ABSTRACT
Objective To determine if price is a barrier to fruit andvegetable consumption for low-income families by com-paring the average cost of a market basket of fruits andvegetables from the Thrifty Food Plan and the DietaryGuidelines for Americans 2005(2005 Dietary Guidelines),investigating variations in price by neighborhood incomeand by type of supermarket, and estimating the influenceof a 2005 Dietary Guidelines fruit and vegetable basketon the food budget of a low-income family.
Design A market basket survey was conducted at 25 su-permarkets across three time periods to allow for sea-sonal variation in produce prices.
Setting Stores were selected from census tracts with avariety of income levels in Sacramento, CA, and Los An-geles, CA.
Main outcome measures The average cost of a Thrifty FoodPlan and 2005 Dietary Guidelines market basket forfruits and vegetables.
Statistical analyses performed Student t tests were used tocompare the mean cost of market baskets.
Results The 2005 Dietary Guidelines market basket cost4% less than the Thrifty Food Plan (P0.001), and wassignificantly less expensive in low-income areas at $65(P0.05), and in bulk supermarkets at $59 (P0.05). The2005 Dietary Guidelines market basket would require alow-income family to devote 43% to 70% of their foodbudget to fruits and vegetables.
Conclusions Public policies should examine ways to makefruits and vegetables more affordable to low-incomefamilies.
To assist in protecting Americans from the leadingcauses of chronic illnesses such as heart disease,diabetes, and certain types of cancer, the DietaryGuidelines for Americans 2005(2005 Dietary Guidelines)increased the recommended daily servings for fruits andvegetables from five to nine (based on a reference 2,000-kcal diet) (1). Because eating certain types of fruits andvegetables have been shown to provide specific healthbenefits, the 2005 Dietary Guidelines also recommendsspecific amounts of certain types of vegetables, includinglegumes, dark-green vegetables, and orange vegetables.For example, eating dark-green vegetables has been as-sociated with a lower incidence of many chronic diseases,including lung and stomach cancers, non-Hodgkin’s lym-phoma, and stroke (2-5).
Despite the known health benefits of a diet rich infruits and vegetables, only 40% of Americans meet theformer 5-A-Day guidelines, and fewer than 10% appear tomeet the newer 2005 Dietary Guidelines general andsubgroup recommendations for fruits and vegetables (6).Higher-income consumers are more likely to meet dietaryrecommendations. Using National Health and NutritionExamination Survey 2001-2002 data, people in house-holds with an annual income of more than $25,000 con-sume an average of 5.56 servings of fruits and vegetablesa day, whereas people in households making less than$25,000 consume 5.04 servings a day. People in house-holds with more than $25,000 in annual income consumefewer daily servings of starchy vegetables (1.28 vs 1.41),more dark-green vegetables (0.29 vs 0.2), and more or-ange vegetables (0.2 vs 0.16) than people in householdswith less than $25,000 in annual income (7).
One of the suggestions for how to lower the risk ofdiet-related chronic disease among low-income consum-ers is through increased consumption of fruits and vege-tables. Previous efforts have focused on the individualwith nutrition education, and public food assistance pro-grams like the Special Supplemental Nutrition Programfor Women, Infants, and Children and the Food StampProgram. Although these programs have been successfulin increasing the consumption of fruits and vegetablesamong the target population (8-11), disparities betweenhigh- and low-income consumers still exist (7,12 ). As aresult, increasing attention has been focused on how thefood environment supports the choice to eat more health-fully ( 13-15 ).Food prices are one part of the food environment, andmay be one reason for lower fruit and vegetable consump-tion among low-income consumers. Price, along with tasteand convenience, is a leading influence on food choices(16). Previous research on food prices using market basket studies has shown that lower-income neighborhoodsfrequently have higher food prices than higher-incomeneighborhoods ( 17-19 ). Smaller stores tend to chargehigher prices, and low-income urban centers have fewer,smaller supermarkets; therefore, food prices tend to behigher in those neighborhoods (18,19). In addition, thewarehouse and supercenter food stores that have the lowestprices (20) have largely bypassed low-income neighbor-hoods. Market basket studies have also shown that thecost to eat more healthful alternatives to standard fooditems (ie, whole-wheat breads instead of white breads,lean meats, and nonfat dairy products) is greater by 17%to 19% ( 21). None of these studies have reported resultsfor just the fruit and vegetable portion of the marketbasket.
Low-income consumers report that fruit and vegetableprices are a barrier to consumption ( 22,23). In a survey ofnearly 800 low-income consumers, about one third re-ported that cost was a barrier to healthful eating ( 24).Observed expenditures seem to support this contention.American households allocate only 15% to 18% of theirfood-at-home budget to fruits and vegetables, and thisproportion is consistent across income levels (25,26). Astudy on actual expenditures on food by low-income con-sumers shows that the cost of the average diet amonglow-income people is also a lower cost per kilocalorie dietthan one that meets the 1999 Dietary Guidelines ( 27).This diet is higher in fat and lower in nutrients than thediets of higher income consumers.
Price may pose a significant challenge to the ability oflow-income consumers to meet the 2005 Dietary Guide-lines recommendations for fruits and vegetables. First, agreater number of servings are recommended, increasingthe total cost above the previous 5-A-Day targets. Second,dark-green and orange vegetables and legumes encour-aged by the 2005 Dietary Guidelines tend to cost morethan starchy vegetables ( 25). If the cost of the 2005 Di-etary Guidelines fruit and vegetable market basket con-stitutes a higher proportion of the family food budget,consumers may find the increased cost difficult to meet,and little progress will be made in increasing fruit andvegetable consumption in low-income groups. Therefore,the cost of the 2005 Dietary Guidelines market basket isimportant information for policy makers in reviewingfood assistance benefit levels, and for nutrition educatorsin developing effective food strategies for low-incomehouseholds.
The purpose of this study was to examine the priceenvironment for fruits and vegetables by investigatingthree research questions: Is the cost significantly more ifthey purchased a fruit and vegetable market basket thatmeets the newer 2005 Dietary Guidelines compared tothe 1995 guidelines reflected in the Thrifty Food Plan? Dofruit and vegetable prices vary by neighborhood incomelevel and store type? and, What is the affect of the newdietary guidelines for fruits and vegetables on the foodbudget of a low-income family?
METHODS
The data collection for this study consisted of developingthe Thrifty Food Plan and 2005 Dietary Guidelines mar-ket baskets and surveying supermarkets for food prices.The hypotheses were tested by analyzing cost differencesby neighborhood income level and by store type, and costdifferences between the Thrifty Food Plan and 2005 Di-etary Guidelines market basket.
Developing the Market Baskets of Items to be Surveyed
The market baskets in this study include all of the fruitsand vegetables on the Thrifty Food Plan shopping list(28). The Thrifty Food Plan is commonly used in marketbasket studies because it was developed to demonstratethat low-income consumers can eat healthfully on foodstamp allocations ( 17,29,30 ). Furthermore, it directly re-flects theDietary Guidelines for Americans 1995 , and theservings listed in the Food Guide Pyramid (31). TheThrifty Food Plan market basket includes all of the fruitsand vegetables on the Thrifty Food Plan shopping list inthe amounts specified by the US Department of Agricul-ture. The list consists of a variety of low-cost fruits andvegetables that fall into each of the 2005 Dietary Guide-lines subgroups ( Table 1).
Because the US Department of Agriculture had not yetdeveloped menus that meet the 2005 Dietary Guidelinesat the time the study was conducted, the new quantitiesfor the 2005 Dietary Guidelines fruit and vegetable marketbasket were estimated in the following manner (Table 1).First, the same items on the Thrifty Food Plan shoppinglist were used because they are all relatively low-cost.Second, the 2005 Dietary Guidelines–recommended num-ber of cups was calculated for 2 weeks for a family similarin age and sex to the Thrifty Food Plan family: a managed 19 to 30 years (2,400-kcal level), a woman aged 19 to30 years (2,000-kcal level), a boy aged 4 to 8 years (1,400-kcal level), and a girl aged 9 to 13 years (1,600-kcal level)(1). A sedentary activity level was chosen for all familymembers to meet the very minimum recommendationsfor fruits and vegetables.
Third, the Thrifty Food Plan shopping list quantitieswere converted into consumable cups (Table 1). To covertthe Thrifty Food Plan shopping list, the 34 items in theThrifty Food Plan were placed into one of the subgroupcategories in the 2005 Dietary Guidelines, such as fruit,legume, dark-green vegetable, orange vegetable, starchyvegetable, or other vegetable ( Table 1). For frozen andcanned produce, the Thrifty Food Plan purchase weightwas converted from pounds or ounces to grams, and thendivided by the weight of1cofthe item in grams. For freshproduce, the 1-c equivalent quantity purchased was thenmultiplied by the percent consumable (to account forwaste from peels, stems, and so on) to arrive at thenumber of servings consumed by cup. For instance, thefollowing formula was used to convert 5.5 lb bananas inthe Thrifty Food Plan shopping list to 10.6 consumablecups (5.5 lb 453.59 g)/150 g i n 1 c bananas)0.64 con-sumable portion of whole banana. The US Department ofAgriculture National Nutrient Database for StandardReference (www.nal.usda.gov/fnic/foodcomp/search/index.html) lists the weight in grams fo r1cofallofthe itemsin the Thrifty Food Plan, as well as the proportion of eachfood that is consumable and that is refuse (eg, stems andpeel).
Once the number of consumable cups for the shoppinglist and the 2005 Dietary Guidelines–recommended num-ber of cups for a family of four for 2 weeks were calcu-lated, the percentage change in the Thrifty Food Plan and1910 November 2007 Volume 107 Number 112005 Dietary Guidelines quantities for each subgroupwere computed (Table 1). Each commodity on the ThriftyFood Plan list was increased or decreased by the samepercentage change for the subgroup. For example, thereare 6 c dark-green vegetables in the Thrifty Food Plan,and 19 c for the 2005 Dietary Guidelines market basket.The amount of dark green vegetables would need to in-crease by 234% to meet the 2005 Dietary Guidelinesguidelines, and so the Thrifty Food Plan quantities forspinach, broccoli, and leaf lettuce were each increased by234%. The result was a final 2005 Dietary Guidelinesshopping list or market basket of fruits and vegetablesthat met the minimum general recommendations andsubgroup recommendations.
Store Surveys
A market basket survey involves people going into storesand recording the lowest price per unit for a specific fooditem. This allows for the direct comparison of costs basedon the actual environment faced by people in differenttypes of stores and different neighborhoods. A cross-sec-tional supermarket price survey was conducted threetimes in stores in Sacramento, CA, and Los Angeles, CATable 1. Fruit and vegetable types and quantities on the Thrifty Food Plan (TFP) 2-week shopping list for a family of four and in the DietaryGuidelines for Americans 2005 (2005 Dietary Guidelines) (1) recommendationsItem UnitsTFP weightas purchasedTFP cupsas consumeda2005 DietaryGuidelines servings (c) Difference (%)Fruits 123.2 98.0 20.5Apples lb 2.75 9.2Applesauce, canned oz 2.00 0.2Bananas lb 5.50 10.6Grapes lb 1.50 4.1Mandarin oranges, canned oz 13.00 1.5Melon lb 2.00 2.9Orange juice, concentrate oz 180.00 67.5Oranges lb 10.19 19.8Peaches, lite, canned oz 52.00 5.9Pears, lite, canned oz 13.00 1.5Vegetables: dark green 5.7 19 233.9Broccoli, frozen oz 6.00 1.1Lettuce, leaf lb 0.81 3.3Spinach, canned oz 10.00 1.3Vegetables: orange 7.1 13 83.2Carrots lb 2.25Vegetables: legumes 12.5 19 52.2Garbanzo beans, canned oz 25.00 3.0Kidney beans, canned oz 42.00 4.7Lima beans, dry oz 6.00 1.0Northern beans, canned oz 9.00 1.0Vegetarian beans, canned oz 25.00 3.0Vegetables: starchy 76.5 28 63.4French fries, frozen oz 11.00 2.8Peas, frozen oz 20.00 3.9Potatoes lb 23.06 69.7Vegetables: other 33.4 47 40.6Cabbage lb 0.25 1.0Celery lb 0.50 2.0Green beans, canned oz 12.00 2.5Green beans, frozen oz 28.00 6.4Green pepper lb 0.44 1.1Mushrooms, canned oz 4.00 0.7Onions lb 3.75 9.6Spaghetti sauce, canned oz 26.00 2.9Tomato paste, canned oz 6.00 0.6Tomato sauce, canned oz 25.00 2.9Tomato soup, canned oz 10.50 1.2Tomatoes lb 0.38 0.9Zucchini lb 0.44 1.5aLeaf lettuce and frozen orange juice are expressed as equivalent half-cup servings.November 2007● Journal of the AMERICAN DIETETIC ASSOCIATION 1911over a 12-month period to account for seasonal fluctua-tions in prices (June 2003, September/October 2003, andMarch/April 2004). Surveyors from the community re-corded the price per pound for fresh produce, and theprice and package size in the case of canned, frozen, ordried items. If more than one of the same item wasavailable (eg, multiple types of apples or brands of cannedfruits), surveyors recorded the item with the lowest priceper unit. The surveys were checked for missing dataimmediately after the surveys were completed, and werechecked again for accuracy of prices within 48 hours by agraduate student in nutrition. There was 77% agreementbetween the original and the checked surveys. Whereitems did not agree, the price from the checked surveywas used in the analysis.
The stores that were surveyed were selected from a corearea of very-low-income neighborhoods in zip codes wherethe median household income was between $17,600 and$27,000 a year. The $27,000-a-year cap was chosen be-cause it is about 130% above the poverty level for a familyof four, which is the income limit for food stamp eligibil-ity. To determine the prices paid by low-income consum-ers willing to travel outside of their neighborhoods, storesfrom a 5-mile radius around the very-low-income neigh-borhoods were selected because some consumers maytravel up to 5 miles to purchase food ( 32).
Ten grocery stores were selected from zip codes withinthe very-low-income core areas. An additional 15 storeswere selected within a 5-mile radius of the core areas.The neighborhoods of these stores varied by medianhousehold income and distance from the core area. Theneighborhoods were low-income neighborhoods with amedian household income between $30,000 and $34,000,medium-income neighborhoods between $42,000 and$46,000, and high-income neighborhoods between $57,000and $64,000. The grocery stores included in the surveywere either a chain supermarket (more than 20,000 sq ft),a small (12,000 to 15,000 sq ft) independent grocery store,or a supermarket that sold bulk food items but was not aclub warehouse that charged a membership fee. In twoinstances, stores had to be substituted when they closedbetween surveys.
Data Analysis
To answer the first research question, we compared theaverage price of the Thrifty Food Plan market basketagainst the 2005 Dietary Guidelines market basket usinga t test to detect significant differences. 2005 DietaryGuidelines fruit and vegetable subgroups for each marketbasket were also compared.
To investigate the second research question on pricedifferences by neighborhood income or by store type, theaverage cost of a 2005 Dietary Guidelines fruit and veg-etable market basket was calculated by summing the costof the fruit or vegetable category over all stores over eachtime period, and then dividing that figure by the totalnumber of stores in the category. A t test was used todetermine if average prices were significantly differentfor a 2005 Dietary Guidelines fruit and vegetable marketbasket in very-low-income neighborhoods compared tolow-, middle-, and high-income areas; and the averageprice in bulk supermarkets compared to prices from in-dependent and chain supermarkets.
To answer the third research question we determinedthe financial effects of meeting the most recent dietaryguidelines on a low-income family’s food budget by calcu-lating the percentage that the average price of a 2005Dietary Guidelines fruit and vegetable market basket invery-low-income areas would comprise the average foodstamp allotment for a California family of four, and thefood-at-home budget for low-income families according tothe Consumer Expenditure Survey.
RESULTS
Comparison of the Thrifty Food Plan and 2005 DietaryGuidelines Market Baskets
To determine if a family would pay more if they followednewer vs the older dietary guidelines, the quantities,average price per serving, and average cost of the 2005Dietary Guidelines market basket and the Thrifty FoodPlan market basket were compared.
Quantity
Following the 2005 Dietary Guidelines recommendationsfor fruits and vegetable consumption, a family of fourwould purchase fewer consumable cups of fruits and veg-etables compared to the shopping list for the Thrifty FoodPlan ( Table 2). The overall reduction is 38 c (14%) due toreductions in fruits (20%) and starchy vegetables (63%).The largest increases from the Thrifty Food Plan to the2005 Dietary Guidelines market basket were in dark-green vegetables (239%), orange vegetables (83%), andlegumes (52%).
Price per Serving
The total average price per serving for all fruits andvegetables was $0.21 ( Table 3). The average price perserving was highest among the fruits ($0.23), dark-greenvegetables ($0.23), and legume subgroups ($0.23). TheTable 2. Cost differences for recommended amounts of fruits andvegetables for a family of four for 2 weeks: The Thrifty Food Plan(TFP) vs the Dietary Guidelines for Americans 2005 (1) (2005Dietary Guidelines)aItem ObservationsTFP($)2005DietaryGuidelines($)Difference($)Differenceas % TFPFruits andvegetables 75 71.66 68.78 2.87 4Fruits 75 42.21 33.55 8.65*** 20Vegetables 75 29.57 35.36 5.79*** 20Dark green 75 2.18 4.61 2.42*** 111Orange 75 1.01 1.86 0.84*** 83Legumes 75 5.81 9.01 3.21*** 55Starchy 75 8.65 3.17 5.48*** 63Other 75 11.80 16.59 4.80*** 41aActual values shown; any difference is due to rounding error.***P0.001.1912 November 2007 Volume 107 Number 11subgroups with the lowest price per serving were orangevegetables ($0.07) and starchy vegetables ($0.14). Orangevegetables cost 70% less than the dark-green vegetables,legumes, and fruits subgroups, and starchy vegetablescost 40% less.
Prices were about the same in the summer 2003 andfall 2003 surveys, but higher in the spring 2004 survey.This could be due to seasonal variation in prices, or gen-eral price inflation during this time period.
Cost
The 2005 Dietary Guidelines market basket cost $68.78,or 4% less than the Thrifty Food Plan market basket(Table 2). There was a 63% decrease in the cost of starchyvegetables, and a 20% decrease in the cost of fruits. Thedecreased cost of starchy vegetables and fruits offset sig-nificant cost increases for dark-green vegetables (111%),orange vegetables (83%), and legumes (55%). Even thoughthe total cost difference was not significant, the change incost for each subgroup was significant (P0.001) giventhe changes in amounts for each market basket.
Prices by Neighborhood Income and Store Type
The average cost of a 2005 Dietary Guidelines fruit andvegetable basket was $68.79$10.47 ( Table 4). The costof fruits and vegetables was 9% higher in Sacramentocompared to Los Angeles ($70.39 vs $64.63). For bothcities the average total price of a Thrifty Food Plan basketof fruits and vegetables was significantly lower in storeslocated in the very-low- and low-income neighborhoodscompared to middle- and high-income neighborhoods. Forinstance, the average cost of a fruit and vegetable marketbasket cost 20% less in very-low-income stores vs middle-income stores ($65 vs $78, P0.05). Middle-income storeshad significantly higher priced fruits, orange, starchy,and other vegetables, whereas higher-income stores hadgenerally higher prices but only the cost of orange vege-tables was significantly greater than very-low-incomestores.
The cost of vegetables in the 2005 Dietary Guidelinesmarket basket was also significantly lower in supermar-kets in higher-income neighborhoods than in middle-in-come neighborhoods. There was no significant differencebetween fruits and vegetables prices in stores located invery-low-income and low-income neighborhoods.
Bulk stores offered the lowest priced 2005 DietaryGuidelines fruit and vegetable basket ( Table 4). Fruitsand vegetables from bulk stores cost 14% less than fromindependently owned supermarkets, and 17% less thantraditional chain supermarkets (P0.05). Among subcat-egories, fruits and orange vegetables were significantlymore expensive in chain stores compared to bulk stores.All bulk stores were located in very-low- and low-incomeareas.
Although the average price of a fruits and vegetablebasket was least expensive in the very-low-income neigh-borhoods, prices still varied dramatically across the 10stores located in very-low-income areas (data not shown).In Sacramento, the highest priced fruits and vegetablebasket cost 76% more in the highest vs the lowest pricedstore, whereas in Los Angeles the price difference was65%. In addition, prices in very-low-income neighbor-hoods varied within the same city and supermarket chainby 17%, and within the same city and same bulk storechain by 52%.
Influence of the 2005 Dietary Guidelines Fruit and VegetableBasket on the Family Food Budget
A family of four shopping in a very-low-income neighbor-hood would pay on average $1,688 annually to meet the2005 Dietary Guidelines recommendations ( Table 4). Afamily of four using food stamps in California receives onaverage $3,888 each year ( 33), and so the 2005 DietaryGuidelines fruit and vegetable market basket would re-quire 43% of the food stamp budget. Households in thelowest two income quintiles spend an average of $2,410each year on food at home (26), which means lower-income households would have to allocate 70% of theirfood-at-home budget to the 2005 Dietary Guidelines fruitand vegetable market basket.
DISCUSSION
The lower cost of the 2005 Dietary Guidelines comparedto the Thrifty Food Plan market basket was unexpected,and is the result of how the two market baskets werecompiled. The 2005 Dietary Guidelines market basketwas based on the minimum recommendations for a sed-entary family, whereas the Thrifty Food Plan marketbasket is based on an optimal food plan. However, thedecrease in cups consumed is 17% whereas the decreasein cost is only 4%. The decrease in cost is much lessbecause the cost of the subgroups that decline, fruit andstarchy, have a lower price per serving than the dark-green and legume vegetable subgroups where large in-creases occur.
This study also found that the average price of fruitsand vegetables was significantly less expensive in very-low- and low-income neighborhoods and in bulk super-markets. Although the findings for bulk supermarketsare consistent with the market basket results based ontotal market basket costs of previous studies, the fruitand vegetable market basket cost was lowest in very-low-to low-income neighborhoods. This result is not consis-tent with the results of other market basket studies thatlooked at the cost of a complete market basket (ie, onethat contains breads, dairy, and meat in addition to fruitsTable 3. Average cost per serving for all stores (bulk, independent,and chain in all income levels) and all survey times (June 2003,September/October 2003, and March/April 2004) by Dietary Guide-lines for Americans 2005 (1) fruit and vegetable subgroupSubgroup Cost ($)All fruits and vegetables 0.21Fruits 0.23Dark green vegetables 0.23Orange vegetables 0.07Legumes 0.24Starchy vegetables 0.14Other vegetables 0.19November 2007● Journal of the AMERICAN DIETETIC ASSOCIATION 1913and vegetables), including a broader study using thesame surveys ( 21). In that survey the cost of a completemarket basket was greatest in very-low-and high-incomeneighborhoods. The findings of just the fruit and vegeta-ble market basket suggest that on average low-incomeconsumers would pay less for fruits and vegetables com-pared to their middle- and high-income neighbors. Thelowest average market basket price in bulk supermarketsalso bodes well for low-income consumers because thesemarkets were located exclusively in low- and very-low-income neighborhoods.
Nevertheless, the study results suggest that severalimportant cost barriers exist for low-income consumerswho wish to meet dietary guidelines. First, only the care-ful selection of the store will guarantee that low-incomeshoppers pay less, because prices vary across stores invery-low-income areas by 65% in Los Angeles and 76% inSacramento. Even within the same chain prices variednoticeably.
Second, the cost of a 2005 Dietary Guidelines fruit andvegetable market basket will require substantial changesin the family food budget. As shown in the study byDrewnowski and colleagues (27), increasing the consump-tion of more healthful foods is not simply a matter ofsubstituting grapes and broccoli for cupcakes and chips.This change also involves changing the food budget forconsumers. As stated previously, American familiesspend 15% to 18% of their at-home food budget on fruitsand vegetables. It seems unlikely that consumers wouldbe able to increase their spending on fruits and vegeta-bles by 200% to 400% without substantial changes else-where in the food budget, or from other household expen-ditures. For low-income consumers this may be especiallychallenging because there are few discretionary fundsavailable in these other accounts.
One limitation of this study is that the Thrifty FoodPlan shopping list used an optimal food plan while the2005 Dietary Guidelines market basket is based on theminimum energy requirements (31). This could result inan underestimate of the true difference in cost betweenthe Thrifty Food Plan market basket and the 2005 Di-etary Guidelines market basket. However, it has no in-fluence on the creation of the 2005 Dietary Guidelinesmarket basket or cost associated with it.
Another limitation of this study is that the supermar-kets are located in two urban areas in California, and sothe results may not be generalizable to cities outside ofthe state or to rural areas. Nor did this study evaluate thequality of fresh produce, an important influence on con-sumer food choice. Recent research suggests that low-in-come neighborhoods have significantly lower quality pro-duce, and that low-income consumers are willing to traveloutside of their neighborhoods for better quality (15,34).Simultaneously evaluating the many influences on con-sumer food choices, including price, quality, and proximityof supermarkets, would provide important insight for publichealth interventions that seek to reduce disparities in fruitsand vegetable consumption, diet, and disease.
CONCLUSIONS
The results of this study suggest that the budgetary costof increasing fruit and vegetable consumption to levelsrecommended in the 2005 Dietary Guidelines may bemore of a barrier to healthful eating than the price perserving of fruits and vegetables. Nutrition educationshould take the food price environment into account.Food and nutrition professionals could counsel patients touse bulk and warehouse format stores because they havethe lowest prices, and they could monitor prices at localstores. There is a need to educate consumers about theimportance of increasing their consumption of fruits andvegetables (35), yet these education programs must con-sider the trade-offs required for families to purchase morefruits and vegetables. Education on household budgetingand follow-up with consumers may be needed as peoplework to change spending habits to eat more healthfully.Whether or not consumers would be willing to allocate aTable 4. Average cost of theDietary Guidelines for Americans 2005 fruit and vegetable market basket by neighborhood income and store typeObservations Total ($)Fruit and VegetablesVegetable SubgroupsFruit ($) Vegetables ($)Darkgreen ($) Orange ($) Legumes ($) Starchy ($) Other ($)All stores 75 68.78 33.55 35.36 4.61 1.86 9.01 3.17 16.59Neighborhood incomeVery low 30 64.94 31.60 33.34 4.41 1.60 9.05 2.81 15.77Low 21 66.67 32.84 34.28 4.70 1.76 8.58 2.94 15.84Middle 12 77.82ab37.62ab40.19ab4.89 2.33ab9.66 4.22ab19.09abHigh 12 73.07ab35.60 37.47abc4.63 2.17ab9.82 3.38 17.47Store typeBulk 12 59.38 18.38 37.22 5.82 .80 6.28 3.47 24.63Independent 9 67.75 23.54 44.20 5.36 1.45 6.77 3.53 27.62Chain 54 69.73d23.39d46.41d6.49 .93 6.80 4.29de27.82daSignificantly different mean price from very low income atP0.05.bSignificantly different mean price from low income at P0.05.cSignificantly different mean price from middle income at P0.05.dSignificantly different mean prices from bulk stores at P0.05.eSignificantly different mean prices from independent stores at P0.05.1914 November 2007 Volume 107 Number 11larger proportion of the family food budget to fruits andvegetables depends on their willingness to reduce spend-ing in other areas. Furthermore, education programscould address concerns about food costs by building on theresults of novel studies on food costs. For instance, Dar-mon and colleagues (36) demonstrated that fruits andvegetables are a good value for the nutrition they provide,and Raynor and colleagues (37) found that families spentsignificantly less on food during a 12-month period ofsuccessful weight loss.
Public policies should consider strategies to reduce eco-nomic barriers to meeting dietary guidelines. Some ex-amples of policy approaches include distributing discountcoupons for fruits and vegetables, increasing the foodstamp allocation to better support the 2005 DietaryGuidelines recommendations, and promoting low-costsources of produce such as farmers’ markets and commu-nity supported agriculture. It will probably take a com-bination of policy approaches to ensure that low-incomeconsumers have easy access to low-cost, high-quality pro-duce and can more easily meet the 2005 Dietary Guide-lines recommendations.
References
1. US Department of Health and Human Services and US Department ofAgriculture. Dietary Guidelines for Americans, 2005. 6th edition.Washington, DC: US Government Printing Office, January 2005.2. Hung HC, Joshipura KJ, Jiang R, Hu FB, Hunter D, Smith-WarnerSA, Colditz GA, Rosner B, Spiegelman D, Willett WC. Fruit andvegetable intake and risk of major chronic disease.J Natl Cancer Inst.2004;96:1577-1584.3. Joshipura KJ, Ascherio A, Manson JE, Stampfer MJ, Rimm EB,Speizer FE, Hennekens CH, Spiegelman D, Willett WC. Fruit andvegetable intake in relation to risk of ischemic stroke. JAMA.1999;282:1233-1239.4. World Cancer Research Fund. Food, Nutrition, and the Prevention ofCancer: A Global Perspective. London, UK; 1997.5. Zhang SM, Hunter DJ, Rosner BA, Giovannucci EL, Colditz GA,Speizer FE, Willett WC. Intakes of fruits, vegetables, and relatednutrients and the risk of non-Hodgkin’s lymphoma among women.Cancer Epidemiol Biomarkers Prev. May 2000;9:477-485.6. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SM. Most Americanseat much less than recommended amounts of fruits and vegetables.J Am Diet Assoc. 2006;106:1371-1379.7. Jetter K. Does 5-9 a day pay? Paper presented at International Fruitand Vegetable Alliance. Ottawa, Canada: October 16, 2006.8. Johnson FC, Hotchkiss DR, Mock NB, McCandless P, Karolak M. Theimpact of the AFDC and Food Stamp programs on child nutrition:Empirical evidence from New Orleans. J Health Care Poor Under-served. 1999;10:298-312.9. Lee BJ, Mackey-Bilaver L, Goerge RM. The Patterns of Food Stampand WIC Participation and Their Effects on Health of Low-IncomeChildren. Chicago, IL: Chapin Hall Center for Children of the Uni-versity of Chicago; 2000. JCPR Working Paper No. 129.10. Variyam J, Blaylock J, Lin B-H, Ralston K, Smallwood D. Mother’snutrition knowledge and children’s dietary intakes. Am J Agric Econ.1999;81:373-384.11. Wilde P, McNamara P, Ranney C. The effect of income and foodprograms on dietary quality: A seemingly unrelated regression anal-ysis with error components. Am J Agric Econ.1999;81:959-971.12. Krebs-Smith SM, Kantor LS. Choose a variety of fruits and vegetablesdaily: Understanding the complexities. J Nutr. 2001;131(suppl 2-1):487S-501S.13. French SA, Story M, Jeffery RW. Environmental influences on eatingand physical activity. Annu Rev Public Health. 2001;22:309-335.14. Laraia BA, Siega-Riz AM, Kaufman JS, Jones SJ. Proximity of su-permarkets is positively associated with diet quality index for preg-nancy.Prev Med. 2004;39:869-875.15. Zenk SN, Schulz AJ, Israel BA, James SA, Bao S, Wilson ML. Fruitand vegetable access differs by community racial composition andsocioeconomic position in Detroit, Michigan. Ethn Dis. 2006;16:275-280.16. Glanz K, Basil M, Maibach E, Goldberg J, Snyder D. Why Americanseat what they do: Taste, nutrition, cost, convenience, and weightcontrol concerns as influences on food consumption. J Am Diet Assoc.1998;98:1118-1126.17. Crockett EG, Clancy KL, Bowering J. Comparing the cost of a ThriftyFood Plan market basket in three areas of New York State. J NutrEduc. 1992;24:71-78.18. Fellowes M. From Poverty, Opportunity: Putting the Market to Workfor Lower Income Families . Available at: http://www.brookings.edu/metro/pubs/20060718_povop.htm. Accessed August 11, 2007.19. Kaufman PRL, S.M. Competing forces affect food prices for low-income households. Food Rev. 1997:8-12.20. Leibtag E. Where you shop matters: Store formats drive variation inretail food prices.Amber Waves. 2005;3:13-18.21. Jetter KM, Cassady DL. The availability and cost of healthier foodalternatives. Am J Prev Med. 2006;30:38-44.22. Havas S, Treiman K, Langenberg P, Ballesteros M, Anliker J, Dam-ron D, Feldman R. Factors associated with fruit and vegetable con-sumption among women participating in WIC. J Am Diet Assoc.1998;98:1141-1148.23. Reicks M, Randall JL, Haynes BJ. Factors affecting consumption offruits and vegetables by low-income families. J Am Diet Assoc. 1994;94:1309-1311.24. Eikenberry N, Smith C. Healthful eating: Perceptions, motivations,barriers, and promoters in low-income Minnesota communities.JAmDiet Assoc.2004;104:1158-1161.25. Reed J, Frazao E, Itskowitz R. How much do americans pay for fruitsand vegetables? Available at: http://www.ers.usda.gov/publications/aib790/aib790fm.pdf. Accessed August 11, 2007.26. US Department of Labor. Consumer Expenditures in 2002.Washing-ton, DC: Bureau of Labor Statistics; 2004.27. Drewnowski A, Darmon N, Briend A. Replacing fats and sweets withvegetables and fruits—A question of cost. Am J Public Health. 2004;94:1555-1559.28. The Thrifty Food Plan, 1999 . Washington, DC: US Department ofAgriculture, Center for Nutrition Policy and Promotion; 1999.29. Andrews M, Kantar LS, Lino M, Ripplinger D. Using the USDA’sThrifty Food Plan to assess food availability and affordability. FoodRev. 2001;24:45-53.30. Block D, Kouba J. A comparison of the availability and affordability ofa market basket in two communities in the Chicago area. PublicHealth Nutr. 2006;9:837-845.31. Thrifty Food Plan, 1999: Administrative Report. CNPP-7 ed. Alexan-dria, VA: US Department of Agriculture, Center for Nutrition Policyand Promotion; 1999.32. Rose D, Richards R. Food store access and household fruit and vege-table use among participants in the US Food Stamp Program. PublicHealth Nutr. 2004;7:1081-1088.33. US Department of Agriculture. Food Stamp Program: Averagemonthly benefit per person. Available at: http://fns.usda.gov/pd/fsavgben.htm. Accessed April 24, 2006.34. Zenk SN, Schulz AJ, Hollis-Neely T, Campbell RT, Holmes N,Watkins G, Nwankwo R, Odoms-Young A. Fruit and vegetable intakein African Americans—Income and store characteristics. Am J PrevMed.2005;29:1-9.35. Bazzano LA. The high cost of not consuming fruits and vegetables.J Am Diet Assoc. 2006;106:1364-1368.36. Darmon N, Darmon M, Maillot M, Drewnowski A. A nutrient densitystandard for vegetables and fruits: Nutrients per calorie and nutri-ents per unit cost. J Am Diet Assoc. 2005;105:1881-1887.37. Raynor HA, Kilanowski CK, Esterlis I, Epstein LH. A cost-analysis ofadopting a healthful diet in a family-based obesity treatment pro-gram. J Am Diet Assoc. 2002;102:645-656.
