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Is Price a Barrier to Eating More Fruits and Vegetables for Low-Income Families?

Published:October 19, 2007DOI:https://doi.org/10.1016/j.jada.2007.08.015

      Abstract

      Objective

      To determine if price is a barrier to fruit and vegetable consumption for low-income families by comparing the average cost of a market basket of fruits and vegetables from the Thrifty Food Plan and the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines), investigating variations in price by neighborhood income and by type of supermarket, and estimating the influence of a 2005 Dietary Guidelines fruit and vegetable basket on the food budget of a low-income family.

      Design

      A market basket survey was conducted at 25 supermarkets across three time periods to allow for seasonal variation in produce prices.

      Setting

      Stores were selected from census tracts with a variety of income levels in Sacramento, CA, and Los Angeles, CA.

      Main outcome measures

      The average cost of a Thrifty Food Plan and 2005 Dietary Guidelines market basket for fruits and vegetables.

      Statistical analyses performed

      Student t tests were used to compare the mean cost of market baskets.

      Results

      The 2005 Dietary Guidelines market basket cost 4% less than the Thrifty Food Plan (P<0.001), and was significantly less expensive in low-income areas at $65 (P<0.05), and in bulk supermarkets at $59 (P<0.05). The 2005 Dietary Guidelines market basket would require a low-income family to devote 43% to 70% of their food budget to fruits and vegetables.

      Conclusions

      Public policies should examine ways to make fruits and vegetables more affordable to low-income families.
      To assist in protecting Americans from the leading causes of chronic illnesses such as heart disease, diabetes, and certain types of cancer, the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines) increased the recommended daily servings for fruits and vegetables from five to nine (based on a reference 2,000-kcal diet) (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ). Because eating certain types of fruits and vegetables have been shown to provide specific health benefits, the 2005 Dietary Guidelines also recommends specific amounts of certain types of vegetables, including legumes, dark-green vegetables, and orange vegetables. For example, eating dark-green vegetables has been associated with a lower incidence of many chronic diseases, including lung and stomach cancers, non-Hodgkin’s lymphoma, and stroke (
      • Hung H.C.
      • Joshipura K.J.
      • Jiang R.
      • Hu F.B.
      • Hunter D.
      • Smith-Warner S.A.
      • Colditz G.A.
      • Rosner B.
      • Spiegelman D.
      • Willett W.C.
      Fruit and vegetable intake and risk of major chronic disease.
      ,
      • Joshipura K.J.
      • Ascherio A.
      • Manson J.E.
      • Stampfer M.J.
      • Rimm E.B.
      • Speizer F.E.
      • Hennekens C.H.
      • Spiegelman D.
      • Willett W.C.
      Fruit and vegetable intake in relation to risk of ischemic stroke.
      ,
      World Cancer Research Fund
      Food, Nutrition, and the Prevention of Cancer: A Global Perspective.
      ,
      • Zhang S.M.
      • Hunter D.J.
      • Rosner B.A.
      • Giovannucci E.L.
      • Colditz G.A.
      • Speizer F.E.
      • Willett W.C.
      Intakes of fruits, vegetables, and related nutrients and the risk of non-Hodgkin’s lymphoma among women.
      ).
      Despite the known health benefits of a diet rich in fruits and vegetables, only 40% of Americans meet the former 5-A-Day guidelines, and fewer than 10% appear to meet the newer 2005 Dietary Guidelines general and subgroup recommendations for fruits and vegetables (
      • Guenther P.M.
      • Dodd K.W.
      • Reedy J.
      • Krebs-Smith S.M.
      Most Americans eat much less than recommended amounts of fruits and vegetables.
      ). Higher-income consumers are more likely to meet dietary recommendations. Using National Health and Nutrition Examination Survey 2001-2002 data, people in households with an annual income of more than $25,000 consume an average of 5.56 servings of fruits and vegetables a day, whereas people in households making less than $25,000 consume 5.04 servings a day. People in households with more than $25,000 in annual income consume fewer daily servings of starchy vegetables (1.28 vs 1.41), more dark-green vegetables (0.29 vs 0.2), and more orange vegetables (0.2 vs 0.16) than people in households with less than $25,000 in annual income (
      • Jetter K.
      Does 5-9 a day pay?.
      ).
      One of the suggestions for how to lower the risk of diet-related chronic disease among low-income consumers is through increased consumption of fruits and vegetables. Previous efforts have focused on the individual with nutrition education, and public food assistance programs like the Special Supplemental Nutrition Program for Women, Infants, and Children and the Food Stamp Program. Although these programs have been successful in increasing the consumption of fruits and vegetables among the target population (
      • Johnson F.C.
      • Hotchkiss D.R.
      • Mock N.B.
      • McCandless P.
      • Karolak M.
      The impact of the AFDC and Food Stamp programs on child nutrition: Empirical evidence from New Orleans.
      ,
      • Lee B.J.
      • Mackey-Bilaver L.
      • Goerge R.M.
      The Patterns of Food Stamp and WIC Participation and Their Effects on Health of Low-Income Children.
      ,
      • Variyam J.
      • Blaylock J.
      • Lin B.-H.
      • Ralston K.
      • Smallwood D.
      Mother’s nutrition knowledge and children’s dietary intakes.
      ,
      • Wilde P.
      • McNamara P.
      • Ranney C.
      The effect of income and food programs on dietary quality: A seemingly unrelated regression analysis with error components.
      ), disparities between high- and low-income consumers still exist (
      • Jetter K.
      Does 5-9 a day pay?.
      ,
      • Krebs-Smith S.M.
      • Kantor L.S.
      Choose a variety of fruits and vegetables daily: Understanding the complexities.
      ). As a result, increasing attention has been focused on how the food environment supports the choice to eat more healthfully (
      • French S.A.
      • Story M.
      • Jeffery R.W.
      Environmental influences on eating and physical activity.
      ,
      • Laraia B.A.
      • Siega-Riz A.M.
      • Kaufman J.S.
      • Jones S.J.
      Proximity of supermarkets is positively associated with diet quality index for pregnancy.
      ,
      • Zenk S.N.
      • Schulz A.J.
      • Israel B.A.
      • James S.A.
      • Bao S.
      • Wilson M.L.
      Fruit and vegetable access differs by community racial composition and socioeconomic position in Detroit, Michigan.
      ).
      Food prices are one part of the food environment, and may be one reason for lower fruit and vegetable consumption among low-income consumers. Price, along with taste and convenience, is a leading influence on food choices (
      • Glanz K.
      • Basil M.
      • Maibach E.
      • Goldberg J.
      • Snyder D.
      Why Americans eat what they do: Taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption.
      ). Previous research on food prices using market basket studies has shown that lower-income neighborhoods frequently have higher food prices than higher-income neighborhoods (
      • Crockett E.G.
      • Clancy K.L.
      • Bowering J.
      Comparing the cost of a Thrifty Food Plan market basket in three areas of New York State.
      ,

      Fellowes M. From Poverty, Opportunity: Putting the Market to Work for Lower Income Families. Available at: http://www.brookings.edu/metro/pubs/20060718_povop.htm. Accessed August 11, 2007.

      ,
      • Kaufman P.R.L.
      Competing forces affect food prices for low-income households.
      ). Smaller stores tend to charge higher prices, and low-income urban centers have fewer, smaller supermarkets; therefore, food prices tend to be higher in those neighborhoods (

      Fellowes M. From Poverty, Opportunity: Putting the Market to Work for Lower Income Families. Available at: http://www.brookings.edu/metro/pubs/20060718_povop.htm. Accessed August 11, 2007.

      ,
      • Kaufman P.R.L.
      Competing forces affect food prices for low-income households.
      ). In addition, the warehouse and supercenter food stores that have the lowest prices (
      • Leibtag E.
      Where you shop matters: Store formats drive variation in retail food prices.
      ) have largely bypassed low-income neighborhoods. Market basket studies have also shown that the cost to eat more healthful alternatives to standard food items (ie, whole-wheat breads instead of white breads, lean meats, and nonfat dairy products) is greater by 17% to 19% (
      • Jetter K.M.
      • Cassady D.L.
      The availability and cost of healthier food alternatives.
      ). None of these studies have reported results for just the fruit and vegetable portion of the market basket.
      Low-income consumers report that fruit and vegetable prices are a barrier to consumption (
      • Havas S.
      • Treiman K.
      • Langenberg P.
      • Ballesteros M.
      • Anliker J.
      • Damron D.
      • Feldman R.
      Factors associated with fruit and vegetable consumption among women participating in WIC.
      ,
      • Reicks M.
      • Randall J.L.
      • Haynes B.J.
      Factors affecting consumption of fruits and vegetables by low-income families.
      ). In a survey of nearly 800 low-income consumers, about one third reported that cost was a barrier to healthful eating (
      • Eikenberry N.
      • Smith C.
      Healthful eating: Perceptions, motivations, barriers, and promoters in low-income Minnesota communities.
      ). Observed expenditures seem to support this contention. American households allocate only 15% to 18% of their food-at-home budget to fruits and vegetables, and this proportion is consistent across income levels (

      Reed J, Frazao E, Itskowitz R. How much do americans pay for fruits and vegetables? Available at: http://www.ers.usda.gov/publications/aib790/aib790fm.pdf. Accessed August 11, 2007.

      ,
      US Department of Labor
      Consumer Expenditures in 2002.
      ). A study on actual expenditures on food by low-income consumers shows that the cost of the average diet among low-income people is also a lower cost per kilocalorie diet than one that meets the 1999 Dietary Guidelines (
      • Drewnowski A.
      • Darmon N.
      • Briend A.
      Replacing fats and sweets with vegetables and fruits—A question of cost.
      ). This diet is higher in fat and lower in nutrients than the diets of higher income consumers.
      Price may pose a significant challenge to the ability of low-income consumers to meet the 2005 Dietary Guidelines recommendations for fruits and vegetables. First, a greater number of servings are recommended, increasing the total cost above the previous 5-A-Day targets. Second, dark-green and orange vegetables and legumes encouraged by the 2005 Dietary Guidelines tend to cost more than starchy vegetables (

      Reed J, Frazao E, Itskowitz R. How much do americans pay for fruits and vegetables? Available at: http://www.ers.usda.gov/publications/aib790/aib790fm.pdf. Accessed August 11, 2007.

      ). If the cost of the 2005 Dietary Guidelines fruit and vegetable market basket constitutes 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 and vegetable consumption in low-income groups. Therefore, the cost of the 2005 Dietary Guidelines market basket is important information for policy makers in reviewing food assistance benefit levels, and for nutrition educators in developing effective food strategies for low-income households.
      The purpose of this study was to examine the price environment for fruits and vegetables by investigating three research questions: Is the cost significantly more if they purchased a fruit and vegetable market basket that meets the newer 2005 Dietary Guidelines compared to the 1995 guidelines reflected in the Thrifty Food Plan? Do fruit and vegetable prices vary by neighborhood income level and store type? and, What is the affect of the new dietary guidelines for fruits and vegetables on the food budget of a low-income family?

      Methods

      The data collection for this study consisted of developing the Thrifty Food Plan and 2005 Dietary Guidelines market baskets and surveying supermarkets for food prices. The hypotheses were tested by analyzing cost differences by neighborhood income level and by store type, and cost differences between the Thrifty Food Plan and 2005 Dietary Guidelines market basket.

      Developing the Market Baskets of Items to be Surveyed

      The market baskets in this study include all of the fruits and vegetables on the Thrifty Food Plan shopping list (
      ). The Thrifty Food Plan is commonly used in market basket studies because it was developed to demonstrate that low-income consumers can eat healthfully on food stamp allocations (
      • Crockett E.G.
      • Clancy K.L.
      • Bowering J.
      Comparing the cost of a Thrifty Food Plan market basket in three areas of New York State.
      ,
      • Andrews M.
      • Kantar L.S.
      • Lino M.
      • Ripplinger D.
      Using the USDA’s Thrifty Food Plan to assess food availability and affordability.
      ,
      • Block D.
      • Kouba J.
      A comparison of the availability and affordability of a market basket in two communities in the Chicago area.
      ). Furthermore, it directly reflects the Dietary Guidelines for Americans 1995, and the servings listed in the Food Guide Pyramid (
      ). The Thrifty Food Plan market basket includes all of the fruits and vegetables on the Thrifty Food Plan shopping list in the amounts specified by the US Department of Agriculture. The list consists of a variety of low-cost fruits and vegetables that fall into each of the 2005 Dietary Guidelines subgroups (Table 1).
      Table 1Fruit and vegetable types and quantities on the Thrifty Food Plan (TFP) 2-week shopping list for a family of four and in the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines) (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ) recommendations
      ItemUnitsTFP weight as purchasedTFP cups as consumed
      Leaf lettuce and frozen orange juice are expressed as equivalent half-cup servings.
      2005 Dietary Guidelines servings (c)Difference (%)
      Fruits123.298.0−20.5
      Appleslb2.759.2
      Applesauce, cannedoz2.000.2
      Bananaslb5.5010.6
      Grapeslb1.504.1
      Mandarin oranges, cannedoz13.001.5
      Melonlb2.002.9
      Orange juice, concentrateoz180.0067.5
      Orangeslb10.1919.8
      Peaches, lite, cannedoz52.005.9
      Pears, lite, cannedoz13.001.5
      Vegetables: dark green5.719233.9
      Broccoli, frozenoz6.001.1
      Lettuce, leaflb0.813.3
      Spinach, cannedoz10.001.3
      Vegetables: orange7.11383.2
      Carrotslb2.25
      Vegetables: legumes12.51952.2
      Garbanzo beans, cannedoz25.003.0
      Kidney beans, cannedoz42.004.7
      Lima beans, dryoz6.001.0
      Northern beans, cannedoz9.001.0
      Vegetarian beans, cannedoz25.003.0
      Vegetables: starchy76.528−63.4
      French fries, frozenoz11.002.8
      Peas, frozenoz20.003.9
      Potatoeslb23.0669.7
      Vegetables: other33.44740.6
      Cabbagelb0.251.0
      Celerylb0.502.0
      Green beans, cannedoz12.002.5
      Green beans, frozenoz28.006.4
      Green pepperlb0.441.1
      Mushrooms, cannedoz4.000.7
      Onionslb3.759.6
      Spaghetti sauce, cannedoz26.002.9
      Tomato paste, cannedoz6.000.6
      Tomato sauce, cannedoz25.002.9
      Tomato soup, cannedoz10.501.2
      Tomatoeslb0.380.9
      Zucchinilb0.441.5
      a Leaf lettuce and frozen orange juice are expressed as equivalent half-cup servings.
      Because the US Department of Agriculture had not yet developed menus that meet the 2005 Dietary Guidelines at the time the study was conducted, the new quantities for the 2005 Dietary Guidelines fruit and vegetable market basket were estimated in the following manner (Table 1). First, the same items on the Thrifty Food Plan shopping list were used because they are all relatively low-cost. Second, the 2005 Dietary Guidelines–recommended number of cups was calculated for 2 weeks for a family similar in age and sex to the Thrifty Food Plan family: a man aged 19 to 30 years (2,400-kcal level), a woman aged 19 to 30 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) (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ). A sedentary activity level was chosen for all family members to meet the very minimum recommendations for fruits and vegetables.
      Third, the Thrifty Food Plan shopping list quantities were converted into consumable cups (Table 1). To covert the Thrifty Food Plan shopping list, the 34 items in the Thrifty Food Plan were placed into one of the subgroup categories in the 2005 Dietary Guidelines, such as fruit, legume, dark-green vegetable, orange vegetable, starchy vegetable, or other vegetable (Table 1). For frozen and canned produce, the Thrifty Food Plan purchase weight was converted from pounds or ounces to grams, and then divided by the weight of 1 c of the item in grams. For fresh produce, the 1-c equivalent quantity purchased was then multiplied by the percent consumable (to account for waste from peels, stems, and so on) to arrive at the number of servings consumed by cup. For instance, the following formula was used to convert 5.5 lb bananas in the Thrifty Food Plan shopping list to 10.6 consumable cups (5.5 lb×453.59 g)/150 g in 1 c bananas)×0.64 consumable portion of whole banana. The US Department of Agriculture National Nutrient Database for Standard Reference (www.nal.usda.gov/fnic/foodcomp/search/index.html) lists the weight in grams for 1 c of all of the items in the Thrifty Food Plan, as well as the proportion of each food that is consumable and that is refuse (eg, stems and peel).
      Once the number of consumable cups for the shopping list and the 2005 Dietary Guidelines–recommended number of cups for a family of four for 2 weeks were calculated, the percentage change in the Thrifty Food Plan and 2005 Dietary Guidelines quantities for each subgroup were computed (Table 1). Each commodity on the Thrifty Food Plan list was increased or decreased by the same percentage change for the subgroup. For example, there are 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 increase by 234% to meet the 2005 Dietary Guidelines guidelines, and so the Thrifty Food Plan quantities for spinach, broccoli, and leaf lettuce were each increased by 234%. The result was a final 2005 Dietary Guidelines shopping list or market basket of fruits and vegetables that met the minimum general recommendations and subgroup recommendations.

      Store Surveys

      A market basket survey involves people going into stores and recording the lowest price per unit for a specific food item. This allows for the direct comparison of costs based on the actual environment faced by people in different types of stores and different neighborhoods. A cross-sectional supermarket price survey was conducted three times in stores in Sacramento, CA, and Los Angeles, CA over a 12-month period to account for seasonal fluctuations in prices (June 2003, September/October 2003, and March/April 2004). Surveyors from the community recorded the price per pound for fresh produce, and the price and package size in the case of canned, frozen, or dried items. If more than one of the same item was available (eg, multiple types of apples or brands of canned fruits), surveyors recorded the item with the lowest price per unit. The surveys were checked for missing data immediately after the surveys were completed, and were checked again for accuracy of prices within 48 hours by a graduate student in nutrition. There was 77% agreement between the original and the checked surveys. Where items did not agree, the price from the checked survey was used in the analysis.
      The stores that were surveyed were selected from a core area of very-low-income neighborhoods in zip codes where the median household income was between $17,600 and $27,000 a year. The $27,000-a-year cap was chosen because it is about 130% above the poverty level for a family of four, which is the income limit for food stamp eligibility. To determine the prices paid by low-income consumers willing to travel outside of their neighborhoods, stores from a 5-mile radius around the very-low-income neighborhoods were selected because some consumers may travel up to 5 miles to purchase food (
      • Rose D.
      • Richards R.
      Food store access and household fruit and vegetable use among participants in the US Food Stamp Program.
      ).
      Ten grocery stores were selected from zip codes within the very-low-income core areas. An additional 15 stores were selected within a 5-mile radius of the core areas. The neighborhoods of these stores varied by median household income and distance from the core area. The neighborhoods were low-income neighborhoods with a median household income between $30,000 and $34,000, medium-income neighborhoods between $42,000 and $46,000, and high-income neighborhoods between $57,000 and $64,000. The grocery stores included in the survey were 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 a club warehouse that charged a membership fee. In two instances, stores had to be substituted when they closed between surveys.

      Data Analysis

      To answer the first research question, we compared the average price of the Thrifty Food Plan market basket against the 2005 Dietary Guidelines market basket using a t test to detect significant differences. 2005 Dietary Guidelines fruit and vegetable subgroups for each market basket were also compared.
      To investigate the second research question on price differences by neighborhood income or by store type, the average cost of a 2005 Dietary Guidelines fruit and vegetable market basket was calculated by summing the cost of the fruit or vegetable category over all stores over each time period, and then dividing that figure by the total number of stores in the category. A t test was used to determine if average prices were significantly different for a 2005 Dietary Guidelines fruit and vegetable market basket in very-low-income neighborhoods compared to low-, middle-, and high-income areas; and the average price in bulk supermarkets compared to prices from independent and chain supermarkets.
      To answer the third research question we determined the financial effects of meeting the most recent dietary guidelines on a low-income family’s food budget by calculating the percentage that the average price of a 2005 Dietary Guidelines fruit and vegetable market basket in very-low-income areas would comprise the average food stamp allotment for a California family of four, and the food-at-home budget for low-income families according to the Consumer Expenditure Survey.

      Results

      Comparison of the Thrifty Food Plan and 2005 Dietary Guidelines Market Baskets

      To determine if a family would pay more if they followed newer vs the older dietary guidelines, the quantities, average price per serving, and average cost of the 2005 Dietary Guidelines market basket and the Thrifty Food Plan market basket were compared.

      Quantity

      Following the 2005 Dietary Guidelines recommendations for fruits and vegetable consumption, a family of four would purchase fewer consumable cups of fruits and vegetables compared to the shopping list for the Thrifty Food Plan (Table 2). The overall reduction is 38 c (14%) due to reductions in fruits (−20%) and starchy vegetables (−63%). The largest increases from the Thrifty Food Plan to the 2005 Dietary Guidelines market basket were in dark-green vegetables (239%), orange vegetables (83%), and legumes (52%).
      Table 2Cost differences for recommended amounts of fruits and vegetables for a family of four for 2 weeks: The Thrifty Food Plan (TFP) vs the Dietary Guidelines for Americans 2005 (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ) (2005 Dietary Guidelines)
      Actual values shown; any difference is due to rounding error.
      ItemObservationsTFP ($)2005 Dietary Guidelines ($)Difference ($)Difference as % TFP
      Fruits and vegetables7571.6668.78−2.87−4
      Fruits7542.2133.55−8.65
      P<0.001.
      −20
      Vegetables7529.5735.365.79
      P<0.001.
      20
      Dark green752.184.612.42
      P<0.001.
      111
      Orange751.011.860.84
      P<0.001.
      83
      Legumes755.819.013.21
      P<0.001.
      55
      Starchy758.653.17−5.48
      P<0.001.
      −63
      Other7511.8016.594.80
      P<0.001.
      41
      a Actual values shown; any difference is due to rounding error.
      low asterisklow asterisklow asterisk P<0.001.

      Price per Serving

      The total average price per serving for all fruits and vegetables was $0.21 (Table 3). The average price per serving was highest among the fruits ($0.23), dark-green vegetables ($0.23), and legume subgroups ($0.23). The subgroups with the lowest price per serving were orange vegetables ($0.07) and starchy vegetables ($0.14). Orange vegetables cost 70% less than the dark-green vegetables, legumes, and fruits subgroups, and starchy vegetables cost 40% less.
      Table 3Average cost per serving for all stores (bulk, independent, and chain in all income levels) and all survey times (June 2003, September/October 2003, and March/April 2004) by Dietary Guidelines for Americans 2005 (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ) fruit and vegetable subgroup
      SubgroupCost ($)
      All fruits and vegetables0.21
      Fruits0.23
      Dark green vegetables0.23
      Orange vegetables0.07
      Legumes0.24
      Starchy vegetables0.14
      Other vegetables0.19
      Prices were about the same in the summer 2003 and fall 2003 surveys, but higher in the spring 2004 survey. This could be due to seasonal variation in prices, or general 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 starchy vegetables, and a 20% decrease in the cost of fruits. The decreased cost of starchy vegetables and fruits offset significant cost increases for dark-green vegetables (111%), orange vegetables (83%), and legumes (55%). Even though the total cost difference was not significant, the change in cost for each subgroup was significant (P<0.001) given the changes in amounts for each market basket.

      Prices by Neighborhood Income and Store Type

      The average cost of a 2005 Dietary Guidelines fruit and vegetable basket was $68.79±$10.47 (Table 4). The cost of fruits and vegetables was 9% higher in Sacramento compared to Los Angeles ($70.39 vs $64.63). For both cities the average total price of a Thrifty Food Plan basket of fruits and vegetables was significantly lower in stores located in the very-low- and low-income neighborhoods compared to middle- and high-income neighborhoods. For instance, the average cost of a fruit and vegetable market basket cost 20% less in very-low-income stores vs middle-income stores ($65 vs $78, P≤0.05). Middle-income stores had significantly higher priced fruits, orange, starchy, and other vegetables, whereas higher-income stores had generally higher prices but only the cost of orange vegetables was significantly greater than very-low-income stores.
      Table 4Average cost of the Dietary Guidelines for Americans 2005 fruit and vegetable market basket by neighborhood income and store type
      ObservationsTotal ($)Fruit and VegetablesVegetable Subgroups
      Fruit ($)Vegetables ($)Dark green ($)Orange ($)Legumes ($)Starchy ($)Other ($)
      All stores7568.7833.5535.364.611.869.013.1716.59
      Neighborhood income
      Very low3064.9431.6033.344.411.609.052.8115.77
      Low2166.6732.8434.284.701.768.582.9415.84
      Middle1277.82
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      37.62
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      40.19
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      4.892.33
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      9.664.22
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      19.09
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      High1273.07
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      35.6037.47
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      Significantly different mean price from middle income at P<0.05.
      4.632.17
      Significantly different mean price from very low income at P<0.05.
      Significantly different mean price from low income at P<0.05.
      9.823.3817.47
      Store type
      Bulk1259.3818.3837.225.82.806.283.4724.63
      Independent967.7523.5444.205.361.456.773.5327.62
      Chain5469.73
      Significantly different mean prices from bulk stores at P<0.05.
      23.39
      Significantly different mean prices from bulk stores at P<0.05.
      46.41
      Significantly different mean prices from bulk stores at P<0.05.
      6.49.936.804.29
      Significantly different mean prices from bulk stores at P<0.05.
      Significantly different mean prices from independent stores at P<0.05.
      27.82
      Significantly different mean prices from bulk stores at P<0.05.
      a Significantly different mean price from very low income at P<0.05.
      b Significantly different mean price from low income at P<0.05.
      c Significantly different mean price from middle income at P<0.05.
      d Significantly different mean prices from bulk stores at P<0.05.
      e Significantly different mean prices from independent stores at P<0.05.
      The cost of vegetables in the 2005 Dietary Guidelines market basket was also significantly lower in supermarkets in higher-income neighborhoods than in middle-income neighborhoods. There was no significant difference between fruits and vegetables prices in stores located in very-low-income and low-income neighborhoods.
      Bulk stores offered the lowest priced 2005 Dietary Guidelines fruit and vegetable basket (Table 4). Fruits and vegetables from bulk stores cost 14% less than from independently owned supermarkets, and 17% less than traditional chain supermarkets (P<0.05). Among subcategories, fruits and orange vegetables were significantly more expensive in chain stores compared to bulk stores. All bulk stores were located in very-low- and low-income areas.
      Although the average price of a fruits and vegetable basket was least expensive in the very-low-income neighborhoods, prices still varied dramatically across the 10 stores located in very-low-income areas (data not shown). In Sacramento, the highest priced fruits and vegetable basket cost 76% more in the highest vs the lowest priced store, whereas in Los Angeles the price difference was 65%. In addition, prices in very-low-income neighborhoods varied within the same city and supermarket chain by 17%, and within the same city and same bulk store chain by 52%.

      Influence of the 2005 Dietary Guidelines Fruit and Vegetable Basket on the Family Food Budget

      A family of four shopping in a very-low-income neighborhood would pay on average $1,688 annually to meet the 2005 Dietary Guidelines recommendations (Table 4). A family of four using food stamps in California receives on average $3,888 each year (

      US Department of Agriculture. Food Stamp Program: Average monthly benefit per person. Available at: http://fns.usda.gov/pd/fsavgben.htm. Accessed April 24, 2006.

      ), and so the 2005 Dietary Guidelines fruit and vegetable market basket would require 43% of the food stamp budget. Households in the lowest two income quintiles spend an average of $2,410 each year on food at home (
      US Department of Labor
      Consumer Expenditures in 2002.
      ), which means lower-income households would have to allocate 70% of their food-at-home budget to the 2005 Dietary Guidelines fruit and vegetable market basket.

      Discussion

      The lower cost of the 2005 Dietary Guidelines compared to the Thrifty Food Plan market basket was unexpected, and is the result of how the two market baskets were compiled. The 2005 Dietary Guidelines market basket was based on the minimum recommendations for a sedentary family, whereas the Thrifty Food Plan market basket is based on an optimal food plan. However, the decrease in cups consumed is 17% whereas the decrease in cost is only 4%. The decrease in cost is much less because the cost of the subgroups that decline, fruit and starchy, have a lower price per serving than the dark-green and legume vegetable subgroups where large increases occur.
      This study also found that the average price of fruits and vegetables was significantly less expensive in very-low- and low-income neighborhoods and in bulk supermarkets. Although the findings for bulk supermarkets are consistent with the market basket results based on total market basket costs of previous studies, the fruit and vegetable market basket cost was lowest in very-low- to low-income neighborhoods. This result is not consistent with the results of other market basket studies that looked at the cost of a complete market basket (ie, one that contains breads, dairy, and meat in addition to fruits and vegetables), including a broader study using the same surveys (
      • Jetter K.M.
      • Cassady D.L.
      The availability and cost of healthier food alternatives.
      ). In that survey the cost of a complete market basket was greatest in very-low-and high-income neighborhoods. The findings of just the fruit and vegetable market basket suggest that on average low-income consumers would pay less for fruits and vegetables compared to their middle- and high-income neighbors. The lowest average market basket price in bulk supermarkets also bodes well for low-income consumers because these markets were located exclusively in low- and very-low-income neighborhoods.
      Nevertheless, the study results suggest that several important cost barriers exist for low-income consumers who wish to meet dietary guidelines. First, only the careful selection of the store will guarantee that low-income shoppers pay less, because prices vary across stores in very-low-income areas by 65% in Los Angeles and 76% in Sacramento. Even within the same chain prices varied noticeably.
      Second, the cost of a 2005 Dietary Guidelines fruit and vegetable market basket will require substantial changes in the family food budget. As shown in the study by Drewnowski and colleagues (
      • Drewnowski A.
      • Darmon N.
      • Briend A.
      Replacing fats and sweets with vegetables and fruits—A question of cost.
      ), increasing the consumption of more healthful foods is not simply a matter of substituting grapes and broccoli for cupcakes and chips. This change also involves changing the food budget for consumers. As stated previously, American families spend 15% to 18% of their at-home food budget on fruits and vegetables. It seems unlikely that consumers would be able to increase their spending on fruits and vegetables by 200% to 400% without substantial changes elsewhere in the food budget, or from other household expenditures. For low-income consumers this may be especially challenging because there are few discretionary funds available in these other accounts.
      One limitation of this study is that the Thrifty Food Plan shopping list used an optimal food plan while the 2005 Dietary Guidelines market basket is based on the minimum energy requirements (
      ). This could result in an underestimate of the true difference in cost between the Thrifty Food Plan market basket and the 2005 Dietary Guidelines market basket. However, it has no influence on the creation of the 2005 Dietary Guidelines market basket or cost associated with it.
      Another limitation of this study is that the supermarkets are located in two urban areas in California, and so the results may not be generalizable to cities outside of the state or to rural areas. Nor did this study evaluate the quality of fresh produce, an important influence on consumer food choice. Recent research suggests that low-income neighborhoods have significantly lower quality produce, and that low-income consumers are willing to travel outside of their neighborhoods for better quality (
      • Zenk S.N.
      • Schulz A.J.
      • Israel B.A.
      • James S.A.
      • Bao S.
      • Wilson M.L.
      Fruit and vegetable access differs by community racial composition and socioeconomic position in Detroit, Michigan.
      ,
      • Zenk S.N.
      • Schulz A.J.
      • Hollis-Neely T.
      • Campbell R.T.
      • Holmes N.
      • Watkins G.
      • Nwankwo R.
      • Odoms-Young A.
      Fruit and vegetable intake in African Americans—Income and store characteristics.
      ). Simultaneously evaluating the many influences on consumer food choices, including price, quality, and proximity of supermarkets, would provide important insight for public health interventions that seek to reduce disparities in fruits and vegetable consumption, diet, and disease.

      Conclusions

      The results of this study suggest that the budgetary cost of increasing fruit and vegetable consumption to levels recommended in the 2005 Dietary Guidelines may be more of a barrier to healthful eating than the price per serving of fruits and vegetables. Nutrition education should take the food price environment into account. Food and nutrition professionals could counsel patients to use bulk and warehouse format stores because they have the lowest prices, and they could monitor prices at local stores. There is a need to educate consumers about the importance of increasing their consumption of fruits and vegetables (
      • Bazzano L.A.
      The high cost of not consuming fruits and vegetables.
      ), yet these education programs must consider the trade-offs required for families to purchase more fruits and vegetables. Education on household budgeting and follow-up with consumers may be needed as people work to change spending habits to eat more healthfully. Whether or not consumers would be willing to allocate a larger proportion of the family food budget to fruits and vegetables depends on their willingness to reduce spending in other areas. Furthermore, education programs could address concerns about food costs by building on the results of novel studies on food costs. For instance, Darmon and colleagues (
      • Darmon N.
      • Darmon M.
      • Maillot M.
      • Drewnowski A.
      A nutrient density standard for vegetables and fruits: Nutrients per calorie and nutrients per unit cost.
      ) demonstrated that fruits and vegetables are a good value for the nutrition they provide, and Raynor and colleagues (
      • Raynor H.A.
      • Kilanowski C.K.
      • Esterlis I.
      • Epstein L.H.
      A cost-analysis of adopting a healthful diet in a family-based obesity treatment program.
      ) found that families spent significantly less on food during a 12-month period of successful weight loss.
      Public policies should consider strategies to reduce economic barriers to meeting dietary guidelines. Some examples of policy approaches include distributing discount coupons for fruits and vegetables, increasing the food stamp allocation to better support the 2005 Dietary Guidelines recommendations, and promoting low-cost sources of produce such as farmers’ markets and community supported agriculture. It will probably take a combination of policy approaches to ensure that low-income consumers have easy access to low-cost, high-quality produce and can more easily meet the 2005 Dietary Guidelines recommendations.
      This research was partially funded by the California Cancer Research Program under grant agreement 01-15551 with the California Department of Health Services, and National Institutes of Health grant no. K12 HD051958, Building Interdisciplinary Research Careers in Women’s Health.
      The authors thank DeShawn Wynn, Patricia Dawkins, Thelma Eaton, and Joyce Guinyard for coordinating the price surveys; the community workers who collected the data; and anonymous reviewers who made valuable comments on an earlier draft.

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      Biography

      D. Cassady is an assistant professor and J. Culp is a community health program supervisor, Department of Public Health Sciences, and K. M. Jetter is an assistant research economist, Agricultural Issues Center, University of California, Davis.