Testing the price and affordability of healthy and current (unhealthy) diets and the potential impacts of policy change in Australia

The Price of Foods, Beverages, and Diets in Australia: An Updated Systematic Review

CONTEXT

The price and affordability of food are priorities for public health and health equity; however, Australia lacks a consistent method to evaluate healthy versus unhealthy diets, creating a gap in routine food price reporting.

OBJECTIVE

This review aimed to identify and summarize recent methods used to assess and monitor the price and/or affordability of food and beverages in Australia using a health lens.

DATA SOURCES

Four academic databases (MEDLINE Complete, Global Health, CINAHL Complete, and Business Source Complete) were searched in English from 2016 to 2022. Relevant gray literature was searched through Google Scholar and government websites.

DATA EXTRACTION

Five reviewers screened titles and abstracts, and full-text screening was conducted by 1 reviewer, with eligibility confirmed by a second reviewer. The quality of studies was assessed using the Joanna Briggs Institute "Checklist for Analytical Cross-Sectional Studies."

DATA ANALYSIS

Twenty-five eligible studies were identified. Eleven studies used a version of the Healthy Diets Australian Standardized Affordability and Pricing protocol to collect prices for a "healthy" diet modelled on dietary guidelines and an "unhealthy" diet based on a habitual Australian diet. These studies consistently found unhealthy diets to be more expensive than healthy diets. Other identified methods included assessing the price of household diets across healthy baskets (n = 6), store types (n = 5), a planetary health diet (n = 1), packaged foods according to their Health Star Rating (n = 1), a fruit and vegetable basket (n = 1), school canteen foods against a traffic light system (n = 1), and weekly healthy meal plans (n = 1). Healthy diets tended to be less costly than less healthy diets, but both diets were often unaffordable in regional areas, for people on low incomes, and for First Nations peoples.

CONCLUSION

Consistent country-wide application of methods for monitoring the price and affordability of foods and diets in Australia is needed-including tailored approaches for priority groups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022333531.

Sustainability and cost of typical and heart-healthy dietary patterns in Australia

Study objective

The aim was to quantify and compare the environmental and financial impact of two diets: a heart-healthy Australian diet (HAD) and the typical Australian diet (TAD).

Design

The study involved a secondary analysis of two modelled dietary patterns used in a cross-over feeding trial.

Setting

The evaluation focused on two-week (7-day cyclic) meal plans designed to meet the nutritional requirements for a reference 71-year-old male (9000 kJ) for each dietary pattern.

Main outcome measures

The environmental footprint of each dietary pattern was calculated using the Global Warming Potential (GWP*) metric, taking into account single foods, multi-ingredient foods, and mixed dishes. Prices were obtained from a large Australian supermarket.

Results

The HAD produced 23.8 % less CO2 equivalents (CO2e) per day (2.16 kg CO2e) compared to the TAD (2.83 kg CO2e per day). Meat and discretionary foods were the primary contributors to the environmental footprint of the TAD, whereas dairy and vegetables constituted the largest contributors to the HAD footprint. However, the HAD was 51 % more expensive than the TAD.

Conclusion

Transitioning from a TAD to a HAD could significantly reduce CO2 emissions and with benefits for human health and the environment. Affordability will be a major barrier. Strategies to reduce costs of convenient healthy food are needed. Future studies should expand the GWP* database and consider additional environmental dimensions to comprehensively assess the impact of dietary patterns. Current findings have implications for menu planning within feeding trials and for individuals seeking to reduce their carbon footprint while adhering to heart-healthy eating guidelines.

Tunneling, cognitive load and time orientation and their relations with dietary behavior of people experiencing financial scarcity - an AI-assisted scoping review elaborating on scarcity theory

BACKGROUND

The concept of a financial scarcity mindset has raised much attention as an explanation for poor decision-making and dysfunctional behavior. It has been suggested that financial scarcity could also impair dietary behavior, through a decline in self-control. Underlying cognitive mechanisms of tunneling (directing attention to financial issues and neglecting other demands), cognitive load (a tax on mental bandwidth interfering with executive functioning) and time orientation (a shift towards a present time horizon, versus a future time horizon) may explain the association between financial scarcity and self-control related dietary behavior. The current scoping review gathers recent evidence on how these mechanisms affect dietary behavior of people experiencing financial scarcity. It builds on a theoretical framework based on insights from behavioral economics and health psychology.

METHODS

A literature search was executed in six online databases, which resulted in 9.975 papers. Search terms were tunneling, cognitive load and time orientation, financial scarcity, and dietary behavior. Screening was performed with ASReview, an AI-ranking tool. In total, 14 papers were included in the scoping review. We used PRISMA-ScR guidelines for reporting.

RESULTS

Limited evidence indicates that a scarcity mindset could increase tunneling, through attentional narrowing on costs of food, which then directly impacts dietary behavior. A scarcity mindset involves experiencing financial stress, which can be understood as cognitive load. Cognitive load decreases attentional capacity, which could impair self-control in dietary choices. Financial scarcity is related to a present time orientation, which affects dietary choices by shifting priorities and decreasing motivation for healthy dietary behavior.

CONCLUSIONS

A scarcity mindset affects dietary behavior in different ways. Tunneling and a shift in time orientation are indicative of an attentional redirection, which can be seen as more adaptive to the situation. These may be processes indirectly affecting self-control capacity. Cognitive load could decrease self-control capacity needed for healthy dietary behavior because it consumes mental bandwidth. How a changing time orientation when experiencing financial scarcity relates to motivation for self-control in dietary behavior is a promising theme for further inquiry.

Food in my life: How Australian adolescents perceive and experience their foodscape

Food choice has long been recognized as an interaction between psychological, social, cultural, economic, and biological forces through life course events and experiences. Adolescence is a particularly sensitive life stage during which personal and external environments influence food decisions and attitudes that can have long-term implications. Young people represent future households, yet little is understood about their perspectives on, and experiences of, their foodscape. To address this, a photovoice study with thirty-two students was undertaken at three state high schools with differing foodscapes in South East Queensland (Australia). Adolescent perspectives on foodscapes highlighted the food in front of them (either common or favourite foods), food routines, their emotional relationship with food, and the important role that family has in shaping their relationship with food (in particular mothers). Adolescents demonstrated an astute awareness of healthy/good and unhealthy/bad foods in relation to ingredients, ways of eating and different types of foods. Yet they expressed noticeable confusion on this matter, referring to some foods as "healthy-ish", or describing a "balanced" diet as consuming something healthy followed by something unhealthy. We found that adolescents are inundated by discretionary foods on a daily basis, however, are not particularly cognisant of them. These findings have direct implications for preventative health messages targeting adolescents.

Do 20-minute neighbourhoods moderate associations between work and commute hours with food consumption?

OBJECTIVE

To examine associations between work and commute hours with food consumption and test whether neighbourhood type (20-minute neighbourhood (20MN)/non-20MN) moderate associations.

DESIGN

Cross-sectional analysis of the Places and Locations for Activity and Nutrition study (ProjectPLAN). Exposures were work hours (not working (0 h), working up to full-time (1-38 h/week), working overtime (> 38 h/week)), and among those employed, combined weekly work and commute hours (continuous). Outcomes were usual consumption of fruit, vegetables, takeaway food, snacks and soft drinks, and number of discretionary food types (takeaway, snacks and soft drinks) consumed weekly. Generalised linear models were fitted to examine associations between each exposure and outcome. The moderating role of neighbourhood type was examined through interaction terms between each exposure and neighbourhood type (20MN/non-20MN).

SETTING

Melbourne and Adelaide, Australia, 2018-2019.

PARTICIPANTS

Adults ≥ 18 years old (n 769).

RESULTS

Although all confidence intervals contained the null, overall, patterns suggested non-workers and overtime workers have less healthy food behaviours than up-to-full-time workers. Among those employed, analysis of continuous work and commute hours data suggested longer work and commute hours were positively associated with takeaway consumption (OR = 1·014, 95 % CI 0·999, 1·030, P-value = 0·066). Patterns of better behaviours were observed across most outcomes for those in 20MN than non-20MN. However, differences in associations between work and commute hours with food consumption across neighbourhood type were negligible.

CONCLUSIONS

Longer work and commute hours may induce poorer food behaviours. There was weak evidence to suggest 20MN moderate associations between work and commute hours with food consumption, although behaviours appeared healthier for those in 20MN.

Impact and evaluation of an online culinary nutrition course for health, education and industry professionals to promote vegetable knowledge and consumption

BACKGROUND

Poor diet, including inadequate vegetable intake, is a leading risk factor for noncommunicable disease. Culinary and nutrition education provided to trainee and practising health and education professionals is an emerging strategy to promote improved dietary intake, including vegetable consumption. We evaluated the impact and feasibility of an online culinary medicine and nutrition (CM/CN) short course for health, education and vegetable industry professionals. The course aimed to improve participants' skills and confidence to prepare vegetables, knowledge of evidence-based nutrition information and recommendations for improving vegetable consumption and diet quality.

METHODS

A pre-post study consisting of two separate groups participating in two course rounds recruited practising professionals (n = 30) working in health; community, adult and/or culinary education; and the vegetable industry. Evaluation assessed diet quality, vegetable consumption barriers, cooking and food skill confidence, nutrition knowledge and process measures.

RESULTS

Seventeen participants (68%) completed the programme. Pre- to postintervention statistically significant increases in vegetables (M 1.3, SD 2.2), fruit (M 1.6, SD 3.1), and breads and cereal (M 1.1, SD 1.7) intakes were observed. Statistically significant increases and large effect sizes for mean food skill confidence scores (M 8.9, SD 15.4, Cohen's d 0.56) and nutrition knowledge scores (M 6.2, SD 15.4, Cohen's d 0.83) were also observed pre- to postintervention.

CONCLUSIONS

The short online course was feasible and improved diet quality, food skill confidence and nutrition knowledge. Online CM/CN education for practising professionals represents a promising area of research. Future research involving a larger study sample and a more rigorous study design such as a randomised control trial is warranted.

Developing a Mediterranean Healthy Food Basket and an Updated Australian Healthy Food Basket Modelled on the Australian Guide to Healthy Eating

Introduction: Australian healthy food baskets are typically modelled off the Government Guidelines for healthy eating. However, these baskets have not been updated recently, nor has there been a Mediterranean Diet basket developed for an Australian population despite research suggesting high adherence is possible and subsequent health benefits observed. Food baskets typically only present the nutrition profile or the cost of a basket, seldom both. Methods: Baskets were developed based on the Australian Guide to Healthy Eating, The Mediterranean Diet and typical Australian dietary intake (Western Diet). Four reference families were created based on data from Australian censuses and population statistics. Seven-day meal plans for reference families were entered into Foodworks software and aimed to meet 100% of nutrition and energy requirements. Basket costs were calculated from Coles Australia online. Results: The AGHE basket met all NRVs except for VLCN3 for the 7-year-old male (73% adequate intake). The Mediterranean Diet met all NRVs except zinc (44-year-old male) ranging from 98 to 257% of the RDI. The Western Diet failed to meet NRVs for numerous nutrients. The MedDiet baskets were generally cheaper ($78 for a one-person household to $285 for a four-person household) than AGHE and Western Diet. Discussion: Meeting nutrition requirements over seven days for zinc can be challenging for males. Fortified products provide an opportunity to improve nutrient profile; however, nutrient intake should equilibrate over time. Further, cost saving strategies can increase affordability. This research suggests a MedDiet is not more costly than a typical Western Diet or healthy AGHE diet.

Healthy Food Prices Increased More Than the Prices of Unhealthy Options during the COVID-19 Pandemic and Concurrent Challenges to the Food System

Food prices have escalated due to impacts of the COVID-19 pandemic on global food systems, and other regional shocks and stressors including climate change and war. Few studies have applied a health lens to identify the most affected foods. This study aimed to assess costs and affordability of habitual (unhealthy) diets and recommended (healthy, equitable and more sustainable) diets and their components in Greater Brisbane, Queensland, Australia from 2019 to 2022 using the Healthy Diets Australian Standardised Affordability and Pricing protocol. Affordability was determined for reference households at three levels of income: median, minimum wage, and welfare-dependent. The recommended diet cost increased 17.9%; mostly in the last year when the prices of healthy foods, such as fruit, vegetables and legumes, healthy fats/oils, grains, and meats/alternatives, increased by 12.8%. In contrast, the cost of the unhealthy foods and drinks in the habitual diet 'only' increased 9.0% from 2019 to 2022, and 7.0% from 2021 to 2022. An exception was the cost of unhealthy take-away foods which increased by 14.7% over 2019-2022. With government COVID-19-related payments, for the first time recommended diets were affordable for all and food security and diets improved in 2020. However, the special payments were withdrawn in 2021, and recommended diets became 11.5% less affordable. Permanently increasing welfare support and providing an adequate minimum wage, while keeping basic, healthy foods GST-free and increasing GST to 20% on unhealthy foods, would improve food security and diet-related health inequities. Development of a Consumer Price Index specifically for healthy food would help highlight health risks during economic downturns.

The Diet Quality of Food-Insecure Australian Adults-A Nationally Representative Cross-Sectional Analysis

Poor diet quality exacerbates risks for acute and chronic conditions. People experiencing food insecurity have an increased likelihood of lower diet quality; however, this has not been investigated in the Australian context. The aim of this cross-sectional study was to examine whether the diet quality of Australian adults differed according to their household food security status. Data were analysed from a nationally representative sample (≥19 years; n = 9115) collected as part of the National Nutrition and Physical Activity Survey 2011-12. Household food security status and socio-demographic and health characteristics were assessed using data from an 18-module health interview. A 24 h dietary recall was used to estimate food and nutrient intakes and to calculate the Dietary Guidelines Index (DGI). DGI is a food-based score (0 to 130) that assesses adherence to the 2013 Australian Dietary Guidelines. Survey-weighted linear regression models, adjusted for age and sex, were used to examine diet quality (total DGI and component scores), and total energy and nutrient intake by food security status. Adults from food-insecure households had a mean total DGI score 3.5 points lower (95% CI -5.57, -1.46) than food-secure adults (p = 0.001). Adults from households experiencing food insecurity, when compared to those who were food-secure, had several lower DGI component scores including for dietary variety (1.6 vs. 2.3, p = 0.009), fruit (3.8 vs. 5.0, p = 0.001) and vegetables (3.7 vs. 4.4, p = 0.010). Adults from food-insecure households consumed on average more carbohydrates (45.6 vs. 43.3, p = 0.004) and total sugar (21.8 vs. 19.0, p = 0.003) as a percentage of daily energy and less protein (18.5 vs. 17.2, p = 0.004), mono-unsaturated fats (11.2 vs. 11.8, p = 0.026) as a percentage of daily energy, and fibre (20.1 vs. 23.0, p = 0.003), than food-secure adults. Sub-optimal diet may be one of the contributing factors to, or outcomes of, poorer health in food-insecure populations. Food security interventions are required to better address nutrition in food-insecure households and should be tailored to the health and socio-demographic characteristics of this population.

Adherence to Mediterranean Diet in Croatia: Lessons Learned Today for a Brighter Tomorrow

Non-communicable diseases (NCD) and lifestyle, particularly diet, have a close relationship. Based on the recent statistics, Croatian men and women lead in European overweight lists, which implies pessimistic prognosis in terms of incidence and prevalence of NCDs in the future. One of the possible solutions to overcome weight problems is turn to traditional balanced and sustainable diets, such as the Mediterranean diet. In this study, we assessed adherence towards Mediterranean diet using a validated questionnaire in an online survey and associated adherence scores with several demographic and anthropometric data. Based on the results of a validated Mediterranean Diet Adherence Screener (N = 3326), we assessed the adherence score to be 7.6 ± 2.5. The score tended to depend on sex, residence, age, education, income, and body mass index (BMI); indeed, women, residents of a coastal part of the country, older volunteers, those possessing a higher education degree, those with higher income, and those with lower BMI were associated with higher scores. As income was one of the significant findings related to higher adherence scores, we developed a dietary plan complying with Mediterranean diet principles that, on average, costed less than the average traditional balanced diet menu. Taken together, this study brought new findings regarding target groups who need to be encouraged to make lifestyle changes, and highlighted the first steps on how to make them.

Lay perceptions of diabetes mellitus and prevention costs and benefits among adults undiagnosed with the condition in Singapore: a qualitative study

Background

Therapeutic lifestyle changes can reduce individual risk of type 2 diabetes (T2D) by up to 58%. In Singapore, rates of preventive practices were low, despite a high level of knowledge and awareness of T2D risk and prevention. The study explored the context of the discrepancy between knowledge and practices in T2D prevention among adults undiagnosed with the condition.

Methods

In-depth interviews with 41 adults explored lay beliefs of T2D and the sources of these perceptions, subjective interpretation of how T2D may impact lives, and perceived costs and benefits of practising preventative behaviours. Purposive sampling was used to maximise the variability of participants in demographic characteristics. Thematic analysis was conducted to identify themes related to the domains of inquiry.

Results

Participants’ risk perceptions were influenced by familial, social, and cultural contexts of the representation and management of T2D conditions. The adverse effects of T2D were often narrated in food culture. The cost of adopting a healthy diet was perceived at a high cost of life pleasure derived from food consumption and social interactions. Inconveniences, loss of social functions, dependency and distress were the themes related to T2D management. Participants’ motivation to preventive practices, such as exercise and weight loss, were influenced by short-term observable benefits.

Conclusions

T2D risk communication needs to be addressed in emotionally impactful and interpersonally salient ways to increase the urgency to adopt preventative behaviours. Shifting perceived benefits from long-term disease prevention to short-term observable wellbeing could reduce the response cost of healthy eating.

Developing and Piloting a Novel Ranking System to Assess Popular Dietary Patterns and Healthy Eating Principles

A multitude of weight loss diets exist. However, no one diet has been proven to be superior, despite their claims. Resultingly, this creates confusion amongst consumers and conflicting nutrition messages. The aim of the ranking system was to evaluate a range of dietary pattern’s nutrition profile and financial costs, as well as their potential long-term sustainability and associated adverse effects. Nutrition profile is typically the focal point of weight loss diets with less attention focused towards other factors that may affect their suitability. Five popular diets (Keto, Paleo, Intermittent Fasting, Optifast, and 8 Weeks to Wow) and two energy restricted healthy eating principles (Australian Guide to Healthy Eating and the Mediterranean Diet) were compared for diet quality, cost, adverse effects, and support for behaviour change. In general, healthy eating principles scored more favourably compared to popular weight loss diets in all categories. Lower carbohydrate diets tended to score lower for diet quality due to restricting multiple food groups, had more associated adverse effects and did not encourage behaviour change compared to the other weight loss diets. Optifast was the only weight loss diet to receive a negative score for cost. There should be considerations when undertaking a change to dietary patterns beyond nutrition profile. Diets indeed vary in terms of diet quality, and in addition can be costly, incur adverse effects, and disregard behaviour change which is important for sustainable weight loss and maintenance. This ranking system could create a reference point for future comparisons of diets.

Modelling the Impact of Reducing Ultra-Processed Foods Based on the NOVA Classification in Australian Women of Reproductive Age

Women of reproductive age have a high proportion of overweight/obesity and an overall poor nutritional intake and diet quality. Nutritional modelling is a method to forecast potential changes in nutrition composition that may offer feasible and realistic changes to dietary intake. This study uses simulation modelling to estimate feasible population improvements in dietary profile by reducing ultra-processed food (UPF) consumption in Australian women of reproductive age. The simulation used weighted data from the most recent 2011-2012 National Nutrition and Physical Activity Survey. A total of 2749 women aged 19-50 years was included, and 5740 foods were examined. The highest daily energy, saturated fat, and added sugar and sodium came from UPF. Reducing UPF by 50% decreased energy intake by 22%, and saturated fat, added sugar, sodium, and alcohol by 10-39%. Reducing UPF by 50% and increasing unprocessed or minimally processed foods by 25% led to a lower estimated reduction in energy and greater estimated reductions in saturated fat and sodium. Replacement of 50% UPF with 75% of unprocessed or minimally processed foods led to smaller estimated reductions in energy and nutrients. Our results provide insight as to the potential impact of population reductions in UPF, but also increasing intake of unprocessed or minimally processed foods, which may be the most feasible strategy for improved nutritional intake.

Cost and affordability of healthy, equitable and more sustainable diets in the Torres Strait Islands

OBJECTIVES

To assess the cost, cost differential and affordability of current and recommended (healthy, equitable, culturally acceptable and more sustainable) diets in the Torres Strait Islands and compare with other Queensland locations.

METHODS

The Aboriginal and Torres Strait Islander Healthy Diets ASAP (Australian Standardised Affordability and Pricing) methods protocol was applied in five randomly selected communities in the Torres Strait Islands.

RESULTS

The current diet was 32% more expensive than that recommended; 'discretionary' foods comprised 64% of the current diet cost. Families could save at least A$281.38 a fortnight by switching to recommended diets. However, these cost 35-40% more than elsewhere in Queensland. Recommended diets would cost 35% of median and 48% of welfare household income in the Torres Straits.

CONCLUSIONS

While less expensive than the current diet, recommended diets are unaffordable for most households. Consequently, many Torres Strait Islander families are at high risk of food insecurity and diet-related disease.

IMPLICATIONS FOR PUBLIC HEALTH

Urgent policy action is required to further lower the relative price of recommended diets, and also increase household incomes and welfare supplements to equitably improve food security and diet-related health, and contribute to environmental sustainability in the Torres Strait Islands.

Costing recommended (healthy) and current (unhealthy) diets in urban and inner regional areas of Australia using remote price collection methods

OBJECTIVE

To compare the cost and affordability of two fortnightly diets (representing the national guidelines and current consumption) across areas containing Australia's major supermarkets.

DESIGN

The Healthy Diets Australian Standardised Affordability and Pricing protocol was used.

SETTING

Price data were collected online and via phone calls in fifty-one urban and inner regional locations across Australia.

PARTICIPANTS

Not applicable.

RESULTS

Healthy diets were consistently less expensive than current (unhealthy) diets. Nonetheless, healthy diets would cost 25-26 % of the disposable income for low-income households and 30-31 % of the poverty line. Differences in gross incomes (the most available income metric which overrepresents disposable income) drove national variations in diet affordability (from 14 % of the median gross household incomes in the Australian Capital Territory and Northern Territory to 25 % of the median gross household income in Tasmania).

CONCLUSIONS

In Australian cities and regional areas with major supermarkets, access to affordable diets remains problematic for families receiving low incomes. These findings are likely to be exacerbated in outer regional and remote areas (not included in this study). To make healthy diets economically appealing, policies that reduce the (absolute and relative) costs of healthy diets and increase the incomes of Australians living in poverty are required.

Toddler foods and milks don't stack up against regular foods and milks

AIM

To compare the cost and nutritional profiles of toddler-specific foods and milks to 'regular' foods and milks.

METHODS

Cross-sectional audit of non-toddler specific ('regular') foods and milks and secondary analysis of existing audit data of toddler specific (12-36 months) foods and milks in Australia.

MAIN FINDINGS

The cost of all toddler-specific foods and milks was higher than the regular non-toddler foods. Foods varied in nutritional content, but toddler foods were mostly of poorer nutritional profile than regular foods. Fresh milk cost, on average, $0.22 less per 100 mL than toddler milk. Toddler milks had higher mean sugar and carbohydrate levels and lower mean protein, fat, saturated fat, sodium and calcium levels per 100 mL, when compared to fresh full fat cow's milk.

CONCLUSIONS

Toddler specific foods and milks cost more and do not represent value for money or good nutrition for young children.

Parental work hours and household income as determinants of unhealthy food and beverage intake in young Australian children

OBJECTIVE

This study examined parental work hours and household income as determinants of discretionary (energy dense, nutrient poor) food and beverage intake in young children, including differences by eating occasion.

DESIGN

Secondary analysis of cross-sectional data. Three hierarchical regression models were conducted with percent energy from discretionary food and beverages across the day, at main meals, and at snack times being the outcomes. Dietary intake was assessed by 1x24-hour recall and 1-2x24-hour food record(s). Both maternal/paternal work hours were included, and total household income. Covariates included household, parent and child factors.

SETTING

Data from the NOURISH/SAIDI studies were collected between 2008-13.

PARTICIPANTS

Participants included 526 mother-child dyads (median(IQR) child age 1.99(1.96,2.03) years). Forty-one percent of mothers did not work while 57% of fathers worked 35-40 hours/week. Most (85%) households had an income of ≥$50k AUD/year.

RESULTS

Household income was consistently inversely associated with discretionary energy intake (β= -0.12 to -0.15). Maternal part-time employment (21-35 hours/week) predicted child consumption of discretionary energy at main meals (β=0.10, p=0.04). Paternal unemployment predicted a lower proportion of discretionary energy at snacks (β= -0.09, p=0.047).

CONCLUSIONS

This work suggests that household income should be addressed as a key opportunity-related barrier to healthy food provision in families of young children. Strategies to reduce the time burden of healthy main meal provision may be required in families where mothers juggle longer part-time working hours with caregiving and domestic duties. The need to consider the role of fathers and other parents/caregivers in shaping children's intake was also highlighted.

Developing and implementing a new methodology to test the affordability of currently popular weight loss diet meal plans and healthy eating principles

Background

Weight loss diets continue to rise in popularity; however, the associated costs are seldom reported. Certain weight loss diets may be unaffordable and differ from their traditional nutrition composition to include non-conventional premium products. In contrast, healthy eating principles such as the Australian Guide to Healthy Eating (AGHE) and the Mediterranean Diet (MedDiet) place an emphasis on fresh produce and staple foods but are sometimes thought to be unaffordable. A new methodology was piloted to assess the cost of weight loss diets using seven meal plans.

Methods

Seven meal plans were analysed to quantify the absolute grams required of all ingredients across seven days and multiplied by the cost of the ingredient per gram to determine the total cost of each ingredient based on unit size and price. The weekly grocery shopping cost was determined through summation of all ingredients and their entire unit size to compare weekly costs.

Results

Weekly meal plans (absolute grams) cost between $93-193AUD. The AGHE meal plan was the least expensive and 8 Weeks to Wow was the most expensive. Weekly grocery shopping of entire units cost between $345-$625AUD, over $100AUD greater than the spending of an average Australian ($237AUD/week).

Conclusions

The financial feasibility for long-term sustainment of weight loss diets may be questionable for groups including low-income earners and low socioeconomic status. Further, when dietary patterns are adapted for weight loss, or followed by consumers, deviations from foundational principles tend to occur which may influence overall cost.

Benchmarking as a Public Health Strategy for Creating Healthy Food Environments: An Evaluation of the INFORMAS Initiative (2012-2020)

Diet-related noncommunicable diseases (NCDs) and obesity are the leading contributors to poor health worldwide. Efforts to improve population diets need to focus on creating healthy food environments. INFORMAS, established in 2012, is an international network that monitors and benchmarks food environments and related policies. By 2020, INFORMAS was active in 58 countries; national government policies were the most frequent aspect benchmarked. INFORMAS has resulted in the development and widespread application of standardized methods for assessing the characteristics of food environments. The activities of INFORMAS have contributed substantially to capacity building, advocacy, stakeholder engagement, and policy evaluation in relation to creating healthy food environments. Future efforts to benchmark food environments need to incorporate measurements related to environmental sustainability. For sustained impact, INFORMAS activities will need to be embedded within other existing monitoring initiatives. The most value will come from repeated assessments that help drive increased accountability for improving food environments.

Dietary Intake, Cost, and Affordability by Socioeconomic Group in Australia

Few Australians consume diets consistent with the Australian Dietary Guidelines. A major problem is high intake of discretionary food and drinks (those not needed for health and high in saturated fat, added sugar, salt and/or alcohol). Low socioeconomic groups (SEGs) suffer particularly poor diet-related health. Surprisingly, detailed quantitative dietary data across SEGs was lacking. Analysis of the most recent national nutrition survey data produced habitual intakes of a reference household (two adults and two children) in SEG quintiles of household income. Cost and affordability of habitual and recommended diets for the reference household were determined using methods based on the Healthy Diets Australian Standardised Affordability and Pricing protocol. Low SEGs reported significantly lower intakes of healthy food and drinks yet similarly high intakes of discretionary choices to high SEGs (435 serves/fortnight). Total habitual diets of low SEGs cost significantly less than those of high SEGs (AU$751/fortnight to AU$853/fortnight). Results confirmed low SEGs cannot afford a healthy diet. Lower intakes of healthy choices in low SEGs may help explain their higher rates of diet-related disease compared to higher SEGs. The findings can inform potential policy actions to improve affordability of healthy foods and help drive healthier diets for all Australians.

Affordability of Heathy, Equitable and More Sustainable Diets in Low-Income Households in Brisbane before and during the COVID-19 Pandemic

The COVID-19 pandemic has increased food insecurity worldwide, yet there has been limited assessment of shifts in the cost and affordability of healthy, equitable and sustainable diets. This study explores the impact of the COVID-19 pandemic and income supplements provided by the Australian government on diet cost and affordability for low-income households in an Australian urban area. The Healthy Diets ASAP method protocol was applied to assess the cost and cost differential of current and recommended diets before (in 2019) and during the COVID-19 pandemic (late 2020) for households with a minimum-wage and welfare-only disposable household income, by area of socioeconomic disadvantage, in Greater Brisbane, Queensland, Australia. Data were collected between August and October, 2020, from 78 food outlets and compared with data collected in the same locations between May and October, 2019, in an earlier study. The price of most healthy food groups increased significantly during the pandemic-with the exception of vegetables and legumes, which decreased. Conversely, the price of discretionary foods and drinks did not increase during the pandemic. The cost of the current and recommended diets significantly increased throughout this period, but the latter continued to be less expensive than the former. Due to income supplements provided between May and September 2020, the affordability of the recommended diet improved greatly, by 27% and 42%, for households with minimum-wage and welfare-only disposable household income, respectively. This improvement in the affordability of the recommended diet highlights the need to permanently increase welfare support for low-income families to ensure food security.

Diet Quality following Total Meal Replacement Compared with Food-Based Weight-Loss Diets in Postmenopausal Women with Obesity: A Secondary Analysis of the TEMPO Diet Trial

BACKGROUND

Severely energy-restricted diets that utilize meal-replacement products are the most effective dietary treatment for obesity. However, there are concerns they may fail to educate individuals on how to adopt a healthy food-based diet after weight loss.

OBJECTIVES

The aim of this research was to compare changes in diet quality following total meal replacement compared with food-based weight-loss diets.

METHODS

In this secondary analysis of a randomized controlled trial, 79 postmenopausal women aged 45-65 y, with a BMI (in kg/m2) of 30-40, were randomly assigned to either a total meal-replacement diet (energy intake restricted by 65-75% relative to requirements) for 16 wks, followed by a food-based diet (energy intake restricted by 25-35% relative to requirements) until 52 wks, or the food-based diet for the entire 52-wk period. Diet quality was scored at baseline and 52 wks using the Healthy Eating Index for Australian Adults, with score changes compared between groups using an independent t test.

RESULTS

Diet quality improved from baseline in both groups, but less so in the total meal-replacement group, with a mean (SD) increase of 3.6 (10.8) points compared with 11.8 (13.9) points in the food-based group, resulting in a mean between-group difference of -8.2 (P = 0.004; 95% CI: -13.8, -2.7) points. This improvement in diet quality within both groups was mostly driven by a reduction in the intake of discretionary foods. Intake remained below the recommendations at 52 wks for 4 of the 5 food groups in both dietary interventions.

CONCLUSIONS

In postmenopausal women with obesity, weight-loss interventions that involve either a total meal-replacement diet or a food-based diet both improve diet quality, however, not sufficiently to meet recommendations. This highlights the importance of addressing diet quality as a part of all dietary weight-loss interventions. This trial is registered with the Australia and New Zealand Clinical Trials Registry as 12612000651886.

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence

BACKGROUND

Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples' concerns and priorities about food and nutrition in order to inform policies to improve health equity.

METHODS

MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies-published from January 2008-that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health.

RESULTS

Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture.

CONCLUSIONS

Documenting Aboriginal and Torres Strait Islander Peoples' lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Adoption of healthy and sustainable diets in Mexico does not imply higher expenditure on food

The relative cost of healthy and sustainable diets is key for their adoption in different countries. Using a newly developed modelling tool that generates different diet baskets, we compared the costs of diets following the EAT-Lancet healthy reference diet, the Mexican dietary guidelines and locals' current food intake. On average, the cost of the EAT-Lancet healthy reference diet baskets was 21% lower than that of the Mexican dietary guidelines baskets, and 40% lower than that of the current intake baskets (29% lower if the comparison was isocaloric). Findings were similar over time (2011-2018) and by geographic region. The higher cost associated with the larger amount of fruits, vegetables, legumes and nuts in healthy and sustainable diets was surpassed by the savings associated with their lower amount of animal protein sources, sugar-sweetened beverages and discretionary foods. We conclude that transitioning to better diets in Mexico is possible without a higher expenditure on food.

Ultra-processed food consumption, socio-demographics and diet quality in Australian adults

OBJECTIVE

To examine how socio-demographic characteristics and diet quality vary with consumption of ultra-processed foods (UPF) in a cross-sectional nationally representative survey of Australian adults.

DESIGN

Using a 24-h recall, this cross-sectional analysis of dietary and socio-demographic data classified food items using the NOVA system, estimated the percentage of total energy contributed by UPFs and assessed diet quality using the Dietary Guideline Index (DGI-2013 total and components). Linear regression models examined associations between socio-demographic characteristics and diet quality with percentage of energy from UPF.

SETTING

Australian Health Survey 2011-2013.

PARTICIPANTS

Australian adults aged ≥ 19 years (n 8209).

RESULTS

Consumption of UPF was higher among younger adults (aged 19-30 years), adults born in Australia, those experiencing greatest area-level disadvantage, lower levels of education and the second lowest household income quintile. No significant association was found for sex or rurality. A higher percentage of energy from UPF was inversely associated with diet quality and with lower DGI scores related to the variety of nutritious foods, fruits, vegetables, total cereals, meat and poultry, fish, eggs, nuts and seeds, legumes/beans, water and limits on discretionary foods, saturated fat and added sugar.

CONCLUSIONS

This research adds to the evidence on dietary inequalities across Australia and how UPF are detrimental to diet quality. The findings can be used to inform interventions to reduce UPF consumption and improve diet quality.

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

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

Cost and Affordability of Healthy, Equitable and Sustainable Diets in Low Socioeconomic Groups in Australia

Few Australians consume a healthy, equitable and more sustainable diet consistent with the Australian Dietary Guidelines (ADGs). Low socioeconomic groups (SEGs) suffer particularly poor diet-related health problems. However, granular information on dietary intakes and affordability of recommended diets was lacking for low SEGs. The Healthy Diets Australian Standardised Affordability and Pricing protocol was modified for low SEGs to align with relevant dietary intakes reported in the National Nutrition Survey 2011–2012(which included less healthy and more discretionary options than the broader population), household structures, food purchasing habits, and incomes. Cost and affordability of habitual and recommended diets of low SEGs were calculated using prices of ‘standard brands’ and ‘cheapest options’. With ‘standard brands’, recommended diets cost less than habitual diets, but were unaffordable for low SEGs. With ‘cheapest options’, both diets were more affordable, but recommended diets cost more than habitual diets for some low SEGs, potentially contributing to perceptions that healthy food is unaffordable. The study confirms the need for an equity lens to better target dietary guidelines for low SEGs. It also highlights urgent policy action is needed to help improve affordability of recommended diets.

Affordability of current, and healthy, more equitable, sustainable diets by area of socioeconomic disadvantage and remoteness in Queensland: insights into food choice

Background

Poor diet is the leading preventable risk factor contributing to the burden of disease globally and in Australia, and is inequitably distributed. As the price of healthy foods is a perceived barrier to improved diets, evidence on the cost and affordability of current (unhealthy) and recommended (healthy, more equitable and sustainable) diets is required to support policy action.

Methods

This study applied the Healthy Diets ASAP (Australian Standardised Affordability and Pricing) methods protocol to measure the cost, cost differential and affordability of current and recommended diets for a reference household in Queensland, Australia. Food prices were collected in 18 randomly selected locations stratified by area of socioeconomic disadvantage and remoteness. Diet affordability was calculated for three income categories.

Results

Surprisingly, recommended diets would cost 20% less than the current diet in Queensland as a whole. Households spent around 60% of their food budget on discretionary choices (that is, those not required for health that are high in saturated fat, added sugar, salt and/or alcohol). Queensland families would need to spend around 23% of their income on recommended diets. However, recommended diets would not be affordable in low socioeconomic or very remote areas, costing 30 and 35% of median household income respectively. The government supplements due to the SARS-CoV-2 pandemic would improve affordability of recommended diets by 29%.

Conclusions

Study findings highlight that while price is one factor affecting consumer food choice, other drivers such as taste, convenience, advertising and availability are important. Nevertheless, the study found that recommended diets would be unaffordable in very remote areas, and that low-income families are likely experiencing food stress, irrespective of where they live in Queensland. Policy actions, such as increasing to 20% the current 10% tax differential between basic healthy, and unhealthy foods in Australia, and supplementing incomes of vulnerable households, especially in remote areas, are recommended to help improve diet equity and sustainability, and health and wellbeing for all.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01481-8.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS/SETTINGS

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

MAIN OUTCOME MEASURES

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

STATISTICAL ANALYSES PERFORMED

Associations were estimated using linear regressions.

RESULTS

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

CONCLUSIONS

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

Diet and Economic Modelling to Improve the Quality and Affordability of the Australian Diet for Low and Medium Socioeconomic Households

Food costs are a barrier to healthier diet selections, particularly for low socioeconomic households who regularly choose processed foods containing refined grains, added sugars, and added fats. In this study, the objectives were to: (i) identify the nutrient density-to-cost ratio of Australian foods; (ii) model the impact of substituting foods with lower nutrient density-to-cost ratio with those with the highest nutrient density-to-cost ratio for diet quality and affordability in low and medium socioeconomic households; and (iii) evaluate food processing levels. Foods were categorized, coded for processing level, analysed for nutrient density and cost, and ranked by nutrient density-to-cost ratio. The top quartile of nutrient dense, low-cost foods included 54% unprocessed (vegetables and reduced fat dairy), 33% ultra-processed (fortified wholegrain bread and breakfast cereals <20 g sugars/100 g), and 13% processed (fruit juice and canned legumes). Using substitution modelling, diet quality improved by 52% for adults and 71% for children across all households, while diet affordability improved by 25% and 27% for low and medium socioeconomic households, respectively. The results indicate that the quality and affordability of the Australian diet can be improved when nutritious, low-cost foods are selected. Processing levels in the healthier modelled diets suggest that some ultra-processed foods may provide a beneficial source of nutrition when consumed within national food group recommendations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identifying trends over time in food affordability: The Illawarra Healthy Food Basket survey, 2011-2019

OBJECTIVE

To determine the affordability of a healthy food basket (HFB) for welfare recipients and average income earners in 2019 and to compare trends from 2011.

METHODS

Fifty-seven food items' prices were collected from fifteen stores across five suburbs representing low, medium and high socio-economic status. Costs were compared with average weekly income and welfare payments to assess the baskets' affordability for a family of four and five.

RESULTS

In 2019, a HFB was affordable (below 30% of household income) for a five-person reference family with a pensioner, representing 24.8% of weekly welfare payments, but not for a four-person reference family (33.0%). The cost of the HFB increased slightly over time from AU$288.91 in 2011 to AU$291.79 in 2019. The food affordability improved for a family of five including a pensioner over this period due to an increase of average weekly earnings and welfare payments.

CONCLUSION

In 2019, the HFB was affordable for a five-person family; however, a four-person family receiving welfare benefits would have experienced significant "food stress," with the food basket costing above 30% of household income.

IMPLICATIONS FOR HEALTH PROMOTION

Inequity in the affordability of healthy food is a major public health concern and one that demands recognition and national action. The impact of policies affecting welfare support and wages needs to be considered, as well as food pricing strategies and possible food subsidies for those at greatest risk of food insecurity.

Food havens not swamps: a strength-based approach to sustainable food environments

The current paper provides a critical review of food environments' literature, with a focus on the metaphoric typology that has been developed over recent decades. This has tended to focus understandably on harmful food environments using well-known metaphors: that of food deserts, food swamps and food mirages. The purpose of the review was to consider the current typology in relation to what constitutes healthy food environments, and the implications for population groups in low socioeconomic environments who are often disadvantaged by current food systems and unhealthy food environments. The paper posits a new term, alongside the notion of the food oasis, that of food havens. Oasis indicates a small place of plenty in a setting of scarcity. Haven extends the boundaries of plenty in society by positing places and settings of refuge and safety, even sanctuary from which health and well-being can be attained and supported. We argue for focusing on creating such sustainable food environments so as to proliferate and promote examples of what needs to be done urgently in the fight to transform global food environments for the health of people particularly those that are vulnerable and the planet. Elements of the food haven as proposed in this paper have been drawn from indigenous perspectives-these include Māori and Pacific worldviews. Future research should consider what food environments might look like in different contexts and how we might move away from food swamps and deserts to food oases and havens; and utilize these positive motifs to go further in creating whole sustainable food environments encompassing all of society.

A systematic scoping review of the habitual dietary costs in low socioeconomic groups compared to high socioeconomic groups in Australia

Background

Low socioeconomic groups (SEGs) in Australia are less likely to consume diets consistent with the Australian Dietary Guidelines (ADGs) and suffer poorer health than the broader population. The unaffordability, or perceived high cost, of healthy diets may be a factor. Detailed data on the cost of habitually consumed diets is required in order to inform strategies to alleviate socioeconomic impacts on dietary intake.

This systematic scoping review aims to identify the cost of the habitual dietary intake of low SEGs in Australia, in terms of the whole diet and its composite foods, in comparison to the cost in higher SEGs.

Methods

A systematic search of peer-reviewed literature since 2000 and key government and non-government organisation (NGO) websites was undertaken. Data were extracted, synthesised and analysed in relation to study populations, dietary cost assessment measures, socioeconomic measures, and dietary cost and affordability.

Results

The review identified four studies meeting inclusion criteria. Results confirmed that overall, low SEGs spend a lower amount, yet a higher proportion of household income, on food and drinks than higher SEGs. Quantitative comparison of the dietary costs between included studies was not possible due to difference in populations and study metrics. Costs of the habitual diet in these studies were not reported for ADG food groups, so did not allow for assessment of the healthfulness of the dietary intake or comparison with costs of recommended diets at food group level.

Conclusions

Existing research does not provide sufficiently granular data of the costs of habitual diets of low SEGs in comparison to higher SEGs or data in a form that can inform strategies and interventions to improve dietary intake and diet-related health of low SEGs in Australia. Future empirical health research requires more granular measures of habitual spending on ADG food groups across SEGs.

The Healthiness of Food and Beverages on Price Promotion at Promotional Displays: A Cross-Sectional Audit of Australian Supermarkets

Supermarket environments can strongly influence purchasing decisions. Price promotions are recognised as a particularly persuasive tactic, but the healthiness of price promotions in prominent in-store locations is understudied. This study compared the prevalence and magnitude of price promotions on healthy and unhealthy food and beverages (foods) displayed at prominent in-store locations within Australian supermarkets, including analyses by supermarket group and area-level socio-economic position. A cross-sectional in-store audit of price promotions on foods at key display areas was undertaken in 104 randomly selected stores from major Australian supermarket groups (Woolworths, Coles, Aldi and independents) in Victoria, Australia. Of the display space dedicated to foods with price promotions, three of the four supermarket groups had a greater proportion of display space devoted to unhealthy (compared to healthy) foods at each promotional location measured (end of aisles: 66%; island bins: 53%; checkouts: 88%). Aldi offered very few price promotions. Few measures varied by area-level socio-economic position. This study demonstrated that price promotions at prominent in-store locations in Australian supermarkets favoured unhealthy foods. Marketing of this nature is likely to encourage the purchase of unhealthy foods, highlighting the need for retailers and policy-makers to consider addressing in-store pricing and placement strategies to encourage healthier food environments.

Obesity: a sociological guide for health practitioners

Obesity is a condition of excess body fat that has been identified as one of the most serious public health problems of the 21st century. Obesity is a leading preventable cause of death globally and increases the likelihood of cardiovascular disease, diabetes and various cancers. Obesity worldwide has tripled in the adult population over the past 40 years, with 13% of the world's adult population now obese, leading to calls for control of a global obesity epidemic. Causes of obesity can be delineated at individual, societal and systemic levels, highlighting the need for analysis that transcends the biomedical paradigm to explore the sociological influences of this condition. The pathophysiology of why obesity occurs has not changed within recent history, but the way that people live their lives and the cultural understandings that evolve within communities have. This article describes the interaction between obesity and the social environment, explores the meaning of obesity within the context of health and considers the social determinants of obesity within the community. It also discusses the influences of the professional-patient exchange in obesity, the comprehension of obesity as a disease and the challenges of addressing obesity within the healthcare system.

Streamlined data-gathering techniques to estimate the price and affordability of healthy and unhealthy diets under different pricing scenarios

OBJECTIVE

To determine the reliability of streamlined data-gathering techniques for examining the price and affordability of a healthy (recommended) and unhealthy (current) diet. We additionally estimated the price and affordability of diets across socio-economic areas and quantified the influence of different pricing scenarios.

DESIGN

Following the Healthy Diets Australian Standardised Affordability and Pricing (ASAP) protocol, we compared a cross-sectional sample of food and beverage pricing data collected using online data and phone calls (lower-resource streamlined techniques) with data collected in-store from the same retailers.

SETTING

Food and beverage prices were collected from major supermarkets, fast food and alcohol retailers in eight conveniently sampled areas in Victoria, Australia (n 72 stores), stratified by area-level deprivation and remoteness.

PARTICIPANTS

This study did not involve human participants.

RESULTS

The biweekly price of a healthy diet was on average 21 % cheaper ($596) than an unhealthy diet ($721) for a four-person family using the streamlined techniques, which was comparable with estimates using in-store data (healthy: $594, unhealthy: $731). The diet price differential did not vary considerably across geographical areas (range: 18-23 %). Both diets were estimated to be unaffordable for families living on indicative low disposable household incomes and below the poverty line. The inclusion of generic brands notably reduced the prices of healthy and unhealthy diets (≥20 %), rendering both affordable against indicative low disposable household incomes. Inclusion of discounted prices marginally reduced diet prices (3 %).

CONCLUSIONS

Streamlined data-gathering techniques are a reliable method for regular, flexible and widespread monitoring of the price and affordability of population diets in areas where supermarkets have an online presence.

3-Year effect of weight loss via severe versus moderate energy restriction on body composition among postmenopausal women with obesity - the TEMPO Diet Trial

We have previously shown that a severely energy-restricted diet leads to greater loss of weight, fat, lean mass and bone mineral density (BMD) at 12 months in postmenopausal women with obesity than a moderately energy-restricted diet. We now aim to evaluate whether these effects are sustained longer term (ie, at 36 months). 101 postmenopausal women were randomized to either 12 months of moderate (25 to 35%) energy restriction with a food-based diet (moderate intervention), or 4 months of severe (65 to 75%) energy restriction with a total meal replacement diet followed by moderate energy restriction for 8 months (severe intervention). Body weight and composition were measured at 0, 24 and 36 months. Participants in the severe intervention lost ~1.5 to 1.7 times as much weight, waist circumference, whole-body fat mass and visceral adipose tissue compared to those in the moderate intervention, and were 2.6 times more likely (42% versus 16%) to have lost 10% or more of their initial body weight at 36 months (P < 0.01 for all). However, those in the severe versus moderate intervention lost ~1.4 times as much whole-body lean mass (P < 0.01), albeit this was proportional to total weight lost and there was no greater loss of handgrip strength, and they also lost ~2 times as much total hip BMD between 0 and 36 months (P < 0.05), with this bone loss occurring in the first 12 months. Thus, severe energy restriction is more effective than moderate energy restriction for reducing weight and adiposity in postmenopausal women in the long term (3 years), but attention to BMD loss in the first year is required.

Trial registration

Australian New Zealand Clinical Trials Registry Reference Number: 12612000651886, anzctr.org.au.

A tale of two cities: the cost, price-differential and affordability of current and healthy diets in Sydney and Canberra, Australia

BACKGROUND

The perception that healthy foods are more expensive than unhealthy foods has been reported widely to be a key barrier to healthy eating. However, assessment of the relative cost of healthy and unhealthy foods and diets is fraught methodologically. Standardised approaches to produce reliable data on the cost of total diets and different dietary patterns, rather than selected foods, are lacking globally to inform policy and practice.

METHODS

This paper reports the first application, in randomly selected statistical areas stratified by socio-economic status in two Australian cities, of the Healthy Diets Australian Standardized Affordability and Pricing (ASAP) method protocols: diet pricing tools based on national nutrition survey data and dietary guidelines; store sampling and location; determination of household incomes; food price data collection; and analysis and reporting. The methods were developed by the International Network on Food and Obesity/NCD Research, Monitoring and Action Support (INFORMAS) as a prototype of an optimum approach to assess, compare and monitor the cost and affordability of diets across different geographical and socio-economic settings and times.

RESULTS

Under current tax policy in Australia, healthy diets would be 15-17% less expensive than current (unhealthy) diets in all locations assessed. Nevertheless, healthy diets are likely to be unaffordable for low income households, costing more than 30% of disposable income in both cities surveyed. Households spent around 58% of their food budget on unhealthy food and drinks. Food costs were on average 4% higher in Canberra than Sydney, and tended to be higher in high socioeconomic locations.

CONCLUSIONS

Health and fiscal policy actions to increase affordability of healthy diets for low income households are required urgently. Also, there is a need to counter perceptions that current, unhealthy diets must be less expensive than healthy diets. The Healthy Diets ASAP methods could be adapted to assess the cost and affordability of healthy and unhealthy diets elsewhere.

Food Environment Typology: Advancing an Expanded Definition, Framework, and Methodological Approach for Improved Characterization of Wild, Cultivated, and Built Food Environments toward Sustainable Diets

The food environment is a critical place in the food system to implement interventions to support sustainable diets and address the global syndemic of obesity, undernutrition, and climate change, because it contains the total scope of options within which consumers make decisions about which foods to acquire and consume. In this paper, we build on existing definitions of the food environment, and provide an expanded definition that includes the parameter of sustainability properties of foods and beverages, in order to integrate linkages between food environments and sustainable diets. We further provide a graphical representation of the food environment using a socio-ecological framework. Next, we provide a typology with descriptions of the different types of food environments that consumers have access to in low-, middle-, and high-income countries including wild, cultivated, and built food environments. We characterize the availability, affordability, convenience, promotion and quality (previously termed desirability), and sustainability properties of food and beverages for each food environment type. Lastly, we identify a methodological approach with potential objective and subjective tools and metrics for measuring the different properties of various types of food environments. The definition, framework, typology, and methodological toolbox presented here are intended to facilitate scholars and practitioners to identify entry points in the food environment for implementing and evaluating interventions that support sustainable diets for enhancing human and planetary health.

Increasing Food Expenditure in Long Day-care by an Extra $0.50 per Child/Day Would Improve Core Food Group Provision

Early childhood education and care services are a significant feature of Australian family life, where nearly 1.4 million children attended a service in 2019. This paper reports on the cost of food provided to children in long day-care (LDC) services and extrapolates expenditure recommendations to support food provision compliance. A cross-sectional audit of LDC services in metropolitan Perth was conducted to determine food group provision by weighing raw ingredients of meal preparation—morning tea, lunch, and afternoon tea (MT, L, AT). Ingredients were costed at 2017 online metropolitan pricing from a large supermarket chain. Across participating services, 2 days of food expenditure per child/day ranged between $1.17 and $4.03 across MT, L, AT, and averaged $2.00 per child/day. Multivariable analysis suggests that an increase of $0.50 per child/day increases the odds of a LDC service meeting >50% of Australian Dietary Guideline (ADG) recommendations across ≥4 core food groups by fourfold (p = 0.03). Given the fact that the literature regarding food expenditure at LDC services is limited, this study provides information about food expenditure variation that impacts planning and provision of nutritionally balanced menus recommended for children. An average increase of food expenditure of $0.50 per child/day would increase food provision compliance.

Sustained adherence to a Mediterranean diet and physical activity on all-cause mortality in the Melbourne Collaborative Cohort Study: application of the g-formula

Background

Adherence to a traditional Mediterranean diet has been associated with lower mortality and cardiovascular disease risk. The relative importance of diet compared to other lifestyle factors and effects of dietary patterns over time remains unknown.

Methods

We used the parametric G-formula to account for time-dependent confounding, in order to assess the relative importance of diet compared to other lifestyle factors and effects of dietary patterns over time. We included healthy Melbourne Collaborative Cohort Study participants attending a visit during 1995–1999. Questionnaires assessed diet and physical activity at each of three study waves. Deaths were identified by linkage to national registries. We estimated mortality risk over approximately 14 years (1995–2011).

Results

Of 22,213 participants, 2163 (9.7%) died during 13.6 years median follow-up. Sustained high physical activity and adherence to a Mediterranean-style diet resulted in an estimated reduction in all-cause mortality of 1.82 per 100 people (95% confidence interval (CI): 0.03, 3.6). The population attributable fraction was 13% (95% CI: 4, 23%) for sustained high physical activity, 7% (95% CI: − 3, 17%) for sustained adherence to a Mediterranean-style diet and 18% (95% CI: 0, 36%) for their combination.

Conclusions

A small reduction in mortality may be achieved by sustained elevated physical activity levels in healthy middle-aged adults, but there may be comparatively little gain from increasing adherence to a Mediterranean-style diet.

Measuring Rural Food Environments for Local Action in Australia: A Systematic Critical Synthesis Review

Poor diet is a significant contributor to obesity and chronic disease. With all being more prevalent in rural than urban Australia, modifying the food environment is a potential intervention point to improve the health of rural populations. This review examined the applicability of measurement tools used in rural food environment research for rural Australia. Six electronic databases were searched for peer-reviewed literature, published in English between 2006 and 2018, including at least one objective measure of the Community or Consumer Food Environment in a rural or mixed rural/urban context. One-hundred and seventy-seven papers were returned after removal of duplicates, with a final review of 25. Most studies were cross-sectional, with one intervention study of quasi-experimental design. Nine studies employed a conceptual model; there was considerable variability in tools used; and few described psychometric testing. The most common attribute measured was price, followed by available healthy options. The findings of this review do not offer a suite of ‘gold standard’ measurement tools known to be reliable, valid and sensitive to change to assess the community or consumer food environments in rural Australian towns. However, recommendations are proposed to progress this important area of research within a rural context.

Dealing with Too Little: The Direct Experience of Scarcity does not Affect Snack Intake

Background

The experience of scarcity provides an explanation for the relatively unhealthy diets of people with low income. Causal evidence for an effect of direct experiences of scarcity on eating behaviour is lacking.

Methods

Two studies (N = 81, N = 115) tested and refined a self‐developed trade‐off task, in which participants' resources were restricted (scarcity condition) or unrestricted (no‐scarcity condition), for manipulating experiences of scarcity. Two further studies (N = 95, N = 122) were performed to test whether scarcity results in greater calorie consumption from snacks and lower self‐reported self‐regulation of eating.

Results

The scarcity manipulation appeared successful. A significant main effect of scarcity on eating was not found; however, an interaction effect between hunger and scarcity bordered on significance, such that those in the scarcity condition consumed more calories under low hunger. In the second experiment, participants were instructed to eat prior to participation to lower their hunger level. No difference between conditions was found in calorie consumption and self‐regulation of eating.

Conclusion

Although the trade‐off task appeared to evoke scarcity experiences, the present research could not support the notion that these result in unhealthier eating. A more nuanced view of the influence of scarcity on eating is needed.

Assessing Support for Advantaged and Disadvantaged Groups: A Comparison of Urban Food Environments

Individuals from lower-socio-economic status (SES) communities have increased risk of developing obesity in developed countries such as Australia. Given the influence of the environment on dietary behaviour, this paper seeks to examine food environments in areas of differing social advantage. An established measurement tool (the NEMS-Nutrition Environment Measurement Survey), that captures aspects of support for healthy eating within restaurants (NEMS-R) and grocery/convenience stores (NEMS-S), was applied to both a high-SES and a low-SES suburb within Brisbane, Australia. The study found a significantly more supportive restaurant food environment in the high-SES suburb, with greater access to and availability of healthful foods, as well as facilitators for, reduced barriers to, and substantially more nutrition information for healthful eating. A higher number of outlets were found in the high-SES suburb, and later opening times were also observed. Overall, the results from stores (NEMS-S) suggest poor support for healthful eating across both suburbs. This study highlights how food environments in low-SES regions continue to be less supportive of healthful eating. Public health strategies must move beyond individual-focused strategies to ensure that our most disadvantaged, low-SES communities have an equal opportunity to access healthful foods.