N° 83 | November 2013

Spending on vegetable and fruit consumption could reduce all-cause mortality among older adults.

Food insecurity in vulnerable groups

The WHO asserts that the global food price crisis threatens public health and jeopardizes the health of the most disadvantaged groups such as women, children, the elderly and low-income families1. Economic factors play a crucial role and could affect personal nutrition status and health. Poorer households facing food insecurity may be in fear of running out of food, or money to buy food, and face food scarcity. In many cases, they purchase cheaper foods than usual or simply go without food for a day or more2.

Economic factors could threaten elderly diets and health

Some elderly people are at risk of malnutrition because of food insufficiency, with consequential lower intakes of various nutrients. In these instances the foods which provide these nutrients, like vegetables and meat are missing from their dietary variety3. For this group, the choice and consumption of food is determined especially by quality, taste, health and economic considerations4. Moreover, poor elders often have to curb their spending on food to have money for medical expenses (ironically, often nutritionally related)5.

Better dietary quality costs more

The food cost of healthy diets may be more burdensome. In a recent study, we found that, despite taking account of livelihood and income (personal or household), a more diverse diet was associated with higher total food expenditure among a representative Taiwanese elderly population6. Elders of lower socioeconomic status tended to choose foods which would have cost less. In addition, elders with the best dietary diversity spent about twice as much on meats and vegetables as those whose dietary diversity was the worse. Compared to those with poor dietary diversity, the best dietary diversity group’s expenditure on dairy and fruits was fourfold and six-fold, respectively.

Vegetable and fruit expenditures are associated with less risk of death in the elderly

Wealthy households have higher expenditures on animal-source foods, vegetables, and fats and oils compared to moderately and severely food-insecure households7. Greater vegetable, legume (beans), and fruit intakes are linked to reduced risk of all-cause mortality in older populations8-10. This may be because of a corresponding reduction in the intake of other less nutritious foods11. In rural Indonesia, households that spend a greater proportion on plant foods have a lower under-5 child mortality12. In our study of Taiwanese elders, fruit and vegetable (F&V) - but not other food - expenditures, had a protective effect on all-cause mortality. Those whose vegetable intake was Q4 (61-80th percentiles) but not Q5 (81-100th percentiles) had a 45% lower all-cause mortality compared to those in Q1 (the lowest 20%), and for fruit had a 36% lower all-cause mortality13. The amount of food consumed in this group (Q4) for vegetables was 463 g/d and for fruit 377 g/d, which met WHO recommendations. This fits in with public health policy that encourages people to eat five servings of fruit and vegetables a day10,13. Moreover, if older adults increased food expenditure by NT$15 (or US$0.50) per day, with vegetables they would have a 12% lower risk of death, and with fruit, a 10% lower risk of death. A NT$15 increase for each of these food expenditures should not be an economic barrier for most older Taiwanese, but may well be for the socioeconomically marginalized.

Policy implications

That greater F&V intakes can benefit survival is evident9,10. However, physical factors such as chewing ability14 and economic factors can limit F&V intakes among older adults. Indeed, the entire food system contributes to the availability, affordability and utility of F&V intakes; in this regard, it is noteworthy that shopping, food storage and food preparation are involved and improve health outcomes15,16. Public health policy should not only focus on promoting healthy diets or increasing F&V intake per se, but on the reduction of economic barriers to affordable healthy foods, especially F&V. Health departments also need to plan for seasonality and natural disasters (such as typhoons in Taiwan), which can alter the F&V supply dramatically and drive up prices quickly. The resultant unaffordability for the economically marginalized, notably elders and the socially disadvantaged may thereby be minimized. It is clear that attention to food budgeting, with an emphasis on F&V, should form a part of food and health policy.

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  2. Sarlio-Lahteenkorva S, Lahelma E. Food insecurity is associated with past and present economic disadvantage and body mass index. J Nutr 2001;131(11):2880-2884.
  3. Lee JS, Frongillo EA, Jr. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr 2001;131(5):1503-1509.
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  5. Wu Y. Why do so few elderly use food stamps? Retrieved July 16, 2013, from <http://www.ifigr.org/workshop/fall09/wu.pdf>.
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  8. Lee MS, Huang YC, Su HH, Lee MZ, Wahlqvist ML. A simple food quality index predicts mortality in elderly Taiwanese. J Nutr Health Aging 2011;15(10):815-821.
  9. Nothlings U et al. Intake of vegetables, legumes, and fruit, and risk for all-cause, cardiovascular, and cancer mortality in a European diabetic population. J Nutr 2008;138(4):775-781.
  10. Bellavia A et al. Fruit and vegetable consumption and all-cause mortality: a doseresponse analysis. Am J Clin Nutr. First published ahead of print June 26, 2013 as doi: 10.3945/ajcn.112.056119.
  11. Campbell AA et al. Household rice expenditure and maternal and child nutritional status in Bangladesh. J Nutr 2010;140(1):189S-194S.
  12. Campbell AA et al. Greater household expenditures on fruits and vegetables but not animal source foods are associated with decreased risk of under-five child mortality among families in rural Indonesia. J Nutr 2008;138(11):2244-2249.
  13. Lo Y-T et al. Spending on vegetable and fruit consumption could reduce all-cause mortality among older adults. Nutr J 2012;11(1):113.
  14. Lee MS et al. Chewing ability in conjunction with food intake and energy status in later Life affects survival in Taiwanese with the metabolic syndrome. J Am Geriatr Soc 2010;58(6):1072-1080.
  15. Chang YH et al. Frequent shopping by men and women increases survival in the older Taiwanese population. J Epidemiol Community Health. 2012;66(7):e20.
  16. Chen RC et al. Cooking frequency may enhance survival in Taiwanese elderly. Public Health Nutr. 2012;15(7):1142-1149.