, the energy density of 1% milk, orange juice, and cola is 1.8 kJ/g (17, 43). Several studies have suggested that water contained in foods has a more pronounced effect on satiety than does water contained in beverages (40, 44). Foods with a high moisture content, such as vegetables and fruit, allow the consumer to "feel full on fewer calories" (40).
Whereas the energy density of foods can be obtained from nutrient-composition tables, calculation of the energy density of the total diet is more difficult. Such calculations generally include all foods and caloric beverages but exclude noncaloric beverages and water (45-47). In some cases, both caloric and noncaloric beverages were excluded (45, 46). High-energy-density diets are those that include more fast foods, snacks, and desserts, whereas diets lower in energy density are those that are higher in vegetables and fruit (48). Higher dietary energy density tends to be positively associated with total energy intakes and with the percentage of energy from fat (45). In the United States, the energy density of the children's diets was inversely associated with the percentage of energy from sugars, most likely because of the high consumption of energy-dilute soft drinks (45). However, the relation between dietary energy density and overweight has been difficult to establish, given that it is confounded by age and energy expenditure. High energy intakes in cross-sectional studies need not be evidence of hyperphagia, but may reflect the higher energy intakes of younger or more active persons (39). No community-based data have shown a causal connection between dietary energy density and overweight.
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ENERGY-DENSE FOODS ARE MORE PALATABLE |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Human taste preferences for sugar and fat are either innate or acquired very early in life (55). Studies with children have consistently shown that familiarity, sweetness, and energy density are the chief determinants of food preference (56). Very young children learn to prefer novel nonsweet flavors once the flavors have been associated with a concentrated source of energy, such as starch or fat (56, 57). Studies of the food preferences of 3–4-y-old children showed that preferences were driven by familiarity and the energy density of the foods (58). Children preferred the more energy-dense foods and gave higher ratings to chocolate cookies and potato chips than to vegetables and fruit (58).
Preferences can also be shaped by repeated exposures (59, 60) or by a positive association with postingestive metabolic consequences of a food (61, 62). Mothers may also influence children's food choices through their own preferences. In a recent study, based on proxy reports, mothers indicated that their children liked energy-dense foods such as pizza, chocolate chip cookies, and sweetened breakfast cereals, whereas low-energy-density tomatoes, cucumbers, and cabbage were disliked by children and their mothers (62). Whether induced by innate taste preferences, early exposure, or other environmental factors, long-term dietary exposure to sugar and fat may have permanent metabolic consequences on the organism (50).
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HIGH ENERGY DENSITY MEANS LOW ENERGY COSTS |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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. Energy density values were taken from food composition tables and from Rolls and Barnett (40), whereas energy costs were based on supermarket prices in Seattle collected in the winter of 2003. The energy cost of cookies or potato chips was 20 cents/MJ (1200 kcal/$), whereas that of fresh carrots was 95 cents/MJ (250 kcal/$). The energy cost of soft drinks was, on average, 30 cents/MJ (875 kcal/$), whereas that of orange juice from concentrate was 143 cents/MJ (170 kcal/$). Fats and oils, sugar, refined grains, potatoes, and beans represented some of the lowest-cost options and provided dietary energy at minimal cost. As indicated by the logarithmic scale, the differential in energy costs between sugar and strawberries was in the order of several thousand percent.
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The current US diet derives close to 50% of energy from added sugars and fat (63, 64). Data from the Economic Research Service of the USDA (65) show that the per capita availability of caloric sweeteners and fats and oils each increased by 20% between 1977 and 1997. Retail price increases during that time were much lower for sweets and fats than for vegetables and fruit. Other studies have shown that foods identified as accounting for the greatest increase in energy intake by Americans during that time were salty snacks, desserts, soft drinks, fruit drinks, hamburgers and cheeseburgers, Mexican food, and pizza (66). In 1977–1978, these foods combined accounted for 18.1% of the dietary energy consumed by Americans (> 2y) and for 27.7% of energy in 1994–1996. For the most part, many such foods are composed of refined grains, added sugars, and fats.
Studies on dietary choices leading to obesity have focused overwhelmingly on the sugar and fat content of snacks, fast foods, beverages, and confectionery (67, 68). Epidemiologic studies have linked diets composed of fats and sweets, potatoes, and refined grains with higher glycemic indexes and a higher risk of obesity and type 2 diabetes (69). Obese patients were accordingly advised to replace fats and sweets with a more prudent dietary pattern characterized by a high intake of fruit, vegetables, whole grains, poultry, and fish (70, 71). Among public health measures for the prevention of obesity are the need to restrict the consumption of energy-dense snacks and sugar-sweetened soft drinks and to increase the consumption of whole grains and energy-dilute vegetables and fruit (15).
The inverse relation between energy density and energy cost suggests that "obesity-promoting" foods are simply those that offer the most dietary energy at the lowest cost. Given the differential in energy costs between energy-dense and energy-dilute foods, the advice to replace fats and sweets with fresh vegetables and fruit may have unintended economic consequences for the consumer (71).
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INCOME DISPARITIES AFFECT DIET QUALITY |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Income disparities had more of an effect on diet quality than on total energy intakes. HEI scores were typically higher for women than for men and improved with increasing age, education, and income (72, 74). Figure 5, which is based on 1994–1996 CSFII (Continuing Survey of Food Intakes of Individuals) data, it is shown that HEI scores were higher for the wealthier and better-educated groups. Education had a stronger effect on diet quality than did incomes. Although African Americans had the lowest HEI scores, scores for Latinos and Asians were no different from those for whites. Strong associations between higher household incomes and higher quality diets were also obtained in studies conducted in Canada (76), France (77), the United Kingdom (75, 78-80), and other countries of the European Union (81, 82).
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Health disparities among US population groups are related to inequalities in SES (20). Some of these disparities may be mediated by an unequal access to a healthy diet (83, 84). Whereas "good" diets were associated with higher education and incomes, "poor" diets were associated with overweight. In USDA studies (72), female CSFII respondents aged > 19y with "poor" diets had a BMI of 26.4 compared with 24.8 for females whose diets were "good." For males, "poor" diets were associated with a BMI of 26.8, as opposed to 25.7 for "good" diets (72).
The effect of SES variables on diet quality has normally been ascribed to a higher educational level or to a greater awareness of health issues among higher-income respondents (72). However, nutrition knowledge alone does not necessarily lead to a healthy diet (85-87). Another possibility is that healthier diets cost more and are beyond the reach of many low-income families.
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DO HEALTHY DIETS COST MORE? |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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To achieve a healthy diet it may be necessary to spend more money (77, 79, 84). The UK Women's Cohort Study (89) is one of the few observational studies to have explored food costs, perceived and actual, in a study cohort of 15 191 women aged 35–69 y. Women in the healthiest diet group spent an additional 617 pounds sterling (US$1000) per year on food relative to the least-healthy diet group, with vegetables and fruit accounting for the largest amount of the cost. Yet almost 71% in the healthiest diet group and 60% in the least-healthy group did not agree that it was more expensive to eat a healthier diet, contrary to evidence obtained from the study itself. Cade et al (89) concluded that the individual assessment of diet costs was, to a large extent, a matter of subjective perception rather than of objective facts.
There is substantial evidence that food purchases are influenced by food costs (90-93). Several studies have mentioned diet costs as a barrier to dietary change, especially among low-income respondents (79, 84, 92, 93). Dietary variety and the consumption of fresh produce were generally associated with higher food costs. In USDA studies, total energy intakes or percentage of energy from fat varied little with incomes or participation in the Food Stamp Program (FSP) (84, 94). In contrast, a greater dietary variety and higher consumption of vegetables and fruit were associated with higher education and higher income levels (74, 76, 92). Recent USDA/Economic Research Service analyses of food and nutrient intakes by income, defined in relation to poverty status, showed the same link between incomes and diet quality (94). Although there was not much difference in energy or macronutrient intakes by income and no difference in the consumption of basic commodities (milk, meat, and grains), there were major income-related differences in the consumption of (among other foods) lettuce and lettuce-based salads; melons, berries, and other fruit; (94), and carbonated sodas. The proportion of women consuming salads and fruit on a given day was double for the highest-income group (> 350% poverty) relative to the lower-income group (< 131% poverty) (94).
Observational data on the costs of freely chosen diets are limited. The Consumer Expenditure Survey, conducted by the Bureau of Labor Statistics, collects household data on food expenditures for the Consumer Price Index (95). The USDA CSFII provides data on individual food consumption and nutrient intakes (96). The Consumer Expenditure Survey does not report quantities of foods purchased, whereas the CSFII does not collect data on the cost of the foods consumed. Neither database can provide information about diet quality in relation to diet costs. The USDA Food Stamp Survey does report food use and food price data but it is limited to food-assistance recipients. Further studies on diet quality in relation to diet costs represent a major research need (88, 94). As yet, there are no data that would allow us to link all of the dietary and economic variables into a causal chain.
In the absence of large-scale community studies, few intervention studies purport to show that healthful diets are not more expensive than are less healthful diets. One study (97), based on only 20 families with an obese 8–12-y-old child undergoing treatment, and a high attrition rate (20/31) showed that a decrease in family energy intakes from 1881 to 1338 kcal/person was indeed associated with a decrease in diet costs from US$6.77 to US$5.04. However, energy costs per 1000 kcal actually increased by > 10% (from US$3.69 to US$4.11). Nonetheless, the authors concluded that a more healthful diet was not more expensive than the typical American diet (97).
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FOOD SPENDING IN THE UNITED STATES |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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. The drop in food spending was disproportionately greater than the drop in spending on other goods.
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The corollary of Engel's Law (98) is that low-income families spend a higher proportion of disposable income on food. Whereas households with incomes > US$70 000/y spent 7% of after-taxes income on food, low-income families (range: US$10–15 000/y) spent close to 25% (99). Food costs were an issue, especially for low-income families and elderly female respondents. Focus groups conducted with FSP participants reported that all groups reported food price as the most important consideration in making food choices (100, 101). As noted in a report by Basiotis et al (100), "the most important factor in choosing and preparing foods was to ensure that no one would complain they are still hungry."
Economic factors may help explain why low-income respondents are least likely to eat healthy diets and suffer from some of the highest rates of obesity and type 2 diabetes (20). We hypothesize that consuming energy-dense foods, and energy-dense diets, is an important strategy used by low-income consumers to stretch the food budget. Energy-dense foods carry a lower price tag, which allows for a higher energy consumption at a lower cost (64, 71). Energy-dense foods also tend to be well-liked, even perceived as a reward—a factor that would reinforce their initial selection and repeated consumption. In general, taste is rated ahead of health and variety as an influence on food purchases and consumption patterns (102).
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REDUCTIONS IN COST INCREASE ENERGY DENSITY |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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The foods were selected by using a nonlinear programming model that selected diets meeting specified nutritional criteria, with individual foods subject to cost constraints. Palatability was considered, but foods were not optimized for this objective. Given nutritional and cost constraints, the recommended foods featured grains and legumes, low-cost meats, and added sugars and fat. Among the foods recommended for a week for a family of 4 were potatoes (12 lb, 5443 g), pasta and rice (6 lb, 2722 g), beans (3 lb, 1361 g), bread (3 lb, 1361 g), sugar (1 lb, 454 g), lemonade (1 gallon, 3.8 L), added fats (2 lb, 907 g), frozen turkey (5 lb, 2268 g), and frozen orange juice (6 lb, 2722 g). The allotment of leaf lettuce was 4 oz (113 g)/wk, which reflects sharply higher energy costs for fresh produce. In 1999, the cost of TFP foods for the "reference family" (men and women aged 20–50 y with 2 children aged 6–8 y and 9–11 y) that met food guide pyramid guidelines was US$98.40/wk. This cost is equivalent to US$3.50 · person-1 · d-1, the amount of food stamp benefits.
A recent study conducted in France used linear programming to model the composition of the French diet after the imposition of cost constraints (106). Analyses were based on dietary data for 837 adults that had been collected in an observational study in the Val-de-Marne region (107, 108). Nutrient analyses were based on a food-composition table, which was developed by the French National Institute of Health and Medical Research. Estimated national prices for 55 foods—excluding baby foods, rarely consumed foods, and alcohol—were added to the database. The prices were provided by the National Institute of Statistics and Economic Studies and were supplemented with retail prices from supermarkets in the Paris area. Linear programming was designed to be consistent with the usual food consumption in France and to minimize any departure from the usual French diet.
The imposition of cost constraints reduced the proportion of energy contributed by fruit, vegetables, meat, and dairy products and increased the proportion of energy contributed by cereals, added fats, and sweets. The resulting diet was identical in composition to that observed among lower-SES groups and contained the least amounts of ß-carotene and vitamin C. Consistent with the energy-cost hypothesis, a reduction in diet costs led to diets high in added sugars and fats, as shown in Figure 7.
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OBESITY AND FOOD-ASSISTANCE PROGRAMS |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Few low-income households meet the twin objectives of spending less than the TFP amount and buying foods that contribute to a healthful diet (110). Those few people that did meet these objectives spent a larger share of the food dollar on grains, fruit, vegetables, and milk and less on meat, soft drinks, sweets, fats, and alcohol. However, according to USDA surveys, most low-income respondents spent their limited food dollars on energy-dense foods that were largely composed of added sugars and fat (88, 94).
Studies that used more global measures of diet quality were more successful in showing the benefits of the FSP or the Supplementary Nutrition Program for Women Infants and Children (WIC). These studies found that the consumption of the 5 main food guide pyramid food groups (ie, those other than fats and sweets) increased as incomes increased (100). Studies conducted by the Center for Nutrition Policy and Promotion using 1989–1991 CSFII data (100) found that WIC participation and, to a lesser extent, the FSP were associated with higher-quality diets, as indexed by HEI scores. Otherwise, little is known about the effects of food-assistance programs on diet quality and dietary energy density. Another research gap concerns measures of acceptance for individual foods and participant satisfaction with the overall quality of the diet. Such information would be useful in tracking satisfaction with food choices provided or recommended by food-assistance programs.
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OBESITY: AN ECONOMIC HYPOTHESIS |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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Television advertising has been cited as a factor contributing to higher energy and fat intakes (112, 113) and so has the marketing of energy-dense foods (15). In 1997, food manufacturers, food retailers, and food services reportedly spent US$11 billion on advertising, much of it on foods containing added sugars and fat (8). Studies suggest that some of this advertising may be targeted at children and at low-income consumers (113). As indicated above, such foods provide energy at a much lower cost than do fresh vegetables and fruit, which are perceived as luxury items and are not always easily accessible. Growing portion sizes are another example of how the food industry provides inexpensive extra energy at lower unit cost. The most commonly cited examples of supersizing (114) tend to involve foods composed of refined grains, added sugars, and fat.
The notion of the economic costs of obesity invariably refers to the costs of obesity and related diseases to society (115). There has been little emphasis on the low economic costs of becoming obese. At world market prices, the cost of refined sugar is 10 cents/lb (454 g). In other words, close to 80 000 kJ can be purchased for $US1 (64). The current economic hypothesis is that high energy intakes, not only in the United States but worldwide, may be driven by the very low cost and reinforced by positive hedonic properties of energy-dense foods.
Obesity has been linked with the excessive consumption of both sugars and fats. Whether fat as opposed to sugar consumption is to blame is a controversial issue (9, 116-118). Some researchers believe that excessive carbohydrate, as opposed to fat, consumption is responsible for the current obesity epidemic. This argument rests on the observation that the percentage of energy from fat decreased from 38% to 34% between 1976–1980 and 1988–1991, whereas the prevalence of obesity increased (116-118).
The relation between a rise in obesity rates and the decrease in the percentage of energy from fat was shown previously (116) and is illustrated in Figure 8. The exact same inverse relation can be shown for a rise in obesity rates and the decrease in the percentage of disposable income that is spent on food (Figure 9). In reality, both incomes and total fat consumption (in g/d) have continued to increase, as have total energy intakes. One mechanism to hold down diet costs is to increase the energy density of the diet through the consumption of more grains and added sugars and fats. Obesity rates increase as energy intakes increase, but food spending (as a percentage of income) decreases disproportionately relative to spending on other goods.
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OBESITY AS A PUBLIC HEALTH PROBLEM |
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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The hypothesis that healthier diets may indeed cost more has many policy implications. One issue is whether economic incentives can promote healthful eating more effectively than do current strategies, on the basis of theoretical models for behavioral change. The USDA has linked a lower consumption of added sugars among WIC participants to the provision of WIC-supplied juices and cereals (94). There are also studies on price supports for vegetables and fruit and on the manipulation of snack prices in vending machines to encourage the consumption of lower-fat items (119). If this economic approach is to be successful, we need a better understanding of how food prices affect consumer food choices and the selection of a healthy diet.
Reducing the energy density of the diet is a worthy objective; the question is, can it be achieved without simultaneously increasing the cost and reducing the palatability of the diet? If long-term compliance with recommended diets is to be achieved by persons with a limited food budget, the foods must be affordable and acceptable (120). More work is needed to explore strategies for systematically shifting taste and food preferences in the direction of less energy-dense foods. A shift to a diet with a greater emphasis on fruit, vegetables, and whole grains would be consistent with the gradual change in consumption from full- to reduced-fat dairy products seen over the past 30 y (121).
The current focus of obesity research has been on environmental factors that promote inactive lifestyles and excess energy intakes (122). The present economic approach suggests that food choices and diet quality are influenced by social and economic resources and by food costs. Low-cost, energy-dense diets are likely to contain added sugars and vegetable fats. Such diets have been and will continue to be associated with obesity and overweight. However, the relevant features of obesity-promoting diets may not be the percentage of energy from sugar or fat (119, 120) but rather high palatability and low energy cost. These issues are inextricably linked to agricultural commodity prices, imports, tariffs, and trade. Americans are gaining more and more weight while consuming more added sugars and fats and are spending a lower proportion of their income on food. No longer a purely medical issue, obesity has become a societal and public health problem.
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TOPABSTRACTINTRODUCTIONPOVERTY AND OBESITYENERGY-DENSITY COST FRAMEWORKENERGY DENSITY INFLUENCES ENERGY...ENERGY-DENSE FOODS ARE MORE...HIGH ENERGY DENSITY MEANS...INCOME DISPARITIES AFFECT DIET...DO HEALTHY DIETS COST...FOOD SPENDING IN THE...REDUCTIONS IN COST INCREASE...OBESITY AND FOOD-ASSISTANCE...OBESITY: AN ECONOMIC HYPOTHESISOBESITY AS A PUBLIC...REFERENCES |
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|
|
|
|
|
|
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|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
 B. A. Rabin, T. K. Boehmer, and R. C. Brownson Cross-national comparison of environmental and policy correlates of obesity in Europe Eur J Public Health, February 1, 2007; 17(1): 53 - 61. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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|
|
|
|
 |
|
 N. M. Wells, S. P. Ashdown, E. H. S. Davies, F. D. Cowett, and Y. Yang Environment, Design, and Obesity: Opportunities for Interdisciplinary Collaborative Research Environment and Behavior, January 1, 2007; 39(1): 6 - 33. [Abstract] [PDF]
|
|
|
|
 |
|
 L. E. Kelly and B. J. Patterson Childhood Nutrition: Perceptions of Caretakers in a Low-Income Urban Setting The Journal of School Nursing, December 1, 2006; 22(6): 345 - 351. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Thomas Obesity prevention programs for children and youth: why are their results so modest? Health Educ. Res., December 1, 2006; 21(6): 783 - 795. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. F. Meyers, R. J. Karp, and J. G. Kral Poverty, Food Insecurity, and Obesity in Children Pediatrics, November 1, 2006; 118(5): 2265a - 2266. [Full Text] [PDF]
|
|
|
|
|
|
P. H. Casey, P. M. Simpson, J. M. Gossett, M. L. Bogle, C. M. Champagne, C. Connell, D. Harsha, B. McCabe-Sellers, J. M. Robbins, J. E. Stuff, et al. The Association of Child and Household Food Insecurity With Childhood Overweight Status Pediatrics, November 1, 2006; 118(5): e1406 - e1413. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Kranz Meeting the Dietary Reference Intakes for Fiber: Sociodemographic Characteristics of Preschoolers With High Fiber Intakes Am J Public Health, September 1, 2006; 96(9): 1538 - 1541. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. E. Simon, M. Von Korff, K. Saunders, D. L. Miglioretti, P. K. Crane, G. van Belle, and R. C. Kessler Association Between Obesity and Psychiatric Disorders in the US Adult Population. Arch Gen Psychiatry, July 1, 2006; 63(7): 824 - 830. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J J Reilly Obesity in childhood and adolescence: evidence based clinical and public health perspectives. Postgrad. Med. J., July 1, 2006; 82(969): 429 - 437. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. A. Miech, S. K. Kumanyika, N. Stettler, B. G. Link, J. C. Phelan, and V. W. Chang Trends in the association of poverty with overweight among US adolescents, 1971-2004. JAMA, May 24, 2006; 295(20): 2385 - 2393. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. A. Mendoza, A. Drewnowski, A. Cheadle, and D. A. Christakis Dietary Energy Density Is Associated with Selected Predictors of Obesity in U.S. Children J. Nutr., May 1, 2006; 136(5): 1318 - 1322. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
X. Gao, P. E. Wilde, A. H. Lichtenstein, and K. L. Tucker The 2005 USDA Food Guide Pyramid Is Associated with More Adequate Nutrient Intakes within Energy Constraints than the 1992 Pyramid J. Nutr., May 1, 2006; 136(5): 1341 - 1346. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. W. Higgins, L. Young, S. Cunningham, and P.-J. Naylor Out of the Mainstream: Low-Income, Lone Mothers' Life Experiences and Perspectives on Heart Health Health Promot Pract, April 1, 2006; 7(2): 221 - 233. [Abstract] [PDF]
|
|
|
|
|
|
J. C. Lumeng, S. Rahnama, D. Appugliese, N. Kaciroti, and R. H. Bradley Television Exposure and Overweight Risk in Preschoolers Arch Pediatr Adolesc Med, April 1, 2006; 160(4): 417 - 422. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. J. Jones and E. A. Frongillo The Modifying Effects of Food Stamp Program Participation on the Relation between Food Insecurity and Weight Change in Women J. Nutr., April 1, 2006; 136(4): 1091 - 1094. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Cummins and S. Macintyre Food environments and obesity--neighbourhood or nation? Int. J. Epidemiol., February 1, 2006; 35(1): 100 - 104. [Full Text] [PDF]
|
|
|
|
|
|
B. J Rolls, L. S Roe, and J. S Meengs Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake Am. J. Clinical Nutrition, January 1, 2006; 83(1): 11 - 17. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. Janssen, W. F Boyce, K. Simpson, and W. Pickett Influence of individual- and area-level measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents Am. J. Clinical Nutrition, January 1, 2006; 83(1): 139 - 145. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. A. Laraia, A. M. Siega-Riz, C. Gundersen, and N. Dole Psychosocial Factors and Socioeconomic Indicators Are Associated with Household Food Insecurity among Pregnant Women J. Nutr., January 1, 2006; 136(1): 177 - 182. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. F. Jyoti, E. A. Frongillo, and S. J. Jones Food Insecurity Affects School Children's Academic Performance, Weight Gain, and Social Skills J. Nutr., December 1, 2005; 135(12): 2831 - 2839. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Lang and G. Rayner Obesity: a growing issue for European policy? Journal of European Social Policy, November 1, 2005; 15(4): 301 - 327. [Abstract] [PDF]
|
|
|
|
 |
|
 V. W. Chang and D. S. Lauderdale Income Disparities in Body Mass Index and Obesity in the United States, 1971-2002 Arch Intern Med, October 10, 2005; 165(18): 2122 - 2128. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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|
|
|
|
 |
|
 E Stamatakis, P Primatesta, S Chinn, R Rona, and E Falascheti Overweight and obesity trends from 1974 to 2003 in English children: what is the role of socioeconomic factors? Arch. Dis. Child., October 1, 2005; 90(10): 999 - 1004. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
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|
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, fruit and vegetables; 
, meat, fish, and eggs; 
, fats and sweets. 1 Euro = US$1.1. Adapted from reference 
