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LETTER TO THE EDITOR |
Nutrition Research Unit
476 INSERM/1260 INRA
27 Bd Jean Moulin
13385 Marseille Cedex 05
France
E-mail: nicole.darmon{at}univmed.fr
Nutritional Sciences Program
School of Public Health and Community Medicine
University of Washington
Seattle, WA
E-mail: adamdrew{at}u.washington.edu
Dear Sir:
We thank Karp for his encouraging words. The links between food, diets, and incomes have indeed been remarked on by a diversity of authors, ranging from Jean-Anthelme Brillat-Savarin in 1825 to John Boyd Orr in 1936. Karp's description of how food choices are affected by soaring prices was recently echoed in statements made by Margaret Chan, the Director General of the World Health Organization. Speaking at the High-level Conference on World Food Security in Rome on 3 June 2008 (1), Chan said, "Food choices are highly sensitive to price. The first items to drop out of the diet are usually healthy foods—fruits, vegetables and high quality sources of protein....Nutrient-poor staples are often the cheapest way to fill hungry stomachs."
Those statements are directly supported by our research on the relation between diet quality and diet cost (2). Energy-dense foods that are nutrient-poor are the cheapest option for the low-income consumer (3). Whereas higher food spending does not guarantee a higher-quality diet, reducing food expenditures below a certain minimum virtually ensures that the resulting diets will be nutrient-poor and energy-dense. Computer optimization programs, driven by cost constraints only, consistently create diets with compositions that resemble those that are consumed by disadvantaged groups (4). In contrast, higher-quality diets not only cost more but are more likely to be consumed by the more affluent.
Many of these facts are strenuously denied by some nutritionists, both in the United States and elsewhere. One contention is that healthy foods cost no more than unhealthy ones. In a 2004 report, the Economic Research Service of the US Department of Agriculture contended that 3 servings of fruit and 4 servings of vegetables, mostly fresh, could be obtained for as little as 64 cents, leaving 84% of the food budget left over to buy other foods (5). Frozen broccoli spears were deemed to be a better economic value than were cookies or chocolate, despite their feeble energy content and low satiating power. The clear implication was that most low-income Americans could afford a healthy diet; but simply chose not to. Low-income households selecting low-cost, energy-dense foods are typically accused of laziness, self-indulgence, or moral failure (6). The recent rise in food prices that has begun to affect the middle class has helped put our earlier work in a new and much sharper perspective (7).
We agree with Karp on the importance of culture and social norms. Important work by social and medical anthropologists has focused on food resource allocation within the family (8). Obesity and malnutrition have been shown to coexist, not only within the same strata of society but also within the same household. One important question is why limited household education and incomes have a disproportionate impact on women's health. The strongest socioeconomic gradient for obesity is typically observed for women, not men. Indeed, the global obesity epidemic is, to some extent, a women's health problem.
We agree that food-assistance programs such as WIC can serve to bring previously inaccessible foods within reach of lower-income mothers and their young children. The new WIC package, in particular, aims to promote the consumption of whole grains, vegetables, and fruit by lower-income households. Given that the WIC package is to remain cost-neutral, it will be interesting to screen the new food options with nutrient profiling techniques that are able to assess both nutrients per calorie and nutrients per dollar (9). Bonuses or vouchers enabling Food Stamp Program recipients to purchase more vegetables and fruit, farm to cafeteria programs, and the US Department of Agriculture's Fruit and Vegetable Pilot Program for schools are all examples of how food interventions can be based on economic incentives.
Food-guidance systems, based on nutrient profiling models, can help consumers identify nutrient-rich foods at an affordable cost (10). The 2005 Dietary Guidelines for Americans stressed the need to select nutrient-rich foods in preference to discretionary calories. Efforts are being made to help identify such foods through front-of-pack labeling or the regulation of nutrition and health claims. Persons with limited food budgets will need additional assistance in selecting foods with a favorable nutrient content relative to price.
The dual burden of disease, undernutrition and overweight, now faced by developing nations is an economic issue that is directly linked to poverty and food costs. The relation between food, health, and income should again become a priority for global public health. The major policy and political challenge for global nutrition is to ensure a supply of affordable healthy foods to all.
ACKNOWLEDGMENTS
No conflicts of interest were declared.
REFERENCES
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