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Dietary Diversity Predicts Type of Medical Expenditure in Elders
Yuan-Ting Lo, PhD; Mark L. Wahlqvist, MD; Yu-Hung Chang, PhD; Senyeong Kao, PhD; and Meei-Shyuan Lee, DPH

Dietary Diversity Predicts Type of Medical Expenditure in Elders

Yuan-Ting Lo, PhD; Mark L. Wahlqvist, MD; Yu-Hung Chang, PhD; Senyeong Kao, PhD; and Meei-Shyuan Lee, DPH
Greater dietary diversity is associated with lower emergency and hospitalization utilization and expenditures, and identifies a policy direction for nutritionally disadvantaged groups.
With sensitivity analyses, the findings were unchanged Except for emergency attendance, there were significantly positive linear relationships between DDS and medical utilization (Figures 2A and 2B). Medical spending on preventive care and dental services increased along with the DDS in a significant dose-response manner (Figure 2C). However, those with a lower DDS had higher emergency expenditures,  hospitalization expenditures, and total expenditures. Furthermore, those with a DDS of 3 or lower had an annual total medical expenditure of NT $57,400, whereas those with a DDS of 6 had a lower total medical expenditure of NT $53,100 (Figure 2D).


We expected to find that greater dietary diversity would be associated with lower overall medical expenditures. However, this hypothesis was demonstrable only for emergency attendance and hospitalization. Outpatient visits led to increased expenditures for preventive care and dental services.

Dietary Diversity Score as a Valid Indicator for Dietary Quality

The DDS is based on 1-day food intakes, which may not represent long-term dietary habits.11 Although misclassification is possible, the energy and nutrient intake and dietary patterns of community-dwelling elderly people are generally stable.9,26,27 The validity of DDS in this cohort is evident from previous studies where it provided predictive capacity and was significantly associated with known sociodemographic characteristics and mortality.3,9 Moreover, DDS is an integrative score and represents an eating pattern that characterizes the overall diet with relative stability. 9

Diet and Socioeconomic Factors in Medical Expenditure

A healthy diet is one of the 8 core objectives for the Taiwanese Health Promotion Project for the Elderly (2009-2012).”15 The average personal medical expenditure of individuals aged more that 60 years was approximately NT $80,000 to NT $120,000 in 2006 and reached NT $123,000 in 2010. This amount is greater than that for other age groups.14,15,28 A study from the United States has suggested that modest to aggressive changes in diet (reduction in energy, sodium, and saturated fat) can improve health and reduce annual national medical expenditure by $60 to $120 billion.29 Hence, a healthy diet in any aging population could help reduce health-related and nutritionally related medical care costs. Although this study found expenditure savings in acute care for those with a higher DDS, that was not so for preventive and ambulatory care. Individuals with a better socioeconomic status may exhibit greater health-seeking behavior,30 given that better dietary quality is associated with a higher socioeconomic status.9,31,32 Because those with lower incomes may cut back on basic needs like food and medication, they may avoid a more costly diverse diet, leading to food insecurity and greater acute care expenditure.3,33

Dental Care, Nutrition, and Overall Health

Oral health is often overlooked as a health indicator for the elderly.34,35 Oral health problems, including missing teeth, illfitting dentures, cavities, gum disease, and infection, can cause difficulty in eating, with a resulting compromise in dietary quality.35 Elders with impaired dentition have consistently lower scores on the Healthy Eating Index.36 For older adults, chewing difficulty and lower socioeconomic status are associated  with less dietary guideline compliance.37 Poor dental health is also associated with higher mortality.26,38,39 Participants with a less diverse diet used fewer dental services. Possible reasons for fewer dental visits by elders with poor dietary quality may include limited mobility or financial constraints (eg, denture fees).34,35,40,41 Oral health and nutrition have a synergistic, bidirectional relationship.42 In addition, social inequalities among older adults are related to dietary quality.32

International Comparisons

A Swedish intervention study on individualized meals and nutritional status among older people compared the direct healthcare costs of those living in municipal residential homes with those of a control group. After 1 year of intervention, the intervention group had higher healthcare costs in primary healthcare, although costs for total health and hospital care were equivalent because of a small sample size and short follow-up time.43 The findings of that study are consistent with ours, except that our participants were community-dwelling elders. Similarly, the Australian Longitudinal Study on Women’s Health showed that middle-aged women who had a higher diet quality had fewer Medicare  (the national universal health insurance scheme) claims but higher healthcare costs.44 The sensitivity analyses in the present study show that better dietary quality was associated with less utilization of and lower expenditures for emergency services and hospitalization, and lower total medical costs. Those who follow more nutritious dietary patterns may also engage in other health-seeking behaviors with healthsystem costs, but these behaviors may enable down streamsavings due to less use of costly, more acute emergency and inpatient services.43-46

We used sensitivity analyses for several reasons. Firstly, the elderly who died in the first year of follow-up might have experienced weakness or prior disease. Secondly, the use and  cost of health services during the last year of life can vary substantially for older people.47,48 However, these analyses did not alter the findings.

Strengths and Limitations

The major strength of the present study is that we were able to combine a national nutrition survey with National Health Insurance data, so as to evaluate the extent to which the cost of medical services was related to diet in the elderly.

However, the study has a number of limitations. First, whereas the Taiwanese NHI covers 99% of the population, there are out-of-pocket expenses not covered by the NHI.23,49 Affluent households are better able to afford the medical services not covered by the NHI compared with disadvantaged households. Thus, this study may underestimate the medical costs of households with a higher  socioeconomic status. Second, there is still social disparity in healthcare access and affordability despite efforts to overcome this  disparity,50 which also leads to errors in estimating medical service use and costs. Finally, the NHI in Taiwan is a unique universal health insurance coverage system,13 and our findings may not apply to other countries.23


We investigated the relationship between dietary quality and medical care utilization and expenditures among a general Asian population. Elderly individuals with better dietary quality, as determined by a higher DDS, required fewer emergency and hospitalization services but obtained more preventive and ambulatory care. The findings have important implications for nutrition-related health service policy. Such a policy should pay close attention to socially disadvantaged groups with poorer dietary quality.

Author Affiliations: From Graduate Institute of Life Sciences (Y-TL), National Defense Medical Center, Taiwan, Republic of China; Division of Preventive Medicine and Health Services Research (MLW), Institute of Population Health Sciences, National Health Research Institutes, Taiwan, Republic of China; School of Public Health (MLW, SK, M-SL), National Defense Medical Center, Taiwan, Republic of China; Monash Asia Institute (MLW, M-SL), Monash University, Victoria, Australia; Division of Health Policy Translation (Y-HC), Institute of Population Health Sciences, National Health Research Institutes, Taiwan, Republic of China.

Funding Sources: Financial support was provided by the National Science Council (NSC100-2320-B-016-005) and the National Health Research Institutes.

Authorship Information: Concept and design (Y-TL, MLW, Y-HC, SK, M-SL); acquisition of data (MLW, M-SL); analysis and interpretation of data (Y-TL, MLW, Y-HC, M-SL); drafting of the manuscript (Y-TL, MLW, M-SL); critical revision of the manuscript for important intellectual content (MLW, Y-HC, SK, M-SL); statistical analysis (Y-TL); obtaining funding (MLW, M-SL); administrative, technical, or  logistic support (MLW, M-SL); and supervision (MLW, M-SL).

Author Disclosures: The authors (Y-TL, MLW, Y-HC, SK) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to: Professor Meei-Shyuan Lee, DPH, School of Public Health, National Defense Medical Ct, 161 Minchuan East Rd, Sec 6, Taipei, Taiwan 114, Republic of China. E-mail:
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