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Public health taxes on less healthy food and beverage products have been shown to be effective in various settings. However, it is unclear if observed reductions in the quantity of taxed products purchased is a result of price increases due to the tax or the accompanying messaging and if the effects are influenced by the level of support for such taxes within the population. 941 adults residing in Singapore were randomized and asked to shop in one of four versions of a fully functional on-line experimental grocery store: 1) no tax control; 2) implicit tax showing only post-tax prices (i.e., 20 % higher than control prices) on high-in-calorie products; 3) fake tax showing pre-tax prices and a label falsely indicating that the price includes a 20 % tax on high-in-calorie products; and 4) explicit tax showing the same label as in 3) and an actual 20 % price increase applied to the high-in-calorie products. The proportion of high-in-calorie products purchased was 14 % in the control arm. We were unable to reject the null hypothesis of no effect in the implicit tax arm compared to control (0.08, 95 % CI -3.31 to 1.77) or in the fake tax arm compared to the control (2.59, 95 % CI -5.04 to 0.00) but observed a statistically significant 3.35 percentage point decrease (95 % CI -6.01 to -0.5) in the explicit tax arm compared to control. We were unable to reject the null hypothesis of no effect in any of the outcomes related to diet quality. Individuals who support the tax showed greater responsiveness to the explicit and fake taxes compared to those who do not (price elasticities of demand of -1.38 and -0.51 respectively). Results suggest that reductions in the proportions of high-in-calorie products purchased may be largely attributable to explicit messaging rather than to price increases. However, even when effective, policymakers should recognize that changes in purchasing patterns may not improve diet quality and that results may not generalize to other areas where levels of support differ., Competing Interests: Declarations of Competing Interest The authors declare no conflicts of interest, including employment, consultancies, stock ownership, honoraria, paid expert testimony, patients or patent applications and travel grants., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: The Supplemental Nutrition Assistance Program provides financial assistance for food and beverage purchases to approximately 1 in 7 Americans, with benefits distributed once monthly. Most Supplemental Nutrition Assistance Program benefits are spent early in the month, leading to decreased caloric intake later in the month. The effects of this early benefit depletion on the types of foods and beverages purchased over the course of the month is unclear., Methods: Using individually tracked sales data from 950 participants enrolled in 2 supermarket-based RCTs in Maine (October 2015-April 2016 and October 2016-June 2017), purchases of selected food categories by Supplemental Nutrition Assistance Program participants (n=248) versus nonparticipants (n=702) in the first 2 weeks compared with the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month were examined. Analyses were completed in 2019., Results: For Supplemental Nutrition Assistance Program participants, adjusted mean food spending decreased 37% from the first 2 weeks to the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month (p<0.0001) compared with a 3% decrease (p=0.02) for nonparticipants. The decline in spending by Supplemental Nutrition Assistance Program participants occurred in all examined categories: vegetables (-25%), fruits (-27%), sugar-sweetened beverages (-30%), red meat (-37%), convenience foods (-40%), and poultry (-48%). Difference-in-difference estimators comparing Supplemental Nutrition Assistance Program participants with nonparticipants were statistically significant (p<0.05) for all examined categories., Conclusions: In the second half of the Supplemental Nutrition Assistance Program benefit month, individuals reduced purchases of all examined categories. More research is needed to understand the impact of these fluctuations in spending patterns on the dietary quality of Supplemental Nutrition Assistance Program participants., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

This paper uses the large cross sectional survey of 8544 workers in nine industries (pig iron, bar iron, steel, coal, coke, cottons, woolens, and glass) in the United States and five European countries (Belgium, Great Britain, France, Belgium, and Switzerland) to examine inequality in the industrial working class in the late nineteenth century. The paper looks at incomes, the food budget share (estimated using the Almost Ideal Demand System), and home ownership. The results show regular gradients with the unskilled workers doing less well than semi-skilled and skilled workers. Despite the lack of proprietors, farmers, and other groups with significant income from property, such surveys can be useful in the study of the historical aspects of inequality., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The consumption of ultra-processed foods in the U.S. and globally has increased and is associated with lower diet quality, higher energy intake, higher body weight, and poorer health outcomes. This study drew on individual-level data on measured height and weight from U.S. Department of Veterans Affairs medical records for adults aged 20 to 64 from 2009 through 2014 linked to food and beverage price data from the Council for Community and Economic Research to examine the association between the price of ultra-processed foods and beverages and adult body mass index (BMI). We estimated geographic fixed effects models to control for unobserved heterogeneity of prices. We estimated separate models for men and women and we assessed differences in price sensitivity across subpopulations by socioeconomic status (SES). The results showed that a one-dollar increase in the price of ultra-processed foods and beverages was associated with 0.08 lower BMI units for men (p ≤ 0.05) (price elasticity of BMI of -0.01) and 0.14 lower BMI units for women (p ≤ 0.10) (price elasticity of BMI of -0.02). Higher prices of ultra-processed foods and beverages were associated with lower BMI among low-SES men (price elasticity of BMI of -0.02) and low-SES women (price elasticity of BMI of -0.07) but no statistically significant associations were found for middle- or high-SES men or women. Robustness checks based on the estimation of an individual-level fixed effects model found a consistent but smaller association between the price of ultra-processed foods and beverages and BMI among women (price elasticity of BMI of -0.01) with a relatively larger association for low-SES women (price elasticity of BMI of -0.04) but revealed no association for men highlighting the importance of accounting for individual-level unobserved heterogeneity., (Copyright © 2019 Elsevier B.V. All rights reserved.)

In this article we test the hypothesis that the secular increase in heights in the course of the second half of the nineteenth century was associated with the rise of the breadwinner-homemaker household. In these 'modern' households, women raised the living standards (quality and quantity of food, hygiene and care) for all members, especially the children. We model the assumed contributions to the family budget by age and gender of household members, and find that a strong imbalance between consumers and producers in the household put severe strains on effective resource allocation, leading to lower net nutrition and lower young adult heights. We suggest a carefully calibrated consumer/producer ratio as an indicator to capture these effects. The ratio is not meant to replace others, and we show that sibling rank order as well as gender preferences also played a role in intra-household resource allocation. For our research, we have used a database with reconstructed life histories (including co-residence) of 3003 Dutch army recruits. Our results indicate that the consumer/producer ratio as experienced by recruits in their early life indeed had a strong impact (-1,8 cm) on their heights. However, this effect differed by social class, which can be explained by differences in acceptance of the income pooling model., (Copyright © 2019 Elsevier B.V. All rights reserved.)

A lifelong gluten-free diet is the only available treatment for coeliac disease at present. However, the high price of gluten-free substitute foods is likely to generate a welfare loss for consumers who drop gluten from their diet. Using original data on retail prices in four major UK supermarkets and consumption data from the UK Living Cost and Food Survey, we simulate the welfare change associated to a switch to the gluten-free diet. Within the "Bread and Cereals" category, retail price data show that the average price of gluten-free products is £1.12/100g relative to £ 0.59/100g of gluten-containing products. Our estimates indicate that on average in the UK coeliac consumers have to pay an extra £ 10 per week to maintain their utility levels prior to the dietary switch. This correspond to 29% of the weekly food budget. Results by income quartile are suggestive of regressive effects and the welfare loss for low-income consumers is estimated at 36% of their food budget compared to 24% of high-income consumers., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Globalization via free trade and investment agreements is often implicated in the obesity pandemic. Concerns center on how free trade and investment agreements increase population exposure to unhealthy, high-calorie diets, but existing studies preclude causal conclusions. Few studies of free trade and investment agreements and diets isolated their impact from confounding changes, and none examined any effect on caloric intake, despite its critical role in the etiology of obesity. This study addresses these limitations by analyzing a unique natural experiment arising from the exceptional circumstances surrounding the implementation of the 1989 Canada-U.S. Free Trade Agreement., Methods: Data from the UN (2017) were analyzed using fixed-effects regression models and the synthetic control method to estimate the impact of the Canada-U.S. Free Trade Agreement on calorie availability in Canada, 1978-2006, and coinciding increases in U.S. exports and investment in Canada's food and beverage sector. The impact of changes to calorie availability on body weights was then modeled., Results: Calorie availability increased by ≅170 kilocalories per capita per day in Canada after the Canada-U.S. Free Trade Agreement. There was a coinciding rise in U.S. trade and investment in the Canadian food and beverage sector. This rise in calorie availability is estimated to account for an average weight gain of between 1.8 kg and 12.2 kg in the Canadian population, depending on sex and physical activity levels., Conclusions: The Canada-U.S. Free Trade Agreement was associated with a substantial rise in calorie availability in Canada. U.S. free trade and investment agreements can contribute to rising obesity and related diseases by pushing up caloric intake., (Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Although one in seven Americans receives Supplemental Nutrition Assistance Program (SNAP) benefits, little is known about how these benefits for food are spent because individual-level sales data are not publicly available. The purpose of this study is to compare transactions made with and without SNAP benefits at a large regional supermarket chain., Methods: Sales data were obtained from a large supermarket chain in the Northeastern U.S. for a period of 2 years (April 2012-April 2014). Multivariate multiple regression models were used to quantify relative differences in dollars spent on 31 predefined SNAP-eligible food categories. Analyses were completed in 2016., Results: Transactions with SNAP benefit use included higher spending on less healthful food categories, including sugar-sweetened beverages ($1.08), red meat ($1.55), and convenience foods ($1.34), and lower spending on more healthful food categories, such as fruits (-$1.51), vegetables (-$1.35), and poultry (-$1.25) compared to transactions without SNAP benefit use., Conclusions: These findings provide objective data to compare purchases made with and without SNAP benefits. Next steps should be to test proposed SNAP modifications to determine whether they would have the intended effect of promoting healthier purchasing patterns among SNAP beneficiaries., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The Supplemental Nutrition Assistance Program (SNAP) is the largest federal food assistance program designed to alleviate food insecurity and improve dietary intake. This study assessed the opinions of SNAP participants and food-insufficient nonparticipants on their perceptions of the program and strategies to improve its nutritional impact., Methods: This study surveyed 387 individuals via Amazon Mechanical Turk, of whom 118 were SNAP participants and 269 were food insufficient but not enrolled in SNAP (nonparticipants). Open-ended questions were coded and analyzed for thematic content. For closed-ended questions, response frequencies were compared using chi-square tests. Data were analyzed in 2016., Results: SNAP participants reported that the program successfully served its primary purpose: to allow individuals to buy enough food to make ends meet and reduce food insecurity. Importance was placed on buying food for their children/families and the ability to allocate money for other expenses. To improve the nutritional impact, SNAP participants suggested more nutrition education, increasing the benefit allotment, incentivizing healthful foods, and excluding unhealthful foods for purchase with SNAP. When participants and nonparticipants were asked to choose between SNAP and a nutritionally enhanced program combining healthy incentives with exclusions for sugary beverages (i.e., SNAP+), 68% of participants and 83% of nonparticipants chose SNAP+. Of those who initially chose SNAP, 68% of participants and 64% of nonparticipants chose SNAP+ if paired with a 50% increase in total benefits., Conclusions: SNAP participants and food-insufficient nonparticipants support policies that facilitate purchases of healthful foods and limit purchases of unhealthful foods, specifically sugary beverages., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Individual and environmental factors dynamically interact in shaping income inequalities in healthy food consumption. The agent-based model, Health Behaviors Simulation (HEBSIM), was developed to describe income inequalities in healthy food consumption. It simulates interactions between households and their environment. HEBSIM was used to explore the impact of interventions aimed at reducing food consumption inequalities., Methods: HEBSIM includes households and food outlets. Households are characterized by location, composition, income, and preference for food. Decisions about where to shop for food (fruit/vegetable stores, supermarkets, or discount supermarkets) and whether to visit fast food outlets are based on distance, price, and food preference. Food outlets can close and new food outlets can enter the system. Three interventions to reduce healthy food consumption inequalities were tested: (1) eliminating residential segregation; (2) lowering the prices of healthy food; and (3) providing health education. HEBSIM was quantified using data from Statistics Netherlands, Statistics Eindhoven, and the GLOBE study (2011)., Results: The model mimicked food consumption in Eindhoven. High-income households visited healthy food shops more often than low-income households. Eliminating residential segregation had the largest impact in reducing income inequalities in food consumption, but resulted partly from a worsening in healthy food consumption in high-income households. Lowering prices and health education could also substantially reduce inequalities. Most interventions took 5-10 years to reach their (almost) full effects., Conclusions: HEBSIM is a promising tool for studying dynamic interactions between households and their environment and for assessing the impact of interventions on income inequalities in food consumption., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Under the current version of the Supplemental Nutrition Assistance Program (SNAP), participants can purchase virtually any food or beverage (collectively, food). Research indicates that SNAP recipients may have worse dietary quality than income-eligible nonparticipants. Policymakers have urged the U.S. Department of Agriculture (USDA) to pilot SNAP purchasing restrictions intended to support a healthier diet, and state legislators have proposed similar bills. The USDA rejected these invitations, stating that it would be administratively and logistically difficult to differentiate among products, amid other concerns. However, the USDA's Dietary Guidelines for Americans and the Supplemental Nutrition Program for Women, Infants, and Children (WIC) do just that. Further, state governments define and differentiate among foods and beverages for tax purposes. This paper reviews several factors intended to inform future policy decisions: the science indicating that SNAP recipients have poorer diet quality than income-eligible nonparticipants; the public's support for revising the SNAP program; federal, state, and city legislators' formal proposals to amend SNAP based on nutrition criteria and the USDA's public position in opposition to these proposals; state bills to amend eligible foods purchasable with SNAP benefits; state retail food tax laws; and the retail administration and program requirements for both WIC and SNAP. The paper finds that the government has a clear ability to align SNAP benefits with nutrition science and operationalize this into law., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

We propose a calibrated dynamic model of food consumption choices and body weight to study changes in daily caloric intake, weight, and the away-from-home share of calories consumed by adult men and women in the U.S. during the period between 1971 and 2006. Calibration reveals substantial preference heterogeneity between men and women. For example, utility losses stemming from weight gains are ten times greater for women compared to men. Counterfactual experiments show that changes in food prices and household income account for half of the increase in weight of adult men, but only a small fraction of women's weight. We argue that quantitative models of food consumption choices and body weight have a unique role to play in future research in the economics of obesity., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Lack of access to healthy foods may explain why residents of low-income neighborhoods and African Americans in the U.S. have high rates of obesity. The findings on where people shop and how that may influence health are mixed. However, multiple policy initiatives are underway to increase access in communities that currently lack healthy options. Few studies have simultaneously measured obesity, distance, and prices of the store used for primary food shopping., Purpose: To examine the relationship among distance to store, food prices, and obesity., Methods: The Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health study conducted baseline interviews with 1,372 households between May and December 2011 in two low-income, majority African American neighborhoods without a supermarket. Audits of 16 stores where participants reported doing their major food shopping were conducted. Data were analyzed between February 2012 and February 2013., Results: Distance to store and prices were positively associated with obesity (p<0.05). When distance to store and food prices were jointly modeled, only prices remained significant (p<0.01), with higher prices predicting a lower likelihood of obesity. Although low- and high-price stores did not differ in availability, they significantly differed in their display and marketing of junk foods relative to healthy foods., Conclusions: Placing supermarkets in food deserts to improve access may not be as important as simultaneously offering better prices for healthy foods relative to junk foods, actively marketing healthy foods, and enabling consumers to resist the influence of junk food marketing., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Context: An independent evaluation of the Healthy Weight Commitment Foundation (HWCF) marketplace pledge found that the participating companies met and exceeded their interim 2012 sales reduction pledge., Evidence Acquisition: This follow-up study conducted in 2013 used purchase data from 2000 to 2012 among U.S. households with children and compared trends in calorie purchases of HWCF, non-HWCF name brands, and private label (PL) products in the pre-pledge period (2000-2007) and the post-pledge period (2008-2012); controlled for potential effects of concurrent changes in demographic and economic factors, including the Great Recession and food prices; and assessed whether the HWCF marketplace pledge was associated with reductions in consumer packaged goods (CPG) calorie purchases by households with children., Evidence Synthesis: There has been a significant per capita decline in average daily CPG caloric purchases between 2000 and 2012 among households with children from all brand categories. Based on pre-pledge trends, declines in CPG caloric purchases were already occurring. However, post-pledge reductions in calories purchased from HWCF brands were less than expected, and reductions in calories purchased from non-HWCF name brands and PLs were greater than expected after economic, sociodemographic, and secular factors were accounted for., Conclusions: If the 16 HWCF companies had been able to maintain their pre-pledge trajectory, there should have been an additional 42 kcal/capita/day reduction in calories purchased from HWCF products in 2012 among households with children. A lack of change in total CPG calories purchased between 2011 and 2012 calls into question the sustainability of the decline and a need for continued monitoring., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Corporate voluntary pledges to improve the health of Americans have not been held to either explicit measurable outcomes or a framework for independent evaluation. The Healthy Weight Commitment Foundation (HWCF), whose members include 16 of the nation's leading consumer packaged goods (CPG) food and beverage manufacturers, voluntarily pledged to collectively sell 1 trillion fewer calories in the U.S. marketplace by 2012 (against a 2007 baseline), and sell 1.5 trillion fewer calories by 2015. This paper presents the findings of an independent evaluation of the 2012 HWCF marketplace pledge, conducted in 2013. The 16 HWCF companies collectively sold approximately 6.4 trillion fewer calories (-10.6%) in 2012 than in the baseline year of 2007. Taking into account population changes over the 5-year period of 2007-2012, CPG caloric sales from brands included in the HWCF pledge declined by an average of 78 kcal/capita/day. CPG caloric sales from non-HWCF national brands during the same period declined by 11 kcal/capita/day, and there were similar declines in calories from private label products. Thus, the total reduction in CPG caloric sales between 2007 and 2012 was 99 kcal/capita/day. This independent evaluation is the first to evaluate food industry compliance with its calorie reduction pledges and to assess how sales from the CPG food and beverage sector are changing. An accompanying paper investigates the extent to which the HWCF pledge affected household-level changes in CPG calories purchased, controlling for important economic and sociodemographic factors affecting household food purchases over this period., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

One of the Zeitgeists of the field for the study of ingestive behavior is that organisms are endowed with internal self-regulatory mechanisms that ensure optimal nutrition. However, the alarming increase in the prevalence of obesity challenges us to reconsider the extent to which internal regulatory mechanisms affect food intake, especially in a free market economy. Cued by the pioneering work of George Collier and his students, we have been examining food intake (demand) in mice when the effort or price of food is manipulated. We present two new experiments in mice that investigate the effect of energy yield per unit of food earned on working for food. The first experiment shows that when the nominal energy yield of each food pellet is halved by cellulose dilution, mice show relatively inelastic calorie-related demand despite the fact the cellulose diluted diet is unpalatable. The second experiment shows that the size of the pellet reinforcer does not have a major effect on food demand except in the extreme condition of small reward and high unit price. New analyses of distributions of responding are presented which suggest that mice work for "target" numbers of food rewards with only a small influence of price or energy gain., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: U.S. dietary studies from 2003 to 2010 show decreases in children's caloric intake. We examined purchases of consumer packaged foods/beverages in the U.S. between 2000 and 2011 among households with children aged 2-5 years., Purpose: To describe changes in consumer packaged goods (CPG) purchases between 2000 and 2011 after adjusting for economic indicators, and explore differences by race, education, and household income level., Methods: CPG purchase data were obtained for 42,753 U.S. households with one or more child aged 2-5 years using the Nielsen Homescan Panel. Top sources of purchased calories were grouped, and random effects regression was used to model the relationship between calories purchased from each group and race, female head of household education, and household income. Models adjusted for household composition, market-level unemployment rate, prices, and quarter, with Bonferroni correction for multiple comparisons (α=0.05)., Results: Between 2000 and 2011, adjusted total calories purchased from foods (-182 kcal/day) and beverages (-100 kcal/day) declined significantly. Decreases in purchases of milk (-40 kcal); soft drinks (-27 kcal/day); juice and juice drinks (-24 kcal/day); grain-based desserts (-24 kcal/day); savory snacks (-17 kcal/day); and sweet snacks and candy (-13 kcal/day) were among the major changes. Changes in CPG purchases differed significantly by race, female head of household education, and household income., Conclusions: Trends in CPG purchases suggest that solid fats and added sugars are decreasing in the food supply of U.S. preschoolers. Pronounced differences by race, education, and household income persist., (Published by Elsevier Inc.)

In this paper, we used a randomized experiment, the Moving to Opportunity for Fair Housing Demonstration (MTO) study, to assess whether several environmental attributes are causes of obesity. To accomplish our objective, we linked the MTO data with several external data sources that provide information on potential determinants of obesity including food prices, restaurant and food store availability, physical activity facility availability, the prevalence of crime and population density. We find that the environmental factors we examined are unable to explain the observed decrease in obesity associated with the MTO experiment among low-income minority women., (Copyright © 2013 Elsevier B.V. All rights reserved.)

The high obesity rates and poor diet quality in the United States, particularly among low income populations, are often attributed to low income, low food access, and high food prices of healthy foods. This paper discusses these associations and questions some of the metrics used to measure food prices. The paper argues that 1. On average, Americans consume diets that need improvement and there is only a very limited relationship between income and diet quality; 2. The way the food price is measured makes a difference in the perception of how expensive healthy and less healthy food is; 3. The way Americans allocate their food budgets between healthy and less healthy foods is not in line with healthy diets; and 4. At any food spending level there are households that purchase healthy (and unhealthy) diets, including budgets at or below the maximum allotment for the Supplemental Nutrition Assistance Program (SNAP) which provides a means for low-income households to purchase food. Our key finding is that healthy foods and diets are affordable, but policy makers, nutrition educators, researchers and the media need to focus on promoting this message, and providing additional guidance on making the changes for Americans to switch to a healthy and affordable diet., (Published by Elsevier Inc.)

Background: To induce consumers to purchase healthier foods and beverages, some policymakers have suggested special taxes or labels on unhealthy products. The potential of such policies is unknown., Purpose: In a controlled field experiment, researchers tested whether consumers were more likely to purchase healthy products under such policies., Methods: From October to December 2011, researchers opened a store at a large hospital that sold a variety of healthier and less-healthy foods and beverages. Purchases (N=3680) were analyzed under five conditions: a baseline with no special labeling or taxation, a 30% tax, highlighting the phrase "less healthy" on the price tag, and combinations of taxation and labeling. Purchases were analyzed in January-July 2012, at the single-item and transaction levels., Results: There was no significant difference between the various taxation conditions. Consumers were 11 percentage points more likely to purchase a healthier item under a 30% tax (95% CI=7%, 16%, p<0.001) and 6 percentage points more likely under labeling (95% CI=0%, 12%, p=0.04). By product type, consumers switched away from the purchase of less-healthy food under taxation (9 percentage point decrease, p<0.001) and into healthier beverages (6 percentage point increase, p=0.001); there were no effects for labeling. Conditions were associated with the purchase of 11-14 fewer calories (9%-11% in relative terms) and 2 fewer grams of sugar. Results remained significant controlling for all items purchased in a single transaction., Conclusions: Taxation may induce consumers to purchase healthier foods and beverages. However, it is unclear whether the 15%-20% tax rates proposed in public policy discussions would be more effective than labeling products as less healthy., (Copyright © 2013 American Journal of Preventive Medicine.)

Background: The National School Lunch Program has been guided by modest nutrient standards, and the palatability of meals, which drives consumption, receives inadequate attention. School food waste can have important nutritional and cost implications for policymakers, students, and their families., Purpose: Nutrient losses and economic costs associated with school meal waste were examined. The study also assessed if school foods served were valid proxies for foods consumed by students., Methods: Plate waste measurements were collected from middle school students in Boston attending two Chef Initiative schools (n=1609) and two control schools (n=1440) during a 2-year pilot study (2007-2009) in which a professional chef trained cafeteria staff to make healthier school meals. The costs associated with food waste were calculated and the percentage of foods consumed was compared with a gold standard of 85% consumption. Analyses were conducted in 2010-2011., Results: Overall, students consumed less than the required/recommended levels of nutrients. An estimated $432,349 of food (26.1% of the total food budget) was discarded by middle school students annually at lunch in these Boston middle schools. For most meal components, substantially less than 85% was consumed., Conclusions: There is substantial food waste among middle school students in Boston. Overall, students' nutrient consumption levels were below school meal standards, and foods served were not valid proxies for foods consumed. The costs associated with discarded foods are high; if translated nationally for school lunches, roughly $1,238,846,400 annually is wasted. Students might benefit if additional focus were given to the quality and palatability of school meals., (Copyright © 2013 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Cardiovascular diseases (CVD) cost Americans billions of dollars per year. High cholesterol levels, which are closely related to dietary habits, are a major contributor to CVD. In this article, we study whether changes in food prices are related to cholesterol levels and whether taxes or subsidies on particular foods would be effective in lowering cholesterol levels and, consequently, CVD costs. We find that prices of vegetables, processed foods, whole milk and whole grains are significantly associated with blood cholesterol levels. Having analyzed the costs and benefits of government interventions, we find that a subsidy of vegetables and whole grains would be an efficient way to reduce CVD expenditures., (Published by Elsevier B.V.)

Background: The relative affordability of energy-dense versus nutrient-rich foods may promote socioeconomic disparities in dietary quality and obesity. Although supermarkets are the largest food source in the American diet, the associations between SES and the cost and nutrient content of freely chosen food purchases have not been described., Purpose: To investigate relationships of SES with the energy cost ($/1000 kcal) and nutrient content of freely chosen supermarket purchases., Methods: Supermarket shoppers (n=69) were recruited at a Phoenix AZ supermarket in 2009. The energy cost and nutrient content of participants' purchases were calculated from photographs of food packaging and nutrition labels using dietary analysis software. Data were analyzed in 2010-2011., Results: Two SES indicators, education and household income as a percentage of the federal poverty guideline (FPG), were associated with the energy cost of purchased foods. Adjusting for covariates, the amount spent on 1000 kcal of food was $0.26 greater for every multiple of the FPG, and those with a baccalaureate or postbaccalaureate degree spent an additional $1.05 for every 1000 kcal of food compared to those with no college education. Lower energy cost was associated with higher total fat and less protein, dietary fiber, and vegetables per 1000 kcal purchased., Conclusions: Low-SES supermarket shoppers purchase calories in inexpensive forms that are higher in fat and less nutrient-rich., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Low-income, urban African-American youth are at higher risk for obesity and less likely to meet dietary recommendations than white, higher-income youth. Patterns of food purchasing among youth likely contribute to these disparities, but little published information is available., Purpose: To investigate food purchasing behaviors of low-income, urban African-American youth., Methods: A total of 242 African-American youth, aged 10-14 years, were recruited from 14 recreation centers in low-income, predominantly African-American neighborhoods in Baltimore MD. Youth reported the amount of money typically spent on food, the source of this money, the place of purchase, and frequency of purchase for 29 foods and beverages. Data were collected in 2008-2009 and analyzed in 2009-2010., Results: Youth reported spending an average of $3.96 on foods and beverages in a typical day. Corner stores were the most frequently visited food source (youth made purchases at these stores an average of 2.0 times per week). Chips, candy, and soda were the most commonly purchased items, with youth purchasing these an average of 2.5, 1.8, and 1.4 times per week, respectively. Older age was associated with more money spent on food in a typical day (p<0.01)., Conclusions: Food purchasing among low-income, urban African-American youth is frequent and substantial. Interventions aimed at preventing and treating obesity in this population should focus on increasing access to healthy foods in their neighborhoods, especially in corner stores., (Copyright © 2011 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Energy-dense foods are relatively cheap sources of energy but typically have a low nutrient density. People with a low income may therefore select a relatively less healthy diet. The high energy density of such diets helps explain the association between obesity and low socioeconomic status. Most studies have been carried out in highly developed countries. We have extended this research to South Africa. Some foods, such as oats, beans, carrots, and apples, are moderately priced sources of energy and are healthy (i.e., they have a low energy density and are nutrient dense). However, such foods are likely to be less desired than many other foods, such as candy, cookies, jam, and chocolate, that have a similar cost (in terms of food energy) but are less healthy. We compared the cost of a typical South African diet with a healthier one. On average, the healthier diet costs 69% more, but this estimate is greatly affected by food choices. For a family whose household income is exceeded by one-third of the population, this increased expenditure represents about 30% of total household income. This could be decreased to about 10% to 15% if a healthy diet is carefully designed. Overall, a healthy diet is unaffordable for most South Africans. This shows the importance of not only educating people in developing countries to the importance of a healthy diet but also explaining how to make such a diet affordable. A more effective strategy is government intervention that manipulates food prices., (Copyright © 2011 Elsevier Inc. All rights reserved.)

High BMI and obesity contribute to the Russian health crisis. Previous studies have shown that weight status varies along socioeconomic lines but remains largely unaffected by economic shocks over time. This study is the first that explicitly analyses the impact of food prices on adult BMI and obesity in the Russian Federation. Using panel data from the Russia Longitudinal Monitoring Survey from 1994 to 2005, that included 10,551 urban respondents over 18 years, a reduced form weight demand function is estimated. Controlling for individual heterogeneity by a fixed-effects model, price-weight elasticities are derived. The main result is that food prices are not the essential determinants of BMI and obesity in Russia. Elasticities of BMI with respect to single food prices are low and show absolute values smaller than 0.01. However, some products like chicken meat, milk, onions and butter show significant price effects on body mass. A 20% increase in the price of chicken meat would cause a reduction in body weight of 112 g on average. In contrast to the United States, it is mainly high-income households that show significant weight reactions to food prices in Russia. Separate regressions by gender showed significant effects of milk and butter prices on male BMI and of onion prices on female BMI. The risk of being obese is even less affected by price., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Objective: We investigated the availability of healthier food choices and whether a healthier diet costs more than a diet commonly eaten by low-income families in South Africa., Methods: We visited 21 food stores in 14 rural towns of the Western Cape province of South Africa. We recorded the price and availability of 66 food items, including both commonly consumed foods as well as healthy options., Results: Healthier food choices are available in supermarkets. However, many towns only have small food stores with a limited selection of healthy foods. We compared the prices of six commonly consumed foods with healthier versions of those foods (e.g., whole-wheat bread in place of white bread). Healthier foods typically cost between 10% and 60% more when compared on a weight basis (Rand per 100 g), and between 30% and 110% more when compared based on the cost of food energy (Rand per 100 kJ). Next, we compared the extra cost of a healthier diet compared to a typical South African menu. On average, for an adult male, the healthier diet costs Rand 10.2 (US$1.22) per day more (69% more). For a household with five occupants, the increased expenditure on food by eating a healthier diet is approximately Rand 1090 per month (US$140); this represents a high proportion (>30%) of the total household income for most of the population., Conclusion: Healthier food choices are, in general, considerably more expensive than commonly consumed foods. As a result, a healthy diet is unaffordable for the large majority of the population., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Obesity poses substantial costs both to the individual and society, mainly through its impact on health and labor productivity. Because obesity is more prevalent among the poor some have raised concerns that food assistance programs may encourage excess weight. This paper investigates whether the U.S. Food Stamp Program contributes to adult participants' weight as measured by body mass index (BMI). Results suggest that the typical female food stamp participant's BMI is indeed more than 1 unit higher than someone with the same socioeconomic characteristics who is not in the program. For the average American woman, who is 5 ft 4 in. (1.63 m) tall, this means an increase in weight of 5.8 pounds (2.6 kg). While this association does not prove that the Food Stamp Program causes weight gain, it does suggest that program changes to encourage the consumption of high-nutrient, low-calorie foods should be considered.

The potential effect that food prices may have on the health of the U.S. population needs to be further explored, particularly in light of the rising food prices currently being observed. Declining food prices over time have been singled out as a main contributor, for example, to the rising trend in obesity. In this paper we use data from the Bureau of Labor Statistics, the American Chamber of Commerce Researchers Association, the Consumer Expenditure Survey, and the United States Department of Agriculture to analyze trends in various types of food prices, to create a food price index, and to estimate the price of a calorie. Results may be used by future researchers in estimating the health implications of these trends. We find that while the general trend in food prices has been declining, that of restaurant meal prices and prices of fruits and vegetables has risen over time. It is doubtful that the decline in food prices has been sufficiently large to account for the large increase in caloric intake that is said to have contributed to the obesity epidemic in the U.S.

Clinical vitamin A deficiency is characterized by night blindness and greater morbidity and mortality. The aim of this study was to examine the relationships between household food expenditures and night blindness among nonpregnant women of childbearing age among families in the slums of Jakarta, Indonesia. In a cross-sectional study of 42 974 households in the Indonesian Nutrition Surveillance System, 1998 to 2003, night blindness was assessed in nonpregnant women. Food expenditures were divided into 5 major categories as follows: plant-based foods (fruits and vegetables), animal-based foods, eggs, other nongrain foods, and grain foods (primarily rice), calculated as percentage of total weekly per capita food expenditure, and expressed in quintiles. The proportion of households with night blindness in nonpregnant women was 0.72%. Plant-based food, animal-based food, and eggs were associated with reduced odds of night blindness (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.33-0.67; P < .0001, and OR, 0.47; 95% CI, 0.29-0.76; P = .002; OR, 0.62; 95% CI, 0.44-0.85; P = .004), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders. Grain food expenditures were associated with increased odds of night blindness among nonpregnant women (OR, 2.80; 95% CI, 1.86-4.22; P < .0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. This study suggests that nonpregnant women are at greater risk of clinical vitamin A deficiency where families spend more on rice and less on animal and plant-based foods, a situation that is more typical when food prices are high.

As obesity becomes increasingly prevalent, many people are trying to control their body weight through dieting, with mitigated results. We analyzed the impact of weight loss on food choice by recording the grocery basket composition of 100 participants, using their grocery receipts. Participants also anonymously completed a questionnaire about age, sex, diet, recent body weight change, reasons for recent body weight changes, and perceived difficulties in losing weight. Participants who had deliberately lost weight chose more dairy products, meat, and sweets and fewer fruits and vegetables than did controls. Passive weight-losers were similar to controls in their food choices. Active weight-losers show a stronger desire for high-caloric intake, probably because of a behavioral mechanism that seeks to maintain their original body weight set-point.

Linear programming methods, indicators of nutritional adequacy from the Indian Council of Medical Research and household expenditure survey data from the National Sample Survey Organization were used to construct poverty lines for India. Poverty ratios were calculated for 1993--1994 and 1999--2000 on the basis of nutritional adequacy poverty lines and compared to official estimates of poverty based on energy requirements. Nutritional adequacy poverty lines are higher than official poverty lines, particularly in rural areas. The application of nutritional adequacy poverty lines points to greater rural-urban poverty differences than in official estimates. Declines in rural poverty during the 1990s were also slower under the nutritional adequacy definition, especially in south India. There is a greater degree of rural-urban and regional bias in nutritional adequacy poverty reduction than suggested by official data. Inter-state variations in changes in nutritional poverty and official poverty in the 1990s are largely explained by differences in assumptions on overall price movements. However, relative price movements in food items also played a role, particularly the slow increase in prices of cereals and edible oils in comparison to the prices of pulses, and in some southern states, compared to milk and vegetable prices as well.

Objectives: We investigated the relation between parental tobacco use and malnutrition in children <5 y of age and compared expenditures on foods in households with and without tobacco use., Methods: Tobacco use, child anthropometry, and other factors were examined in a stratified, multistage cluster sample of 77 678 households from the Bangladesh Nutrition Surveillance Project (2005-2006). Main outcome measurements were stunting, underweight, and wasting, and severe stunting, severe underweight, and severe wasting. Secondary outcomes included the proportion of household expenditures spent on food., Results: The prevalence of parental tobacco use was 69.9%. Using the new World Health Organization child growth standards, prevalences of stunting, underweight, and wasting were 46.0%, 37.6%, and 12.3%, respectively. After adjusting for potential confounders, parental tobacco use was associated with an increased risk of stunting (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.12-1.21, P < 0.0001), underweight (OR 1.17, 95% CI 1.12-1.22, P < 0.0001), and wasting (OR 1.10, 95% CI 1.03-1.17, P = 0.004), and severe stunting (OR 1.16, 95% CI 1.10-1.23, P < 0.0001), severe underweight (OR 1.21, 95% CI 1.13-1.30, P < 0.0001), and severe wasting (OR 1.14, 95% CI 0.98-1.32, P = 0.09). Households with tobacco use spent proportionately less per capita on food items and other necessities., Conclusions: In Bangladesh parental tobacco use may exacerbate child malnutrition and divert household funds away from food and other necessities. Further studies with a stronger analytic approach are needed. These results suggest that tobacco control should be part of public health strategies aimed at decreasing child malnutrition in developing countries.

Since the start in Italy and Denmark more than 10 years ago the application of fats and oils without trans fatty acids (TFA) has increased all over the world. Today the food industry uses enormous resources to decrease the content of TFA in existing and new products. The food industry has in most cases succeeded in making consumer accepted products without TFA-most of the quality issues have been related to the technological properties of the fat- and oil-based ingredients. The change from the traditional process of selective hydrogenation to fractionation and interesterification has caused a change in the demand of vegetable oils and process capacities in the market, but until now most of these changes has been absorbed by the market without significant changes in the cost of the raw materials.

This article highlights characteristics of two related yet distinct economic approaches to addressing the current obesity epidemic in the United States: the general taxation of soft drinks, snack foods, and/or fast foods, and the application of pricing incentives/disincentives on foods sold in schools and worksites. The article specifically focuses on the: (1) rationale for, (2) potential barriers and limitations to, and (3) possible unintended consequences of implementing these policy interventions at the state level. Novel empirical evidence showing strong positive associations between the presence of state-level taxation on soft drinks or snack foods between 1991 and 1998 and relative changes in obesity prevalence over the same time period is further presented. The article concludes by summarizing the similarities and dissimilarities of the two approaches, and by emphasizing some of the gaps and priorities regarding these strategies that should be addressed in future research and policies to best effect obesity prevention.

Background: Many people, especially low-income consumers, do not successfully follow dietary recommendations to eat more whole grains and less fat and added sugar. The food environment may have a significant impact on the choice by low-income consumers to eat healthier foods, as both the availability and price of healthier food items may limit their ability to eat a healthier diet. We investigated the cost and availability of a standard market basket of foods, and a healthier basket that included low-fat meat and dairy and whole grain products., Methods: Market-basket surveys were conducted in 25 stores in Los Angeles and Sacramento. Stores were selected from neighborhoods that were varied by income and surveyed three times from September 2003 to June 2004. The average cost of a standard market basket (based on the U.S. Department of Agriculture's Thrifty Food Plan [TFP]) and a healthier market basket was calculated from these prices and compared using a standard t-test to determine if they were significantly different from each other. The analysis was conducted in 2005., Results: In neighborhoods served by smaller grocery stores, access to whole-grain products, low-fat cheeses, and ground meat with <10% fat is limited. Among all items that were unavailable, 64% were in small grocery stores. For the 2-week shopping list, the average TFP market-basket cost was $194, and the healthier market-basket cost was $230. The average cost of the healthier market basket was more expensive by $36 due to higher costs of whole grains, lean ground beef, and skinless poultry. The higher cost of the healthier basket is equal to about 35% to 40% of low-income consumers' food budgets of $2410 a year., Conclusions: The lack of availability in small grocery stores located in low-income neighborhoods, and the higher cost of the healthier market basket may be a deterrent to eating healthier among very low-income consumers. Public policies should take the food environment into account in order to develop successful strategies to encourage the consumption of healthier foods.

The highest rates of obesity in the United States occur among population groups with the highest poverty rates and the least education. The impact of socioeconomic variables on obesity may be mediated, in part, by the low cost of energy-dense foods. The observed inverse relationship between energy density of foods, defined as available energy per unit weight (kilocalories per gram or megajoules per kilogram), and energy cost (dollars per kilocalorie or dollars per megajoule) means that diets based on refined grains, added sugars, and added fats are more affordable than the recommended diets based on lean meats, fish, fresh vegetables, and fruit. Taste and convenience of added sugars and added fats can also skew food choices in the direction of prepared and prepackaged foods. Paradoxically, attempting to reduce diet costs may lead to the selection of energy-dense foods, increased energy intakes, and overweight. The present energy-cost framework provides an economic explanation for the observed links between obesity and the food environment, with diet cost as the principal intervening variable. If higher food costs represent both a real and perceived barrier to dietary change, especially for lower-income families, then the ability to adopt healthier diets may have less to do with psychosocial factors, self-efficacy, or readiness to change than with household economic resources and the food environment. Continuing to recommend costly diets to low-income families as a public health measure can only generate frustration and culpability among the poor and less-well educated. Obesity in America is, to a large extent, an economic issue.