The Cost of Healthy Eating

Portland State University Portland State University

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University Honors Theses University Honors College

Spring 6-16-2024

The Cost of Healthy Eating The Cost of Healthy Eating

Diana Prychyna

Portland State University

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Prychyna, Diana, "The Cost of Healthy Eating" (2024).

University Honors Theses.

Paper 1543.

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The Cost of Healthy Eating

Diana Prychyna

An undergraduate honors thesis submitted in partial fulﬁllment of the

requirements for the degree of

Bachelor of Science

University Honors

and

Public Health Studies: Health Services Administration

Thesis Advisor

Dr. Bory Kea, MD, MCR, FACEP

Portland State University

2024

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Introduction

In the United States, 6.7 million adults are affected by Heart Failure (HF) each year

, and

there are nearly 1 million Emergency Department (ED) visits for Acute Heart Failure (AHF)

each year

. Over 80% of those patients seen in the ED for AHF are hospitalized

, and 25% of

patients that are hospitalized, are readmitted, or die within 30 days after discharge from the

hospital

. Many care transition programs have been created to improve care transitions for these

patients at the time of their discharge from the hospital, including our Implementation Program,

Get With the Guidelines in Emergency Department Patients With Heart Failure (GUIDED-HF).

Since July of 2016

, GUIDED-HF has proven to help improve these adverse health outcomes

(quality of care and outcome disparities, hospital readmissions within 30 days after discharge, or

death within 30 days of discharge

)

6-8

. However, we have not focused any of our efforts on

helping improve the same adverse health outcomes as listed above for the population of patients

who visit the ED for AHF-related reasons/symptoms and are discharged directly home without

hospital admission (~15-20% of the 1 million AHF cases in the ED each year)

. A new study was

created to apply the implementation program, GUIDED-HF, to this population to improve their

adverse health outcomes as well.

To further explain the care transition program, the GUIDED-HF Implementation Program

is a self-care coaching program designed to improve self-care maintenance in patients

. The

study has created ‘Self-Care Coaches’, which are trained research coordinators that assist in

delivering the GUIDED-HF Implementation Program. The Implementation Program has 4 main

areas that Self-Care Coaches focus on during home health visits with patients. These four areas

are disease education, lifestyle interventions, guideline recommendations for medications and

device referrals, and outpatient follow-up appointments

. The Self-Care Coach evaluates a

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patient’s current self-care maintenance and educates patients in their self-care: setting up a

follow-up appointment with a primary care provider and cardiologist, promoting adherence to

prescription medications, monitoring weight and symptoms, eating a low-sodium diet, increasing

fluid intake and daily exercise/activity, and limiting harmful habits such as smoking

. Self-Care

Coaches are also provided with various resources that they can offer to patients. Some of these

resources include a low-sodium cookbook (Don’t Pass the Salt!) created by the American

Association of Heart Failure Nurses, tracking templates for weight and water pill intake, and

weight scales, to name a few.

As a Self-Care Health Coach for GUIDED-HF’s Implementation Program, important

gaps in self-care maintenance in a specific patient population have been identified that are not

addressed by our intervention program. This patient population consists of older adults, those of

retirement age (62 or older), living alone in a one-person household, who receive government

assistance (food stamps income from the federal Supplemental Nutrition Assistance Program

(SNAP)), and who experience struggles with daily living and affording a Heart Failure-friendly

diet. According to the American Heart Association, Centers for Disease Control and Prevention,

and the National Heart, Lung, and Blood Institute, a Heart Failure-friendly diet consists of fresh

fruits and vegetables, whole grains, plant protein, and lean poultry, while avoiding processed

foods, high-sodium, and high-sugar foods

9-11

. These patients, after receiving the cookbook

provided by GUIDED-HF, “Don’t Pass the Salt!” from the American Association of Heart

Failure Nurses, reported that they could not afford a Heart Failure-friendly diet with the

assistance they currently receive from the SNAP program. There is a pressing need to understand

why a patient, 62 years of age or older, living alone in a one-person household, and receiving

government assistance, cannot afford a Heart Failure-friendly diet. This is imperative to increase

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understanding of whether the SNAP program is offering a sufficient amount of food stamps

income for people who have chronic diseases such as heart failure and need to eat a specific diet,

and adjusting for our current economy and inflation; how this common social determinant of

health (economic stability) is affecting our specific population in question; and to investigate

what alternative solutions are available, if there are any.

Our overall goal was to understand if a Heart Failure-friendly diet is affordable on a food

stamps income from the SNAP program and to investigate if there are any alternative solutions to

lift this financial burden off of patients. We hypothesized that the current food stamps income

from the SNAP program for a one-person household would not be sufficient to sustain a Heart

Failure-friendly diet, but that there would be alternative solutions, and that the results of this

study would be substantial and contribute to the growing research on social determinants of

health and the link between health status and economic stability.

Aims:

This study has 3 different aims to better understand if a Heart Failure-friendly diet is

affordable on a SNAP food stamps income and to investigate if there are any alternative

solutions to lift this financial burden off of patients, if there is a financial burden:

Aim #1:

o Evaluate if a 1-month-long randomly chosen meal plan from the GUIDED-HF

cookbook will be affordable (using only Fred Meyer grocery stores) on a food

stamps income for a retired adult living in a one-person household in Portland,

and in Hillsboro, Oregon, and compare the results.

Aim #2:

o Evaluate the GUIDED-HF cookbook to determine the least expensive and most

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expensive recipes for breakfast, lunch, and dinner, then evaluate if a 1-month long

meal plan based on the least expensive and most expensive meals will be

affordable (using only Fred Meyer grocery stores) on a food stamps income for a

retired adult living in a one-person household in Portland, and in Hillsboro,

Oregon, and compare the results.

Aim #3:

o Evaluate available resources that distribute food or meals to residents in Portland,

and Hillsboro, Oregon, and discuss how they can be potential, alternative, or

concurrent solutions to the food stamps budget for a retired adult living in a one-

person household.

Methods:

For this study, we collected data on: the SNAP maximum monthly allotment for a retired

adult living in a one-person household, the cost of each meal from the GUIDED-HF provided

cookbook to determine meal plan costs, and the available resources in Portland and Hillsboro,

Oregon. The duration of this research study was 30 days based on the required meal plan length

needed to compare the cost of healthy eating to the SNAP maximum monthly allotment

information mentioned above. Data was collected between October and November of 2023.

We collected data on the federal SNAP maximum monthly allotment for a retired adult

living in a one-person household from the United States Department of Agriculture Food and

Nutrition Service publicly available data source. We collected the federal SNAP maximum

monthly allotment limit as opposed to a state-specific limit because state limits do not exist and

are solely based on the federal limits that are set for all states in the US.

Utilizing the GUIDED-HF provided cookbook, we created three 1-month-long meal

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plans consisting of 1) a randomly-selected meal plan, 2) a least-expensive meal plan, and 3) a

most-expensive meal plan. For all three meal plans, we separated the recipes in the GUIDED-HF

cookbook into breakfast, lunch, and dinner recipes based on our discretion. For the randomly-

selected meal plan, we assigned each recipe in each category (breakfast, lunch, and dinner) a

number, and then a computer random number generator had generated a number for each

category that was then selected as the randomly-chosen meal for the meal plan. For instance, we

had 20 recipes in the lunch category, which were labeled between 1 and 20. Using a random

number generated with a minimum of 1 and a maximum of 20, the number 12 was selected,

which corresponded with the recipe for “Curried Chicken”. For the least-expensive and the most-

expensive meal plans, the selected recipes for breakfast, lunch, and dinner were assigned after

collecting data on all the recipes and their respective costs.

Based on the ingredients in each recipe from the GUIDED-HF cookbook, we collected

data on the costs of these ingredients online at Fred Meyer grocery stores*. We chose 1 Fred

Meyer grocery store within the largest cities in Multnomah County (Portland) and Washington

County (Hillsboro)**. We collected and sorted data by the city/county (Portland/Multnomah

County and Hillsboro/Washington County). To collect the price data of each ingredient for each

recipe, we used the Fred Meyer website to select a specific Fred Meyer grocery store and to filter

products according to “In-Store” and “SNAP EBT Eligible” items only. We then searched for

each ingredient for each recipe and selected the smallest and least-expensive option available

(we collected the price of the whole item and not its specific portion size respective to the recipe,

i.e. the price of a whole bottle of olive oil as opposed to the price of a portion required for a

recipe, however, we did search for the smallest size and least-expensive option available in an

effort to make the recipe and meal plan costs as accurate as possible).

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After collecting the price data of each ingredient for each recipe, we calculated the total

cost of each recipe, then aggregated the price data to collect the daily meal plan cost, and the

monthly meal plan cost. We then analyzed whether or not these same three meals, if eaten every

day for one month (for breakfast, lunch, and dinner), would be affordable based on a food stamps

income for a one-person household. We also compared the data collected in Portland in

Multnomah County versus in Hillsboro in Washington County to determine if there is any

variation in ingredient prices/meal costs by city/county. In total, we collected six meal plan costs;

the cost of the 1) randomly-selected, 2) least-expensive, and 3) most-expensive meal plan at the

Portland Fred Meyer location, and the Hillsboro Fred Meyer location.

*Fred Meyer is a hypermarket grocery store chain found in all parts of the Portland Metropolitan area, and is a

lower-priced store that has both organic and conventional food. It was bought by Kroger in 1998. The cost of

all ingredients can be found using their website or app, and one can select a specific store within a city or

county.

**We are choosing 1 Fred Meyer grocery store from the city of Portland in Multnomah County and the city of

Hillsboro in Washington County as these are the most populated cities in each county, and the GUIDED-HF

study has study sites in Portland (OHSU) and Hillsboro (HMC). The Fred Meyer grocery store from the city

of Portland in Multnomah County is located at 100 NW 20

Pl, Portland, OR 97209. The Fred Meyer grocery

store from the city of Hillsboro in Washington County is located at 6495 SE Tualatin Valley Hwy, Hillsboro,

OR 97123.

Results:

Collected from the United States Department of Agriculture Food and Nutrition Service

publicly available data source, the SNAP maximum monthly allotment for a 1-person household

is $291

. In the State of Oregon, this maximum monthly allotment for a retired older adult living

alone may be lower than the federal maximum monthly allotment based on a variety of factors

such as out-of-pocket medical costs and shelter costs

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Meal Plans/Meals

Recipe Description

Portland Meal

Cost for 1-Day

Hillsboro Meal

Cost for 1-Day

Randomly-Selected

Breakfast

Easy Pancakes

$7.27

$7.17

Lunch

Curried Chicken

$38.89

Dinner

Aunt Gloria’s Greens

$9.81

Total 1-Day Cost:

$55.97

$55.87

Least-Expensive

Breakfast

Easy Pancakes

$7.27

$7.17

Lunch

Easy Rolled Biscuits

$4.68

Dinner

Easy Drop Biscuits

$4.68

Total 1-Day Cost:

$16.63

$16.53

Most-Expensive

Breakfast

Fresh Blueberry Muffins

$25.92

$25.82

Lunch

Sweet and Sour Chicken Tenders

with Rice

$48.38

Dinner

Turkey Stuffing

$56.63

Total 1-Day Cost:

$130.93

$130.83

Table 1: Breakdown of all Six Meal Plans by 1-Day Costs According to Meal/Recipe and City.

Meal Plans/Meals

Recipe Description

Portland Meal

Cost for 30-Day

Hillsboro Meal

Cost for 30-Day

Randomly-Selected

Breakfast

Easy Pancakes

$218.10

$215.10

Lunch

Curried Chicken

$1,166.70

Dinner

Aunt Gloria’s Greens

$294.30

Total 30-Day Cost:

$1,679.10

$1,676.10

Least-Expensive

Breakfast

Easy Pancakes

$218.10

$215.10

Lunch

Easy Rolled Biscuits

$140.40

Dinner

Easy Drop Biscuits

$140.40

Total 30-Day Cost:

$498.90

$495.90

Most-Expensive

Breakfast

Fresh Blueberry Muffins

$777.60

$774.60

Lunch

Sweet and Sour Chicken

Tenders with Rice

$1,451.40

Dinner

Turkey Stuffing

$1,698.90

Total 30-Day Cost:

$3,927.90

$3,924.90

Table 2: Breakdown of all Six Meal Plans by 30-Day Costs According to Meal/Recipe and City.

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Graph 1: Federal SNAP Maximum Monthly Allotment Compared to Monthly Meal Plan Costs

Graph 1: by City.

Table 1 is a breakdown of the cost of all six meal plans by each meal/recipe and each city

for one day. Table 2 is a breakdown of the cost of all six meal plans by each meal/recipe and each

city for 30 days. Graph 1 is a comparison of the 30-day meal plan costs for each city to the

SNAP maximum monthly allotment for a retired adult living in a one-person household.

For the randomly-selected meal plan, the breakfast meal was “Easy Pancakes”, the lunch

meal was “Curried Chicken” and the dinner meal was “Aunt Gloria’s Greens”. At the Portland

Fred Meyer location, the cost of this meal plan for one day was $55.97, and a 30-day meal plan

costs $1,679.10. At the Hillsboro Fred Meyer location, the cost of this meal plan for one day was

$55.87, and a 30-day meal plan costs $1,676.10.

For the least-expensive meal plan, the breakfast meal was “Easy Pancakes”, the lunch

meal was “Easy Rolled Biscuits”, and the dinner meal was “Easy Drop Biscuits”. At the Portland

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Fred Meyer location, the cost of this meal plan for one day was $16.63, and a 30-day meal plan

costs $498.90. At the Hillsboro Fred Meyer location, the cost of this meal plan for one day was

$16.53, and a 30-day meal plan costs $495.90.

For the most-expensive meal plan, the breakfast meal was “Fresh Blueberry Muffins”, the

lunch meal was “Sweet and Sour Chicken Tenders with Rice”, and the dinner meal was “Turkey

Stuffing”. At the Portland Fred Meyer location, the cost of this meal plan for one day was

$130.93, and a 30-day meal plan costs $3,927.90. At the Hillsboro Fred Meyer location, the cost

of this meal plan for one day was $130.83, and a 30-day meal plan costs $3,924.90. For all three

meal plans, the meal plans were $3 cheaper when shopping at the Hillsboro Fred Meyer location

as opposed to the Portland Fred Meyer location.

The only ingredient that contributed to this cost difference for all three meal plans was

eggs, which were $0.10 cheaper at the Hillsboro Fred Meyer location than at the Portland Fred

Meyer location.

In the State of Oregon, there are numerous food resource options available to the public.

Some food resource options are completely free and available to the public without restrictions,

or requiring some contact and reporting information like name and household or SNAP income,

while others have eligibility requirements that individuals must meet, such as having an income

level below the federal poverty line. One particular website, 211info.org, has a list of over 1,000

food resources that are available in Oregon and Southwest Washington, which include state and

local government resources, nonprofit organization resources, food pantries, farmers markets,

and more

. Specific to the city of Portland, there are food pantries, food markets, and food banks

at a variety of locations. The Oregon Food Bank has a Food Finder website

to assist individuals

in finding resources near them. Specific to the city of Hillsboro, there is a Free Food Market

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the Hillsboro Food Pantry

, a “Food 2 You” Program

, and many more food resources offered

by Hillsboro-based churches

Conclusions/Discussion:

As a Self-Care Health Coach for GUIDED-HF’s Implementation Program, important

gaps in self-care maintenance in a specific patient population have been identified that are not

addressed by our intervention program. Retired older adults who receive government assistance

in the form of food stamps from the SNAP program reported not being able to afford a Heart

Failure-friendly diet based on the cookbook provided by GUIDED-HF. This inspired the creation

of a sub-study, The Cost of Healthy Eating, which focused on understanding if a retired older

adult living alone could afford a Heart Failure-friendly diet based on meal plans created from the

GUIDED-HF cookbook and respective meal costs collected from Fred Meyer grocery stores in

two urban cities in Oregon, Portland and Hillsboro.

Based on the data and results, all six meal plans exceeded the SNAP maximum monthly

allotment. The SNAP maximum monthly allotment for a one-person household is $291. In

Portland, the randomly chosen 30-day meal plan costs a total of $1,679.10, the least expensive

30-day meal plan costs a total of $498.90, and the most expensive 30-day meal plan costs a total

of $3,927.90. In Hillsboro, the randomly chosen 30-day meal plan costs a total of $1,676.10, the

least expensive 30-day meal plan costs a total of $495.90, and the most expensive 30-day meal

plan costs a total of $3,924.90.

An important note to remember is that the true cost of a meal could not be calculated as

each meal called for a certain amount/portion of an ingredient, and an individual would have to

purchase the full-sized item at a grocery store. This study and the cost of each meal were

calculated as if an individual would have to repurchase the full-sized ingredients every day for

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each meal. Although this is not the case in real life, due to the limitations of this study, the data

was collected this way, and the results were interpreted based on those prices. Further research,

evaluation, and analysis are needed to find the true cost of a meal and compare it to the SNAP

maximum monthly allotment for a one-person household in order to better assess the

affordability of healthy eating against economic realities for retired adults with Heart Failure.

Limitations:

Given our data collection methods in this study, many limitations need to be recognized

and acknowledged. First, this study only considered the older adults (those of retirement age)

population. Although individuals under 62 years of age may also receive a food stamps income

from the SNAP program, there are other programs they may become eligible for as well, such as

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Additionally,

this study only looked at one-person households, as multiple-person households create an

endogenous variable that may be difficult to measure, since their food stamps income may be

used to purchase food for all individuals in the household, or they may receive additional

benefits to support all individuals in the household. There are also other variables we were

unable to assess in this research study. Depending on where an individual lives, there may be

factors that affect their ability to go to the cheapest grocery store, or in the case of this specific

study, a Fred Meyer grocery store. The distance of the store from their home will affect their

ability to go to that store. The cost of gas, health stamina (if they can walk to the store), and the

safety of their neighborhood, are just a few examples of variables that need to be acknowledged.

Lastly, we could not acknowledge the nutritional value of meal plans, due to the format of the

cookbook and the nature of this study, however, the nutritional value of meal plans is important

with respect to healthy eating, which may or may not increase the costs of a meal plan.

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Acknowledgements:

Work reported in this thesis was inspired by the Patient-Centered Outcomes Research

Institute (PCORI) DI-2020C2-20363 GUIDED-HF Study and supported by the National

Institutes of Health Common Fund and Office of Scientific Workforce Diversity under three

awards UL1GM118964, RL5GM118963, and TL4GM118965, administered by the National

Institute of General Medical Sciences.

The work is solely the responsibility of the author and does not necessarily represent the

official view of the Patient-Centered Outcomes Research Institute or National Institutes of

Health.

A special thank you to my PI/Thesis Advisor, Dr. Bory Kea, MD, MCR, FACEP, Center

for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon

Health & Science University, and team: Miriam R. Elman, MS, School of Public Health, Oregon

Health & Science University-Portland State University; Joy Kim, BS, Center for Policy and

Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health &

Science University; Karen F. Miller, RN, MPA, Vanderbilt University; Deonni P. Stolldorf, PhD,

RN, Vanderbilt University; Sean P. Collins, MD, MSc, Vanderbilt University.

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