International Journal of

Environmental Research
and Public Health

Article
Healthy Food Prices Increased More Than the Prices of
Unhealthy Options during the COVID-19 Pandemic and
Concurrent Challenges to the Food System
Meron Lewis * , Lisa-Maree Herron , Mark D. Chatfield, Ru Chyi Tan , Alana Dale, Stephen Nash
and Amanda J. Lee

School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia
* Correspondence: m.lewis@uq.edu.au

Abstract: Food prices have escalated due to impacts of the COVID-19 pandemic on global food
systems, and other regional shocks and stressors including climate change and war. Few studies
have applied a health lens to identify the most affected foods. This study aimed to assess costs
and affordability of habitual (unhealthy) diets and recommended (healthy, equitable and more
sustainable) diets and their components in Greater Brisbane, Queensland, Australia from 2019 to 2022
using the Healthy Diets Australian Standardised Affordability and Pricing protocol. Affordability
was determined for reference households at three levels of income: median, minimum wage, and
welfare-dependent. The recommended diet cost increased 17.9%; mostly in the last year when
the prices of healthy foods, such as fruit, vegetables and legumes, healthy fats/oils, grains, and
meats/alternatives, increased by 12.8%. In contrast, the cost of the unhealthy foods and drinks in the
habitual diet ‘only’ increased 9.0% from 2019 to 2022, and 7.0% from 2021 to 2022. An exception was
the cost of unhealthy take-away foods which increased by 14.7% over 2019–2022. With government
COVID-19-related payments, for the first time recommended diets were affordable for all and food
security and diets improved in 2020. However, the special payments were withdrawn in 2021, and
Citation: Lewis, M.; Herron, L.-M.; recommended diets became 11.5% less affordable. Permanently increasing welfare support and
Chatfield, M.D.; Tan, R.C.; Dale, A.; providing an adequate minimum wage, while keeping basic, healthy foods GST-free and increasing
Nash, S.; Lee, A.J. Healthy Food GST to 20% on unhealthy foods, would improve food security and diet-related health inequities.
Prices Increased More Than the Prices Development of a Consumer Price Index specifically for healthy food would help highlight health
of Unhealthy Options during the risks during economic downturns.
COVID-19 Pandemic and Concurrent
Challenges to the Food System. Int. J. Keywords: diet cost; diet affordability; food security; COVID-19; Australia
Environ. Res. Public Health 2023, 20,
3146. https://doi.org/10.3390/
ijerph20043146

Academic Editor: Małgorzata Godala 1. Introduction

Received: 18 January 2023
Poor diet is the leading single preventable risk factor contributing to the burden of
Revised: 7 February 2023 disease in Australia and globally [1]. Less than 4% of Australian adults consume a diet
Accepted: 8 February 2023 consistent with the recommendations of the Australian Dietary Guidelines (ADGs) [2],
Published: 10 February 2023 with over 35% of dietary energy derived from unhealthy discretionary food and drinks [3].
Relatedly, more than two thirds (67%) of Australian adults and 25% of children aged
two to 17 years are overweight or obese [4]. In Australia, rates of obesity, poor-quality
diet, and diet-related chronic disease (including type 2 diabetes, heart disease, and some
Copyright: © 2023 by the authors. cancers [1,5]) follow a socioeconomic gradient [6–8].
Licensee MDPI, Basel, Switzerland. Ensuring food security is key to reducing prevalence of obesity and chronic disease
This article is an open access article particularly in low socioeconomic groups. Food security is a fundamental human right [9].
distributed under the terms and It means everyone is able to obtain at all times a sufficient quantity of quality (safe and
conditions of the Creative Commons
nutritious) food that meets their preferences to sustain “an active and healthy life” [10].
Attribution (CC BY) license (https://
Food security is determined by availability, accessibility, affordability, and acceptability
creativecommons.org/licenses/by/
of food.
4.0/).

Int. J. Environ. Res. Public Health 2023, 20, 3146. https://doi.org/10.3390/ijerph20043146 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 3146 2 of 17

The affordability of healthy diets is impacted by both the cost of food and drinks and
the household financial resources available. Economic access to food implies that people
“have sufficient money to purchase the food they want to eat, to meet cultural and social as
well as health and nutritional norms; that this money is not absorbed in other expenditure
demands (rent, fuel, debt repayment, etc.); [and] that people can . . . obtain food in ways
which are dignified and in keeping with social norms” [11]. Income level, income shocks
and rising costs of living are key determinants of economic access to healthy food [12–14].
As with all diets, recommended diets (which are healthy, equitable, and sustainable
consistent with the Australian Dietary Guidelines (ADGs) [2]) are considered unaffordable
when they cost more than 30% of household income [15]. When a household needs to
spend more than 25% of their disposable income on healthy food, they may experience
“food stress” and are vulnerable to food insecurity [16]. Before the COVID-19 pandemic,
families relying on government welfare/financial assistance had to spend over a third of
their household income to buy a recommended diet, and households in rural and remote
areas on low incomes needed to spend an even greater proportion [17].
Prior to COVID-19, estimates of the prevalence of food insecurity in Australia were
around 4 to 14% in the general population and up to 82% in low-income groups [18]. Over
the past three years, food insecurity has increased significantly [19,20]. According to the
latest national Hunger Report from Australian food charity Foodbank, extrapolating re-
sponses from a nationally representative survey conducted in July 2022, 21% of Australians
had experienced severe food insecurity in the past 12 months (up from 17% in 2021) [19].
Of those experiencing food insecurity, 64% cited increased or high living expenses and
42% reported “reduced or low income or government benefits” as a key cause [19].
Previous studies have assessed diet costs during the COVID-19 pandemic and, op-
portunistically, the impact on diet affordability of government economic responses that
boosted incomes for many low-income households [17,21]. In response to COVID-19 im-
pacts, including increased unemployment, in 2020 the Australian Government introduced
“JobKeeper” payments to help businesses pay employees who were stood down, and also
lump sum Economic Support Payments and a fortnightly Coronavirus Supplement (here-
after abbreviated as ESP and CS) for eligible recipients of some income support payments,
including the unemployment benefit “JobSeeker” [22]. Diet costs increased from 2019 to
2020, largely driven by rising prices of most healthy food groups [21]. However, increased
income support meant that for the first time, welfare-dependent families had economic
access to recommended diets [17,21].
Food prices have continued to escalate since 2020 due to global, national, and re-
gional shocks and stressors, including the impacts of climate change, increasing frequency
and severity of extreme weather events (bushfires and floods), the Russian invasion of
Ukraine, and changing demographics (such as reduced immigration and increased internal
migration to rural areas [23]), as well as disruptions to food production and supply due to
impacts on workforces of COVID-19-related public health restrictions [24–27]. These fac-
tors also contributed to increased costs of fuel, feed, and fertiliser, exacerbating increasing
food prices.
This study aimed to assess costs of habitual (unhealthy) diets and recommended diets
in Greater Brisbane in 2021 and 2022, and compared results with those reported from earlier
studies in 2019 and 2020 [21], to explore changing costs and affordability in the context of
these shocks and stressors.

2. Materials and Methods

The Healthy Diets ASAP (Australian Standardised Affordability and Pricing) methods
protocol [28] was applied to assess the cost, cost differential, and affordability of habitual
(unhealthy) and recommended (healthy, more equitable and sustainable) diets in the Greater
Brisbane region of Queensland, Australia annually from 2019 to 2022. Findings from 2019
and 2020 have been previously reported [17,21]. This study collected and analysed data in
Int. J. Environ. Res. Public Health 2023, 20, 3146 3 of 17

2021 and 2022 and compared diet cost, cost differentials, and affordability across the four
timepoints. All cost values are provided in Australian dollars ($).
The Healthy Diets ASAP protocol is consistent with the International Network for
Food and Obesity/non-communicable diseases Research, Monitoring and Action Support
(INFORMAS) framework’s ‘optimal’ approach to assess diet price and affordability [29],
addressing limitations of earlier efforts to measure food cost and affordability in Aus-
tralia [30,31]. Details of the background, description, collaborative development process,
application, and testing of the protocol have been published previously [28,32].
The protocol has five parts: standardised habitual and recommended diet pricing tools;
store location and sampling; calculation of median gross and minimum wage disposable
income; food price data collection; and analysis and reporting [28].

2.1. Diet Pricing Tools

The diet pricing tools specify the types of foods and drinks in the habitual and rec-
ommended diets and quantities for a reference household of four (adult male and female
31–50 years of age, a 14-year-old boy, and an 8-year-old girl) per fortnight [28]. The rec-
ommended diet contains healthy food and drinks, in line with the recommendations of
the ADGs [2]. The habitual diet is based on reported dietary intake data from the most
recent Australian Health Survey National Nutrition and Physical Activity Survey (NNPAS)
2011–2013 [3]. It includes some healthy food and drinks in lower amounts than recom-
mended in the ADGs, and many discretionary foods and drinks (defined by the ADGs
as not being necessary for health and high in saturated fat, added sugar, sodium and/or
alcohol) [2]. The recommended diet contains slightly less energy (33,610 kJ/day) for the ref-
erence household than the habitual diet (33,869 kJ/day), and is more sustainable, requiring
less water, protecting biodiversity, and generating 25% lower greenhouse gas emissions in
its production [33]. Table 1 lists the types of food and drinks included in each diet pricing
tool. Detailed lists of components and quantities have been published previously [28].
Table 1. Food and drinks included in the Healthy Diets ASAP diet pricing tools.

Habitual (Unhealthy) Diet Recommended (Healthy, Equitable, More Sustainable) Diet

• Healthy foods and drinks as per the seven food groups in
the ‘Recommended diet’ column; in reduced amounts • Water (bottled)
reflecting reported intakes • Fruit: apples, bananas, oranges
• Artificially sweetened beverages • Vegetables: potatoes, broccoli, white cabbage, iceberg
• Discretionary (unhealthy) foods and drinks: lettuce, onion, carrot, pumpkin, tomatoes, sweetcorn
(canned), four bean mix (canned), diced tomatoes (canned),
# Drinks: sugar sweetened beverages baked beans (canned), frozen mixed vegetables, frozen
# Cereals, snacks, and desserts: muffin, sweet peas, salad vegetables in sandwich
biscuits, savoury crackers, confectionary, chocolate, • Grain (cereals): wholegrain cereal biscuits (Weet-bix™),
potato crisps, muesli bar, mixed nuts (salted), ice rolled oats, cornflakes, wholemeal bread, white bread,
cream, fruit salad (canned in juice) white rice, white pasta, dry water crackers, bread in
# Processed meats: beef sausages, ham sandwich
# Spreads, sauces, condiments, and ingredients: • Lean meats and alternatives: beef mince and steak, lamb
butter, tomato sauce, salad dressing, white sugar chops, cooked chicken, tuna (canned), eggs, peanuts
# Convenience meals: frozen lasagne, chicken soup (unsalted), meat in sandwich
(canned), frozen fish fillet (crumbed), instant • Milk, yoghurt, and cheese: cheddar cheese (full fat,
noodles, meat and vegetable stew (canned) reduced fat), milk (full fat, reduced fat), yoghurt (full fat
# Fast food: pizza, meat pie, hamburger, potato plain, reduced fat flavoured)
chips/fries • Unsaturated oils and spreads: olive oil, sunflower oil,
# Alcohol: beer (full strength), white wine canola (margarine)
(sparkling), red wine, whisky

2.2. Store Locations and Sampling

Food and drink price data for 2019 were sourced from a previous survey using the
Healthy Diets ASAP protocol to assess diet costs and affordability in locations through-
out Queensland [17,21]. The Australian Bureau of Statistics’ (ABS) Statistical Geography
Standard classes medium-sized geographical areas into SA2 locations, where communities
Int. J. Environ. Res. Public Health 2023, 20, 3146 4 of 17

“interact together socially and economically” [34]. In 2019, SA2 locations across Queensland
were stratified into quintiles of socioeconomic disadvantage based on the Socioeconomic
Indexes for Areas (SEIFA) Index of Relative Socioeconomic Disadvantage [35]. Eigh-
teen locations in SEIFA quintiles 1 (most disadvantaged), 3 (median disadvantaged) and
5 (least disadvantaged) were randomly selected for inclusion; the final samples included
10 locations in Greater Brisbane (3, 4, and 3 locations in SEIFA quintiles 1, 3, and 5, re-
spectively). In 2020, restriction of movement implemented as a public health measure
in response to the COVID-19 pandemic meant data collection in stores beyond Greater
Brisbane was not possible. Hence, only the 10 SA2 locations in Greater Brisbane included
in the 2019 sample were re-surveyed for food prices in 2020 [21]. Additionally, because
of the pandemic, one of the large supermarket chains did not allow ‘unnecessary’ store
visits (e.g., for research purposes) so prices from that supermarket were collected from its
website matched to the SA2 locations. Previous studies comparing in-store to online prices
have found insignificant price differences [36].
In similar months in 2021 and 2022, food prices were collected in the same 10 loca-
tions in Greater Brisbane. At each location, two large supermarkets (one of each major
supermarket chain), an independent grocery store, a bakery, a fish and chip shop, two fast
food restaurants, and one alcohol outlet were surveyed. As per the Healthy Diets ASAP
protocol [28], if a store had closed since the previous survey, a similar, proximate food
outlet was surveyed instead. In 2021 and 2022, prices were collected online for the two
supermarkets in all locations and collected in-store for the remaining outlets. In 2022, a
duplicate set of prices were collected in-store from the large supermarkets in two locations
for validation.

2.3. Price Data Collection

Price data were collected by trained research assistants, following the Healthy Diets
ASAP protocol, between August and October each year. Collection of price data in 2019
and 2020 has been detailed elsewhere [17,21]. In 2021, food price data were collected by
L.-M.H. and R.C.T. and in 2022 by L.-M.H., M.L., A.D., and S.N. Permission to collect
data was requested and received from national head offices of large supermarket chains,
and also from store managers in each outlet. The data collection protocol outlines the
procedure followed if the stipulated brands and sizes were not available or were on price
promotion [28].

2.4. Household Income Calculation

Household incomes were calculated as per the Healthy Diets ASAP protocol [28],
using publicly available national data from government agencies. This study assessed diet
affordability for three categories of income for the reference household.
For each timepoint, the median gross household income (before taxation) per fortnight
in each SA2 area was sourced from the ABS 2016 Census Community Profile [37] and
adjusted by the ABS Wage Price Index [38]. Minimum wage disposable and welfare-
dependent household incomes were calculated based on the set of assumptions detailed in
the protocol, using payment entitlement data from Services Australia [39]. Calculations of
minimum wage and welfare-dependent household incomes for 2020 included the ESP and
CS provided between May and September 2020, are detailed elsewhere [21].

2.5. Analysis and Reporting

Food and drink price data were entered into the Healthy Diets ASAP data collection
web portal [40] by R.C.T., A.D. and S.N. Data were double entered, and any discrepancies
were resolved by consensus. Data were cleaned and checked by M.L. and A.J.L. As per
the Healthy Diets ASAP protocol, if a value was missing, the mean price of the item in
other stores in the same SA2 location was substituted. Spreadsheet algorithms generated
results for each location in Microsoft Office Excel files which were cross-checked by M.L.
and A.J.L.
Int. J. Environ. Res. Public Health 2023, 20, 3146 5 of 17

Diet costs and affordability were calculated for each SA2 area surveyed in Greater Bris-
bane. The mean costs of the habitual and recommended diets, and the cost and proportion
of the total spent on different ADG food groups and components, were calculated for the
reference household per fortnight. Results were reported for SA2 SEIFA quintile 1, 3, and 5,
and for Greater Brisbane as a whole. Affordability of habitual and recommended diets was
calculated for households with the three different income levels described above.
The results for each year were compared to relevant findings of previous surveys, to
assess changes in diet costs, cost of ADG food groups and components, and affordability of
the diets. Consumer Price Index of food and non-alcoholic beverages (CPI-food) data for
Brisbane from 2019 to 2022 were sourced from the ABS [41] for comparison with observed
changes in food prices. Statistical analysis was conducted by paired t-tests; statistical
significance was set at p ≤ 0.05.

3. Results
3.1. Selected Locations and Stores Surveyed
In 2019, food prices were collected from 80 outlets in 10 locations in Greater Bris-
bane [17]; in 2020, price data were collected in-store from 68 outlets and online from
10 outlets (supermarkets) [21]; in 2021 prices were collected from 80 outlets: in-store for
60 and online for 20 (supermarkets); and in 2022, prices were collected from 80 outlets:
in-store for 60 and online for 20 (supermarkets). For validation, prices were re-collected
in-store for four supermarket outlets across two locations.

3.2. Diet Cost Data

The mean costs ± standard error (SE) of the habitual and recommended diets and
diet components in Greater Brisbane from 2019 to 2022 are reported in Table 2. Total costs
of the recommended diets and the healthy and discretionary (unhealthy) components of
the habitual diets for the four timepoints are also presented in Figure 1. Diet cost data
for each location surveyed (Supplementary Figures S1 and S2) and by SEIFA quintile
(Supplementary Table S1) are presented in supplementary files. Cumulative increase in the
cost of the habitual and recommended diets and CPI-food is shown in Figure 2.
Within the manuscript, data are presented and analysed for Greater Brisbane as a
whole, as change in food prices was similar regardless of SEIFA quintiles (Supplementary
Table S1). The duplicated diet costs for prices collected in-store were within 1% of diet costs
for prices collected online from the large supermarkets in two locations.

3.3. Diet Cost in Greater Brisbane, 2022

In 2022, the mean cost of the recommended diet in Greater Brisbane was AUD 729.71
per fortnight for the reference household of two adults and two children (Table 2). The
habitual diet was 18.4% more expensive than the recommended (healthy) diet at a cost of
AUD 863.93 (Table 2). Shifting from a habitual to recommended diet would save households
AUD 134.22 per fortnight on average.
In 2022, nearly 58% of the total cost of the habitual diet was required to purchase
discretionary food and drinks, including takeaway foods (around 20% of total diet cost),
alcoholic drinks (11% of total diet cost), and sugar sweetened drinks (around 4% of total
diet cost) (Table 2).

3.4. Changes in Fortnightly Diet Costs over Time

Between 2019 and 2022, in Greater Brisbane the cost of the recommended diet increased
by 17.9% from AUD 619.04 to AUD 729.71 (p < 0.001) (Table 2). Around three-quarters
of this increase occurred in the 12 months prior to the most recent survey in 2022, during
which time the cost of healthy foods increased 12.8% (p < 0.001) (Table 2, Figure 1).
Int. J. Environ. Res. Public Health 2023, 20, 3146 6 of 17

Table 2. Cost of habitual and recommended diets and component food groups for the reference
household (two adults and two children) per fortnight in Greater Brisbane, in 2019, 2020, 2021
and 2022.

Total Diet and Food Group Costs of the Habitual Diet for the Reference Household
2019 2020 2021 2022
Proportion Proportion Proportion Proportion
Food/Food Mean Cost Mean Cost Mean Cost Mean Cost
of Total of Total of Total of Total
Groups (AUD) ± SE (AUD) ± SE (AUD) ± SE (AUD) ± SE
Cost (%) Cost (%) Cost (%) Cost (%)
Water, bottled 20.35 ± 0.52 2.64% 19.04 ± 0.55 2.39% 19.62 ± 0.37 2.45% 20.27 ± 0.48 2.35%
Fruit 53.38 ± 1.29 6.91% 57.44 ± 0.72 * 7.20% 57.02 ± 0.96 7.12% 58.45 ± 1.01 ˆˆ 6.77%
Vegetables (and
43.59 ± 0.59 5.65% 40.51 ± 0.53 ** 5.08% 40.93 ± 0.52 5.11% 52.38 ± 0.58 *** ˆˆˆ 6.06%
legumes)
Grain (cereal)
44.34 ± 0.63 5.74% 46.17 ± 0.52 * 5.79% 46.6 ± 0.69 5.82% 52.08 ± 0.54 *** ˆˆˆ 6.03%
foods
Lean meats,
poultry, fish, eggs,
96.45 ± 1.15 12.49% 101.86 ± 1.31 * 12.77% 107.12 ± 1.36 ** 13.37% 112.51 ± 1.38 ** ˆˆˆ 13.02%
nuts, seeds and
alternatives
Milk, yoghurt,
cheese and 47.93 ± 0.87 6.21% 55.02 ± 0.42 *** 6.90% 54.25 ± 0.38 * 6.77% 58.91 ± 0.66 *** ˆˆˆ 6.82%
alternatives
Unsaturated oils
1.27 ± 0.02 0.17% 1.30 ± 0.02 * 0.16% 1.41 ± 0.02 *** 0.18% 1.68 ± 0.02 *** ˆˆˆ 0.19%
and spreads
Artificially
sweetened 5.64 ± 0.14 0.73% 6.14 ± 0.07 ** 0.77% 6.14 ± 0.07 0.77% 6.85 ± 0.05 *** ˆˆˆ 0.80%
beverages
Sugar sweetened
31.14 ± 0.50 4.03% 30.82 ± 0.32 3.87% 30.86 ± 0.33 3.85% 34.66 ± 0.46 *** ˆˆˆ 4.01%
beverages
Takeaway foods 149.31 ± 2.22 19.34% 157.76 ± 2.34 *** 19.79% 161.59 ± 1.78 20.17% 171.29 ± 3.20 *** ˆˆˆ 19.83%
Alcoholic
96.36 ± 1.91 12.48% 97.93 ± 0.91 12.28% 91.71 ± 0.27 *** 11.45% 94.62 ± 0.72 ** 10.95%
beverages
All other
discretionary 182.42 ± 3.01 23.62% 183.38 ± 2.09 23.00% 183.88 ± 1.52 22.95% 200.22 ± 2.08 *** ˆˆˆ 23.18%
choices
Total diet 772.20 ± 4.48 100.00% 797.36 ± 3.79 *** 100.00% 801.13 ± 3.99 100.00% 863.93 ± 5.59 *** ˆˆˆ 100.00%
Healthy foods
312.96 ± 3.23 40.53% 327.47 ± 2.55 ** 41.07% 333.09 ± 3.01 ** 41.58% 363.14 ± 3.09 *** ˆˆˆ 42.03%
and drinks
Discretionary
459.24 ± 2.38 59.47% 469.89 ± 2.90 * 58.93% 468.04 ± 1.49 58.42% 500.79 ± 3.75 *** ˆˆˆ 57.97%
foods and drinks
Total diet and food group costs of recommended diet for the reference household
2019 2020 2021 2022
Proportion Proportion Proportion Proportion
Food/Food Mean cost Mean cost Mean cost Mean cost
of total of total of total of total
groups (AUD) ± SE (AUD) ± SE (AUD) ± SE (AUD) ± SE
cost (%) cost (%) cost (%) cost (%)
Water, bottled 20.35 ± 0.52 3.29% 19.04 ± 0.55 2.96% 19.62 ± 0.37 3.03% 20.27 ± 0.48 2.78%
Fruit 72.81 ± 2.52 11.76% 88.31 ± 1.95 *** 13.72% 83.01 ± 1.89 *** 12.83% 89.82 ± 1.10 * ˆˆˆ 12.31%
Vegetables (and
110.36 ± 1.70 17.83% 96.97 ± 1.43 *** 15.07% 101.67 ± 1.5 *** 15.71% 137.14 ± 1.22 *** ˆˆˆ 18.79%
legumes)
Grain (cereal)
109.99 ± 0.75 17.77% 113.86 ± 1.25 * 17.69% 113.98 ± 1.81 17.61% 126.95 ± 1.79 *** ˆˆˆ 17.40%
foods
Lean meats,
poultry, fish, eggs,
184.52 ± 2.76 29.81% 195.83 ± 2.39 * 30.43% 202.68 ± 2.22 * 31.32% 215.63 ± 3.61 ** ˆˆˆ 29.55%
nuts, seeds and
alternatives
Milk, yoghurt,
cheese and 112.59 ± 2.64 18.19% 120.88 ± 1.69 * 18.79% 117.1 ± 1.17 * 18.09% 129.18 ± 1.83 *** ˆˆˆ 17.70%
alternatives
Unsaturated oils
8.42 ± 0.12 1.36% 8.59 ± 0.12 1.33% 9.12 ± 0.15 ** 1.41% 10.72 ± 0.14 *** ˆˆˆ 1.47%
and spreads
Total diet 619.04 ± 7.16 100.00% 643.47 ± 5.84 * 100.00% 647.18 ± 6.94 100.00% 729.71 ± 6.30 *** ˆˆˆ 100.00%
* indicates p ≤ 0.05 difference from previous year; ** indicates p ≤ 0.01 difference from previous year; *** indicates
p ≤ 0.001 difference from previous year; ˆˆ indicates p ≤ 0.01 difference from 2019; ˆˆˆ indicates p ≤ 0.001 difference
from 2019; Bold type indicates the total diet cost.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW

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Figure
Figure
Figure
1. Cost
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and recommended
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Brisbane, 20192019
2019 to 2022.
to2022.
to 2022.

Figure 2. Cumulative increase in the costs of recommended and habitual diets and Consumer Price
Index (CPI) increases, Brisbane, 2019 to 2022.

Within the manuscript, data are presented and analysed for Greater Brisbane as a
Figure
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2019 2020 2021 2022
Proportion of Proportion Proportion of P
Mean Cost Mean Cost Mean Cost Mean Cost
Food/Food Groups Total Cost of Total Cost Total Cost of
Int. J. Environ. Res. Public Health 2023, 20, 3146 8 of 17

to September 2021, the CPI-food for Brisbane increased by 3.8%. During this period, the
assessed cost increases of the recommended diet and the habitual diet were much closer to
CPI-food; however, the cost increases in the recommended diet tended to be higher than
those in the habitual (unhealthy) diet. This differential was exacerbated in 2022 (Figure 2).
The differential between the cost of the habitual and recommended diets was 24.7% in
2019 and was similar for the following two years, being 23.9% in 2020 (p = 0.90) and 23.8%
in 2021 (p = 0.98). However, the cost differential declined significantly to 18.4% from 2021
to 2022 (p < 0.001). In 2022, the recommended diet was relatively more expensive than it
had been compared to the habitual diet in 2019 (p= 0.006).

3.5. Changes in Fortnightly Cost of Food Groups over Time

In the recommended diet, food groups with the highest cost increases from 2019 to
2022 and from 2021 to 2022, respectively, were: vegetables and legumes (20.5% and 34.9%,
both p < 0.001), grain (cereal—mostly wholegrain) foods (15.6% and 11.4%, both p < 0.001),
fruit (23.4%, p < 0.001 and 8.2%, p = 0.010), and healthy fats and oils (27.3%, 17.5%, both
p < 0.001) (Table 2). Notably the cost of ‘vegetables and legumes’ had decreased from 2019
to 2020 (−12.7%, p < 0.001) before increasing from 2020 to 2021 (4.8%, p < 0.001) and then
increased markedly from 2021 to 2022 (34.9%, p < 0.001), as noted previously. Costs of
products in the milk, cheese, and yoghurt group increased initially from 2019 to 2020 (7.4%,
p = 0.012), before declining slightly from 2020 to 2021 (−3.1%, p = 0.018), then rising most
significantly from 2021 to 2022 (10.3%, p < 0.001); an overall increase of 14.7% (p < 0.001)
from 2019 to 2022. The cost increases in the lean meats, poultry, fish, eggs, and plant-based
alternatives group were more consistent throughout the three years, increasing by 6.1%
from 2019 to 2020 (p = 0.011), 3.5% from 2020 to 2021 (p = 0.013), and 6.4% from 2021 to
2022 (p < 0.001), leading to an overall increase of 16.9% (p < 0.001) from 2019 to 2022.
From 2019 to 2022, in contrast to the marked increase in the cost of the healthy foods
and drinks in the recommended diet (17.9%), the cost of all the discretionary (unhealthy)
foods and drinks in the habitual diet increased by ‘only’ 9.0% (Table 2). There was also a
large variation in the price changes within individual components of the latter. For example,
the price of alcoholic drinks was relatively stable from 2019 to 2020, decreased in the first
years of the COVID-19 pandemic (−6.4%, p < 0.001), then increased by 3.2% from 2021 to
2022 (p < 0.001), leading to an overall decrease of −1.8% (p < 0.001) from 2019 to 2022. The
cost of sugar sweetened beverages followed a similar pattern, increasing by 12.3% (p < 0.001)
from 2021–2022, while the cost of artificially sweetened beverages increased throughout
the four timepoints by 21.5% (p < 0.001) (Table 2). Among discretionary (unhealthy) items,
the highest price increases from 2019 to 2022 were in take-away foods (14.7%, p < 0.001);
while increasing by 5.7% (p < 0.001) from 2019 to 2020, the cost of takeaway foods did not
change significantly in the first year of the COVID-19 pandemic, then increased from 2021
to 2022 (6.0%, p < 0.001).

3.6. Changes in Diet Affordability over Time

Table 3 presents household incomes at the three different levels for the reference
household per fortnight and affordability of the recommended diet in Greater Brisbane from
2019 to 2022. Affordability of the recommended diet over time is also presented in Figure 3.
Calculations of the minimum wage disposable household incomes and welfare-dependent
household incomes at the four timepoints are provided in Supplementary Tables S2 and S3.
In 2019, median gross household income per fortnight (AUD 3188.00) was 35% higher
than household income for those on minimum wage (AUD 2358.00) and 83% higher than
households on welfare income (AUD 1739.68). Due to the ESP and CS payments, both the
minimum wage disposable household income and welfare-dependent household income
in Greater Brisbane increased markedly between May and September 2020, by 41.5% and
77.3%, respectively. After the ESP and CS payments ceased early in 2021, both incomes
returned to levels only 17% and 11% higher, respectively, than in 2019 (Table 3).
Int. J. Environ. Res. Public Health 2023, 20, 3146 9 of 17

Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 9 of 17
Table 3. Household incomes (for the reference household of four, per fortnight) and affordability * of
the recommended diet, Greater Brisbane, 2019 to 2022.
(14.7%, p < 0.001); while increasing by 5.7% (p < 0.001) from 2019 to 2020, the cost of take-
2019 2020 2021 in the first year of the COVID-19
away foods did not change significantly 2022 pandemic, then

Household
Affordability of
Household
increased fromof2021 toHousehold
Affordability 2022 (6.0%, p <Affordability
0.001). of
Household
Affordability of
Income (AUD) Recommended Income (AUD) Recommended Income (AUD) Recommended Income (AUD) Recommended
Diet (%) Diet (%) Diet (%) Diet (%)
3.6. Changes in Diet Affordability over Time
Median gross 3188.00 20.8 3248.18 21.2 3317.30 20.9 3377.40 23.2
Table 3 presents household incomes at the three different levels for the reference
Minimum wage
2358.00 26.0 3336.02 19.3 per fortnight2679.10
household 24.1the recommended
and affordability of 2765.86diet in Greater
26.4
Brisbane
disposable
from 2019 to 2022. Affordability of the recommended diet over time is also presented in
Welfare 1739.68 35.6 3084.52
dependent Figure 3.20.3
Calculations of1873.27
the minimum wage 34.6 1937.15 incomes and
disposable household 37.7welfare-
dependent household incomes at the four timepoints are provided in Supplementary Ta-
* cost of diet divided by household income (‘affordable’ is <30% of income).
bles S2 and S3.

Figure 3. Affordability of the recommended diet for reference household of four in Greater Brisbane,
Figure 3. Affordability of 2019
the to
recommended
2022. diet for reference household of four in Greater Brisbane,
2019 to 2022.
Table 3. Household incomes (for the reference household of four, per fortnight) and affordability *
of the recommended diet, Greater Brisbane, 2019 to 2022.
In 2019, the reference household on median household income would have needed to
spend 20.8% of their 2019
income to purchase2020 the recommended diet 2021 in Greater Brisbane, 2022 which
House- Affordability House- Affordability House- Affordability House- Affordability
was affordable. Those households on minimum wage had to pay 26.0% of their household
hold In- of Recom- hold In- of Recom- hold In- of Recom- hold In- of Recom-
income to purchasecome the recommended
mended Diet come diet, so would
mended Diet come have been
mended inDiet
food come
stress. mended
However, Diet
welfare-dependent(AUD) households
(%) could
(AUD)not afford
(%) the recommended
(AUD) (%) diet, (AUD)
which cost(%) 35.6%
ofMedian gross income
household 3188.00 (Table20.8 3, Figure
3248.18
3). 21.2 3317.30 20.9 3377.40 23.2
Minimum
In contrast, for the first time, due to the ESP and CS introduced in 2020, the recom-
wage disposa- 2358.00 26.0 3336.02 19.3 2679.10 24.1 2765.86 26.4
mended ble diet was affordable for the reference household on welfare income, costing 20.3%
of household
Welfare income (Table 3, Figure 3). In addition, in 2020 the household on minimum
1739.68 35.6 3084.52 20.3 1873.27 34.6 1937.15 37.7
wage was no longer in food stress, with the recommended diet costing 19.3% of household
dependent
* cost of diet divided by household income (‘affordable’ is <30% of income)
income. Hence, affordability of the recommended diet and economic access to healthy diets
was similar for vulnerable In households and household
2019, median gross those onincome
median income(AUD
per fortnight in 2020. However,
3188.00) the
was 35% higher
ESP and CS were withdrawn incrementally
than household from
income for those onlate 2020wage
minimum and(AUD removed
2358.00)in early
and 2021.than
83% higher In
2021, welfare-dependent households again could not afford recommended diets, which
cost 34.6% of household income. Those on minimum wage fared better at this time, nar-
rowly avoiding food stress as the recommended diet cost 24.1% of their household income.
However, diet affordability continued to worsen in all households with the increasing cost
of food from 2021 to 2022. While approaching the food stress threshold, those on median
income could still afford the recommended diet which cost 23.2% of their household income
in 2022. Those on minimum wage were again experiencing food stress with the recom-
mended diet costing 26.4% of their household income. Most worryingly, recommended
diets were once again unaffordable for welfare-dependent households, costing 37.7% of
their household income. Since 2019, economic access to healthy diets had reduced by 11.5%
Int. J. Environ. Res. Public Health 2023, 20, 3146 10 of 17

for households on median income, 1.5% for those on minimum income, and 5.0% for those
on welfare.

4. Discussion
The Healthy Diets ASAP protocol was applied to assess the cost, relative cost, and
affordability of habitual (unhealthy) diets and recommended (healthy, equitable and sus-
tainable) diets, for a reference family of two adults and two children at three different
household income levels in Greater Brisbane once a year from 2019 to 2022. This enabled
comparison of diet costs and affordability at timepoints before and during the COVID-19
pandemic and concurrent shocks and stresses at global, national, and regional levels that
may have impacted economic aspects of food security in Greater Brisbane.
The study found that from 2019 to 2021 prices of food and drinks in greater Brisbane
increased gradually consistent with the CPI-food of 3.8% but escalated markedly between
2021 and 2022 (Figure 2). Between September 2021 and 2022, the cost of the healthy food
and drinks comprising the recommended diet increased by an average of 12.8%, nearly
double the rate of the increase in the cost of the discretionary foods and drinks in the
habitual diet during the same period (7.0%), and 42% more than the Brisbane CPI-food in
that period (8.6%).
A major contributor to the increased cost of a healthy diet from 2021 to 2022 was the
increase in fruit, vegetable, and grain prices that has been attributed to heavy rainfall and
flooding in key Queensland food production areas during that year [42]. Other previous
natural disasters, including the wild bushfires of 2019–2020, were likely to have ongoing
impacts on supply [21,43]. In October 2022, the Australian Government Treasury predicted
fruit and vegetables prices would increase a further 8% in the six months following due to
new flood events in Australian food growing regions [42].
Continuing COVID-19-related supply chain disruptions were also reported. These
included reduced workforce, such as reduced availability of international seasonal fruit
pickers due to Australian border closures and forced isolation of workers in manufacturing,
distributing, transport, and retail, including those with COVID-19 and close contacts [44,45].
Other factors included high fuel, and hence high transport costs, and high fertiliser and
feed costs due to the Russian invasion of Ukraine [25,27]. The war has also been linked
with increased cost of cereal products/bread due to constrained global wheat supply and
increased cost of cooking oil [26,46], which grew by 17.5% in the last year of this study.
Another key factor was increasing global and national inflation [25,41]. In Australia,
this exacerbated the increased price of gas and electricity, which are used for cooking, and of
fuel used for shopping [41]. The escalating cost of living also pressured essential spending,
such as on rent and mortgages for housing, which impacted spending on food [41]. As cash
rates rise to combat inflation, this can lead to increased interest payments on borrowing,
also increasing pressure on household budgets [41].
As prices of healthy foods escalate, unhealthy (discretionary and/or ultra-processed)
foods have become relatively cheaper, which influences dietary choices, particularly in
an economic downturn [47,48]. In times of financial stress, families, particularly in low
socio-economic groups, tend to purchase the cheapest and most affordable food; this is
often the less healthy products on price promotion [47,48]. This is worrying given that,
when last measured nationally in Australia (2011–2012), more than one third of adults’
energy intake, and nearly 40% of children’s, was derived from unhealthy, discretionary
food [49]. Total intake of discretionary food and drinks is associated with increased body
mass index, and lower consumption of fruit and vegetables [50]. The relatively greater
increase in the price of healthy, compared to discretionary, food and drinks during the
study likely contributed to reported reductions in the intake of fresh produce, increased
intake of unhealthy foods and weight gain during the COVID-19 pandemic [51,52].
Price is just one of many factors influencing dietary choices. Other aspects of the
‘obesogenic’ food environment [53] that drive food choices include the constant availability
and promotion of unhealthy food and drinks, and convenience. These factors may explain
Int. J. Environ. Res. Public Health 2023, 20, 3146 11 of 17

why the cost of take-away foods increased more than other unhealthy foods and drinks
during this study (Table 2). Better promotion of healthy food and drinks and improvement
in the nutrient profile of some convenience foods (e.g., reduction of salt content [54]) may
contribute to healthier dietary intakes.
A common perception that healthy foods are more expensive than unhealthy options is
also relevant [2,55–58]. However, the studies supporting this are not grounded in reported
dietary intakes such as the Healthy Diets ASAP protocol [28,29,32]. For example, they often
cost arbitrary ‘healthy’ and ‘unhealthy’ food lists and often exclude alcohol and take-away
foods, which comprise 20–25% of the cost of habitual Australian diets [28]. Results are also
reported in different units (price per energy or weight unit, serve or nutrient-density) and
analysis is frequently spurious [59]. Corresponding with findings of previous research,
this study confirmed that healthy diets can be less expensive than habitual diets. Studies
applying the Healthy Diets ASAP protocol have found that habitual diets are 14% to
23% more expensive than the recommended diet in Brisbane [28,32], across regional and
remote areas of Queensland [17], in Sydney and Canberra [60], in regional Victoria [61], in
remote Aboriginal and Torres Strait Islander communities [62,63], and nationally in areas
serviced by the two large supermarket chains [64].
However, the cost differential between the diets reduced in 2022, reflecting the dif-
fering pricing and relative composition of the habitual and recommended diets. As the
recommended diet comprises only healthy food and drinks, its total cost increased at
a higher rate than the total cost of the habitual diet, which includes lesser quantities of
healthy foods but many unhealthy items. A similar differential decrease was identified
also in remote Aboriginal communities in Central Australia; in these communities between
May 2021 and June 2022, the cost of the habitual diet increased approximately 5%, while
the cost of the recommended diet increased by around 10% [65].
Despite the reduced cost differential (18.4% in 2022 down from 24.7% in 2019), the
cost saving for households buying the recommended diet rather than the habitual diet
remained significant in 2022—AUD 134.22 per fortnight for the reference household in
Greater Brisbane. However, this was approximately AUD 20 per fortnight less than during
the preceding years. Especially at a time of increased pressure on household budgets
and financial stress [66], this likely reduced the financial incentive for households to
improve their diet. Urgent action is needed to further increase the relative affordability of
recommended diets compared to habitual diets.
The lower cost of recommended diets compared to habitual diets is largely attributable
to the exemption of “basic, healthy foods” from the 10% Goods and Services Tax (GST)
in Australia, which helps to keep the relative price of healthy food and drinks down.
Modelling studies support increasing the GST on unhealthy food and drinks to 20% to
increase the incentive for consumers to choose healthier options [32,67]. Targeted levies,
such as 30% GST on sugar-sweetened beverages also have been suggested to discourage
intake of specific choices harmful to health [68].
Analysis of data collected annually from 2019 to 2022 highlighted the impact on
affordability of recommended diets during the temporary increases to income support
for the most vulnerable households during the early months of the COVID-19 pandemic.
The ‘natural experiment’ created when the Australian Government provided the ESP and
CS, effectively doubling welfare income for those on JobSeeker in 2020, demonstrated that
increasing household income raised an estimated 646,000 people above the poverty line [69]
and made healthy diets affordable for welfare-dependent families for the first time [21].
Affordability of the recommended diet improved dramatically for low-income house-
holds in 2020, due to government provision of the ESP and CS from April. Affordability of
recommended diets improved by 42% for welfare-dependent households. More than 90%
of recipients of the ESP and CS income supplements reported that they could afford more
healthy foods, including fruit and vegetables [70].
Findings of other studies and surveys confirm a positive impact of increased in-
come support on food security and households’ capacity to buy healthy food [19,71] and
Int. J. Environ. Res. Public Health 2023, 20, 3146 12 of 17

subsequent increases in the prevalence of poverty and food insecurity after the income
supplements decreased and then ceased (March 2021) [19,72]. Recommended diets became
unaffordable for welfare-dependent households again, requiring 34.6% of their disposable
income in 2021, and 37.7% in 2022. Families unable to commit such a large proportion
of their disposable income to food because of other escalating living costs (particularly
rent, household utilities such as electricity, and fuel/transport) report not being able to buy
enough food or skipping meals to save money [73]. Low household income is the most
consistent determinant of food insecurity [74].
The results of this study have highlighted that CPI-food is a blunt economic instrument.
To help more usefully and transparently identify the likely health consequences of the
changing prices of foods, it is recommended that the CPI-healthy food be determined
and reported. A potential model for this was the ABS Australian Dietary Guidelines CPI
reported in 2015 [75].

Limitations
For this study it would have been ideal if COVID-19-related ‘JobKeeper’ payments
made to businesses to support staff whose working hours were reduced during the pan-
demic could have been included in addition to ‘JobSeeker’ payments. However, it was too
difficult to tease out ‘JobKeeper’ entitlements and payments at the household level; hence,
the incomes calculated only reflect those made primarily to low-income households. It
should be noted that median income may have varied for some employees ‘stood down’
during the early years of the COVID-19 pandemic. However, this would not have affected
the findings relevant to households on minimum wage or dependent on welfare.
There are inherent methodological limitations to the Healthy Diets ASAP protocol
that have been reported elsewhere [28]. Most pertinent to this analysis, they include
assumptions used in income calculations that did not include the possibility of low-income
households receiving the JobKeeper supplement in 2020, for example.
The most recent available national dietary intake data were collected in Australia in
2011–2012 [3]. It is likely ‘habitual’ diets of Australian families have changed in line with
changes in the food supply and environment in recent years, including the rapid growth of
meal delivery services [76,77], but recent granular data on diet patterns are not available
currently. It is anticipated that updated national dietary intake data will be available in
2025 from the planned 2023 Australian Intergenerational Health and Mental Health Study
(incorporating the National Nutrition and Physical Activity Survey) [78]. For the first time,
national food security data will also be assessed robustly in this study [78].
The price collection protocol of Healthy Diets ASAP includes collection of the prices of
major Australian brands for packaged food and drinks. Some households, particularly low
socioeconomic households, may choose to purchase lower priced generic products (‘home’
or ‘own’ brands) and/or shop at ‘budget’ supermarkets as a coping strategy to stretch
food budgets [79]. However, when applying this strategy, recommended diets can still
be stressful to afford for welfare-dependent households [79], and are likely to be more so
given the identified price rises of unpackaged healthy foods (such as fruit and vegetables)
in this study.
Surveys were conducted only in urban locations in one state capital city in Australia,
hence observed changes in food costs are not generalisable directly to other locations
nationally, or other countries internationally. However, particularly for low-income groups,
they do highlight current challenges in maintaining economic access to food security and
healthy diets and help explain diet-related health inequities seen in Australia [79,80].

5. Conclusions
Having the ability to adequately feed ourselves is a basic human right; this requires
that food must be affordable without compromising any other essential needs, such as
secure housing (rent) or medicines [81]. Over the three years since 2019, the cost of food
and drinks has escalated, particularly in the most recent year, with the prices of healthy
Int. J. Environ. Res. Public Health 2023, 20, 3146 13 of 17

foods and drinks increasing at almost double the rate of increase in prices of unhealthy
items. The recommended diet remains less expensive than the habitual diet, but the cost
differential reduced significantly between 2021 and 2022, rendering recommended diets
relatively less affordable than habitual (unhealthy) diets. The development and publication
of a CPI-healthy food index would help better identify health and related economic risks.
Findings highlight the potential impact of government policy settings on the affordabil-
ity of food and economic aspects of food security, and hence dietary choices and diet-related
health such as obesity, cardiovascular disease, type 2 diabetes, and some cancers. Despite
effective relief conferred by the ESP and CS while paid, recommended diets have become
increasingly unaffordable for Australian families on low income, and are less affordable
now than before the COVID-19 pandemic. Affordability of healthy food could be guar-
anteed by government commitments to help families access essential needs, and also by
commitments to keep basic, healthy food and drinks GST-free. Additional benefits would
be delivered if GST on unhealthy foods and drinks was increased to 20%. This could help
encourage healthier choices, and the revenue raised could be hypothecated to nutrition and
health promotion programs. Permanently increasing welfare support and providing an
adequate minimum wage would enable low-income households to meet the costs of living
and afford adequate healthy food, to protect their food security and diet-related health.

Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/ijerph20043146/s1, Figure S1: Total recommended diet and food group
costs in all 10 locations (F to O) from 2019 to 2022; Figure S2: Total habitual diet and food group costs
in 10 locations (F to O) from 2019 to 2022; Table S1: Total diet and food group costs by SEIFA quintile
from 2019 to 2022; Table S2: Calculations of minimum wage disposable household incomes for the
reference household per fortnight from 2019 to 2022; Table S3: Calculations of welfare-dependent
household incomes for the reference household per fortnight from 2019 to 2022.
Author Contributions: Conceptualization, A.J.L. and M.L.; methodology, A.J.L. and M.L.; software:
M.L.; sampling, A.J.L. and M.L.; data collection, L.-M.H., R.C.T., S.N., A.D. and M.L.; formal analysis,
A.J.L., M.L., M.D.C., S.N., A.D. and R.C.T.; writing—original draft preparation, A.J.L., L.-M.H. and
M.L.; writing—review and editing, A.J.L., M.L., M.D.C., S.N., A.D., R.C.T. and L.-M.H.; supervision,
A.J.L., M.L. and L.-M.H.; project administration, A.J.L. and M.L.; funding acquisition, A.J.L.; All
authors have read and agreed to the published version of the manuscript.
Funding: Funding for this research study was provided partially by the Australian Government’s
Medical Research Future Fund (MRFF). The MRFF provides funding to support health and medical
research innovation, with the objective of improving the health and wellbeing of Australians. MRFF
funding was provided through The Australian Prevention Partnership Centre under the MRFF
Boosting Preventive Health Research Program (BP3). Further information on the MRFF is available
at www.health.gov.au/mrff (accessed on 3 January 2023). This project has also been supported in
part by the National Health and Medical Research Council (NHMRC) funded Centre of Research
Excellence in Food Retail Environments for Health (RE-FRESH) (APP1152968). The opinions, analysis,
and conclusions in this paper are those of the authors and should not be attributed to the NHMRC.
Institutional Review Board Statement: The University of Queensland Research Ethics Committee
assessed this study as meeting the conditions for exemption from Human Research Ethics Committee
review and approval in accordance with Section 5.1.22 of the National Statement on Ethical Conduct
in Human Research (2007). The Ethics Clearance numbers are 2019000561 and 2021/HE001933. All
data were obtained from publicly available sources and did not involve human participants.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data presented in this study are available in this article and its
Supplementary Materials.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.
Int. J. Environ. Res. Public Health 2023, 20, 3146 14 of 17

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