NOTICE: We are experiencing technical issues with Academy members trying to log into the JAND site using Academy member login credentials. We are working to resolve the issue as soon as possible. Alternatively, if you are an Academy member, you can access the JAND site by registering for an Elsevier account and claiming access using the links at the top of the JAND site. Email us at [email protected] for assistance. Thanks for your patience!

Can Families Eat Better Without Spending More? Improving Diet Quality Does Not Increase Diet Cost in a Randomized Clinical Trial among Youth with Type 1 Diabetes and Their Parents

Published:August 31, 2016DOI:



      Although cost is a frequently cited barrier to healthful eating, limited prospective data exist.


      To examine the association of diet cost with diet quality change.


      An 18-month randomized clinical trial evaluated a dietary intervention.

      Participants and setting

      Youth with type 1 diabetes duration ≥1 year, age 8.0 to 16.9 years, receiving care at an outpatient tertiary diabetes center in Boston, MA, participated along with a parent from 2010 to 2013 (N=136). Eighty-two percent of participants were from middle- to upper-income households.


      The family-based behavioral intervention targeted intake of whole plant foods.

      Main outcome measures

      Diet quality as indicated by the Healthy Eating Index 2005 (HEI-2005) (which measures conformance to the 2005 Dietary Guidelines for Americans) and whole plant food density (cup or ounce equivalents per 1,000 kcal target food groups) were calculated from 3-day food records of youth and parent dietary intake at six and four time points, respectively. Food prices were obtained from two online supermarkets common to the study location. Daily diet cost was calculated by summing prices of reported foods.

      Statistical analyses performed

      Random effects models estimated treatment group differences in time-varying diet cost. Separate models for youth and parent adjusted for covariates examined associations of time-varying change in diet quality with change in diet cost.


      There was no treatment effect on time-varying diet cost for either youth (β –.49, 95% CI –1.07 to 0.08; P=0.10) or parents (β .24, 95% CI –1.61 to 2.08; P=0.80). In addition, time-varying change in diet quality indicators was not associated with time-varying change in diet cost for youth. Among parents, a 1-cup or 1-oz equivalent increase in whole plant food density was associated with a $0.63/day lower diet cost (β –.63, 95% CI –1.20 to –0.05; P=0.03).


      Improved diet quality was not accompanied by greater cost for youth with type 1 diabetes and their parents participating in a randomized clinical trial. Findings challenge the prevailing assumption that improving diet quality necessitates greater cost.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Forouzanfar M.H.
        • Alexander L.
        • Anderson H.R.
        • et al.
        Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 386: 2287-2383
        • de Ferranti S.D.
        • de Boer I.H.
        • Fonseca V.
        • et al.
        Type 1 diabetes mellitus and cardiovascular disease: a scientific statement from the American Heart Association and American Diabetes Association.
        Circulation. 2014; 130: 1110-1130
        • Rovner A.J.
        • Nansel T.R.
        Are children with type 1 diabetes consuming a healthful diet? A review of the current evidence and strategies for dietary change.
        Diabetes Educ. 2009; 35: 97-107
        • Darmon N.
        • Drewnowski A.
        Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: A systematic review and analysis.
        Nutr Rev. 2015; 73: 643-660
        • Food Marketing Institute
        Shopping For Health 2013.
        Rodale, Emmaus, PA2013
        • Fleischhacker S.E.
        • Evenson K.R.
        • Rodriguez D.A.
        • Ammerman A.S.
        A systematic review of fast food access studies.
        Obes Rev. 2011; 12: e460-e471
        • Aggarwal A.
        • Monsivais P.
        • Drewnowski A.
        Nutrient intakes linked to better health outcomes are associated with higher diet costs in the US.
        PLoS ONE. 2012; 7: e37533
        • Bernstein A.M.
        • Bloom D.E.
        • Rosner B.A.
        • Franz M.
        • Willett W.C.
        Relation of food cost to healthfulness of diet among US women.
        Am J Clin Nutr. 2010; 92: 1197-1203
        • Drewnowski A.
        The cost of US foods as related to their nutritive value.
        Am J Clin Nutr. 2010; 92: 1181-1188
        • Monsivais P.
        • Drewnowski A.
        Lower-energy-density diets are associated with higher monetary costs per kilocalorie and are consumed by women of higher socioeconomic status.
        J Am Diet Assoc. 2009; 109: 814-822
        • Rehm C.D.
        • Monsivais P.
        • Drewnowski A.
        The quality and monetary value of diets consumed by adults in the United States.
        Am J Clin Nutr. 2011; 94: 1333-1339
      1. Carlson A, Frazão E. Are healthy foods really more expensive? It depends on how you measure the price. EIB-96, US Department of Agriculture, Economic Research Service, May 2012. Accessed September 2, 2016.

        • Frazão E.
        • Carlson A.
        • Stewart H.
        Energy-adjusted food costs make little economic sense.
        Am J Clin Nutr. 2011; 93: 861
        • Schisterman E.F.
        • Cole S.R.
        • Platt R.W.
        Overadjustment bias and unnecessary adjustment in epidemiologic studies.
        Epidemiology. 2009; 20: 488-495
        • Rolls B.J.
        The relationship between dietary energy density and energy intake.
        Physiol Behav. 2009; 97: 609-615
        • Davis G.C.
        • Carlson A.
        The inverse relationship between food price and energy density: Is it spurious?.
        Public Health Nutr. 2015; 18: 1091-1097
        • Carlson A.
        • Frazão E.
        Food costs, diet quality and energy balance in the United States.
        Physiol Behav. 2014; 134: 20-31
        • Lipsky L.M.
        Are energy-dense foods really cheaper? Reexamining the relation between food price and energy density.
        Am J Clin Nutr. 2009; 90: 1397-1401
        • Nansel T.
        • Haynie D.
        • Lipsky L.
        • Mehta S.
        • Laffel L.
        Little variation in diet cost across wide ranges of overall dietary quality among youth with type 1 diabetes.
        J Acad Nutr Diet. 2015; 115: 433-439.e431
        • Rao M.
        • Afshin A.
        • Singh G.
        • Mozaffarian D.
        Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis.
        BMJ Open. 2013; 3: e004277
        • Monsivais P.
        • Aggarwal A.
        • Drewnowski A.
        Are socio-economic disparities in diet quality explained by diet cost?.
        J Epidemiol Community Health. 2012; 66: 530-535
        • Aggarwal A.
        • Monsivais P.
        • Cook A.J.
        • Drewnowski A.
        Does diet cost mediate the relation between socioeconomic position and diet quality.
        Eur J Clin Nutr. 2011; 65: 1059-1066
        • Walker R.E.
        • Keane C.R.
        • Burke J.G.
        Disparities and access to healthy food in the United States: A review of food deserts literature.
        Health Place. 2010; 16: 876-884
        • Beydoun M.A.
        • Wang Y.
        Do nutrition knowledge and beliefs modify the association of socio-economic factors and diet quality among US adults?.
        Prev Med. 2008; 46: 145-153
        • Beydoun M.A.
        • Wang Y.
        How do socio-economic status, perceived economic barriers and nutritional benefits affect quality of dietary intake among US adults?.
        Eur J Clin Nutr. 2008; 62: 303-313
        • Kumanyika S.K.
        Environmental influences on childhood obesity: Ethnic and cultural influences in context.
        Physiol Behav. 2008; 94: 61-70
        • Kumanyika S.
        • Grier S.
        Targeting interventions for ethnic minority and low-income populations.
        Future Child. 2006; 16: 187-207
        • Devine C.M.
        • Jastran M.
        • Jabs J.
        • Wethington E.
        • Farell T.J.
        • Bisogni C.A.
        “A lot of sacrifices:” Work-family spillover and the food choice coping strategies of low-wage employed parents.
        Soc Sci Med. 2006; 63: 2591-2603
        • Lin H.
        • Carr K.A.
        • Fletcher K.D.
        • Epstein L.H.
        Food reinforcement partially mediates the effect of socioeconomic status on body mass index.
        Obesity (Silver Spring, Md.). 2013; 21: 1307-1312
        • Lloyd H.M.
        • Paisley C.M.
        • Mela D.J.
        Barriers to the adoption of reduced-fat diets in a UK population.
        J Am Diet Assoc. 1995; 95: 316-322
        • Goulet J.
        • Lamarche B.
        • Lemieux S.
        A nutritional intervention promoting a Mediterranean food pattern does not affect total daily dietary cost in North American women in free-living conditions.
        J Nutr. 2008; 138: 54-59
        • Ottelin A.M.
        • Lindstrom J.
        • Peltonen M.
        • et al.
        Costs of a self-selected, health-promoting diet among the participants of the Finnish Diabetes Prevention Study.
        Diabetes Care. 2007; 30: 1275-1277
        • 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.
        J Am Diet Assoc. 2002; 102: 645-656
        • Mitchell D.C.
        • Shannon B.M.
        • McKenzie J.
        • Smiciklas-Wright H.
        • Miller B.M.
        • Tershakovec A.M.
        Lower fat diets for children did not increase food costs.
        J Nutr Educ. 2000; 32: 100-103
        • Cleary J.
        • Casey S.
        • Hofsteede C.
        • Moses R.
        • Milosavljevic M.
        • Brand-Miller J.
        Does a low glycaemic index (GI) diet cost more during pregnancy?.
        Nutrients. 2012; 4: 1759-1766
        • Nansel T.R.
        • Laffel L.M.
        • Haynie D.L.
        • et al.
        Improving dietary quality in youth with type 1 diabetes: Randomized clinical trial of a family-based behavioral intervention.
        Int J Behav Nutr Phys Act. 2015; 12: 58
        • Austin M.
        • Harnack L.
        • Jasthi B.
        • et al.
        Nutrition Data System for Research.
        University of Minnesota, Minneapolis, MN2012
        • Guenther P.M.
        • Reedy J.
        • Krebs-Smith S.M.
        Development of the Healthy Eating Index-2005.
        J Am Diet Assoc. 2008; 108: 1896-1901
        • Guenther P.M.
        • Reedy J.
        • Krebs-Smith S.M.
        • Reeve B.B.
        Evaluation of the Healthy Eating Index-2005.
        J Am Diet Assoc. 2008; 108: 1854-1864
        • Lipsky L.
        • Cheon K.
        • Nansel T.R.
        • Albert P.
        Candidate measures of whole plant food intake are related to biomarkers of nutrition and health in the US population (NHANES 1999-2002).
        Nutr Res. 2012; 32: 251-259
      2. Behavioral Risk Factor Surveillance System Survey Questionnaire. Centers for Disease Control and Prevention, Atlanta, GA2002
      3. A Data Users Guide to the BRFSS Physical Activity Questions: How to Assess the 2008 Physical Ativity Guidelines for Americans. Centers for Disease Control and Prevention, Atlanta, GA2008
      4. US Department of Commerce, US Census Bureau. How the Census Bureau measures poverty. Accessed January 21, 2016.

      5. Fry R, Kochhar R. Are you in the American middle class? Find out with our income calculator. 2015. Accessed May 3, 2016.

      6. Stata version 12. StataCorp LP, College Station, TX; 2012.

        • 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.
        J Am Diet Assoc. 1998; 98: 1118-1126
        • Banks J.
        • Williams J.
        • Cumberlidge T.
        • Cimonetti T.
        • Sharp D.J.
        • Shield J.P.H.
        Is healthy eating for obese children necessarilymore costly for families?.
        Br J Gen Pract. 2012; 62: e1-e5
        • Katz D.L.
        • Doughty K.
        • Njike V.
        • et al.
        A cost comparison of more and less nutritious food choices in US supermarkets.
        Public Health Nutr. 2011; 14: 1693-1699
        • Stewart H.
        • Hyman J.
        • Frazao E.
        • Buzby J.C.
        • Carlson A.
        Can low-income Americans afford to satisfy MyPyramid fruit and vegetable guidelines?.
        J Nutr Educ Behav. 2011; 43: 173-179
        • Hoelscher D.M.
        • Evans A.
        • Parcel G.S.
        • Kelder S.H.
        Designing effective nutrition interventions for adolescents.
        J Am Diet Assoc. 2002; 102: S52-S63
        • Rothman A.J.
        • Sheeran P.
        • Wood W.
        Reflective and automatic processes in the initiation and maintenance of dietary change.
        Ann Behav Med. 2009; 38: S4-S17
      7. University of Wisconsin-Madison Institute for Research on Poverty. How is poverty measured in the United States? Accessed May 3, 2016.

      8. US Department of Agriculture, Center for Nutrition Policy and Promotion. Official USDA food plans: Cost of food at home at four levels, U.S. average, January 2010. Alexandria, VA: Center for Nutrition Policy and Promotion; 2010.

        • Blumenthal S.J.
        • Hoffnagle E.E.
        • Leung C.W.
        • et al.
        Strategies to improve the dietary quality of Supplemental Nutrition Assistance Program (SNAP) beneficiaries: An assessment of stakeholder opinions.
        Public Health Nutr. 2014; 17: 2824-2833
        • Evans A.
        • Banks K.
        • Jennings R.
        • et al.
        Increasing access to healthful foods: A qualitative study with residents of low-income communities.
        Int J Behav Nutr Physical Activity. 2015; 12: S5
        • Foster G.D.
        • Karpyn A.
        • Wojtanowski A.C.
        • et al.
        Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: A randomized controlled trial.
        Am J Clin Nutr. 2014; 99: 1359-1368
      9. Johns Hopkins Center for a Livable Future. Farm Bill: Improving diets of low-income Americans through SNAP pricing incentives, a public health priority: Baltimore, Md. 2012. Accessed January 21, 2016.

        • Larson N.I.
        • Story M.T.
        • Nelson M.C.
        Neighborhood environments: Disparities in access to healthy foods in the U.S.
        Am J Prev Med. 2009; 36: 74-81
        • Wiig K.
        • Smith C.
        The art of grocery shopping on a food stamp budget: Factors influencing the food choices of low-income women as they try to make ends meet.
        Public Health Nutr. 2009; 12: 1726-1734
      10. Fungwe T, Guenther PM, Juan WY, Hiza H, Lino M. The quality of children's diets in 2003-04 as measured by the Healthy Eating Index - 2005. Nutrition Insight 43. Alexandria, VA: Center for Nutrition Policy and Promotion, US Department of Agriculture; 2009. Accessed August 22, 2016.


      T. R. Nansel is a senior investigator, Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.


      L. M. Lipsky is a staff scientist, Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.


      M. H. Eisenberg is a postdoctoral fellow, Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.


      A. Liu is a senior investigator, Biostatistics and Bioinformatics Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.


      S. N. Mehta is an assistant investigator, Section on Genetics and Epidemiology, Joslin Diabetes Center, Boston, MA.


      L. M. B. Laffel is chief, Pediatric, Adolescent, and Young Adult Section, and an investigator, Section on Genetics and Epidemiology, Joslin Diabetes Center, Boston, MA.