Testing the price and affordability of healthy and current (unhealthy) diets and the potential impacts of policy change in Australia

Lee et al. BMC Public Health (2016) 16:315 DOI 10.1186/s12889-016-2996-y RESEARCH ARTICLE Open Access Testing the price and affordability of healthy and current (unhealthy) diets and the potential impacts of policy change in Australia Amanda J. Lee1*, Sarah Kane1, Rebecca Ramsey2, Elizabeth Good3 and Mathew Dick3 Abstract Background: Price and affordability of foods are important determinants of health. Targeted food pricing policies may help improve population diets. However, methods producing comparable data to inform relevant policy decisions are lacking in Australia and globally. The objective was to develop and pilot standardised methods to assess the price, relative price and affordability of healthy (recommended) and current (unhealthy) diets and test impacts of a potential policy change. Methods: Methods followed the optimal approach proposed by INFORMAS using recent Australian dietary intake data and guidelines. Draft healthy and current (unhealthy) diet baskets were developed for five household structures. Food prices were collected in stores in a high and low SES location in Brisbane, Australia. Diet prices were calculated and compared with household incomes, and with potential changes to the Australian Taxation System. Wilcoxen-signed rank tests were used to compare differences in price. Results: The draft tools and protocols were deemed acceptable at household level, but methods could be refined. All households spend more on current (unhealthy) diets than required to purchase healthy (recommended) diets, with the majority (53–64 %) of the food budget being spent on ‘discretionary’ choices, including take-away foods and alcohol. A healthy diet presently costs between 20–31 % of disposable income of low income households, but would become unaffordable for these families under proposed changes to expand the GST to apply to all foods in Australia. Conclusions: Results confirmed that diet pricing methods providing meaningful, comparable data to inform potential fiscal and health policy actions can be developed, but draft tools should be refined. Results suggest that healthy diets can be more affordable than current (unhealthy) diets in Australia, but other factors may be as important as price in determining food choices. Keywords: INFORMAS, Diet prices, Food prices, Diet affordability, Food affordability, Food policy, Food environments, Healthy diets, Obesity prevention, Non-communicable disease * Correspondence: 1 School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia Full list of author information is available at the end of the article © 2016 Lee et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lee et al. BMC Public Health (2016) 16:315 Background Unhealthy diets are now the major preventable risk factor contributing to the burden of disease in globally and in Australia [1] and are driven by ‘obesogenic’ food environments affecting food promotion, availability, accessibility and affordability [2]. Data from the Australian Health Survey 2011-12 [3] show that less than seven percent of Australians consume diets consistent with the recommendations of the Australian Dietary Guidelines (ADGs) 2013; [4] at least 35 % of the energy intake of adults and at least 39 % of the energy intake of children are now derived from unhealthy ‘discretionary’ choices [3], described by the Australian National Health and Medical Research Council as foods and drinks high in saturated fat, added sugar, salt and/or alcohol that are not required for health [4]. Of concern is the contribution of poor diet to the rising rates of overweight and obesity; [4] 25 % of Australian children and 63 % of Australian adults are now overweight or obese [3]. There is an urgent need for nutrition policy actions that can help shift the current intake of the whole population to a healthier diet consistent with dietary recommendations in Australia [4]. Assessing diet price and affordability The public perception that healthy foods are expensive is believed to be a key factor contributing to poor dietary choices and diet-related health inequities [4–6]. In developed countries, greater total spending on food tends to be associated with more nutritious dietary patterns [7]. If populations were to follow dietary recommendations, this may lead to higher food costs, with those households with the lowest incomes being most vulnerable, as they spend less per person on food, but a greater proportion of their total expenditure on food [7]. However, as the relative price of ‘healthy’ and ‘unhealthy’ foods depends on the unit of measure (i.e., per energy unit, nutrient density, serve or weight) [7], it is not always clear whether ‘healthy’ foods are really more expensive than ‘unhealthy’ foods, (e.g., healthy foods such as fruit have a high energy-to-price ratio but can provide specific nutrients at a much lower price than other less healthy foods). Comparisons can be difficult particularly in the context of the total, habitual diet that is the major determinant of diet-related disease [1, 2, 4]. Moreover, as opposed to selected pairs of ‘healthy’ and ‘less healthy’ foods, the relative price and affordability of current (unhealthy) and healthy (recommended) diets rarely have been assessed [7]. The International Network for Food and Obesity/noncommunicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS), a global network of public-interest organisations and researchers that aims to monitor, benchmark and support public and private Page 2 of 22 sector actions to create healthy food environments (i.e., with respect to food composition, labelling, promotion, provision, retailing, price and affordability, and trade and investment) and reduce obesity and non-communicable diseases (NCDs) and their related inequalities [2], has highlighted the need for these data [7]. INFORMAS has identified that, with respect to food price and affordability, the relevant questions which need to be answered to inform public policy are:  What is the relative price and affordability of ‘current’ (unhealthy) and ‘healthy’ (recommended) diets?; and  What would be the effect of potential policy actions on the relative price and affordability of ‘current’ (unhealthy) and ‘healthy’ (recommended) diets? [7] INFORMAS proposes a step-wise framework, comprising ‘minimal’, ‘expanded’ and ‘optimal’ approaches, to monitor price and afford (...truncated)