Research report Dietary diversity and food expenditure as indicators of food security in older Taiwanese q Yuan-Ting Lo a , Yu-Hung Chang b , Meei-Shyuan Lee a,c,d , Mark L. Wahlqvist a,c,d,e,⇑ a Graduate Institute of Life Sciences, National Defense Medical Center, Taiwan, ROC b Division of Health Policy Translation, Institute of Population Health Sciences, National Health Research Institutes, Taiwan, ROC c School of Public Health, National Defense Medical Center, Taiwan, ROC d Monash Asia Institute, Monash University, Victoria, Australia e Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli 35053, Taiwan, ROC article info Article history: Received 24 June 2011 Received in revised form 18 August 2011 Accepted 30 September 2011 Available online 5 October 2011 Keywords: Dietary Diversity Score (DDS) Social security Food cost Taiwanese elderly Food security Poverty abstract Food quality is a measure of food security in vulnerable groups. The elderly are often nutritionally vulnerable, but how much of this is reflected in food quality and determined by financial status is unclear. We determined whether expenditure on dietary quality challenges food security in the aged. We used the representative Elderly Nutrition and Health Survey in Taiwan during 1999–2000 (n = 1783), and evalu- ated dietary quality by a Dietary Diversity Score (DDS, range: 0–6) based on a 24-h dietary recall. Monthly mean national food prices were used to estimate food expenditure. In general, it was found to cost more to achieve a greater DDS. The food expenditure of subjects whose DDS = 6 was 2.20 times greater than the DDS 63 group, after controlling for covariates. Elders of lower socioeconomic status tended to choose foods which would have cost less. However, a sub-group of elders who achieve the highest DDS with lim- ited money offer approaches to food-money management. Nutrition policy directed to food insecure groups, like the aged, could employ health promotion strategies which reduce financial barriers to healthy eating. Ó 2011 Elsevier Ltd. All rights reserved. Introduction Food security is a growing concern worldwide and its measure can facilitate development of improved health policy. Researchers use proxy measures such as coping strategy indices, food expendi- ture, and dietary diversity for different aspects of food security (Bar- rett, 2010; Thorne-Lyman et al., 2010). Food diversity has been shown to be important for health – both in increasing the likelihood of nutrient adequacy and lowering mortality rates (Bernstein et al., 2002; Kant, Schatzkin, Harris, Ziegler, & Block, 1993; Lee, Huang, Su, Lee, & Wahlqvist, 2011; Marshall, Stumbo, Warren, & Xie, 2001; Wahlqvist, Kouris-Blazos, & Savige, 2002; Wahlqvist & Specht, 1998). Hence, dietary diversity is a health-related indicator for die- tary quality and a useful means of measuring food security (Hoddi- nott & Yohannes, 2002; Ruel, 2003). The Dietary Diversity Score (DDS) considers both food group numbers and servings and, as developed by Kant, can be a practical and simple tool for these pur- poses in individuals (Kant et al., 1993). It has demonstrable predic- tive power for health outcomes, notably mortality, for the elderly in particular (Lee et al., 2011), unlike some other available food vari- ety instruments where such evidence is pending (FAO, 2008, 2011; Hodgson, Hsu-Hage, & Wahlqvist, 1994; Ruel, 2003). For older people, the choice and consumption of food is deter- mined especially by quality, taste, health and economic consider- ations (Lilley, 1996). However, only a few studies have considered the economics of food choice (Cade & Booth, 1990; Drewnowski, Darmon, & Briend, 2004; Lo, Chang, Lee, & Wahlqvist, 2009; Monsiv- ais & Drewnowski, 2007). That food cost of healthy diets is likely to be more burdensome is evident in Western food patterns (Kettings, Sinclair, & Voevodin, 2009), but few studies have considered this possibility in Asian food cultures or older groups. Taiwan has a higher elderly poverty rate compared to twelve Western OECD countries (Tai & Pixley, 2008) and poor elders often have to curb their spending on food to have money for medical ex- penses (Wu, 2009), despite a national health insurance scheme. There is a need to identify means by which food security might be achieved in the face of limited resources for Taiwanese elderly. The present study explores the association between DDS as a measure of food quality and security in relation to food expendi- ture among a representative Taiwanese elderly population. 0195-6663/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2011.09.023 q Acknowledgments: We are thankful for the financial support provided by the National Science Council (NSC100-2320-B- 016-005) and the National Health Research Institutes for food price data collection. The Institute of Biomedical Sciences of Academia Sinica and the Research Centre for Humanities and Social Sciences, Centre for Survey Research, Academia Sinica, provided the NASHIT Elderly dataset. ⇑ Corresponding author. E-mail address: profmlw@nhri.org.tw (M.L. Wahlqvist). Appetite 58 (2012) 180–187 Contents lists available at SciVerse ScienceDirect Appetite journal homepage: www.elsevier.com/locate/appet