Introduction
Noncommunicable diseases (NCDs) cause 90% of deaths in the Czech Republic, of which approximately 10 and 20% are preventable for men and women, respectively [
1]. In 2017, the World Health Organization (WHO) estimated that approximately 25,600 lives could be saved if the country adopts WHO’s “best buys”, which are WHO’s recommended interventions for the prevention of NCDs and which include promotion of a healthy diet [
2]. By the end of 2016, 19% of the Czech population were obese and 63 and 48% of Czech men and women were overweight [
3], making the Czech Republic one of the leading European nations in this area [
4]. Overweight and obesity increase the risk of developing diabetes mellitus type 2 (T2D) [
5], the prevalence of which is rising particularly in men and which was associated with 2.2% of Czech deaths [
6].
In the Czech Republic, only 9% of the population consumed the recommended minimum of five portions of fruit and vegetable per day while 46% consumed no vegetable or fruit daily [
7]. Unhealthy eating habits, including high consumption of alcohol, saturated fat, salt and refined carbohydrates as well as a low consumption of vegetables and fruit, are among the most important behavioural risk factors for CVDs [
8] and eating micronutrient-dense foods with low energy density can help prevent both noncommunicable diseases (NCDs) and micronutrient deficiencies [
2,
9].
However, micronutrient-dense foods are relatively expensive [
10] so especially low income families may buy less and increase the risk of malnutrition [
11]. Indeed the prevalence of obesity in the Czech Republic is higher among those with low socio-economic status (SES) compared with high SES, similar to other EU countries [
12]. Health inequalities in the Czech Republic are considered to be associated with obesity, T2D and high blood pressure [
13‐
15]. Ultra-processed foods, sugars, and fats provide low cost energy sources and are designed to taste good, have a long shelf-life and are time-saving in contrast to nutrient-dense foods, such as raw lean meats, fish and vegetable [
10] and may therefore be preferred by groups with a low socio-economic status. In 2016, the proportion of the Czech population at potential risk of poverty was estimated to be nearly 10 % (9.7%), based on an yearly income threshold of CZK 128287 [
16].
The main goal of this study is to create a list of locally available foods (= food basket), which are nutritionally adequate, health-promoting, culturally acceptable and affordable for a low socio-economic status family of four in Czech Republic. Once created, this food basket (FB) could be considered as the basis for Czech food-based dietary guidelines (FBDGs), from where low income families get information to help reduce their health inequalities related to diet-associated non-communicable diseases. Moreover, the study investigates to which extent cultural acceptability, which is approximated by the similarity to observed food consumption patterns, is affected by the food budget.
Discussion
The optimization of a food basket for a Czech family of four has shown that it is possible for the family to obtain a nutritionally adequate, yet low-cost diet. The budget of CZK 128 (€ 4.9) was identified as minimum to afford a diet fulfilling the EERs, AMDRs, and RDIs for this family. The cost of CZK 128 (€ 4.9) is slightly higher compared to what researchers found in other European countries such as Denmark, where the cheapest FB for a family of four cost approximately DKK 27 (€ 3.6) per day [
28]. The most affordable food basket contains only 13 food items, which in addition to creating a very monotonous diet is a diet very low in dietary diversity and so should not be recommended as a basis for FBDG in Czech Republic. Besides the poor food diversity, the suggested daily amounts of single foods for the reference family, i.e. almost 10 kg of eisberg lettuce, are inappropriate for human consumption and therefore culturally unacceptable. In order to increase the attractiveness and social acceptability of the food basket composition and more realistically align with Czech consumer’s expectations, further calculations were necessary to minimize the deviation from current dietary patterns.
In the LCFB, food items with good nutrition-to-cost ratio were selected, suiting the approach of „nutrient profiling“. Nutrient profiling ranks food items based on their nutrient content and can help to identify foods with high nutritional quality for their price, including their contribution to a healthy diet [
41]. Food items such as milk, lettuce, wholegrain flour, barley groats, pasta, chicken liver, herring, vegetable fat spreads, olive oil and poppy seeds were selected by the algorithm in the lowest-cost FB. These foods are part of food groups including: fruit, vegetable, whole grains, refined grains, milk, (vegetable) fats, and nuts & seeds which have a good nutritional quality relative to their price [
41]. The nutrients listed in Table
4 were identified as price-determining and are the ones that consumers actually pay for, other nutrients are naturally present in sufficient amounts. For example, if the RNI for calcium will decrease for each family member or more low-cost foods with sufficiently high calcium content will be available, the FB will become cheaper. The same would apply if there was no upper RNI for sodium for mother and boy. Nevertheless, one of the main limitations of the LCFB, along with its low dietary diversity, is its high deviation (686% on average) from the reported food intake patterns of the Czech population.
In order to address this, the relative weight difference of 79 food groups to the food intake data was minimised, while the overall maximum cost of foods and nutritional adequacy were all enforced by LP, in order to design a FB that fulfills the EERs, AMDRs and RNIs, is culturally acceptable and affordable. This resulted in an optimised minimum wage family food basket (MWFB) costing CZK 178 (€ 6.9) with an average deviation of 10.1%. This can be considered as being fairly similar to reported food intake patterns while offering an opportunity for change towards healthier diets. For example, this food basket is based on a 66% reduction of salt content compared with food intake data along with an inreased consumption of vegetables and cereals, the major part of the latter being wholegrain (Fig.
2).
According to the Ministry of Health of the Czech Republic, the average national daily salt consumption in 2016 has been about 15–16 g and hereby clearly above the recommended limits of 5 g per day [
42]. This intake was also higher than averge daily European consumption of 8–12 g. High salt intake contributes to high blood pressure and increased risk of cardiovascular disease [
43], which are the most prevalent causes of death in the Czech Republic [
16]. Reduction in salt intake was identified as one of the most cost-effective measures to improve population health, especially in terms of preventing CVDs [
43] and this is recognized by the Czech Ministry of Health. The nutritional composition of the MWFB additionally supports a reduction in CVD and high blood pressure incidence by guaranteeing a sufficiently high intake of potassium (Table
1), which is considered to counteract the adverse health effect of elevated sodium intake [
43].
Although the food baskets were optimized on nutrient-based constraints, epidemiological studies rather focus on the health effects of foods and food groups. The MWFB suggests decreased consumption of meat by 52% compared with current consumption trends of the Czechs. The average daily intake of meat and meat products by Czechs was in 2016 about 220 g per day. There is convincing evidence that an elevetad meat intake is associated with increased risk of developing cancer, primarily in the colorectum [
44] and the suggested reduction of meat intake can be assumed to contribute to a reduction of this risk. This risk reduction may further be supported by the significantly higher amounts of milk as a higher intake of calcium-rich diets is associated with a lower incidence of breast and colon cancer [
44]. This effect, however may be limited in the MWFB as, although the amount of milk is considerably increased, the content of milk products is moderately decreased.
The MWFB, if used as a basis for FBDG would also help to promote increased consumption of vegetables – only 9.1% consume the recommeded intake of 5 or more portions per day and more than 43% of Czechs reported not to achieve at least one portion per day [
7]. The amount of vegetable in this MWFB is suggested to increase by 6%, while fruits and juices should be reduced by 74%. The nutrients found in fruits and juices were calculated to be more expensive than those in vegetables. In the case of imported fruits, transport and storage costs determine fruit to be „luxury goods “for Czech low-income families and juices were not included at all in the MWFB (Table S2). Consumption of cereals is suggested by the MCFB model to increase by 20% and due to the lower cost includes mostly unprocessed items, such as wheat and rye flour, being in part as wholegrain variants.
The amount of milk in the FB is suggested to be increased by 484%, while, at the same time, milk products should be reduced by 50%. This recommendation is based on the fact that the nutrients present in milk become more expensive when processed into milk products. The suggested reduction of sweets and confectionery from category „Others “complies with the WHO recommendation of decreasing sugar intake to less than 5% of the total energy intake [
45] in order to maintain a healthy body weight and prevent dental caries. High intake of low-energy-density foods such as vegetable and cereals has been associated with lower body weights and overall better health [
9].
The aim of this study is to recommend how to modify the Czech Food Based Dietary Guidelines when a cost constraint is considered for low income consumers. Therefore the recommended nutrient intakes (RNIs), within pre-defined energy amounts, were applied to ensure all nutrients are covered by the foods in the food baskets. The results support the development of Czech FBDG in terms of proportion of the food groups that should be recommended overall, including specific food items. Moreover, the financial affordability of a nutritionally adequate diet, where only the cost of the raw foods are considered, has been calculated. Also in what proportion each food group comprise the total cost is calculated, which may be useful for Czech authorities either to better plan social benefits or other measures to help low income families out of poverty. In addition such proportions may help guide agriculture or horticulture policies in Czech and national food security measures regarding what foods to produce and which to import. Several non-EU governments, such as Canada, Australia and the US, use LP for estimation of how much money their population need to afford nutritionally adequate diet [
28]. This study could therefore support national government in planning social and welfare policies.
Based on the comparison of the generated MWFB and reported food intake patterns of the Czech population in 2016, the FBDGs for a low-income Czech family of four could include the considerations listed in Table
7.
Table 7Recommendations for a Czech family of four living on minimum wage to achieve a food supply that is nutritionally adequate and that is as similar as possible to observed food supply patterns in the Czech Republic
- Increase your vegetable consumption to up to 570 g per day |
- Consume by 20% more cereals, preferably wholegrain |
- Drink more milk every day, up to 2.2 l daily |
- Reduce consumption of milk products, such as cheese or yoghurts by half |
- Consume more vegetable-based fats and oils up to 290 g per day |
- Reduce your meat consumption by half, to about 200 g per day |
- Reduce consumption of fruits and juices by 2/3 to about 190 g per day |
- Eat by 60% less salt and no more than 12 g per day |
- Reduce consumption of sweets and confectionery, especially sugar and biscuits to 1/3 |
- Consume on average around 20 g of nuts and seeds, such as peanuts or sesame seeds per day |
- Consume on average around 40 g of pulses, such as yellow peas or beans per day (~ 20 g raw weight) |
Vitamin D has not been considered in the list of minimum thresholds during the calculations, as it’s not part of the micronutrients for which a RNI value has been released for the Czech Republic [
29]. A recent study by
Bischofova et al. state that dietary intake of vitamin D was in more than 95% of Czech population below the recommended RDIs [
46]. Public health interventions directly promoting intake of vitamin D, through supplements, could be more effective. Evaluation of this intervention would be required and compared with promotion of a higher vitamin D intake through FBDGs. The main dietary source of vitamin D among Czechs was eggs [
46], and this food group was absent from the MWFB for low-income family. Preliminary calculations identified fatty fish to be the most cost-effective source of vitamin D, but the cultural acceptability among the Czech population and its local cost would need to be overcome.
Even though
Maillot M et al. argue that foods with the least favourable nutrient profile, for example sweets or salty snacks, can still contribute up to 41% of the energy intake to a nutritionally adequate dietary pattern [
47], items such sweetened beverages and sweets were not included in the LCFB by the LP algorithm. However, optimizing for similarity, a certain amount of foods from this category (and even alcoholic beverages) would have been enforced into the FB for low-income and median-income families. Given that usual dietary habits play a major role in preferred dietary choices [
48], the elimination of these “unfavourable” foods might increase the reluctance of low-income consumers to adopting FBDGs. However, foods or beverages considered to have the potential to harm human health such as alcohol should not become part of the recommendations.
Limitations
The cost of the food baskets in this study only applies to the purchase of food and it does not include expenses associated with food storage (cooling, freezing) and food preparation such as those linked to energy, transport, cooking equipment and time. The FBs are designed for a reference Czech family of four and do not apply to people who are outside the reference age ranges and to individuals with special nutritional needs such as pregnant women and people with food intolerance or allergy. Cost linked to avoidable food waste or foods that spoil after purchase are not considered. The prices of foods used in this study were collected online and may moderately differ from prices effective in supermarkets and at other retailers. However, as the online trading of foods has to stay competitive to the over-the-counter selling, major differences in food prices are unlikely.
Conclusion
The main goal of this study was to develop food baskets for a Czech family of four with low socio-economic status, living on minimum monthly wages. It has been demonstrated that nutritionally adequate foods, but not diets, are affordable for families living on the minimum wages. The results of this study present foods and proportions of food categories which are necessary for a nutritionally balanced diet (Table
7). The study suggests the food basket MWFB is the FB that is recommended to form the basis of Czech FBDGs for low income families. Implementation of these FBDGs would assist in the prevention of both micronutrient deficiencies and NCDs such as high blood pressure, type 2 diabetes, CVDs and obesity.
Preparation of meals by low income families based on these FB could be a topic for further investigations including qualitative studies on acceptability of the suggested food supply. Further research investigating other barriers towards compliance with FBDG among Czech consumer would allow more targeted implementation and promotion of guidelines.
This study can promote constructive discussion among nutritionists and policy makers in the Czech Republic. Inter-sectoral collaboration among various ministries, agriculture, horticulture, health and education, is required where they the implications of this study can be discussed with regard to helping to reduce social inequalities in Czech society.
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