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Nutraceuticals and Functional Foods Institute, Laval University, Québec, Canada G1K 7P4
* To whom correspondence should be addressed. E-mail: simone.lemieux{at}aln.ulaval.ca.
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ABSTRACT |
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 TOP ABSTRACT IntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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0.01) and to reduced dietary cost for red meat, refined grains, desserts and sweets, and fast food (P 0.008). In conclusion, these data suggest that adherence to a nutritional intervention program promoting the Mediterranean food pattern is not associated with increased daily dietary cost or energy cost but led to a reduction in energy density. Consequently, increased cost should not be considered a barrier to the promotion and adoption of a Mediterranean diet.
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Introduction |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Generally, nutritional intervention aims at improving cardiovascular risk profile, but the efficacy of dietary changes in the long term on CVD risk factors is dependent on compliance (3–6). Changing food consumption is not an easy task, because many factors influence food choices. Studies have shown that costs related to food purchases may become a barrier to adopt a healthier diet, because consumers believe that a healthy diet is more expensive than their usual diet (7–9). Surprisingly, there is a paucity of data on whether the costs related to a diet in accordance to dietary guidelines differ considerably from the costs of consuming a typical westernized diet. Previous European studies (10–13) have indicated that a healthier diet is more expensive than a more traditional diet. Dietary cost is usually determined as total costs relative to food consumption. Studies have also attempted to determine the energy cost that corresponds to dietary cost per calorie consumed (13). It has been suggested that the main factor associated with the increase in dietary cost was expense related to fruits and vegetables (11). However, these studies were cross-sectional and did not specifically evaluate the effect of changing the diet through a nutritional intervention on the dietary cost. Stender et al. (14) reported in Danish children under treatment for familial hypercholesterolemia that dietary costs were significantly higher than in children following no particular diet. In contrast, dietary cost did not increase in young children adhering to a low-fat diet over a 12-mo period (15) and following the adoption of a healthy diet in a family-based obesity treatment (16). It must be stressed that costs related to adhering to a Mediterranean dietary pattern have not yet been evaluated.
Some researchers have reported no association between increased consumption of foods with low-energy density and decreased energy intake or an increased satiety (17–19). Low-energy density diets are also generally considered as healthier than diets with higher energy density values (20,21). The inverse relationship between energy density of foods and their energy cost suggests that energy-dense diets are likely to be associated with lower costs related to food purchases (12,13,22,23). Based on this, it has been suggested that high-energy density diets, which are generally higher in dietary fat and refined sugars, are likely to be less expensive and to influence consumers' food choices, thereby influencing the development of obesity (24).
The aim of this study was therefore to investigate the impact of a nutritional intervention promoting the Mediterranean diet on changes in dietary cost, energy cost, and energy density. For that purpose, we studied a group of healthy women aged between 30 and 65 y from the Québec City metropolitan area.
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Subjects and Methods |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Intervention. The study was conducted in 2 phases as previously described (25). The first phase started in August 2001 (late summer phase) and the second phase began in January 2002 (winter phase). Each phase was conducted using a similar 12-wk intervention design. The nutritional intervention spanned over the 12-wk period. The intervention included 2 group sessions with 8 participants per group. The first group session took place during wk 1 of the intervention. During this 2-h session, the registered dietitian explained the major principles of the Mediterranean diet and health benefits associated with this food pattern. Four weeks after the beginning of the intervention, subjects participated in a Mediterranean cooking lesson during which they had to produce a complete meal. A registered dietitian administered a validated administered FFQ at screening (t = 0) and then at wk 6, 12, and 24 (26).
Individual sessions took place during wk 1, 6, and 12 of the intervention to evaluate dietary changes and to select further objectives to increase adherence to the Mediterranean food pattern. During individual sessions, the registered dietitian used the FFQ and the Mediterranean food pyramid to identify and promote dietary changes to be undertaken. Suggested modifications were always adapted to the participant's food preferences to personalize the objectives. Registered dietitians involved in the study performed unannounced qualitative 24-h recalls by telephone at wk 2, 4, 8, and 10. The objective of these recalls was to provide support and to reinforce the key principles of the Mediterranean diet. Three registered dietitians were trained to provide a standardized intervention. The same dietitian was in charge of the 2 group sessions for all groups included in the study. The participant always met with the same dietitian during the individual sessions. Women did not receive any specific recommendation to limit changes in dietary cost, i.e. no special emphasis was made on cheaper foods instead of more expensive foods. Subjects attended a follow-up visit 12 wk after the end of the nutritional intervention (wk 24). During that session, women completed a FFQ to evaluate the long-term effect of the nutritional intervention program promoting the Mediterranean food pattern.
Anthropometry. At wk 0, 6, 12, and 24, body weight, waist circumference, and height were measured according to the procedures recommended at the Airlie Conference on the Standardization of anthropometric measurements (27) and BMI was calculated. Briefly, height was measured to the nearest millimeter with a stadiometer and body weight was measured to the nearest 0.1 kg on a calibrated balance. Participants removed their shoes for these last measurements. Waist circumference was measured in duplicate at the mid distance between iliac crest and last rib margin while the woman was in a standing position; the measurement was recorded to the nearest millimeter.
Mediterranean dietary score. Women completed a validated FFQ at screening (t = 0) and then at wk 6, 12, and 24 (25). The FFQ was previously described by Goulet et al. (26). Briefly, a registered dietitian administered the FFQ based on typical foods that are available in Québec. It contains 91 items and 33 subquestions. The FFQ reflected Quebecers' food habits and food items were listed in food groups (vegetables; fruits; legumes, nuts, and seeds; cereals and grain products; milk and dairy products; meat/processed meat; poultry; fish; eggs; sweets; oils and fats; fast foods and drinks). Because of the nature of our nutritional intervention, the design of our FFQ aimed at documenting with enough details the consumption of typical items of the Mediterranean diet such as type of oils, whole grain products, and legumes. One of the 3 registered dietitians involved in the study administered the 30-min face-to-face FFQ. During the interview, the dietitians used food models for a better estimation of the real portion consumed by the subject. The dietitian questioned each participant about frequency of intake for different foods during the last month and women had to report the frequency of these intakes in terms of day, week, or month. These subquestions allowed a better definition of food items consumed. For example, following the question "How often do you eat yogurt?" the dietitian also asked women about the fat percentage and brand of the yogurt consumed. An open question at the end of the FFQ allowed individuals to report any other foods consumed not listed in the FFQ and to provide details about usual recipes used to better quantify intakes of individual food items.
A partial score varying from 0 to 4 was attributed to each of the 11 components of the pyramid (28). Components of the Mediterranean pyramid are: grains; fruits; vegetables; legumes, nuts, and seeds; olive oil; dairy products; fish; poultry; eggs; sweets; and red meat/processed meat. For food groups at the bottom of the pyramid (grains; fruits; vegetables; legumes, nuts, and seeds; olive oil; fish), a high score reflected high consumption. Inversely, for food groups at the top of the pyramid (red meat/processed meat, sweets, and eggs), a higher score indicated a lower frequency of intake. For dairy products, an intake of 2–3 portions per day was considered as a typical Mediterranean intake and 4 points were allowed for such an intake. For poultry, 4 points were allowed when the mean intake was 3 portions per week. The Mediterranean dietary score (MedScore) could therefore vary between 0 and 44 points (25). Eligible women were those with a MedScore at screening below an arbitrary value of 27, which corresponded to the 75th percentile of the distribution in MedScore determined in a sample of women representative of our study population.
Nutritional analysis. Evaluation of nutrient intakes derived from FFQ was performed using the Nutrition Data System for Research software version 4.03, developed by the Nutrition Coordination Center, University of Minnesota, Minneapolis, MN, Food and Nutrient Database 31, released in November 2000 (29). This database includes >16,000 food items for which the complete nutritional value of 112 nutrients is included. Intakes from vitamin and mineral supplements were not included in the present analysis, which focused on dietary nutrients only. Total energy intake was divided by the total weight of the food and beverages reported to determine daily energy density values (30).
Questionnaires to assess potential barriers and benefits associated with the adoption of a Mediterranean food pattern. Each participant was required to complete a questionnaire at wk 0 of the nutritional intervention to obtain information on socioeconomic variables: educational level, mean family annual income, marital status, number of children, type of job; and information that was more closely related to food habits (31). A group of 30 women from the Quebec City metropolitan area who represented the same age range as subjects of the this study pretested the entire questionnaire administered at wk 0. Each participant also completed questionnaires at wk 12 and 24 that evaluated more specifically barriers and benefits associated with the adoption of a Mediterranean food pattern.
Cost of the Mediterranean diet. Prices used in the calculation of food costs were obtained from a large supermarket in the Quebec City metropolitan area. Many items of the FFQ represent a group of foods rather than an individual food item. A total of 227 specific foods were used to represent the 91 items of the FFQ. For each specific food, 1 to 6 prices were sampled for each item and then averaged to determine the mean cost per serving of the corresponding FFQ item (servings were based on the serving size preestablished in the FFQ). For example, the registered dietitian asked participants about their fruit consumption and indicated their frequency of intake for fruits in the FFQ. Because price varies according to the type of fruits, we averaged the prices from 3 different types of fruits. Because the intervention was undertaken during 2 periods of the year, i.e. late summer and winter, we generated 2 price lists (list 1 for summer and list 2 for winter) to take into account seasonal price variations for participants tested at various periods of the year. However, the same price list was used when determining food costs of a given participant at 0, 6, 12, and 24 wk. To determine the cost of food items of the FFQ, we calculated the mean cost per serving of that food and dietary cost was obtained by multiplying the amount of food consumed per day by the mean cost per serving. Costs of individual food items were added to obtain total dietary cost. We calculated daily energy cost by dividing total daily energy intake by total dietary cost.
Data analyses.
Data collected at the beginning (wk 0) and after wk 12 and 24 for MedScore and the variables related to dietary costs were compared using ANOVA for repeated measures to identify time effects from the GLM procedure. In the presence of significant time effects, we used contrast analyses to determine which means differed. Because the intervention was conducted in 2 phases, terms reflecting the potential phase-effect were systematically entered in each statistical analysis model to account for potential interaction with the treatment effect. A total of 62 participants attended the follow-up visit (wk 24). Baseline values were carried forward for participants with missing data at wk 24. The dietary variables were log transformed when necessary to obtain a normal distribution. We computed Pearson correlations to quantify associations among variables. The level for significance was set at an 
level of P < 0.05. Values in the text are means ± SD. All analyses were performed with the SAS statistical package version 8.02 (SAS Institute).
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Results |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Neither total dietary cost nor energy cost at wk 12 or 24 changed significantly from baseline (Table 1). However, as shown in Table 1, dietary costs related to fruits and vegetables; legumes, nuts, and seeds; whole grain products; low-fat dairy products; olive and canola oil; poultry; and fish increased after wk 12 of nutritional intervention (P 0.01). In contrast, dietary cost for refined grain products, red meat, sweets and desserts, and fast food decreased significantly after 12 wk of intervention. Moreover, 12 wk after the end of the intervention (wk 24), the increased dietary costs remained significant for fruits, legumes, nuts, seeds, whole grain products, poultry, and fish and the decreased dietary costs remained significant for red meat, sweets, desserts, and fast foods compared with values obtained at week 0 (P 0.05). Total dietary cost and total energy cost did not differ between the 2 phases (late summer vs. winter).
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0.0001, respectively). The MedScore and energy cost or total dietary cost measured at wk 0 and 12 were not associated (P = 0.15). Change in energy density and change in energy cost between wk 0 and 12 were not correlated, whereas change in energy density was significantly related to change in total daily dietary cost (r = 0.26; P = 0.03) (Fig. 1). Energy density and energy cost at wk 0 (r = 0.40, P = 0.0004), 12 (r = 0.43, P = 0.0001), and 24 (r = 0.35, P = 0.01) were positively associated.
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Discussion |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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The Mediterranean diet is well recognized for its health benefits from a cardiovascular standpoint among Mediterranean and non-Mediterranean populations (32–35). Implementing a Mediterranean diet in a North American country may be challenging, because many factors may affect food choices, such as cultural influence, taste, and cost (7,8,36–38). Previous data identified cost as a barrier in the adoption of a diet in accordance to dietary guidelines. These data also suggested that cost could influence food selection. Analysis of dietary cost in our study indicated that total daily dietary cost did not significantly change following a 12-wk intervention promoting the Mediterranean food pattern. These findings were similar to those of Mitchell et al. (15) and Raynor et al. (16) who reported results of nutritional interventions promoting a low-fat diet in the United States. Their data and ours indicate that overall change in the diet toward healthier foods is not more expensive, suggesting that cost should not be considered systematically as a barrier in the adoption of a healthier food pattern (15,16).
We based our analyses of dietary costs in response to the nutritional intervention on our food list derived from the FFQ. When we asked women about their perception regarding food-related costs during the intervention, 60% reported that they perceived no change in their dietary cost, 8% perceived a decrease, and 32% perceived an increase during the intervention. The fact that almost one-third of the participants indicated they felt that dietary cost increased is somewhat discordant with our calculated total daily dietary cost which did not change. This can be attributed to the fact that our calculations of dietary costs did not take into account food costs related to other family members. In fact, in a real life setting, food habits of other members of the family also influence total dietary cost.
In our study, we noted an association between planning food purchases as a function of weekly discounts in grocery flyers and a reduction in food costs following the 12 wk of intervention. These results suggest that women who planned their food purchases to take advantage of weekly discounts may have had a greater flexibility and may have been more eager to adapt their meals accordingly, which ultimately resulted in reduced dietary costs. Previous data indicated that women who planned their food purchases adhered more closely to the Mediterranean dietary pattern (31). Therefore, we hypothesize that dietary cost reduction may have had a positive influence on the adherence to the food pattern in women planning food purchases according to weekly discounts.
Our results also emphasized that the reduction in energy density in response to the intervention was not accompanied by an increase in total daily dietary costs or energy cost and was due to a redistribution of budget among food groups. Accordingly, it has been suggested by Rolls et al. (20) that one way to decrease food cost while eating a low-energy density diet is by using inexpensive food items such as legumes and beans. Moreover, the fact that we promoted low-energy dense foods and inexpensive food items such as legumes throughout the intervention may help explain why energy density decreased following our intervention and why we observed no effect on total daily energy cost. Consequently, the perception that switching to a healthier diet following dietary guidelines automatically results in higher dietary costs is most likely attributable to the fact that the focus is on adding new healthy foods to the diet. There is no consideration for the fact that less healthy foods are being reduced or eliminated (red meat, sweets, and fast foods in our study).
One limitation of this study is that we estimated dietary costs using a food price list, derived from the FFQ, based on the mean of 1 to 6 prices per item obtained at a large supermarket from the Québec City metropolitan area. Although this method has been used by others (16), it does not take into account the changes in food choices that might have occurred within each food group in response to the intervention. In fact, it is possible that the mean cost per portion for the different food groups would either increase or decrease in response to the nutritional intervention. We chose to use the FFQ because of its convenience and also because it provides information about food intakes that are representative of a longer period of time (1 mo) than what would be obtained with a food record (usually 3 to 7 d). We acknowledge that using food records instead of FFQ and then calculating precisely food cost for all specific foods consumed could have resulted in slightly different results in terms of dietary costs. Also, it is important to emphasize that relative to the Canadian population, our sample overrepresented working status (92.0 vs. 59.6%), university educational level (64.0 vs. 17.2%), and underrepresented women having annual familial incomes <20,000 Canadian dollars (CAN$) (0 vs. 51.2%) (31,39,40). It has been suggested that the diet of low income consumers, for whom food price is a key factor determining food choice, may be high in sugar and fat simply because these are the cheapest source of dietary energy available (41). Consequently, underrepresentation of women of low socioeconomic status (SES) in the this study may have biased our observations. Indeed, we cannot exclude the fact that women involved in our study were already allocating a greater proportion of their budget to food-related expenses compared with lower-income women. It is therefore possible that nutritional changes provoked by the intervention resulted in substitution of foods of more equivalent cost than what would have been achieved among women with lower SES.
In conclusion, these results suggest that the adoption of a low-energy dense, healthy Mediterranean diet in a North American context is not more expensive than the usual, less healthy diet in disease-free women of relatively high SES status. In addition, these findings support the belief that nutritional education programs should address food cost issues to help attenuate or eliminate the cost barrier to the implementation or recommendation of dietary modifications.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Author disclosures: J. Goulet, B. Lamarche, and S. Lemieux, no conflicts of interest.
3 Abbreviations used: CAN$, Canadian dollars; CVD, cardiovascular disease; MedScore, Mediterranean Dietary Score; SES, socioeconomic status.
Manuscript received 12 July 2007. Initial review completed 17 August 2007. Revision accepted 26 October 2007.
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LITERATURE CITED |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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