Blair Harmon and Dr. Rickelle Richards- Dept. Nutrition, Food Science, & Dietetics
Introduction
Celiac disease is an autoimmune disorder in which the body attacks the lining of the small intestine when gluten is present, which can lead to poor absorption of nutrients resulting in malnutrition.1 The only medical treatment for people with this condition is life-long adherence to a gluten-free diet. The prevalence of celiac disease has continued to rise in the United States, with recent estimates of 1 in 141 people having celiac disease, suggesting this is a common health condition today.2,3
Previous studies have concluded that gluten-free foods are two to three times more expensive than similar glutencontaining foods.4,5 Because a gluten-free diet is required for the entire life of someone after diagnosis of celiac disease, the cost of it can be quite substantial, especially if multiple family members are affected. 6 The lack of affordability and the higher prices of gluten-free foods may lead to noncompliance of persons with celiac disease.5,6 In a previous qualitative study, conducted by Darko et al.6 one woman who had celiac disease reported difficulty in consuming a gluten-free diet because of limited household economic resources.
The Supplemental Nutrition Assistance Program (SNAP), a federal food assistance program, provides monthly monetary benefits or allotments to low-income households (defined as 130% or less of the poverty level) for purchasing food based on estimates calculated through the Thrifty Food Plan.7 Although SNAP is designed to supplement low-income household food supplies by providing 70% of monthly food expenditures, SNAP benefits (or allotments) often become the principle source of money spent on food, if not the only source.8
SNAP allotments are not altered based on health conditions, which may put a further financial strain on lowincome households’ food budgets.7 It is possible that the necessity of purchasing specialty foods, such as glutenfree products, to manage a health condition may pose an even greater financial strain on families who are already stretched to provide an adequate food supply for their household.8,6 Thus, the purpose of this study was to determine how the cost of a gluten-free diet, using the most economical prices and grocery stores commonly shopped in by low-income households, compares to SNAP allotments for low-income households. We hypothesized that weekly SNAP allotments would be insufficient to cover the cost of a gluten-free diet.
Methods
To estimate the costs of gluten-free foods, two researchers recorded the brand name, type, quantity, and price of available gluten-free products from three grocery stores in Utah County, during March 2013 and May-July 2013. The selection of stores was based on previous research conducted in the study location in which low-income households reported most commonly shopping for food 6 and included a local grocery store, a regional grocery store, and a nationwide grocery store chain. For each food product identified, the ingredients list was reviewed and classified a gluten-free food if it met the following definition: an absence of wheat, malt, barley, kamut, triticale, and spelt in the ingredients list and no statement that the product might have contained wheat.1 Information on whole grain gluten-free products was also collected. Products were considered whole grain if the primary ingredient of the product was the whole kernel of the plant including the bran, endosperm, and germ; for example, oatmeal, whole grain cornmeal, brown rice, and popcorn.9
The Thrifty Food Plan is a method set forth by the United States Department of Agriculture that projects food costs for individuals to obtain a healthy diet at the lowest prices and forms the basis for SNAP allotments.9 The TFP specifies the projected amount of pounds of foods that individuals (based on age and gender) should consume each week – in total and subdivided by six food categories and 29 subcategories. In the present study, we only collected data for TFP food categories that include gluten-containing products (grains, meats and beans, vegetables, milk products, and other foods), and to ensure that we captured a wide array of foods within each food category, the TFP extended food list was used to find comparable gluten-free products for each of the food categories.9 For example, under the grain category, the whole grain breads subcategory in the TFP extended food list includes food items such as “whole wheat, multigrain, or pumpernickel breads, rolls, bagels, scones, English muffins, biscuits, tortillas, and pancakes,” so we found comparable gluten-free products that were available at each of the three stores. This study was deemed exempt by Brigham Young University Institutional Review Board, and was deemed exempt under federal regulation 45 CFR §46.101(b).
Statistical Methods
The dollar amount of weekly SNAP benefits estimated for individuals is published according to the same age and gender categories as the estimated pounds of food in the TFP.9 The first step was to determine the estimated costs designated to each of the food categories and subcategories in the TFP. This was calculated by taking the proportion of pounds from each food category and subcategory, by gender and age, and multiplying it by the total SNAP allotment amounts averaged for the available food cost data during the data collection period (March, May, and July 2013; June 2013 consisted of annual average cost data, thus was not used in the analysis).7 For example, the amount estimated to be consumed from the grains food category by a female aged 19-50 years is estimated to be 2.77 lbs. per week by the TFP, which is 8.3% of the total weekly food amount (33.51 lbs.), and when multiplied by the total averaged weekly SNAP allotment of $37.50 is equal to $3.10.
The second step in our analysis was to estimate the food costs of gluten-free foods and then compare them to the SNAP allotment amounts (both total amounts and by food categories and subcategories). Data collected from the three food stores was organized into the appropriate food category and subcategory based on the TFP. Recorded weight amounts from the food packages were converted to one-pound equivalents and cost per pound of food, with the most economical price of products comparable to the gluten counterparts retained under each category and subcategory. This step and all other calculations were done independently by two researchers and reconciled to ensure no data entry errors were present, prior to further data analysis being performed.
We then determined the estimated costs designated to each of the food categories and subcategories; this was calculated by taking the proportion of pounds from each food category and multiplying it by the total SNAP allotment amounts. For example, women 19-50 years old were allotted 0.38 pounds of whole grain cereals per week. The cost of whole grain cereals at store A was $3.44. Then, $3.44 was multiplied by 0.38 pounds to get a total of $1.31 for whole grain cereals from store A. For the food categories that did not contain gluten foods (fruits and vegetables), we used the prices estimated by the TFP. Foods costs were then averaged across the three stores to generate a total average food cost amount for each food category and subcategory. For each food group category and subcategory, descriptive comparisons (percent differences) were made between TFP estimated costs per week and total average grocery store food costs. Microsoft Excel (v. 2010) was used to organize and compute food cost per pounds data and Statistical Packages for Scientists (SPSS, v. 21, 2012, IBM) was used for descriptive comparison analyses.
Results
Average prices per pound of gluten-free foods ranged from $2.45 to $5.85 across TFP food groups. The food group with the highest average combined store cost was the other foods group, with the grains group following closely behind, with only $0.30 per lb less, on average. The most costly subcategories in the other foods groups were coffee and tea and ready-to-serve and condensed soups. The subcategory of the grain category with the highest cost was non-whole grain products, which included all gluten-free pastas, cereals, breads, rice, cakes, pies, cookies, snacks, and flour. Within this same category the cheapest subcategory was popcorn and other wholegrain snacks, at $3.25 per lb. The food group category with the cheapest average combined store cost per pound was milk products, at $2.45 per lb. Within this category, the all cheeses subcategory was the most expensive, at $4.09, and the milk drinks and desserts subcategory, including products like almond milk, soymilk, ice cream and frozen yogurt, at $1.53, was the lowest cost per pound of food.
Prices per lb of gluten-free foods were more expensive at local grocery stores than regional and national grocery stores for the grains, vegetables, meats and beans, and other foods food groups. Milk products were fairly comparable across all stores, with an average of $2.45 per lb.
Discussion
The findings from the current study showed that gluten-free products were more expensive than the cost estimates of the TFP across all food groups and subgroups for every age category, thus supporting our initial hypothesis. The implications of our results are that among low-income households who have someone in their household with celiac disease, the receipt of SNAP benefits would require them to have higher foods costs to follow their medically prescribed diet than the allotted SNAP amounts based on TFP estimates.
Because SNAP does not take into account medically-prescribed diets when calculating benefits amounts for households, our study suggests that households with an individual who has celiac disease may not be able to use their benefits to the same extent as other SNAP households without an individual who needs a medicallyprescribed gluten-free diet. This suggests less food overall in the household to meet dietary needs or more non- SNAP dollars must be spent on food costs, thereby mitigating the full supplemental food benefits of the program and potentially placing an even heavier burden on low-income households to have adequate, safe food supply.
References
- Celiac Disease Foundation. Gluten-Free Diet. Available at: https://www.celiac.org/index.php?option=com_content&view=article&id=138&Itemid=239. Accessed June 18, 2013
- Green PR, Lee A. Celiac disease: an emerging epidemic. J Nutr Food Sci. 2005;1:245-251.
- Rubio-Tapia, A, Ludvigsson JF, Brantner TL, et al. The prevalence of celiac disease in the united states. Am J Gastroenterol. 2012;107(10):1538-44.
- Singh J, Whelan K. Limited availability and higher cost of gluten-free foods. J Hum Nutr Diet. 2011;24(5):479- 486.
- Stevens L, Rashid M. Gluten-free and regular foods: a cost comparison. Can J Diet Practice Res. 2008;69:147- 150.
- Darko J, Eggett DL, Richards R. Shopping behaviors of low-income families during a 1-month time period. J. Nutr Educ Behav. 2012:1-10.
- U.S. Dept. Agri, Center Nutr Policy Promotion. Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, January 2012.
- Golan E, Stewart H, Kuchler F, Dong Diansheng. Can low income Americans afford a healthy diet. Amber Waves U.S. Dept. Agri. 2006;6(5):26-33.
- Carlson A, Lino M, Juan W-Y, Handson K, Basiotis PP. Thrifty Food Plan. U.S. Dept. Agri, Center Nutr Policy Promotion; 2006. National Digestive Diseases Information Clearinghouse. Celiac Disease. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/#1 Accessed June 24, 2013