The Real Co$t of a Healthy Diet

Healthful Foods Are Out of Reach for Low-Income Families in Boston, Massachusetts
AUGUST 2005
The Real Co$t of a Healthy Diet
A Community-Based
Food Security Project at
Boston Medical Center
Supported by the
Claneil Foundation and
Project Bread
Executive Summary
Undernutrition and Overweight Are Increasing
Among America?s Low-Income Families| Millions of United States households face
significant barriers to healthy eating.| Improved access to healthful foods can
prevent or improve the health consequences
of undernutrition and overweight.
The Food Stamp Program Provides
Essential Nutrition Assistance for Millions
of Low-Income Families| Over 25 million Americans rely on Food Stamps
to supplement their food budget.| However, the Food Stamp Program reaches only
54% of eligible persons in the United States,
and very few recipients receive the maximum
benefit allotment.
Food Stamp Benefit Amounts Are Based on the
Outdated US Department of Agriculture (USDA)
Thrifty Food Plan (TFP)| The TFP has not been revised since 1999 and
does not adhere to the government?s most recent
nutrition guidelines.| The TFP menu plan assumes that all food is
prepared at home and requires many hours of
cooking, which is not realistic for working families.| The TFP cost does not account for regional variation
in the cost of food and other basic needs.
The Real Cost of a Healthy Diet Project at Boston
Medical Center| This community-based food security project
first assessed the cost of the TFP in Boston, MA,
then assessed the cost of a modified, healthier
diet that adheres to the government?s most recent
nutrition guidelines.| Food costs were compared to nutrition assistance
program benefit amounts to assess the ability
of low-income families to purchase the two
market baskets.
Findings: The Cost of Both the TFP and a
Healthier Diet Exceed Nutrition Assistance
Program Benefit Amounts| On average, the monthly cost of the TFP in the
sampled stores in Boston is $27 more than the
maximum monthly Food Stamp benefit.| On average, the monthly cost of the healthier diet
in the sampled stores in Boston is $148 more
than the maximum monthly Food Stamp benefit.| The costs of both the TFP and the healthier
diet are substantially greater than the average
Food Stamp benefit received by most families
in Boston.| Even when School Meals benefits are added
to average Food Stamp benefits, benefit amounts
are not nearly enough to meet food costs.
Federal Policy Recommendations| Food Stamp benefit amounts should be increased
to reflect the government?s recent nutrition
guidelines and to account for regional differences
in the costs of food and other basic needs.| Benefit calculation methods should be
changed to reflect the current realities facing
low-income families.| Food Stamp Program funding must be increased,
rather than reduced, so that realistic benefit
amounts can reach more eligible families.
State and Local Policy Recommendations| Since Massachusetts has the lowest Food
Stamp participation rate in the country (39%),
increased outreach is urgently needed to encourage
eligible families to participate in the Food
Stamp Program.| Administrative barriers and burdensome application
and verification procedures must be removed
to facilitate families? receipt of Food Stamps.| In addition to improving families? access to
program benefits, interventions are needed with
local stores and merchant associations to improve
the availability and affordability of healthful
foods in local markets.
Table of Contents
Background and Introduction . . . . . . . . . . . . . . . . 1-3
Project Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Limitations of Project Methods . . . . . . . . . . . . . . . 8
Policy Recommendations. . . . . . . . . . . . . . . . . . . . . 9
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-13
Background and Introduction
Undernutrition and Overweight Among
America?s Low-Income Families
Millions of United States households face significant
barriers to healthy eating, leading to high rates of
both undernutrition and overweight among American
families. Both nutrient under-consumption (consuming
too few of some essential nutrients) and energy
over-consumption (consuming an excess of calories)
lead to serious health problems in adults and children.
Both phenomena are related to food insecurity and
poverty. Improved access to healthful foods can
prevent or improve these two conditions and their
associated health consequences.
m mUndernutrition
Under-consumption of nutrients deprives the
body of sufficient energy, protein, vitamins, and
minerals. These deficiencies impair the body?s
ability to fight off infections, and in young children
are linked with deficits in cognitive development,
behavioral and emotional problems, problems
relating with peers, and physical health problems
leading to hospitalizations.1-10
Food-insecure households do not have access to
adequate nutritious food for a healthy diet, either
because they lack sufficient financial resources,
or because reliable sources of affordable healthy
food are not available. In 2003, the latest year
for which data are available, 36.2 million people
were food insecure in the U.S.11
Poverty is a root cause of food insecurity in the
U.S. In 2003, 35.9 million Americans had incomes
below the poverty threshold, which was $18,810
annually for a family of four.12 The rate of food
insecurity was highest (35%) for households in
poverty. Among households with incomes between
100-185% of poverty, 23% were food insecure,
while for those with income levels above 185%
of the poverty line, only 5% were food insecure.11
Other research has found that incomes at or above
200% of the poverty line are necessary for U.S.
families to achieve economic self-sufficiency to
meet basic needs.11
Overweight
Over-consumption of food energy beyond that
needed for activity and growth leads to overweight
and obesity, which are linked to chronic diseases
such as heart disease, diabetes, hypertension,
cancer and stroke, among the leading causes of
death and disability in the United States.13-19
The proportion of the U.S. adult population either
overweight or obese increased from 47% to 65%
between 1976-80 and 1999-02, while the proportion
of children overweight increased from 6% to
16% over this period.20-22
Food Insecurity is associated with overweight
and obesity in parts of the U.S. population, with
food-insecure adults and children in some age/
gender sub-groups at greater risk of overweight.23-28
The possible pathways between food insecurity
and overweight are complex. To prevent family
members from feeling hungry, food insecure households
purchase a limited variety of cheap, energy
dense foods high in fat and added sweeteners and
poor in nutritional quality. At the same time, food
insecure households reduce their consumption
of fresh fruits and vegetables, whole grains, low-fat
dairy, fish, and vegetable protein.29-30
Poverty plays a role in obesity not only through
food insecurity but also through lower education
levels, lack of health insurance, inadequate
healthcare, and lack of safe places to exercise.
While overweight and obesity have increased
among people at all income levels over the past
two decades, those with lower incomes still have
the highest rates of these conditions.31
1
Public Assistance Programs
and the Thrifty Food Plan
In the United States, several national assistance
programs have been created in response to scientific
information about the importance of nutrition
in ensuring healthy pregnancies, children?s growth
and development, and adults? health and workplace
productivity. The primary federal food assistance
programs are the Food Stamp Program, the Special
Supplemental Nutrition Program for Women, Infants
and Children (WIC), and the National School Lunch
and School Breakfast Programs.
Vulnerable American families and individuals
increasingly depend on these assistance programs
to ensure access to adequate, nutritious food. For
example, in January 2005, 25.5 million persons
participated in the Food Stamp Program, nearly
2 million more than in January 2004.32 However,
the Food Stamp Program reaches only 54%
of eligible persons in the United States, leaving
millions of eligible families without benefits.33
Food Stamp maximum benefit amounts are
determined by the US Department of Agriculture?s
(USDA) Thrifty Food Plan (TFP).34 The TFP consists
of food lists and menu plans that serve as the
national standard for a minimally nutritious diet
at the lowest possible cost. However, the TFP
food lists and menu plans have not been revised
since 1999 and do not incorporate the current
guidelines for optimal nutrition, including those
recently published by the USDA and the Department
of Health and Human Services (DHHS).35 In
addition, the TFP menus include many foods that
must be prepared from ?scratch? and require hours
of cooking time,36 which is unrealistic for many
working poor families.
The USDA adjusts the cost of the TFP monthly,
using the Consumer Price Index for specific food
categories.34 However, the TFP is not adjusted for
regional variation in food costs, or for variation
in costs of other necessities such as housing, utility
costs, transportation or health care. Moreover,
although TFP cost determines the maximum allowable
Food Stamp benefit, few families actually
receive the maximum benefit. Nationally, the
average household Food Stamp benefit is only 40%
of the maximum allotment.37
The lack of regionally specific benefit calculations
and the low average benefit may leave many
families unable to ensure the consistent availability
of a nutritious diet for their children. Insufficient
data are available to paint an accurate picture of
the true costs of a healthy diet in various areas
of the United States. Empirical data which reflect
current nutrition recommendations and food costs
can inform food assistance policy decisions.| The Food Stamp Program serves as the first line
of defense against hunger. It enables low-income
families to buy food in authorized stores with coupons
and Electronic Benefits Transfer (EBT) cards.| Maximum Food Stamp benefit amounts are based on
the cost of the USDA Thrifty Food Plan (TFP), which
is outdated and does not adhere to the government?s
most recent nutrition guidelines.| Over 25 million Americans participate in the Food
Stamp Program. Most receive a benefit that is far
below the maximum allotment determined by the
TFP cost.| Food Stamps reach only 54% of eligible persons in
the United States.
2
Introduction to the Real Cost of a
Healthy Diet Project in Boston, MA
The primary goal of the Real Cost of a Healthy Diet
project is to determine whether residents in three
primarily low-income Boston communities who
receive Food Stamps and other assistance program
benefits can afford a healthy diet, given the
availability and prices of foods in large, medium,
and small food markets in their local neighborhood.
Project Objectives
1. To determine the cost and availability of
the TFP market basket in low-income areas
of Boston.
2. To determine the cost and availability of a
modified, healthier market basket in low-income
areas of Boston.
3. To compare food costs with nutrition assistance
program benefits received by low-income
Boston households.
Project Methods| Three Boston neighborhoods were identified
for study: South Dorchester, Mattapan, and the
South End (see Appendix for neighborhood
profiles). Many residents in certain parts of these
communities rely on assistance program benefits
to supplement their food budgets.| Nine stores, one of each size per neighborhood,
were identified by key informants for food price
survey: three small convenience stores/bodegas,
three medium-size markets, and three large
grocery stores (from the same chain supermarket).| Project nutritionists designed a healthier diet
by carefully modifying the TFP menu and recipes
where possible to conform to the most recent
nutrition guidelines from the American Heart
Association (AHA) and the USDA/DHHS.35,38
(Table 1) All changes that were made to the TFP
to create a healthier diet were calculated to
maintain overall caloric equivalence between the
two diets. (Table 2)| Shopping lists were created, including all food
items for the USDA TFP market basket for a
family of four (two adults and two school-age
children), and the alternative items chosen
to be included in the modified, healthier diet.| Collection of food price data occurred in May
2004 and August 2004, in accordance with the
protocol outlined in the USDA Community Food
Security Assessment Toolkit.39 Interns from the
Food Project, a community-based organization
of youth and adults partnering to create social
change through sustainable agriculture, participated
in data collection.
USDA Thrifty Food Plan Food Item
White bread
White rice
White flour
Orange juice
Stick margarine
Ground pork
Red meat
Spaghetti sauce
Canned mushrooms
Vegetable oil
Whole milk and cheese
Tuna fish
Snacks high in fat
Modification to the Thrifty Food Plan
to create a Healthier Diet*
Whole wheat bread
Brown rice
Whole wheat flour
Whole fruit
Liquid margarine
Lean ground pork
Fish or beans
Low-sodium spaghetti sauce
Low-sodium canned mushrooms
Canola oil or olive oil
Low-fat milk and cheese
Water-packed albacore tuna fish
Carrot sticks, yogurt, or whole fruit
Table 2. Sample Modifications to the TFP to Create a
Healthier Diet Market Basket
*Each modification is either a direct substitution for a TFP food item, or an adjustment to
a TFP recipe, maintaining caloric equivalence.
Table 1. USDA/DHHS 2005 Nutrition Guidelines35
Focus On Fruits
Eat 2 cups/day of a variety of fruits, rather than fruit juices.
Vary Your Veggies
Eat more dark green veggies, orange veggies, and beans
and peas.
Get Your Calcium-Rich Foods
Get 3 cups/day of dairy such as low-fat milk, cheese
or yogurt.
Make Half Your Grains Whole Grains
Eat at least 3 ounces of whole grain products/day.
Go Lean With Protein
Choose lean meats and poultry, and vary your protein
choices (more fish, beans, peas, nuts, and seeds).
Know The Limits on Fats, Salt and Sugars
3
How Much Does the Thrifty Food
Plan Cost in Boston?
The TFP market basket priced in Boston neighborhoods
is the Week #2 market basket for a family
of four (man and woman age 20 to 50; one child
age 6 to 8, and one child age 9 to 11).36 The
USDA set the weekly cost of this Thrifty Food Plan
market basket in both May 2004 and August
2004 at $114.80. The monthly cost was $497.30.40
This was the basis for maximum monthly Food
Stamp allotment for this type of family across the
nation at that time.
Table 3 and Figure 1 show the actual cost of
the TFP in nine Boston stores, averaged across
three neighborhoods and averaged over the May
and August 2004 data collection periods in
Boston (results by neighborhood are shown in
the Appendix). The monthly TFP costs in Boston
are compared with the monthly USDA TFP cost
of $497.30.
These results suggest that, overall, low-income
families in Boston relying on Food Stamp benefits
are likely to have difficulty purchasing the basic
TFP market basket, even if they receive the maximum
benefit allotment. The maximum Food Stamp
benefit of $497.30 could not purchase the TFP
market basket in the small and large stores in this
sample, though it was sufficient to purchase the
TFP in the medium-size stores. The Project
Limitations section of this report discusses the
finding of lower prices in the medium stores. On
average, families in Boston relying on the maximum
Food Stamp benefit for their food budget would
fall short by $26.98 each month when trying to
purchase the Thrifty Food Plan. However, since
so few families actually receive the maximum Food
Stamp benefit,37 the monthly shortfall would be
even greater for most families.
Project Findings
FIgure 1. Monthly Cost of the Thrifty
Food Plan (May and August 2004)
Table 3. Average Cost of the Thrifty Food Plan in Boston by Store Size
Weekly Cost Monthly Cost Monthly Difference
TFP in Boston TFP in Boston* USDA TFP Cost ?
Boston TFP Cost
3 Small Stores $126.20 $546.27 - $48.97
3 Medium Stores $111.13 $481.03 + $16.27
3 Large Stores $126.02 $545.49 - $48.19
Average $121.12 $524.26 - $26.98
* Multiply daily cost by 30.3 days, per USDA calculation40
$800
$600
$400
$200
$0
$497.30
$524.26
USDA TFP
Cost
Boston TFP
Cost
4
How Much Does a Healthier Diet
Cost in Boston?
The Healthier Diet Market Basket includes modifications
to the TFP food list and menu plan in order
to create a diet more in line with recent nutrition
guidelines. As described in the Methods section,
the TFP was modified where possible through either
direct substitutions or recipe modifications to create
a diet that more closely follows recent nutrition
guidelines (refer to Tables 1 and 2).35,38
Table 4 and Figure 2 show the cost of the Healthier
Diet Market Basket in nine Boston stores, averaged
across three neighborhoods and averaged over the
May and August 2004 data collection periods
(results by neighborhood are shown in the Appendix).
The monthly costs for the Healthier Diet Market
Basket are compared with the monthly USDA TFP
cost for a four-person family ($497.30).
These results suggest that low-income families
in Boston relying on Food Stamp benefits will have
significant difficulty purchasing a diet that follows
recent nutrition guidelines from the AHA and the
government (USDA/DHHS). Substituting more
whole grains, fruits, vegetables, fish, and lower-fat
items for the food items in the standard TFP market
basket significantly increases the market basket
cost. On average, families in the sampled Boston
neighborhoods relying on the maximum Food Stamp
benefit would fall short by $147.90 each month
when trying to purchase this healthier diet. The
Project Limitations section of this report includes
a discussion of the lower prices in the small and
medium-size stores.
Table 4. Average Cost of a Healthier Diet in Boston by Store Size
Weekly Cost Monthly Cost Monthly Difference
Healthier Diet Healthier Diet* USDA TFP Cost ?
in Boston in Boston Boston Healthier Diet Cost
3 Small Stores $141.39 $612.02 - $114.72
3 Medium Stores $134.28 $581.22 - $83.92
3 Large Stores $171.50 $742.33 - $245.03
Average $149.06 $645.20 - $147.90
* Multiply daily cost by 30.3 days, per USDA calculation40
Figure 2. Monthly Cost of a Healthier
Diet (May and August 2004)
$800
$600
$400
$200
$0
$497.30 $524.26
$645.20
USDA TFP
Cost
Boston TFP
Cost
Boston
Healthier
Diet Cost
5
Missing from the Shelves:
Unavailable Food Items
Table 5 shows the number of food items that were
unavailable at the different-sized stores in Boston,
averaged across neighborhoods and data collection
periods. The smallest stores had the greatest
number of unavailable items. Many healthier food
items were unavailable at both the small and
medium stores, especially whole wheat products,
lean meats and meat alternatives, and low-fat dairy
products. To account for missing items in the
total market basket costs, an assumption was made
about the cost of each missing item by using the
average price of the item from other similarly sized
stores, as outlined in the USDA Community Food
Security Assessment Toolkit.39 If items were not
available at similarly sized stores, the average price
from stores of the next closest size was used.
Boston Food Costs Compared with
Benefits from Both Food Stamps
and School Meals
The previous results illustrate the gap between
the national standard for maximum Food Stamp
benefits and actual food costs in Boston, a gap
that widens significantly when moving from the
TFP to a healthier diet. The next question to
address is, does the gap between benefit levels
and actual food costs persist if a family receives
other nutrition assistance program benefits in
addition to Food Stamps? This question has not
been addressed since a study conducted in Boston
in the late 1980?s.41
Table 6 and Figure 3 compare the average costs
of the TFP and the Healthier Diet in Boston neighborhoods
with the assistance benefits received by
families in Massachusetts in May 2004 from Food
Stamps, School Breakfast Program, and National
School Lunch Program.42 While the previous results
compared food costs with the maximum monthly
Food Stamp benefit amount, these results compare
food costs with the average benefit received by
Massachusetts families. The maximum benefit is
only given to families with no cash income and
no assets. Many Food Stamp recipients are working
poor families who receive benefits that are far lower
than the maximum allotment. The average benefit
received by families in Massachusetts in May 2004
was $159.95,42 significantly less than the maximum
allotment of $497.30.
The benefits received from the average amount
of Food Stamps combined with benefits from school
meals programs are substantially lower than the
cost of either the TFP or the Healthier Diet Market
Basket in the sampled stores. Low-income families
in Boston would need substantial funds from other
sources in order to purchase enough food for their
nutrition and health.
Table 5. Food Items Missing from the Two Market Baskets
TFP Market Basket Healthier Diet Market Basket
Average Number Average Number
Missing Items Missing Items
Small Stores 15.5 items 28.5 items
Medium Stores 3.8 items 15.1 items
Large Stores 1.1 items 3.1 items
6
Although the Food Stamp Program and the school
meals programs were initially intended to provide
only supplemental support for low-income families?
food needs, in reality many families in Boston rely
on these benefits to support the bulk of their food
budget. Low wages combined with the high costs
of housing, healthcare, child care and heating in
Boston put a significant strain on families? budgets
and leave little money available for food expenditure.
Research on the family economic self-sufficiency
standard in Boston found that for a two-parent
family with two school-age children, both adults
must earn at least $11.13 an hour ($47,018 gross
income per year) for the family to be self-sufficient.43
This is nearly double the federal minimum wage,
and significantly more than the median income
levels in the three sampled Boston neighborhoods.
Table 6. Average Nutrition Assistance Program Benefits in Massachusetts Compared with Boston Food Costs
Average 2004 Monthly Difference Monthly Difference
Monthly Benefit* Benefit Level ? Benefit Level ?
Boston TFP Cost Boston Healthier Diet Cost
Food Stamps alone $159.95 - $364.31 - $485.25
Food Stamps + School Breakfast $207.95 - $316.31 - $437.25
Food Stamps + School Breakfast + School Lunch $279.95 - $244.31 - $365.25
*Benefit amount is the average amount received by a family of four in May 2004.
7
Figure 3. Average 2004 MA Monthly Benefits Compared
with Monthly Food Costs
$800
$600
$400
$200
$0
$159.95
$207.95
$279.95
$524.26
$645.20
Boston
TFP
Cost
Food
Stamps +
School
Breakfast
and Lunch
Food
Stamps +
School
Breakfast
Food
Stamps
Boston
Healthier
Diet Cost
This project needs to be replicated in many more
stores and neighborhoods in other parts of
Massachusetts and around the country in order
to create a more comprehensive understanding
of the real cost of a healthy diet. Although Boston
resembles other large cities such as Washington
DC, San Francisco, and New York City in cost of
living,43 the results from the nine stores sampled
in Boston cannot be generalized to all other cities
or regions.
Further study is also needed to explain the unexpected
finding of lower food costs at the mediumsize
stores in these Boston neighborhoods.
Previous studies have highlighted the absence of
large supermarkets in inner-city areas as a barrier
to accessing affordable foods. Of note is that
the medium-size stores in this study appear to
be catering to local ethnic and cultural food preferences
and demand, with inventories that include
many Caribbean or tropical foods. One possible
explanation for their lower food prices is lower
operating costs at these stores due to lower labor
and/or capital costs. Also, medium-sized stores
may be able to lower inventory costs by decreasing
the number of product brands available. It would
be useful to collect qualitative data, in addition to
food price data, in various types of stores to explore
the relationship between food prices and other
factors such as food quality, food availability, store
conditions, and workers? wages, benefits, and safety.
The methods used to account for missing items
may have underestimated the total assumed
costs of the market baskets in the smaller stores,
especially for the Healthier Diet Market Basket
which included many items that the small stores
did not carry. If a food item was not available in
any of the small stores, then the average cost
of that item in the medium-size stores was used
to calculate the total market basket cost, per the
protocol in the USDA Community Food Security
Assessment Toolkit.39 Since medium store costs are
lower than large store costs in this sample, this
method may have artificially reduced the total food
costs at the smaller stores.
Finally, further research is needed to gain a better
understanding about where low-income families
who rely on Food Stamps are actually shopping
and what they are actually buying. Qualitative data
on shopping and purchasing patterns, particularly
among ethnic minority groups, are needed to
inform policy decisions and nutrition interventions
that could improve the health and nutrition of these
sub-populations.
Limitations of Project Methods
8
At the Federal Level
Increase Food Stamp Program Benefit Amounts
By Updating the Thrifty Food Plan. The results of
this study suggest that Food Stamp benefit amounts
should be based on a more realistic measure of
what is needed to purchase a diet consistent with
current nutrition recommendations. This adjustment
could be achieved by updating the TFP menus
and food lists to incorporate the government?s
most recent nutrition guidelines,35 and by adjusting
TFP costs to account for regional differences in
food prices and the cost of basic needs.
Update Food Stamp Benefit Calculations to Reflect
the Realities of Low-Income Families.
The outdated assumption that low-income families
have hours each day available for cooking and
food preparation at home needs to be revised.
In addition, the current Food Stamp benefit calculation
method relies on outdated economic
assumptions, such as the estimate that families
spend 30% of their earnings on food. In reality,
most low-wage families today are only able to spend
about 17% of their total expenditures on food.44
Furthermore, the deductions for childcare and
housing expenses that are currently figured into
Food Stamp benefit calculations are capped at
unrealistically low amounts ($200 per month for
childcare for an infant; $388 per month above 50%
of adjusted net income for shelter costs). Both
of these deductions should be uncapped to account
for the high housing and childcare expenses facing
today?s low-income families.
Increase, Rather than Reduce, Food Stamp Program
Funding. During a time when poverty, food
insecurity, and obesity are on the rise, the Food
Stamp Program is more important than ever to
enable vulnerable Americans to purchase enough
nutritious food. Food Stamps must remain an
entitlement for all eligible families in order to
protect family health and ensure children?s growth
and learning. The Food Stamp Program is effective
and efficient,45 but funding must be enhanced,
rather than depleted, so that realistic benefit
amounts reach more eligible families.
At the State and Local Level
Encourage Eligible Families to Participate in Food
Stamps and Other Nutrition Assistance Programs.
Massachusetts has the lowest Food Stamp participation
rate of any state in the country. Only 39%
of eligible persons received Food Stamps in 2002.33
Increased funding is needed for front line Food
Stamp workers to process more applications and be
accessible in more locations. Applications for other
nutrition assistance programs (such as WIC and
school meals) should be used to generate the Food
Stamp application so that families do not need to
provide duplicate information.
Remove Administrative Barriers and Burdensome
Procedures for Food Stamp Applicants. In order
to facilitate the Food Stamp application and receipt
process for Massachusetts families, the Department
of Transitional Assistance (DTA) should continue
its efforts to improve the communications between
caseworkers and applicants and minimize the
number of verifications required for applicants.
In addition, DTA should enhance worker training
to improve knowledge of program rules and ensure
that eligible families are not denied benefits.
Work With Local Stores and Merchant Associations
to Increase the Availability and Affordability of
Healthful Foods. This study?s findings indicated
the limited availability of healthful foods in neighborhood
stores, particularly small corner stores
and medium-sized markets. Community, state, and
national interventions are needed to encourage
stores to stock affordable, healthier food items
such as whole-grain products, fresh fruits and vegetables,
low-sodium canned foods, and low-fat dairy
products. These efforts, combined with policy
interventions to improve families? access to program
benefits, can help to reduce barriers to healthy
eating and thus improve the health of Americans.
Policy Recommendations
9
Neighborhood Profiles
The Real Cost of a Healthy Diet Project sampled
stores in three Boston neighborhoods: South
Dorchester, Mattapan, and the South End.
Demographic profiles for these three neighborhoods
are shown in Table 7.
Food Costs by Neighborhood
Table 8 and Table 9 show project findings by Boston
neighborhood. Three stores in each neighborhood
were sampled. The costs are averaged over the two
data collection periods: May 2004 and August
2004. Weekly food costs for the TFP and the
Healthier Diet Market Basket can be compared with
the USDA weekly TFP cost of $114.80,40 which
was the national standard for maximum Food Stamp
benefits at the time of data collection.
Appendix
Table 9. Weekly Cost of a Healthier Market Basket in 3 Boston Neighborhoods
South Dorchester South End Mattapan Store Average
Small Store $139.61 $143.94 $140.61 $141.39
Medium Store $142.03 $133.76 $127.03 $134.27
Large Store $167.48 $173.39 $173.62 $171.50
Neighborhood
Average $149.71 $150.36 $147.09 $149.05
Table 8. Weekly Cost of the Thrifty Food Plan in 3 Boston Neighborhoods
South Dorchester South End Mattapan Store Average
Small Store $129.45 $125.14 $123.99 $126.19
Medium Store $128.25 $103.49 $101.65 $111.13
Large Store $122.27 $124.99 $130.78 $126.01
Neighborhood
Average $126.66 $117.87 $118.81 $121.11
10
Table 7. Neighborhood Profiles
South Dorchester South End Mattapan
Population (2000) 63,647 28,160 37,371
Black/African American 27,123 7,053 30,182
Non-Hispanic White 18,870 12,751 1,236
Hispanic 6,495 4,578 4,573
Foreign Born 31% 21% 30%
Poverty Rate 17% 24% 22%
Median Household Income $39,587 $41,590 $32,748
This project is led by a research team from the
Boston Medical Center Department of Pediatrics:
John T. Cook, PhD; Vivien Morris, MS, RD, MPH,
LDN; Nicole Neault, MPH; Deborah A. Frank, MD.
Maria Pontes Ferreira, MS, RD, assisted the team
in 2004 and was essential to data management,
data entry, and development of the Healthier Diet
Market Basket. We are very grateful to the The Food
Project staff and interns for their assistance with
extensive data collection in May and August 2004.
We are also grateful for the collaborative efforts of
Barbara Millen, DPH, RD, FADA from the Boston
University School of Public Health in identifying
research staff, thinking through all aspects of the
project, and reviewing the healthier diet.
We would like to acknowledge Connie Rizoli and
Andrew Schiff at Project Bread, Sara Mixter at the
Boston Medical Center Family Advocacy Program,
and Pat Baker at Massachusetts Law Reform
Institute for their contributions to the policy recommendations
in this report. Many colleagues in the
Boston Medical Center Department of Pediatrics
provided valuable feedback on the text. We are also
appreciative of Deborah Fogel?s editorial assistance.
Acknowledgements
11
Project Funding
The Real Cost of a Healthy Diet Project was made
possible by a generous grant from the Claneil Foundation
in 2004, with continued support in 2005. Additional
support was received from Project Bread in 2004.
Report Design
Communication via Design, Ltd.
Boston, MA
Photography
The Food Project
Getty Images
Stephen Preston
Suggested Citation
Neault N, Cook JT, Morris V, Frank DA. The Real Cost
of a Healthy Diet: Healthful Foods Are Out of Reach for
Low-Income Families in Boston, Massachusetts. Report
published August 2005 by the Boston Medical Center
Department of Pediatrics. Available at:
http://dcc2.bumc.bu.edu/csnappublic/HealthyDiet_Aug2005.pdf
1. Griffith, J.K. The vitamin A paradox. J. Pediatr., 2000;
137(5): 604-607.
2. Weiss, G. Iron and immunity: A double-edged sword
(Review). Eur. J. Clin. Invest., 2002; 32 (Supplement
1): 70-78.
3. Clark, J. Wound repair and factors influencing healing.
Crit. Care Nurs. Quart., 2002; 25(1): 1-12.
4. Ward, D. The role of nutrition in the prevention of infection.
Nursing Standard, 2002; 16(18): 47-52, 54-55.
5. Palacio, A., Lopez, M., Perez-Bravo, F., Monkeberg,
F .& Schlesinger, L. Leptin levels are associated with
immune response in malnourished infants. J. Clin.
Endocrinol. Metab, 2002; 83: 3040-3046.
6. Fairfield, K.M.& Fletcher, R.H. Vitamins for chronic
disease prevention in adults. JAMA, 2002; 287(23):
3116-3126.
7. Shanks, N. & Lightman, L. The maternal-neonatal
neuro-immune interface: Are there long-term implications
for inflammatory or stress-related disease?
J. Clin. Invest. 2001; 108(11): 1567-1573.
8. Aber, J.L., Bennett, N.G., Dalton, C.C. & Jiali, L.
The effects of poverty on child health and development.
Annu. Rev. Publ. Health, 1997; 18: 463-83.
9. McDonald, M.A., Sigman, M., Espinosa, M.P. &
Neumann, C.G. Impact of temporary food shortage on
children and their mothers. Child Dev., 1995; 65:
404-415.
10.Pollitt, E., ed. The relationship between undernutrition
and behavioral development in children: A report of the
International Dietary Energy Consultative Group (IDECG)
workshop on malnutrition and behavior. J. Nutr, 1995;
125(8S): 2211S-2284S.
11.Nord M, Andrews M, Carlson S. Household Food
Security in the United States, 2003. Food Assistance
and Nutrition Research report No. 42, Washington, DC,
October 2004.
12.DeNavas-Walt C, Proctor BD, Mills RJ. Income, Poverty,
and Health Insurance Coverage in the United States:
2003. U.S. Census Bureau, Current Population Reports,
P60-226. U.S. GPO, Washington, DC, August 2004.
13.Pi-Sunyer, F.X. Health Implications of Obesity. Am J Clin
Nutr., 1991; 53:1595S-1603S.
14.Ludwig DS, Pereira MA, Kroenke CH, Hilner JE, Van
Horn L, Slattery ML, Jacobs R. Dietary fiber, weight
gain, and cardiovascular disease risk factors in
young adults. JAMA, 1999; 282(16):1539-46.
15.Haapanen-Niemi N, Miilunpalo S, Pasanen M, Vuori I,
Oja P, Malmberg J. Body Mass Index, physical inactivity
and low level of physical fitness as determinants of
all-cause and cardiovascular disease mortality ? 16 y
follow-up of middle-aged and elderly men and women.
Int J Obes Relat Metab Disord, 2000; 24(11):1465-74.
16.Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S,
Solomon CG, Willet WC. Diet, Lifestyle, and the risk of
type 2 diabetes mellitus in women. N Engl J Med,
2001; 345(11):790-7.
17.Melanson KJ, McInnis KJ, Rippe JM, Blackburn G,
Wilson PF. Obesity and cardiovascular disease risk:
research update. Cardiol Rev, 2001; 9(4):202-7.
18.Okosun IS, Chandra KM, Choi S, Christman J, Dever GE,
Prewitt TE. Hypertension and type 2 diabetes comorbidity
in adults in the United states: risk of overall and regional
adiposity. Obes Res, 2001; 9(1):1-9.
19.Reilly JJ, Methven E, McDowell ZC, Hacking B,
Alexander D, Stewart L, Kelnar CJH. Health consequences
of obesity. Arc Dis Child, 2003; 88:748-752.
20.Flegal KM, Carroll MD, Ogden CL, Johnson CL.
Prevalence and trends in obesity among U.S. adults,
1999-2000. JAMA, 2002; 288:1723-7.
21.Ogden CL, Flegal KM, Carroll MD, Johnson CL.
Prevalence and trends in overweight among U.S.
children and adolescents, 1999-2000. JAMA, 2002;
288:1728-32.
22.Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin
LR, Flegal KM. Prevalence of overweight and obesity
among U.S. children, adolescents, and adults, 1999-
2002. JAMA, 2004; 291:2847-50.
23.Dietz WH. Does Hunger Cause Obesity? Pediatrics,
1995; 95(5):766-7.
24.Olson CM. Nutrition and Health Outcomes Associated
with Food Insecurity. J Nutr, 1999; 129:521S-524S.
25.Alaimo K, Olson C, Frongillo E, Low F. Low family
income and food insufficiency in relation to overweight
in US children: Is there a paradox? Arch Pediatr Adolesc
Med, 2001; 155:1161-67.
References
12
26.Townsend, MS, Peerson J, Love B, Achterberg C,
Murphy SP. Food insecurity is positively related to
overweight in women. J Nutr, 2001; 131:1738-45.
27.Sarlio-L?teenkorva S and Lahelma E. Food insecurity
is associated with past and present economic
disadvantage and body mass index. J Nutr, 2001;
131:2880-84.
28.Adams EJ, et al. Food insecurity is associated with
risk of obesity in California women. J Nutr, 2003;
133:1070-1074.
29.Drewnowski A, Specter SE. Poverty and obesity: the role
of energy density and energy costs. Am J Clin Nutr,
2004; 79:6-16.
30.Bray GA, Nielson SJ, Popkin BM. Consumption of highfructose
corn syrup in beverages may play a role in the
epidemic of obesity. Am J Clin Nutr, 2004; 79:537-43.
31.Rhoades JA, Altman BM, Cornelius LJ. MEPS Statistical
Brief #37: Trends in Adult Obesity in the United States,
1987 and 2001: Estimates for the Noninstitutionalized
Population, age 20 to 64. Agency for Healthcare
Research and Quality, Rockville, MD, January 2004.
Available on-line only at:
http://www.meps.ahrq.gov/papers/st37/stat37.pdf
Accessed 8-3-05.
32.Food Stamp Participation in January 2005 Nearly 2
Million Above January 2004 Level. Food Research and
Action Center.
http://www.frac.org/html/news/fsp/01.05_FSP.html
Accessed 4-13-05.
33.State Food Stamp Participation Rates in 2002. United
States Department of Agriculture, Food and Nutrition
Service. By Laura A. Castner and Allen L. Schirm,
Mathematica Policy Policy Research, Inc. March 2005.
34.The Thrifty Food Plan, 1999: Administrative Report.
By the Staff of Center for Nutrition Policy and
Promotion, United States Department of Agriculture.
CNPP-7.
http://www.usda.gov/cnpp/FoodPlans/TFP99/TFP99Report.pdf
Accessed 2-14-05
35.Dietary Guidelines for Americans, 2005. United States
Department of Health and Human Services and United
States Department of Agriculture.
http://www.healtierus.gov/dietaryguidelines
Accessed 2-19-05
36.Preparing Nutritious Meals at a Minimal Cost. By the
Center for Nutrition Policy and Promotion, United States
Department of Agriculture. CNPP-7B. September 1999.
37.United States Department of Agriculture. Food Stamp
Average Monthly Benefit Per Household: FY 2004.
http://www.fns.usda.gov/pd/fsavghh$.htm
Accessed 4-28-05
38.American Heart Association Dietary Guidelines.
http://www.americanheart.org/presenter.jhtml?identifier=1330
Accessed 4-21-05.
39.Cohen B. Community Food Security Assessment Toolkit.
ERS Contacts: Margaret Andrews and Linda Scott
Kantor ERS E-FAN No. 02-013. 166 pp, July 2002.
Available at http://www.ers.usda.gov/publications/efan02013/,
Accessed 8-19-04.
40.Center for Nutrition Policy and Promotion, United States
Department of Agriculture. Official USDA Food Plans,
Cost of Food at Home at Four Levels.
http://www.cnpp.usda.gov/using3.html Accessed 6-6-05.
41.Wiecha J, Palombo R. Multiple program participation:
Comparison of nutrition and food assistance program
benefits with food costs in Boston, Massachusetts.
Am J Pub Health. 1989; 79(5);591-594.
42.Benefit levels for Food Stamps were obtained from
the Massachusetts Department of Transitional
Assistance. Benefit levels for School Breakfast and
School Lunch were obtained from Massachusetts
Department of Education.
43.Pearce D, Brooks J. The Self-Sufficiency Standard
for Massachusetts. Report prepared for the Women?s
Educational and Industrial Union. 2003.
http://www.weiu.org/pdf_files/MA_Full_Report_Final.pdf
Accessed 4-29-05
44.US Department of Labor, Bureau of Labor Statistics.
Consumer Expenditures in 2002. Report 974, February
2004. http://www.bls.gov/cex/csxann02.pdf Accessed
6-24-05.
45.The Food Stamp Program is Effective and Efficient.
Dorothy Rosenbaum, Center on Budget and Policy
Priorities. http://www.cbpp.org/3-10-05fa.htm Accessed
5-20-05.
13
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Department of Pediatrics
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