The cost of healthy food in rural Victoria

Introduction: The cost of healthy food has been associated previously with the degree of remoteness and socioeconomic status. This study aimed to investigate the factors that influence the cost of food in rural Victoria, Australia. It also aimed to compare the cost of nutritious foods with less healthy foods, and to identify the population sub-groups most vulnerable to economic food insecurity. Methods: A cross-sectional survey of the cost of food was undertaken in 2007 in a convenience sample of 34 supermarkets in rural areas across Victoria using the Victorian Healthy Food Basket (VHFB). The VHFB was designed to meet the nutritional needs of four different family types for a fortnight. Results: The cost of the VHFB for a ‘typical family’ (2 adults, 2 children) was (mean [interquartile range]) $AU402.81 ($26.36). No association was evident between food cost and remoteness as indicated by the Accessibility/Remoteness Index for Australia (ARIA) score, socioeconomic status as indicated by the Socio-Economic Indices for Areas (SEIFA), population size or density, or distance of the town from the state capital, Melbourne. It was more expensive to purchase the VHFB at an independent store (median cost $406.66 [$29.39]) than at a supermarket chain (median cost $394.93 [$26.64]), p<0.05. Vegetables and legumes were the most expensive component of the VHFB to purchase and this food group showed significantly greater variation in food price than cereals (p<0.05), non-core foods (p<0.05) and unhealthy foods (p<0.001). The median cost of the VHFB was most expensive for a typical family and ‘single parent family’ (40% and 37% of welfare income) and least expensive for a single man (29% of income) and elderly pensioner (19% income). Conclusions: The VHFB is an effective tool for assessing economic food security for different population groups. The cost of food in rural Victoria varies in a manner that appears unrelated to remoteness, population, socioeconomic status or distance from the metropolitan centre. Purchase of healthy food requires a considerable proportion of welfare income and may thus be unaffordable


Introduction
The cost of nutritious food is an important determinant of food security, nutritional intake and, thus, health 1 . A number of sub-groups within the population have been identified as particularly vulnerable to food insecurity due to impaired physical access (from disability, lack of transport or geographical remoteness) or economic access (low socioeconomic status) to supplies of healthy food 2 . In Australia, it is well established that food costs are much higher for people living in remote and very remote areas, and that due to reduced food variety and poor quality of fresh foods, people in these areas are at high risk of food insecurity [3][4][5][6][7] . Much less is known of food costs in urban and rural or regional areas.
Recent work has shown that in urban Adelaide, South Australia, with a population size of just over one million 8 , healthy foods are readily available and food costs are lower in urban areas of low socio-economic status 9 . Another Australian study in a south-eastern urban local government area (LGA) of Melbourne, Victoria, suggests that lower socio-economic status areas have poorer access to healthy food 10 . The only published data on food cost and availability in rural and regional Victoria did not show a difference in cost when compared with Melbourne but identified that a complete healthy basket of foods was less likely to be available in the rural areas 3 .
The average Australian household spends 17% of their income on food 11 . For welfare recipients, however, this proportion is substantially higher. Data from surveys indicate that the cost of a healthy basket of food for a family of five reliant on government unemployment benefits accounts for approximately 30% of income 7,9 . Few data are available on the cost of a healthy diet for those sub-groups most vulnerable to food insecurity in Australia, particularly those living in regional areas. This study aimed to investigate the factors that influence cost of food in rural and regional Victoria. It also aimed to compare the cost of nutritious foods with more unhealthy foods, and to identify the relative cost of a healthy basket of foods for a range of different family types receiving government benefits.

Methods
A cross-sectional survey of the cost of food using the VHFB was conducted in a selection of 34 supermarkets in rural and regional areas across Victoria between October and Wodonga) were selected. All stores that were located in the town of the placement were selected unless they supplied less than 90% of the items in the basket, in which case they were excluded. Permission to conduct the survey was obtained by students from the store manager on the day of the survey. Ethics approval was not required to access this public data.
Prices of the cheapest, non-generic brands were recorded in the specified package size. If the specified size was not available, the price of the next smaller size was recorded and quantities adjusted accordingly. No discounted or special prices were recorded.
For each town surveyed, remoteness was determined by use of the Accessibility/Remoteness Index for Australia (ARIA) 15

Thirty-four different stores across 18 towns in 14 Victorian
LGAs (Fig1) were surveyed, ranging in size from 478 to 72 999 persons, with a median of 12 854 persons ( Table 1).
The ARIA scores ranged only from 0.27 to 2.83. In total, towns included covered 29% of Victorian rural and regional LGAs. While 40% of the 20 largest Victorian rural and regional towns (population size above 10 000) were included, less than 5% of the smaller rural and regional towns have been included. Fifteen of the 18 towns (exceptions were Yackandandah, Beechworth and Hall's Gap) were located on a main highway. Stores at which the cost of a VHFB was collected were either from a chain supermarket (chain A or chain B), were small independent supermarkets from a range of different companies (eg 'Foodworks', 'IGA') or were independently owned (56% of total) ( Table 1 , for an independent store purchase and a supermarket purchase, respectively, p = 0.024). Figure 2 indicates the cost of a VHFB relative to income. Both an elderly pensioner (19%) and a single male (29%) would spend a significantly lower proportion of their welfare income on the purchase of a basket than would a four person typical family (40%; p<0.001 and p<0.05, respectively). Table 2 indicates the median cost for different food components of the VHFB, with the cost of vegetables and legumes contributing the greatest proportion of the total cost of the basket, and unhealthy foods contributing the least. The cereal group was inexpensive but contributed one-third of the total energy content and 22% of the total protein content of the basket. The non-core food items were also inexpensive but contributed no protein and only 7% of total energy. Vegetables and legumes showed the greatest variation in price, significantly greater than price variation for cereals (p<0.05), non-core foods (p<0.05) and unhealthy foods (p<0.001).

Discussion
The results of this study provide additional insight into food costs across rural and regional Victoria, and illustrate that healthy food may be unaffordable for some sub-groups in the Victorian population. While work has been undertaken to assess food costs across much of rural and remote Australia 4-6 , there has been little examination on the factors that influence food cost in a population-dense state such as Victoria. The present findings are consistent with a previous study undertaken in rural Victoria on food cost, which found substantial variation in the cost of the same basket of food across the state, and that the basket was less expensive when purchased in larger chain supermarkets rather than in smaller independent stores 3 . While difference in cost with store type may reflect greater store buying power, as reported     Analysis of the cost of different food components of the VHFB indicated the high absolute cost and higher variation in the cost of healthy foods compared with unhealthy food items. Energy-dense, nutrient poor or unhealthy foods have also been shown to be less expensive in other countries 18 .

Reference Family
The variation in the cost of fruit and vegetables in the present study is of concern for food and nutrition security but is somewhat understandable from the transport distance and perishable nature of these food stuffs.
The present study provides a picture of the cost of food for These data build on work already undertaken to show the importance of the affordability of a nutritious diet in order to improve health. It also highlights the need for a national system to monitor healthy food prices to improve consistency and relevance among states and territories, and to take into account the increasingly multicultural food choices. The development and use of a national basket for monitoring food prices has clear benefit by providing important data for governments to assist in planning and addressing food insecurity and nutrition related disease 19,21 .
This glimpse into food costs across rural and regional Victoria illustrates an unexplained variation in food costs across areas, and further supports the notion that healthy food may be unaffordable for population sub-groups in Victoria.

Conclusions
This study investigated the cost of the VHFB across 34 different stores in rural and regional Victoria. With the exception of one significant outlier, there was limited variation in the cost of the basket among stores. There was no association between food cost, ARIA, SEIFA, population density, distance from Melbourne or population size; however, the basket cost was significantly cheaper in large chain stores. Healthy food items had greater variation in cost across the stores compared with the unhealthy foods, and much of this variation remains unexplained. The cost of the basket appears to be most expensive and potentially unaffordable for a typical and single-parent family, and for a single man. This study demonstrated the ability of the VHFB to assess economic food security for different population sub-groups, and highlights the need for a national healthy food basket that better reflects recent food consumption patterns. This would provide national data from which to support the development of food and nutrition policies and improve access to healthy food. This, in turn, would create environments that support healthy food choices and improve population health.