Cost can be a barrier to nutritious food. So can confusion about what actually constitutes nutritious food. Put the two together, and there can be confusion about the relationship between food cost and nutrition -- and that in turn can be costly -- both to the quality of our diets and to our health. So, too, can a misguided (or obsolete) concept of food value -- the ratio of cost to quality.
The conventional wisdom is that more nutritious food costs more. This position is well supported by a large volume of peer-reviewed publications, to which yet another was just added. A study recently published in Health Affairs indicates that people who spend more on their food do a better job approximating federal dietary guidelines.
Specifically, the researchers examined variation in the intake of several nutrients highlighted in the 2010 Dietary Guidelines among adults in King County, Washington.
In the study of moer than 1,000 people, those spending the most on their food came closest to recommended intake of potassium, fiber, Vitamin D and calcium. Those spending the least had the highest intake of saturated fat and added sugar. This, in turn, has been interpreted to support the prevailing view that more nutritious foods are inevitably more expensive.
For those of us who believe that vegetables and fruits for human consumption -- rather than corn and soy for cattle consumption (and other uses, such as the manufacturing of high-fructose corn syrup) -- should be subsidized, it may be just as well to leave it at: "More nutritious food costs more ... " This is a way to promote policy change, and I favor policy change.
But let's face it: Policy change involves advocacy and then waitin' on the world to change. High-profile proponents of fundamental changes to the U.S. Farm Bill include not only writer Michael Pollan, but former Chairman of the Agriculture Committee in the U.S. Senate, Tom Harkin. When the chair of agriculture in the Senate can't get the changes to agriculture legislation he wants, you can guess how soon this mission will be accomplished by the rest of us.
Diet at odds with recommendations for health is a danger both clear and long present. Poor diet is the main reason we are anticipating diabetes in as many as one in three of us by mid-century. So personally, and collectively, we cannot afford to keep on waitin' for the world to change.
It thus becomes important to note that the prevailing view about the cost of food is only part truth to several parts misperception. The misperceptions involve Madison Avenue shenanigans, urban legend, cluelessness, tunnel vision and cultural anachronism.
The one part truth is that fresh produce -- and thus, some of the "most" nutritious food -- truly does cost more. In the King County study, meeting recommended intake for potassium was particularly associated with high food costs, because potassium was coming from pricey vegetables and fruits.
There are efforts to overcome this barrier -- such as providing vouchers in the SNAP program good at farmer's markets and placing baskets of produce in public schools. But still, produce tends to be expensive and may not even be accessible to those least able to afford it. Food deserts, often in the news of late, are notorious for their particular deficiency of fresh produce.
While the high price of produce is a genuine barrier to optimal nutrition for all -- and one that warrants policy change -- the King County study likely exaggerates its impact on nutrient intake. While spending more on food was the pattern associated with higher intake of potassium and other beneficial nutrients observed in the population surrounding Seattle, that doesn't mean spending more is the ONLY way to meet nutrient recommendations. The study simply observed what was happening -- it did not exclude the possibility of less expensive means to the same ends.
Which leads us into consideration of where the view that more nutritious food costs more goes awry.
For starters, there are Madison Avenue shenanigans -- such as attaching higher prices to items that feign superior nutrition, but don't actually offer it. As the principal inventor of a scoring system for overall nutritional quality that has rated roughly 100,000 foods, I have extensive knowledge of how prevalent this phenomenon is. There are literally thousands of products in the U.S. food supply that sport some front-of-pack message implying better nutrition -- fat-reduced, sugar-reduced, lower-salt, multi-grain etc. -- that do not actually offer better nutrition. The message, per se, is true, but it isn't the whole truth.
Fat-reduced peanut butter is a particularly good example. I'm sure no one buys this thinking it will taste better! I'm sure choosy moms choose fat-reduced peanut butter because they think: my kids will eat this and it's better for them. And, for that benefit, they pay extra.
The truth, though, is that fat-reduced peanut butter generally has a bit of healthy oil removed, the fiber content cut in half and substantial additions of sugar and salt relative to the "regular" variety. On the NuVal scale of 1 to 100 (the higher the number, the more nutritious the food), regular peanut butter scores an average of 20 while fat-reduced peanut butter scores an average of 7! Paying more for less nutrition is the literal addition of insult to injury (or vice versa), and one of the reasons why the notion that more nutritious foods always cost more simply isn't true.
Multigrain products are another good example. They often contain vanishingly small quantities of those "multiple" grains, routinely provide less whole grain and fiber than far more humbly packaged alternatives and invariably charge a premium for the multigrain label.
Then, there's the urban legend, which may derive in part from the Madison Avenue's manipulation of public perception, but also derives in part from a blind spot to the full spectrum of food choices. Lentils and beans cost much less than meat, while offering outstanding nutrition and an alternative protein source. Water costs less than soda, while offering a far more "nutritious" means of achieving hydration. There are innumerable instances in which the more nutritious choice costs less.
But alas, the gospel that better nutrition means more expense has taken on a life of its own. Everyone has heard it -- and so everyone tends to repeat it. Perception becomes reality, so most people simply accept that good nutrition is economically disadvantageous. They then stop trying to eat better and simply propagate the urban legend.
The new study in Health Affairs will no doubt feed the urban legend, but it doesn't have to. True, the study shows that those who spend more on food wind up eating better. But those who spend more on food may also shop in different places, have more to spend on food, have more education about food choices and so on. There is no proof here that you must spend more to eat better.
And in fact, I know it isn't so.
Like everyone else, I had heard innumerable times that "more nutritious food costs more," but was never very impressed with the data given to support the claim. So my colleagues and I generated some. We designed a simple experiment: we gave a volunteer shopper criteria for more and less nutritious foods, and had her pick examples of both from multiple food categories. We paid the grocery bill, so she didn't need to worry about prices. We then compared the cost of more and less nutritious foods, category by category, from soup to nuts (well, soda to snacks, anyway). We found no difference. In almost every aisle of almost every supermarket, it's possible to trade up nutrition substantially without spending more money.
So why don't people routinely do so? Cluelessness. I don't mean that as an insult -- I mean literal lack of the clues required to identify the more nutritious foods that don't cost more! I am pleased to say I can help here by providing access to a free program (available in English and Spanish) that teaches the very clues needed to get this job done. As an example, Michael Pollan advises we "eat food, not too much, mostly plants." That's good advice, but hardly helpful when staring down the bread or cereal aisle. But here's a clue that makes that advice actionable: the shorter the ingredient list, the better. The other four are similarly simple and pragmatic -- and shown to work.
Next, there's tunnel vision. We think of the costs of food as if money spent on food has no impact on any other money we spend or make. This is certifiable nonsense. The personal costs of eating badly are enormous: ill health, obesity, high medical bills, absenteeism, presenteeism, lower income. Economists routinely think in terms of "externalities" -- the costs or savings associated with a choice that don't show up on the price tag per se. When thinking about the true costs of our food choices, we would be well advised to do likewise. Eating well is an investment in health, and health provides rich returns in both human potential and dollars.
Lastly, there is a cultural anachronism. Think, for a minute, about how you measure food value. If you are like most people, it's simple: more is better. The all-you-can-eat-buffet exemplifies this attitude, as does "super-sizing."
But is more really better? In an age of epidemic obesity, does more food -- and more calories -- per dollar spent really constitute a bargain? Is it ever a bargain to get more of what you already have too much of?
Throughout most of human history, calories were relatively scarce and hard to get, and physical activity was unavoidable. It was in this context that more food, more calories per unit "expense" (dollars, effort, risk etc.) became the prevailing measure of food value.
But we now live in a modern world where physical activity is scarce and calories are unavoidable. Being poor actually increases the risk of obesity! Increasing our chances of getting fat and sick at no extra charge doesn't exactly sound like a bargain. Getting more food at low cost and then spending a fortune to lose the weight we gained for free does not redound to the credit of our bank account, or common sense. Calories per dollar as a measure of food value is a cultural anachronism. It's long past time to think of nutrition per dollar -- or vitality conferred per dollar -- as a new-age measure of the value of food. On such a scale, even fresh produce is far more economical than we tend to think.
My goal in deconstructing the confusion and costs attached to the nutrition/cost formula is to empower people to make better choices. Armed with the right knowledge and perspective, most of us can likely eat better right now and spend no more money -- and possibly even less -- to get there. Why wait on the world to change when you don't have to?
But the world should change, too. Taking matters into our own hands does not obviate policy change. We still need a Farm Bill that prioritizes people and planet, over corporate profits. We need -- as we are seeing -- efforts to sow access in food deserts.
And we need to be creative so that policy opportunities can get beyond political impasse. There are ways for everyone to win. Consider, for example, that our tax dollars help the SNAP program put food on the tables of one in seven households, to the tune of $100 billion a year. But consider, also, that by and large this program helps poor families consume poor foods on their way to poor health. And then, Medicaid uses more tax dollars to pay the high costs of that poor health.
Imagine, instead, if incentives were used at the point-of-purchase so that the higher the nutritional quality of any given food, the lower the cost. We could directly incentivize more nutritious foods to improve diet and health one better choice at a time. There is every reason to think such a program could save many more disease-care dollars than it spends on food subsidies, so it's logical for the entity that currently pays those bills to ante up. For starters, it could be government involved in both SNAP and Medicaid. But then there's no reason not to extend the thinking to private insurers, which could similarly incentivize more nutritious food choices among their clients through relationships with supermarket chains.
For now, we can acknowledge that the cost of nutritious food is often higher than it should be, and does act as a barrier to better diet and health. But we can also acknowledge that the cost of confusion about the true relationship between nutrition and price is at least as great -- and that's something we can fix right now. No credit card required.
Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz