Mapping access to community-developed healthy food baskets including cost and availability

Introduction

Nutrition is a key determinant of health. Poor dietary intake is associated with deaths from heart disease and cancer (World Cancer Research Fund, 2007) and increased falls and fractures in the elderly (Meijers et al., 2012). Inequalities in diet further exacerbate health inequalities (Faculty of Public Health, 2005). Recent national UK surveys show a clear socio-economic gradient whereby lower income households consume higher fat foods and less fruit and vegetables (DEFRA, 2013). In 2012, UK households spent an average 12% of their income on food and non-alcoholic drinks (DEFRA, 2013). In the lowest income households, the percentage spent on food and non-alcoholic drinks was as much as 17%. This percentage may rise further as food prices increase (Lang and Schoen, 2014), and this rise may affect lower income households’ budgetary capacity to achieve a nutritionally adequate diet (Drewnowski and Darmon, 2005; Hirsch, 2011; Jones et al., 2014). Low household income household has consistently been found to be a significant contributor to household food insecurity in other high-income nations including the USA, Canada, New Zealand and Australia (Carter et al., 2010; Kettings et al., 2009; Palermo and Wilson, 2007).

Recently, in the UK, there has been a rise in food bank usage (London Assembly, 2013) linked to welfare reform by observers (Field et al., 2014) although firm evidence to support this link is limited (Lambie-Mumford et al., 2014). In high-income countries, food insecurity is known to correlate with social risk factors for poor health, including being of minority ethnic background (Nord, 2014), living in a low-income household (Tingay et al., 2003), being older (Lee and Frongillo, 2001; Whelan et al., 2002), a lone-parent (Dowler, 1997) or experiencing social isolation (Lee and Frongillo, 2001).

‘Food poverty’ and ‘food insecurity’ are terms used interchangeably within the literature (Jones et al., 2013; Maxwell, 1996). Both terms agree households’ experience of this includes limited or uncertain physical or economic access to enough safe, nutritious food for a healthy, active life (DEFRA, 2006).

In the absence of a standard measurement of food insecurity at a household level (Jones et al., 2013), food baskets can be a useful indicator of cost and availability of a healthy diet (Anderson et al., 2007; Bowyer et al., 2009). Different food basket tools have been proposed to assess local or regional risk factors for food insecurity. In addition to food baskets reflecting mainstream diets, minority ethnic food baskets have been proposed including those developed with Black Caribbean, Black African (Bowyer et al., 2009), Turkish (Bowyer et al., 2009) and South Asian (Dowler et al., 2001; Oldfield et al., 2001) communities in mind. Healthy food baskets (HFBs) that comprise commonly consumed foods to meet national dietary guidelines have also been used to measure food cost and availability in the USA (Beaulac and Kristjansson, 2009), Australia (Harrison et al., 2007; Palermo and Wilson, 2007) and Scotland (Anderson et al., 2007).

Health promotion activities to address food insecurity and protect those most at risk of lifestyle diseases can be carried out locally and nationally. When conducting local health initiatives around diet, in addition to affordability, the acceptability of suggested diets is important for adherence (Maillot et al., 2010). Few studies have included a consensual approach to developing a HFB. Oldfield et al., (2001) consulted Muslim communities in East London to consider the cultural amendments for a Minimum Income Standard (MIS) for this group, providing valuable information on Bangladeshi diets. In developing a MIS for a socially acceptable standard of healthy living (Hirsch, 2011), Bradshaw et al. (2008) used a consensual approach with community focus groups to devise lists of commonly consumed items and quantified these to meet nutritional requirements. Lists were kept realistic by including snack foods and alcohol. The MIS food lists were unsuitable for this study as prices were only from online sources, and study participants were drawn from small UK towns and rural areas without the ethnic diversity seen in the current study area – five wards in an inner London borough (in North Kensington) home to approximately 45,000 people, of whom 62% are financially vulnerable (Office for National Statistics, 2011). A service review was deemed necessary by the local public health nutrition team because of increasing concern about food insecurity in the wake of the UK financial crisis and fiscal reviews. Elderly residents and new migrants in the current study area had previously been identified by health services as having a high food insecurity risk, although the key factors for their risk of food insecurity would require clarification in order for effective interventions to be devised.

The aim of this study was to develop a HFB tool to measure household food security using input from community members of a range of minority ethnicities. This study then aimed to map affordability, physical access and availability of the new HFB by multicultural low-income households.

Methods

Results

Focus group outcomes informed the final HFB

Community consultation revealed that foods commonly eaten by focus group participants were mostly similar to foods included in the MIS food baskets (Centre for Research in Social Policy, 2008). The foods identified by two or more groups, with group consensus, were incorporated into the HFB, including 15 branded items. Foods in the MIS basket eaten by few or no focus group members were removed. The final HFB for each case study household contained a combination of foods in appropriate quantities to meet energy and nutrient recommendations. The full list of items is shown in Table 1. ¹

OPEN IN VIEWER

Table 1.

Products included in the healthy food basket (HFB) for each case study household for 7 days.

Core basket items (39 items)	British food basket (44 items)	Moroccan food basket (19 items)	Caribbean food basket (24 items)
Low-fat fruit yoghurt	Full-fat fruit yoghurt	Full-fat fruit yogurt	Flora light spread a
Semi-skimmed milk	Whole milk	Whole milk	Plain white flour
Cheddar cheese	Flora light spread a	Couscous	Canned soup
Eggs	Bertolli spread a	Red kidney beans	Sardines in oil
Olive oil	Extra light mayonnaise	Heinz baked beans	Weetabix
Sunflower oil	Dried pasta	Plain white flour	Creamed rice, tin
Rice, long grain	Red kidney beans	Tuna chunks in oil	Birds custard powder a
Tomatoes, canned	Heinz baked beans	Seedless raisins	Hot chocolate, Cadburys Fair Trade a
Peanut butter	Canned soup	Kit Kat Milk Fingers	Jacobs cream crackers
Table salt	Tuna chunks in oil	Variety crisps	Coca Cola cans a
Ground black pepper	Sardines in oil	Pure orange juice, smooth	Diet coke cans a
Porridge oats	Gravy granules	Robinson’s double strength squash a	Soft wholemeal rolls
Peaches, canned in juice	Weetabix	White pitta breads	Vanilla ice cream
Tea bags, PG Tips a	Seedless raisins	Spinach, frozen	McCains straight cut oven chips (frozen) a
Tea bags, herbal	Creamed rice, tin	Bananas	Bramley apples
Coffee, instant granules	Custard, ready to serve	Pears	Potatoes
Sugar	Birds custard powder a	Mushrooms, closed cup	Cabbage, green
Rich tea biscuits	Strawberry jam	Chicken thighs, halal	Butternut squash
Warburtons wholemeal bread a	Hot chocolate, Cadburys Fair Trade a	Olives, green loose	Aubergine
Garden peas, frozen	Kit Kat Milk Fingers		Green bananas
Apples, red	Variety crisps		Cassava
Grapes, white	Jacobs cream crackers		Ginger
Oranges	Pure orange juice, smooth		Bacon rashers
Lemons	Robinson’s double strength squash a		Chicken thighs
Carrots	Coca Cola cans a
Red peppers	Diet coke cans a
Red chillies	Soft wholemeal rolls
Cucumber	Scotch pancakes
Garlic	Vanilla ice cream
Broccoli	Cheese pizza, frozen
Lettuce, iceberg	Birds Eye Cod Fish Fingers, frozen
Sweet potatoes	McCains straight cut oven chips (frozen) a
Onions	Spinach, frozen
Spring onions	Bananas
Tomatoes	Pears
Thyme, fresh, bunch	Apples, Bramley
Beef mince (12% fat or less)	Mushrooms, closed cup
Beef topside joint	Potatoes
White fish fillets, fresh	Cabbage, green
	Bacon rashers
	Lunch ham
	Chicken thighs
	Pork loin chops, lean
	Pork sausages

a

Specific brand included.

Price by store type

Fruit and vegetables purchased from any of the three markets surveyed were cheaper than other store types. Of the 23 fresh fruit and vegetable products, 16 were cheapest at markets (Table 2). Convenience stores and small supermarkets cost most for all food groups. The cost of the basket at a large supermarket depended on the supermarket chain and was not always cheaper than small independent stores. The price online was less than in the large high-street version of the same supermarket chain, and online supermarkets were cheapest for shelf products. Meat and fish were as cheap or cheaper in butchers and fishmongers than large supermarkets. Halal chicken was often cheaper than non-halal. Sweet potato was one of the few speciality vegetables that was comparatively costly, approximately twice as expensive as potatoes. Healthy snacks (yoghurt, fruit and vegetables) were similarly priced to unhealthy snacks (crisps, biscuits and chocolate bars). Unhealthy snacks were more likely to be available in convenience stores than fruit, vegetables or yoghurt. Large supermarkets and online stores had the lowest prices for snacks. The lowest median price for a snack (per serve), by store type, was two sweet biscuits (6 pence) from an online supermarket and 30 g raisins (7 pence) from a small supermarket. Fresh fruit ranged from 9 pence to 53 pence per recommended portion (NHS, 2013) based on weight of a medium piece of fruit in Dietplan 7.

OPEN IN VIEWER

Table 2.

Range in price (GBP) of fresh fruit and vegetables ^a per kilogram by store types.

	Online supermarkets (n = 4)	Large supermarkets (n = 6)	Small supermarkets (n = 5)	Speciality stores (n = 14)	Convenience stores (n = 7)	Market stalls (n = 17)
Bananas	0.68–1.16	0.68–4.12	1.09–1.27	0.59–4.50	1.82–5.39	0.50–1.59
Conference pears	1.85–3.79	1.33–3.21	3.57–3.93	0.99–2.38	1.79–3.02	1.00–4.29
Apples, red	1.27–1.95	1.20–2.20	1.32–3.33	0.99–4.99	1.69–2.36	0.57–2.49
Bramley apples	1.39–1.95	0.68–2.05	0.85–0.85	1.00–1.00	N/A	0.80–2.50
White grapes	2.98–4.50	3.00–4.00	4.00–4.00	2.30–3.99	2.99–7.95	1.50–3.75
Oranges	0.93–1.94	0.98–3.29	0.98–2.88	1.22–2.88	1.82–1.95	0.61–1.95
Lemons	1.88–2.34	1.88–2.13	1.25–2.44	1.56–5.56	1.88–1.88	1.25–2.08
Carrots	0.90–1.10	0.59–1.36	0.80–2.00	0.48–5.50	N/A	0.40–1.99
Mushroom, closed cup	2.68–2.84	1.22–3.34	1.80–4.00	0.90–3.99	3.97–3.99	0.90–3.96
Red peppers	3.97–4.10	2.56–6.49	1.28–4.10	1.40–2.50	2.54–3.99	0.85–3.30
Chilli, small, red	10.00–10.83	6.90–42.19	13.30–22.22	2.50–6.99	12.38–12.38	2.50–6.10
Cucumber	2.00–2.25	1.65–5.00	2.25–4.50	2.50–8.95	3.95–3.95	0.83–2.25
Garlic	6.00–9.40	3.33–9.24	4.00–11.00	1.50–7.00	N/A	3.00–19.80
Broccoli	2.00–2.99	1.00–3.34	3.33–5.63	1.35–1.99	N/A	1.00–2.64
Iceberg lettuce	1.25–2.25	2.50–2.75	2.50–3.00	1.73–2.50	2.48–2.50	0.83–6.00
Onion, brown	0.90–1.20	0.83–2.08	1.00–2.44	0.39–2.49	0.99–1.53	0.40–0.99
Spring onions	4.35–7.39	6.52–11.59	6.52–9.00	N/A	N/A	2.17–4.78
Tomatoes, medium	1.99–2.16	1.96–2.00	2.35–5.50	1.00–4.99	1.99–2.92	0.80–2.35
Thyme	23.33–53.00	26.66–42.19	37.45–37.45	N/A	N/A	33.33–34.00
Cabbage, green	0.80–1.14	0.50–2.50	1.19–1.19	0.59–1.41	1.00–1.00	0.71–1.99
Butternut squash	0.85–1.41	0.83–1.15	0.72–2.92	1.00–3.59	N/A	0.67–1.39
Aubergine	2.00–3.33	1.00–3.33	3.33–4.00	1.39–2.79	0.50–1.65	0.99–3.33
Ginger	2.00–8.00	2.00–6.49	2.39–12.50	1.50–2.95	2.50–2.50	1.00–5.56

Products missing from store type are marked N/A. The minimum price for each food overall is indicated in bold.

a

Starchy vegetables are excluded from comparison as they are categorised in the starchy food group.

Discussion

This study developed a nutritionally complete HFB using community consultation, refined to reflect a healthy diet and checked for acceptability through a second consultation with the local population. Locally consumed foods were mostly consistent with findings from previous HFB studies (Bowyer et al., 2009; Bradshaw et al., 2008). However, our HFB had a larger component of herbs, fresh vegetables and fish as well as ‘unhealthy’ foods, reflecting local practice and providing a more accurate picture of the real-life cost of eating. Although frozen or canned fruit and vegetables are often cheaper than fresh versions, they were not acceptable to focus group participants who did not commonly eat them. Therefore, another unique element was that many fresh fruit and vegetables were included in the basket.

The HFB was widely available, but the cost of fruit, vegetables and lean protein foods was high. This suggests that food insecurity leads to unhealthy diets rather than food insufficiency (Bowyer et al., 2009; Dowler and O’Connor, 2012). Availability of choice at a store had an impact on the cost of an item. For example, the big savings seen from online supermarkets compared to large high-street versions of the same chain were largely because the full range of generic items was available as were the range of packet sizes. Significant savings could be made by shopping around, placing a disproportionate financial burden on the time-poor, those unable to travel and new migrants less familiar with the area (Nord, 2014). These findings support conclusions reached by the Greater London Authority (2013), Jones et al. (2013) and Drewnowski et al. (2012) that food insecurity is symptomatic of personal poverty and of environmental issues around supply and cost of healthier foods. The basket costs less per head in larger households, placing single occupant households (particularly the elderly) at higher risk of food insecurity. Community programmes should, therefore, seek to ease the burden of the extra expense as well as alleviate the impact of social isolation for this group.

It was of note that fruit, vegetables and protein foods were found to be more costly online. These items deserve particular attention as they are essential for a healthy diet and collectively accounted for the majority of the cost of the HFB. Although markets were found to be most economical for purchasing fruit and vegetables, there were some logistical difficulties here including limited availability at some stalls, difficulty in interpreting pricing and price variability within markets. This would clearly disadvantage those with mobility issues or reduced ability to interpret pricing, further complicating the impact of limited funds on food. Fruit and vegetable consumption is falling. Households with the lowest incomes purchase less fruit and vegetables, on average just 2.9 portions per person per day (DEFRA, 2013). The same study found that the main food issue of concern to respondents was food prices, supporting a need for food security interventions in marketplaces to promote lower price produce and improve pricing transparency. In this neighbourhood, promoting a return to local stores and markets would improve affordability of healthier foods as well as increase local capacity to influence food supply.

Interestingly, it was protein foods that accounted for the largest cost in the basket rather than fruit and vegetables as seen in previous international studies (Harrison et al., 2007; Palermo et al., 2008; USDA, 2007). This is likely to be in part due to differences in dietary recommendations.

The high cost of protein foods in the basket may cause low-income households to substitute high-quality protein for cheaper alternatives often high in saturated fat and salt. Results from this study can be used in food security interventions to highlight the cheapest protein sources, which were not intuitive, being a large supermarket for some items and butchers or fishmongers for others. Food security interventions could include information on vegetarian protein options available in the local area. Food security programmes could enable people to bulk-buy staple items online to save on these foods and limit delivery charges incurred from online purchasing by reducing the frequency of orders.

Healthy and unhealthy snacks were approximately the same price. Unhealthy snacks (crisps, biscuits and chocolate) were more available in convenience stores than healthy snacks. The results suggest that high intake of unhealthy snacks may be linked to availability, convenience, child pressure and lack of planning not just actual cost. Heavy reliance on convenience stores, particularly for snacks, is likely to increase obesity risk. The cheapest foods were long life starchy foods and should be incorporated in low budget healthy diets.

The study area is in the top 7% of socially and economically deprived wards in London (Greater London Authority, 2010). The combination of extreme wealth and poverty in this condensed urban area presents large inequalities and can contribute to isolation and reduce availability of affordable options. As evidenced by the price of protein foods, fruit and vegetables in this study and in line with previous findings (Food Standards Agency, 2007), nutrients most likely to be lacking in diets of people with a small food budget in the study area are iron, zinc, vitamin B12, folate, protein as well as fibre. This supports wider findings that those suffering from food insecurity are at increased risk of malnutrition rather than undernutrition, putting them at risk of lifestyle diseases such as obesity that are associated with disproportionate intake of high-fat and high-sugar foods (Food Standards Agency, 2007).

It should be noted that the HFB survey provides insight into the ability to afford an acceptable healthy diet; however, other factors also influence whether a healthy diet is followed. These other factors include cooking methods and eating meals outside the home and may have a considerable bearing on the overall diet.

This study adds to the literature by way of combining an HFB survey with a consensual local diet. It had been acknowledged previously that theoretical published diets often do not reflect actual experience (Rydén and Hagfors, 2011). The major strength of this study was that the HFB is representative of local diets, meaning the final price estimates are likely to reflect real life, and results can be used directly in food security programmes. There were a large number of stores surveyed in this study including all store types present. Standardising training and collection tools used by surveyors improved consistency and accuracy and provides an opportunity to repeat this study. Following the creation of this tool, it would be useful to repeat the study to monitor changes in prices and availability and to evaluate food access interventions.

Conclusion

Findings indicate that a nutritionally complete diet for a range of minority ethnic diets was available locally. The price of fruit, vegetables and lean protein foods was particularly high, cumulatively 57%–63% of the total cost. Therefore, households at risk of food insecurity are unlikely to afford a nutritionally complete diet. The cheapest baskets included fruit and vegetables from markets, protein foods from large supermarkets and online long life and dairy foods. Results suggest that avoiding small supermarkets and convenience stores in this neighbourhood to save money and moving from large supermarkets to local speciality stores (greengrocers, butchers and fishmongers) may create savings. High levels of literacy, numeracy and decision-making skills are, however, required to compare prices, and it may be necessary to shop in at least three store types to reduce costs. Because of this, when coupled with low available funds, the elderly, those with restricted access, time-poor households and those without Internet access are at the highest risk of food insecurity.

This study was undertaken to inform local delivery of food security interventions, although the authors note that policy-makers will also play an important role in increasing access to healthy foods through price and availability. The key findings from this study have been incorporated into local dietetic education groups and nutrition training for volunteers. There are plans to work with local food banks and other community organisations to ensure that findings which can help local people locate healthy more affordable options are included in their client information. Results indicate that food insecurity interventions in the area should include a combination of advocacy for a minimum acceptable income and for local markets coupled with local consumer advice on reducing food costs.