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Published in final edited form as:

J Am Geriatr Soc. 2021 April ; 69(4): 964–971. doi:10.1111/jgs.16971.

Food Insecurity among Older Adults: Ten-Year National Trends

and Associations with Diet Quality
Cindy W. Leung, ScDa, Julia A. Wolfson, PhDa,b
aDepartment of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor,
US
bDepartment of Health Management and Policy, School of Public Health, University of Michigan,
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Ann Arbor, US

Abstract
Background/ Objectives—Food insecurity has emerged as a critical health issue for older
adults. Food insecurity has been shown to disrupt healthy eating patterns, but these associations
have not been widely studied among older adults. The objectives of the present study were to: 1)
examine national trends in food insecurity across a ten-year period, and 2) evaluate the
associations between food insecurity and multiple diet quality indices in a recent and nationally
representative sample of adults aged 60 or older.

Design—Cross-sectional analysis of the 2007–2016 National Health and Nutrition Examination

Surveys
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Setting—Nationally representative sample of the United States

Participants—The analytic sample was comprised of 5,097 adults aged 60 or older, with
household incomes at or below 300% of the federal poverty level

Measurements—Household food security was measured using the 18-item US Household Food
Security Survey Module. Diet was assessed using two 24-hour dietary recalls. Multivariate linear
and logistic regression models examined the associations between household food security and
three evidence-based diet quality indices, adjusting for sociodemographic and health
characteristics.

Results—Across the ten-year period, food insecurity increased significantly from 5.5% to 12.4%
among older adults; this increase was more pronounced among lower-income older adults. From
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the linear regression models, food insecurity was associated with lower scores on the Healthy
Eating Index (β=−1.90, 95% CI −3.70, −0.09), the Alternate Healthy Eating Index-2010 (β=−1.47,
95% CI −2.51, −0.44), and the Mediterranean Diet Score (β=−0.54, 95% CI −1.06, −0.001) after
multivariate adjustment. Further adjustment for the presence of chronic medical conditions did not
attenuate these results.

Corresponding author: Cindy Leung, ScD, MPH, 1415 Washington Heights, SPH I, Ann Arbor, MI 48109, Phone: 734-647-9087,
[email protected].
Author contributions: study concept and design: C.W.L., J.A.W.; analysis and interpretation of data: C.W.L.; preparation of
manuscript C.W.L, J.A.W.
Conflicts of interest: The authors have no conflicts of interest to declare.
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Conclusion—Food insecurity is associated with lower overall diet quality among older adults,
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supporting the need for clinical efforts to identify those at risk of food insecurity and public health
efforts to alleviate food insecurity and promote healthy eating behaviors among older adults.

Keywords
food insecurity; diet quality; healthy eating patterns; National Health and Nutrition Examination
Surveys

INTRODUCTION
Food insecurity, a condition of limited access to nutritious foods due to a lack of financial
resources, has persisted in the United States since national surveys began tracking its
prevalence in 1998.1 Food insecurity has emerged as a critical health issue for older adults
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(ages 60 and older), disproportionately affecting those who live alone, have fixed incomes,
and have chronic health concerns.2–5 Since 2001, the number of older adults experiencing
food insecurity increased from 2.3 million to 5.3 million, and is expected to grow to 8
million by 2050 due, in part, to population growth.2 In 2018, it was estimated that 7.5% of
households with older adults were food-insecure and 8.9% of households with older adults
living alone were food-insecure.1

Core components of the experience of food insecurity involve disruptions to normal eating
patterns, such as eating inexpensive foods of lower quality, eating less than one should, and
skipping meals, all of which are attributed to not having enough money for food. Although
the relationship between food insecurity and dietary outcomes has been previously
examined, studies have predominantly focused on children and adolescents, pregnant
women, and younger adult populations.6–11 Despite the importance of high diet quality for
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healthy aging and chronic disease outcomes,12–15 few studies have examined the
associations between food insecurity and diet quality in older adults. In one study, using data
from the Nutrition Survey of the Elderly in New York State and the Third National Health
and Nutrition Examination Survey (NHANES), older adults (ages 60 years and older) with
food insecurity had lower mean intakes of 12 nutrients than those with food security.16
Another study using data from the Third NHANES found that food insecurity was
associated with lower diet quality among adults 65 and older.17 A more recent study was
conducted among adults aged 49 and older from the Blue Mountains Eye Study. Their
results showed no association between food insecurity and diet quality, though both food
insecurity and diet quality were associated with lower quality of life.18 The existing body of
research is characterized by a lack of recent data to investigate the association between food
insecurity and diet quality in older adults, inconsistencies in findings across studies, varying
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aspects of nutritional status examined in relation to food insecurity (e.g. nutrients, diet
quality indices), and potential residual confounding by household income, a key predictor of
household food security and diet quality. Furthermore, few studies have taken into account
the role that participation in the Supplemental Nutrition Assistance Program (SNAP) may
have on these associations.19, 20 SNAP, formerly the Food Stamp Program, is the largest
federal nutrition assistance program that aims to reduce food security and improve
nutritional intake through benefits that can be used to purchase food.21 Thus, there may be

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differential associations between household food security and diet quality depending on
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whether older adults receive SNAP benefits.

The objectives of the study were to: 1) examine national trends in household food security
across a ten-year period among all older adults aged 60 or older, and 2) evaluate the
associations between household food security and diet quality indices in older adults with
household incomes ≤300% of the federal poverty level (FPL). We further examined effect
modification of the associations between household food security and diet quality indices by
participation in SNAP.

METHODS
Study population
Data for the present study came from 2007–2016 NHANES, an ongoing, multistage survey
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representative of the civilian, noninstitutionalized US population that includes an

oversample of adults aged 60 years and older. To examine ten-year trends of household food
security in the national population, the study sample was comprised of 9,623 adults, ages 60
years and older. For analyses of household food security and diet quality indices, older
adults were excluded for the following reasons: household incomes >300% FPL (n=2,912),
missing dietary data (n=1,590), or missing education, marital status, smoking, or physical
activity data (n=24) resulting in a final analytic sample of 5,097 older adults with household
incomes ≤300% FPL.

Food security status

Household food security was measured using the 18-item US Household Food Security
Survey Module, a widely used instrument from the U.S. Department of Agriculture (USDA).
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22 Briefly, questions are asked in stages about experiences or behaviors related to insufficient

resources to acquire food over the past 12 months. Eight questions pertained to children’s
experiences of food insecurity, which were omitted if no children are present in the
household. Food security is defined as 0 affirmative responses, meaning that all individuals
in the household had sufficient resources for food at all times. Marginal food security is
defined as 1–2 affirmative responses, meaning that individuals within the household may
have had concerns about food running out, but did not exhibit any more severe behavioral
manifestations of food insecurity. Food insecurity is defined as 3 or more affirmative
responses, meaning that individuals within the household reduced the quality, variety, and/or
quantity of food consumed as a result of insufficient resources for food.

Dietary quality indices

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Dietary intake was assessed using two 24-hour dietary recalls conducted by trained
interviewers. The first recall is administered in-person in the Mobile Examination Center.
The second recall is scheduled after the first recall is completed and administered by
telephone 3–10 days later. Standardized protocols are used to ensure all NHANES
participants complete the dietary interviews using the same methods.23, 24 The 24-hour
recall collects information on all foods and beverages consumed from midnight to midnight
of the previous day, including information on the time of consumption, the name of the

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eating occasion, where the food was eaten, etc. The USDA Automated Multiple Pass
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Method is used in the administration of the 24-hour dietary recalls, which consists of the
following five steps: 1) a quick list of all remembered foods, 2) a probe of commonly
forgotten foods and beverages, 3) the eating occasions and times from the previous day, 4)
additional details of each food or beverage consumed, and 5) a final review probe. Dietary
recalls are collected on weekdays and weekend days. The validity of the 24-hour recall
method has been previously established.25, 26

In the present analysis, we examined three diet quality indices: the Healthy Eating Index
(HEI)-2015, the Alternate Healthy Eating Index (AHEI)-2010, and the Mediterranean Diet
(MedDiet) score because they each measure distinct aspects of overall diet quality
(Supplementary Table S1). Data from the NHANES dietary interview files and the USDA
Food Patterns Equivalents Database, which converts food items to standard food groups and
food pattern components, were merged to calculate all diet quality indices. The HEI-2015 is
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a measure of diet quality developed by the USDA Center for Nutrition Policy and Promotion
that measures adherence to the 2015–20 Dietary Guidelines for Americans.27 Scored out of
100 points, the HEI-2015 has nine adequacy components: total fruits, whole fruits, dark
green/orange vegetables and legumes, greens and beans, whole grains, milk/dairy, total
protein foods, seafood and plant proteins, and unsaturated to saturated fatty acid ratio, where
higher scores denote higher intakes; and four moderation components: refined grains,
sodium, added sugars, saturated fats, where higher scores denote lower intakes. The
HEI-2015 score was calculated according to the simple HEI scoring algorithm using the
NHANES dietary interview files and the USDA Food Patterns Equivalents Database through
publicly-available SAS macros.28 The AHEI-2010 is a measure of diet quality predictive of
major chronic disease risk.29 Scored out of 110 points, higher scores are awarded to high
intakes of vegetables, fruits, whole grains, nuts and legumes, long-chain fats, and
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polyunsaturated fats; low intakes of sugar-sweetened beverages and fruit juice, red/processed
meats, trans fats, and sodium; and moderate alcohol intake. Because trans fats is not
available in the NHANES dietary nutrient files, the AHEI-2010 was modified to exclude this
component and the overall score was rescaled to the original total for comparison with
previous studies. The MedDiet score is a measure of adherence to the traditional
Mediterranean diet, which has been associated with healthy aging outcomes among older
adults.30–32 Scored out of 55 points, higher scores are awarded to high intakes of whole
grains, fruits, vegetables, potatoes, legumes, fish, and monounsaturated fats; low intakes of
red meat, poultry, and full-fat dairy products; and moderate alcohol consumption. For
analysis, each of the diet quality indices were examined as both continuous scores and as
quintiles comparing the top quintile to the bottom four quintiles. The decision to compare
the older adults in the top quintile of diet quality to the bottom four quintiles was guided by
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prior literature demonstrating that individuals of the highest diet quality have the lowest
relative risks for diet-sensitive chronic conditions and all-cause mortality.29, 33, 34

Study covariates
Study covariates were chosen based on prior knowledge and previous research on
sociodemographic and health correlates of both food insecurity and diet quality.
Sociodemographic covariates included age (60–64, 65–69, 70–74, 75–79, 80 and older), sex,

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race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other), highest

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educational attainment (<12 years, high school graduate or equivalent, some college, or
college graduate), marital status (married or living with partner, never married, separated or
divorced or widowed), and household income relative to the federal poverty line (FPL) (0–
130% FPL, 131–300% FPL). A missing indicator was used to account for individuals with
missing data on household income relative to the FPL (n=637). Health covariates included
smoking status (never smoker, former smoker, current smoker), and vigorous or moderate
recreational physical activity in a typical week (any, none). We also investigated the prior
diagnosis of chronic medical conditions as a potential intermediate: diabetes, congestive
heart failure, coronary heart disease, angina, myocardial infarction, stroke, emphysema,
thyroid problems, liver condition, and cancer. For analysis, the number of self-reported
chronic medical conditions was categorized as: 0, 1, 2, 3, or 4 or more conditions. SNAP
participation was defined as any receipt of SNAP or food stamp benefits by the study
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participant or any member of their family within the past 12 months.

Statistical analysis
Complex interview and dietary sampling weights were used to account for unequal selection
probabilities, patterns of non-response, and to make nationally representative estimates
across the 10-year period. We first estimated the prevalences of marginal food security and
food insecurity among all older adults and lower-income older adults with household
incomes ≤300% FPL within each two-year NHANES cycle. Linear time trends were
examined for the outcomes of marginal food security and food insecurity using logistic
regression models with survey year modeled as an ordinal predictor variable. Next, we
examined differences in sociodemographic and health characteristics by household food
security status among lower-income older adults with household incomes ≤300% FPL using
χ2 tests. To examine the associations between household food security status and diet
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quality indices among lower-income adults, six multivariate-adjusted regression models

were fit: three multivariate linear regression models were fit for each continuous diet quality
index outcome (HEI-2015, AHEI-2010, and MedDiet); three additional multivariate logistic
regression models were fit for each categorical diet quality index outcome comparing the top
quintile to the bottom four quintiles. All models adjusted for study covariates, as well as
NHANES cycle and total energy intake. Further adjustment of chronic medical conditions
was included in each model to determine the extent to which it mediated the associations
between household food security and diet quality. We then examined potential effect
modification by SNAP participation on the multivariate-adjusted associations between
household food security and continuous diet quality indices among older adults ≤130% FPL,
the income threshold for SNAP. As a sensitivity analysis, we also examined the associations
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between household food security and diet quality in the study sample of older adults at all
income levels (n=9,623).

All statistical tests were 2-sided, and statistical significance was considered at P<0.05.
Statistical analyses were performed using SAS 9.3 (SAS Institute, Cary, NC).

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RESULTS
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Ten-year trends in marginal food security and food insecurity are shown in Figure 1. Among
all older adults, marginal food security increased from 4.8% to 7.5% and food insecurity
increased from 5.5% to 12.4% from 2007–08 to 2015–16. Among older adults ≤300% FPL,
marginal food security increased from 7.1% to 12.2% and food insecurity increased from
8.5% to 20.9% from 2007–08 to 2015–16. All linear time trends were statistically significant
(Ps<0.01).

In the analytic sample of 5,097 lower-income older adults, differences in sociodemographic

and health covariates by household food security status are shown in Table 1. Compared to
their food-secure counterparts, marginally food secure and food-insecure older adults were
more likely to be of younger age, of minority race/ethnicity, have lower educational
attainment, have household incomes at or below 130% FPL, and be separated, divorced or
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widowed (Ps<0.0001). Marginally food secure and food-insecure older adults were also
more likely to be current smokers and engage in less physical activity (Ps<0.0001). In
bivariate analyses, marginally food secure and food-insecure older adults were less likely to
be in the top quintile of the HEI-2015 (P<0.0001), AHEI-2010 (P<0.0001), and MedDiet
scores (P=0.03). There was a marginal difference between household food security and the
presence of chronic medical conditions (P=0.06).

The correlations between the HEI-2015, AHEI-2010, and MedDiet Score ranged from 0.66
to 0.67. Multivariate-adjusted associations between household food security and diet quality
indices are shown in Table 2. For the HEI-2015, food insecurity was significantly associated
with lower continuous scores (β=−1.90, 95% CI −3.70, −0.09, P-trend=0.03) and lower odds
of being in the top quintile (vs. bottom four quintiles) of the HEI-2015 (OR 0.67, 95% CI
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0.47, 0.96, P-trend=0.06). For the AHEI-2010, marginal food security and food insecurity
were associated with lower continuous scores (marginal food security: β=−2.42, 95% CI
−3.76, −1.07; food insecurity: β=−1.47, 95% CI −2.51, −0.44, P-trend=0.0008), and lower
odds of being in the top quintile of the AHEI-2010 (marginal food security: OR 0.58, 95%
CI 0.41, 0.83; food insecurity OR 0.58, 95% CI 0.43, 0.77, P-trend<0.0001). For the
MedDiet score, marginal food security and food insecurity were associated with lower
continuous scores (marginal food security: β= −0.62, 95% CI −1.11, −0.12; food insecurity:
β=−0.54, 95% CI −1.06, −0.01, P-trend=0.02), and lower odds of being in the top quintile of
the MedDiet score (marginal food security, OR 0.69, 95% CI 0.48, 0.99, P-trend=0.56). All
associations persisted after further adjustment for chronic medical conditions. The complete
multivariate-adjusted regression results are provided in Supplementary Tables S2-S3.

There was no evidence that SNAP participation modified the associations between food
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insecurity and diet quality indices (P-interactions>0.10) (data not shown). In sensitivity
analyses, results were similar when examining the associations in older adults across all
income levels (data not shown).

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DISCUSSION
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In this national sample, the prevalence of both marginal food security and food insecurity
increased significantly among adults aged 60 and older from 2007–2016. Independent of
sociodemographic and health characteristics, food insecurity was associated with lower diet
quality, as evident by lower scores across all three indices. These results corroborate prior
studies among older adults that have examined food insecurity in relation to the older
Healthy Eating Index17 and the Total Diet Score.18 Together, there is evidence to suggest
that food insecurity is negatively associated with older adults’ dietary behaviors. Dietary
intake is an integral contributor to healthy aging for older adults.35 The results of the present
study help to shed light on how diet quality may explain, in part, the observed associations
between food insecurity and aging-related outcomes, such as functional limitations,36, 37
chronic disease risk and management,3, 38 cognitive impairment,39–41 and lower self-rated
health.16 In particular, the results that food-insecure older adults were significantly less
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likely to be in the top quintile of HEI-2015 and AHEI-2010 scores may hold clinical
significance, as a recent meta-analysis showed that adults in the top categories of HEI and
AHEI had significantly lower risks of cardiovascular disease, cancer, type 2 diabetes,
neurodegenerative diseases, and all-cause mortality.33 Further research using longitudinal
studies is needed to understand whether the relatively small differences in continuous diet
quality indices scores found in the present study are clinically meaningful.

It is important to note that marginal food security was also significantly associated with
lower AHEI-2010 and MedDiet scores in the present study at magnitudes equal to or greater
than the effect estimates observed between food insecurity and AHEI-2010 or MedDiet
scores. The USDA considers marginal food security to be less severe than food insecurity.
Thus, we expected to observe a gradient in the associations between more severe food
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insecurity and lower diet quality. The finding that older adults with marginal food security
had similar dietary outcomes when compared to older adults with food insecurity suggests
that even the earliest indicators of food insecurity, including mild anxiety about food running
out or not being able to afford a balanced meal, can be associated with more unhealthful
eating patterns. These associations may be driven, in part, by the chronic stress of
experiencing food insecurity, which has been known to alter eating behaviors resulting in
lower diet quality.42, 43 Similarly, other studies of household food security status and diet-
related health outcomes have not been consistent in observing a graded association with
more adverse outcomes. One study found that mild food insecurity, but not severe food
insecurity, was associated with obesity in women,44 while another study found that adults
with marginal food security had the highest odds of metabolic syndrome.45 Further research
of the experiences of older adults with both marginal food security and food insecurity is
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needed to better understand the psychosocial consequences, the behavioral adaptations, and
the coping strategies employed to manage their household food situation at different levels
of uncertainty and severity.

With rising rates of food insecurity among older adults, continued investment in nutrition
programs is needed to simultaneously improve food security and provide healthy food
assistance. This could include efforts to screen for food insecurity in clinical settings,
provide referrals to congregate meal programs and local food pantries, and provide SNAP

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application assistance.46 In the present study, few older adults reported consuming
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congregate meals (8.2%), or receiving home-delivered meals (3.9%). A previous study

among older adults in Florida showed that a home-delivered meal program substantially
improved food insecurity, total caloric intake, and protein intake, and also resulted in
improvements in social isolation and emotional functioning.47 Similarly, a 2019 report
showed that the SNAP participation rate among eligible older adults was only 48%,
compared to 84% among all individuals.48 In the present study, approximately 27% of
income-eligible adults (i.e. households with incomes ≤130% federal poverty level) reported
receiving SNAP in the past year. Because SNAP targets those who experience more severe
food hardships, a prior study found that seniors participating in SNAP had higher levels of
food insecurity, greater need for free food, and more physical disabilities than those who
were not participating in SNAP.49 Leveraging existing programs, such as Meals on Wheels
or SNAP, is critical to meet the nutritional needs of older adults, particularly in areas where
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access to food is challenging or during times of national economic hardship.

The primary limitation of this study is the cross-sectional nature of the data, which precludes
the ability to make causal inferences. Although research in younger populations supports
food insecurity as adversely affecting diet quality, we cannot rule out reverse causation,
whereby poor diet quality leads to chronic health conditions, financial instability, and
subsequently, food insecurity. We also cannot rule out the possibility of unmeasured
confounding by factors such as neighborhood food availability or additional proxies of
socioeconomic status. The decision to use a dichotomous physical activity variable was
guided by the few questions on physical activity administered to NHANES participants and
65% of adults in the analytic sample who reported no activity in a typical week. However,
potential residual confounding by physical activity is another limitation of the analysis.
Finally, dietary intake was captured through two 24-hour recalls using the USDA Automated
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Multiple-Pass Method. Although this approach has been validated, other limitations may
include the food database not capturing all possible foods consumed by NHANES
participants and the fact that NHANES participants were aware that they would be
completing interviews about their dietary intake ahead of time.25 Related to this particular
analysis, older adults with cognitive impairment may also have reduced validity in their
ability to accurately recall their dietary intake in the short-term.50 Another limitation is the
prevalence of chronic medical conditions could also be subject to error if the individual had
an underlying health condition but was not formally diagnosed in a clinical setting.
However, this study also has multiple strengths, including the large sample size, the use of
recently collected data on food insecurity and dietary intake, a focus on overall diet quality
as measured by three evidence-based indices, and adjustment for multiple known
confounders related to food insecurity and diet quality among older adults.
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In the present study, food insecurity, and at times, even marginal food security, were
associated with lower overall diet quality among older adults, supporting the need for
additional food assistance programs to reach this population. Further research is needed to
explore the underlying mechanisms to explain the observed associations, and to better
understand social factors and policy strategies that can improve both food insecurity and
dietary intake among older adults.

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Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Funding support:
This work was supported by the National Institutes of Health (R00 HD084758 to C.W.L. and K01 DK119166 to
J.A.W)

Sponsor’s Role:
The National Institutes of Health had no role in the design, methods, subject recruitment, data collection, analysis
or preparation of this study.

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Figure 1:
Trends in household food security from 2007–16 among A) all older adults and B) lower-
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income older adults (household incomes ≤300% of the federal poverty level)
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Table 1:

Sociodemographic and health characteristics by household food security status among older adults with
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household incomes ≤300% federal poverty level: NHANES 2007-2016

Marginal food secure Food insecure 1

Total (n=5,097) Food secure (n=3,604) P-value
(n=559) (n=934)

n % n % n % n %
Age <0.0001
60-64 1350 24.9 798 22.8 186 29.7 366 33.8
65-69 1047 20.8 689 19.2 126 26.7 232 25.8
70-74 955 18.4 695 18.2 106 19.6 154 18.6
75-79 726 14.8 548 15.8 69 9.1 109 13.0
≥80 1019 21.2 874 24.0 72 14.9 73 8.8
Sex 0.67
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Male 2363 41.1 1686 41.4 253 41.0 424 39.0

Female 2734 58.9 1918 58.6 306 59.0 510 61.0
Race/ethnicity <0.0001
Non-Hispanic White 2399 72.7 1947 78.0 194 60.0 258 49.9
Non-Hispanic Black 1116 11.2 726 9.4 158 17.4 232 17.7
Hispanic 1307 10.7 740 7.6 176 16.2 391 25.5
Other 275 5.4 191 5.0 31 6.3 53 7.0
Educational attainment <0.0001
<12 years 1957 28.0 1214 24.5 244 32.8 499 45.6
High school graduate or
1336 30.0 1011 31.4 130 31.6 195 20.2
equivalent
Some college 1204 27.6 880 28.0 137 24.4 187 27.7
College graduate 600 14.4 499 16.1 48 11.3 53 6.5
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Poverty income ratio <0.0001

≤130% FPL 2015 30.0 1125 23.4 300 45.9 590 58.9
131-<300% FPL 2445 56.9 1968 62.1 212 45.1 265 34.1
Missing 637 13.0 511 14.5 47 8.9 79 7.1
Marital status <0.0001
Married or living with partner 2615 54.2 1937 57.1 264 48.6 414 40.5
Never married 306 5.4 202 5.5 34 4.5 70 5.5
Separated, divorced, widowed 2176 40.4 1465 37.4 261 46.9 450 54.0
Smoking status <0.0001
Never smoker 2446 47.7 1773 48.6 257 44.9 416 43.9
Former smoker 1941 40.0 1423 41.0 212 41.6 306 32.9
Current smoker 710 12.3 408 10.4 90 13.4 212 23.2
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Moderate or vigorous physical

1625 34.8 1237 37.5 142 26.9 246 24.4 <0.0001
activity
Healthy Eating Index-2015
0.001
quintiles
Top quintile (67.3-99.5) 1058 19.6 813 20.9 102 18.5 143 12.6

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Marginal food secure Food insecure 1

Total (n=5,097) Food secure (n=3,604) P-value
(n=559) (n=934)
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n % n % n % n %
Bottom four quintiles
4038 80.4 2791 79.1 456 81.5 791 87.4
(15.1-67.3)
Alternate Healthy Eating
<0.0001
Index-2010 quintiles
Top quintile (54.0-93.3) 1007 20.2 799 22.5 82 12.9 126 11.3
Bottom four quintiles
4089 79.8 2805 77.5 476 87.1 808 88.7
(8.1-53.9)
MedDiet Score quintiles 0.03
Top quintile (26.5-42.0) 1019 18.6 770 19.5 91 13.2 158 16.6
Bottom four quintiles
4077 81.4 2834 80.5 467 86.8 776 83.4
(8.0-26.0)
Chronic medical conditions 0.06
0 conditions 1865 35.4 1322 36.0 205 34.8 338 32.3
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1 condition 1637 32.4 1182 33.1 173 33.1 282 27.7

2 conditions 862 17.7 611 17.3 100 16.5 151 20.5
3 conditions 397 7.7 268 7.4 40 6.2 89 10.2
4 or more conditions 336 6.8 221 6.1 41 9.5 74 9.2

1
From chi-squared tests
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Table 2:

Multivariate-adjusted associations between household food security and diet quality indices among older
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adults with household incomes ≤300% of the federal poverty level

Quintiles of diet quality indices (comparing top quintile

Continuous diet quality indices to bottom four quintiles

Multivariate-adjusted Multivariate-adjusted plus

Multivariate- plus chronic medical 2 chronic medical
adjusted1 1 Multivariate-adjusted 2
conditions conditions

β 95% CI β 95% CI OR 95% CI OR 95% CI

Healthy Eating
Index-2015
Food secure Ref. Ref. Ref. Ref.
Marginally food
secure −1.43 −3.18, 0.33 −1.42 −3.19, 0.35 0.96 0.67, 1.38 0.96 0.67, 1.38
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−3.70, −3.72,
Food insecure −1.90 −0.09 −1.91 −0.10 0.67 0.47, 0.96 0.68 0.47, 0.98
P-trend 0.03 0.03 0.06 0.06
Alternate Healthy Eating
Index-2010
Food secure Ref. Ref. Ref. Ref.
Marginally food −3.76, −3.77,
secure −2.42 −1.07 −2.41 −1.04 0.58 0.41, 0.83 0.58 0.41, 0.83
−2.51, −2.53,
Food insecure −1.47 −0.44 −1.49 −0.45 0.58 0.43, 0.77 0.57 0.43, 0.76
P-trend 0.0008 0.0008 <0.0001 <0.0001
Mediterranean Diet
(MedDiet) Score
Food secure Ref. Ref. Ref. Ref.
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Marginally food −1.11, −1.12,

secure −0.62 −0.12 −0.63 −0.14 0.69 0.48, 0.99 0.69 0.48, 0.99
−1.06, −1.09,
Food insecure −0.54 −0.01 −0.55 −0.02 0.96 0.65, 1.42 0.94 0.64, 1.40
P-trend 0.02 0.02 0.56 0.51

1
Coefficients obtained from linear regression models adjusted for age, sex, race/ethnicity, educational attainment, poverty income ratio, marital
status, smoking status, moderate or vigorous physical activity, and survey year
2
Coefficients obtained from logistic regression models adjusted for age, sex, race/ethnicity, educational attainment, poverty income ratio, marital
status, smoking status, moderate or vigorous physical activity, and survey year
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