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Nutrition

Evaluations Report

Vol. 1 Chapter II. CHARACTERISTICS OF TITLE III NUTRITION PROGRAM PARTICIPANTS
A: CHARACTERISTICS OF PARTICIPANTS

A primary objective of this evaluation is to identify the characteristics of Title III Elderly Nutrition Program (ENP) participants as accurately as possible. This is particularly important for two reasons. First, two of the program's components--the congregate and home-delivered meal programs--are designed to serve somewhat different populations of older individuals needing nutrition and supportive services. Second, although the program is available to any individual 60 years of age or older, amendments to the Older Americans Act (OAA) over the years have required State and Area Agencies on Aging to target program services to persons with the greatest social or economic need, with particular attention to low-income and minority older persons.

This chapter examines the demographic, economic, health, social, food, and nutrition characteristics, as well as the service use, of older persons who receive Title III congregate and home-delivered meals to determine whether the program is serving them as intended and the extent to which the program successfully targets priority subgroups of elderly people. Using data collected from program participants for the current evaluation, as well as from other data sources, this chapter (1) describes the characteristics of meal program participants, compares participants with the overall elderly U.S. population, and describes key differences and similarities between congregate and home-delivered participants; (2) describes changes over time in participant characteristics and use of program services; and (3) assesses program effectiveness in serving special populations of older individuals.

The current evaluation found that Title III of the ENP serves highly vulnerable people with characteristics that tend to put them at increased health and nutritional risk. The program is successful at targeting nutrition services to low-income and minority elderly people. Compared with the overall population of elderly individuals age 60 and older, the elderly individuals served by Title III ENP tend to be older and to have lower incomes. They are also more likely to be members of racial or ethnic minority groups and to live alone. In general, home-delivered participants are older, more functionally impaired, have lower incomes, get out of their homes less often, and have more need for a variety of in-home supportive services than do congregate participants. Older participants in both components of the program, however, are similar along most demographic dimensions, and a significant proportion of congregate participants have low incomes, are racial/ethnic minorities, and have one or more chronic health conditions and impairments. Thus, the program's two components--the congregate and home-delivered meal programs--are reaching the intended targeted groups.

A. CHARACTERISTICS OF PARTICIPANTS

This section of the report describes the characteristics of Title III meal program participants who receive a program meal on a typical day. Emphasis is placed on describing participants along key demographic, health, nutrition, and lifestyle dimensions; comparing participants with the overall elderly population; and describing differences and similarities between congregate and home-delivered meal program participants.

1. Demographic Characteristics

The average Title III congregate meal program participant is 76 years old; the average home-delivered participant is age 78 (Table II.1). Fourteen percent of congregate participants and 26 percent of home-delivered participants are 85 or older. Most congregate and home-delivered meal program participants are female, with the ratio of female to male participants exceeding 2 to 1. More than one-half of Title III meal program participants (57 percent of congregate participants and 60 percent of home-delivered meal participants) live alone. Twenty-eight percent of congregate participants and 16 percent of home-delivered participants reside in rural areas (places with fewer than 2,500 inhabitants).

TABLE II.1

SELECTED DEMOGRAPHIC CHARACTERISTICS OF MEAL PROGRAM PARTICIPANTS

(Percentages, Unless Stated Otherwise)

Characteristic

Title III Congregate

Meal Participants

Title III Home-Delivered

Meal Participants

Overall U.S Elderly

(60+) Populationc

Age




Less than 60

1

2

--

60-74

43

30

67

75-84

42

42

25

85 and older

14

26

8

Average Age (Years)

76

78

72

Female

69

70

58

Live Alone

57

60

25

Rurala

28

16

25

Minority Status




Non-Hispanic blacks

12

18

8

Hispanics

12

5

4

All minorities

27

25

14

Income Status




Below 100% of the DHHS poverty guidelines

34

48

15

Below 200% of the DHHS poverty guidelines

79

90

38

Low-Income Minority b

15

16

4

Unweighted Sample Size

1,040

818

40,116,501

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

  1. Participant zip codes were used to define rural and urban location according to the Census definition. As defined by the Census, urban areas comprise (1) urbanized areas (incorporated places and adjacent densely settled territory with a combined minimum population of 50,000), and (2) all other places with 2,500 or more persons. Rural areas include any area not defined as urban.
  2. "Low-income" refers to less than 100 percent of the DHHS poverty guidelines.
  3. Authors' tabulations based on 1990 Census of Population and Housing Data (U.S. Bureau of the Census, 1994)

DHHS = U.S. Department of Health and Human Services.

Means tests for participation in the meals program are prohibited, yet most participants are poor or near poor. One-third of congregate participants and nearly one-half of home-delivered participants have family incomes below 100 percent of the U.S. Department of Health and Human Services (DHHS) poverty threshold (Table II.1). Most of the rest are among the near poor, with family incomes between 100 and 200 percent of the DHHS poverty threshold. Overall, 79 percent of congregate participants and 90 percent of home-delivered participants have family incomes below 200 percent of the DHHS poverty threshold.

Congregate and home-delivered meal program participants are largely non-Hispanic white elderly individuals, but a significant percentage of participants in both program components are members of racial and ethnic minorities. For example, non-Hispanic blacks constitute approximately 12 percent of congregate participants and 18 percent of home-delivered participants (Table II.1). Hispanics make up another 12 percent and five percent, respectively, of participants in the two components. Overall, racial and ethnic minorities constitute 27 percent of congregate and 25 percent of home-delivered participants.

Along most of the demographic dimensions examined, elderly recipients of home-delivered meals are very similar to congregate meal program participants. However, there are a few notable exceptions. Home-delivered meal program participants are, on average, older and poorer. They are also less likely than congregate participants to reside in rural locations.

On the basis of 1990 Census data, comparing the demographic characteristics of Title III congregate and home-delivered participants with those of all elderly (60 years or older) persons in the United States shows that program participants are more likely to be older and female, live alone, have low income, and belong to a racial or ethnic minority group (see Table II.1). For example, 60 percent of both congregate and home-delivered meal program participants live alone, compared with 25 percent of all elderly persons. About 25 percent each of congregate and home-delivered participants are racial or ethnic minorities, compared with 14 percent of all elderly persons. Approximately 15 percent each of congregate and home-delivered meal program participants are from low-income minority groups, compared with just 4 percent of the overall U.S. elderly population. As discussed in greater detail in Section C, these data indicate that the program successfully attracts and recruits elderly people who have low incomes and are members of racial or ethnic minorities, when their proportion in the overall elderly population is used as a benchmark.

2. Health, Functional Ability, and Mobility

Health Status. The average number of self-reported diagnosed chronic health conditions is 2.4 for congregate participants, compared with 3.0 for home-delivered participants (Table II.2). Forty-one percent of congregate participants have three or more chronic conditions; 59 percent of home-delivered participants have three or more diagnosed chronic conditions. The most common health problems, reported by about one-fifth to more than one-half of Title III participants, include arthritis, hypertension, heart disease, lung or breathing problems, elevated blood cholesterol levels, and diabetes. Eleven to 20 percent of Title III congregate and home-delivered participants also reported a history of stroke or cancer. Eighteen percent of congregate participants and 30 percent of home-delivered participants reported that they recently lost or gained 10 pounds involuntarily. Recent and severe involuntary changes in body weight have been shown to be associated with an increased risk of poor nutritional status and adverse health problems (Nutrition Screening Initiative 1991). Except for high blood cholesterol levels, the prevalence of each chronic condition is higher for home-delivered than congregate participants, for some conditions by twice as much.

TABLE II.2

SELECTED HEALTH CHARACTERISTICS OF MEAL PROGRAM PARTICIPANTS

(Percentages, Unless Stated Otherwise)

Characteristic

Title III Congregate Meal Participants

Title III Home-Delivered Meal Participants

Medical Doctor Has Diagnosed:



Hypertension

52

55

Arthritis

51

64

Heart disease

28

44

High blood cholesterol

28

20

Diabetes

18

25

Breathing/lung problems

18

30

Cancer

13

16

Stroke

11

20

Anemia

9

15

Osteoporosis

7

17

Kidney disease

6

7

Average Number of Diagnosed Chronic Health Conditions

2.4

3.0

Have 3 or More Chronic Health Conditions

41

59

Hospital Stay During the Past Year

25

43

Nursing Home or Convalescent Home Stay During the Past Year

1

5

Hospital or Nursing Home Stay During the Past Year

26

43

Take Three or More Prescription or Over-the-Counter Drugs Daily

40

61

Smoke Cigarettes Regularly

7

11

Three or More Drinks of Alcohol Per Day

2

1

Body Mass Index Below 22 (Indicative of Risk for Nutrient Deficiency)b

19

32

Body Mass Index Above 27 (Indicative of Risk for Obesity)b

42

32

Involuntarily Lost or Gained 10 Pounds in the Past Six Months

18

30

Fair or Poor Current Health

33

63

Has Usual Place for Medical Care

94

95

Health Insurance Coverage



Medicare and private insurance

52

47

Medicare only

23

27

Medicare and Medicaid

11

17

Medicaid only

3

3

Other combinations

8

5

No coverage

4

1

Unweighted Sample Size

1,040

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

  1. Tabulations are based mainly on self-reported data.
  2. Body Mass Index (BMI) is based on measured height and weight. However, if a respondent could not be or refused to be weighted or have his or her height measured, we took self-reported weight and height.

Twenty-five percent of congregate participants reported one or more separate overnight hospital stays during the past year, compared with 43 percent of home-delivered participants (Table II.2). Home-delivered meal program participants were also more likely than congregate participants to have multiple hospital stays during the past year. Eight percent of home-delivered participants had three or more separate hospital stays during the past year, compared with three percent of congregate participants (tabulations not shown). Just one percent of congregate participants reported a nursing or convalescent stay during the past year, compared with five percent of home-delivered participants.

Many elderly participants take multiple medications concurrently, which increases the potential for adverse drug-nutrient interactions; adverse effects of malnutrition on drug absorption, metabolism, or utilization; and risk of malnutrition. Sixty-one percent of home-delivered participants take three or more prescription or over-the-counter drugs daily, whereas 40 percent of congregate participants report taking three or more drugs daily.

About one-third each of Title III congregate participants and home-delivered participants have an estimated Body Mass Index (BMI) in the "ideal" range (between 22 and 27). Most are either over- or underweight, placing them at increased risk for nutrition and health problems. Thirty-two percent of home-delivered participants are estimated to have BMI below 22, indicating that they may be underweight and at risk for health and nutrition-related problems, whereas 42 percent of congregate participants are estimated to have BMI greater than 27, indicating that they may be overweight and at risk for problems related to obesity and nutritional excess.

Significant percentages of Title III participants say they are in "poor" or "fair" health. One-third of congregate participants and nearly two-thirds of home-delivered participants rate their current health as either "poor" or "fair."

Nearly all Title III participants report having a health care provider (clinic, doctor, health center, or other) where they can go when they are ill and need health advice or routine care. Virtually all have private or public health insurance coverage. Four percent of congregate participants and just one percent of home-delivered participants report not having either private or public health care insurance. About half of congregate and home-delivered participants have Medicare and private health insurance.

Overall, the health characteristics of Title III congregate and home-delivered meal participants differ in a number of important ways. Compared with congregate participants, home-delivered participants are nearly twice as likely to report being in "poor" or "fair" health and are more likely to report multiple chronic health problems. Home-delivered meal program participants are nearly twice as likely to have had a hospital or nursing home stay during the past year and are nearly three times as likely to have had multiple hospital stays. They are more likely than congregate participants to be taking multiple prescription drugs and over-the-counter medications. Among home-delivered meal participants, proportionately more are underweight by BMI standards and proportionately fewer are overweight. However, congregate and home-delivered participants report a similar overall number of diagnosed chronic health conditions, and congregate participants report a health profile that also places them at risk for nutrition-related problems. Indeed, at least half of congregate participants and home-delivered meal participants have nutrition-related chronic diseases. For example, significant minorities of both groups--one-fifth of congregate and nearly one-third of home-delivered meal participants--may be underweight, and the prevalence of obesity, which imposes risk for complications of chronic disease, may be high in both groups.

Compared with the overall elderly population, both congregate and home-delivered meal program participants generally fare worse on most of the health dimensions examined for which we have comparable data. (Data on health characteristics of the overall elderly population are not shown in Table II.2.) Home-delivered participants are considerably less healthy relative to the overall elderly population. For example, 48 percent of all elderly (age 65 and older) have arthritis, compared with 51 percent and 64 percent of congregate and home-delivered participants, respectively. Thirty-eight percent of all elderly people (age 65 and older) have hypertension, compared with about 50 percent each of congregate and home-delivered meal program participants. Sixty-three percent of home-delivered participants and 33 percent of congregate participants rate their current health as "fair or poor," compared with 29 percent of the overall elderly population.

Functional Status. A substantial proportion of Title III home-delivered meal program participants are severely functionally impaired and need daily help performing one or more activities critical for them to remain in their homes or the community and to avoid unnecessary and costly institutionalization. Sixty-five percent of home-delivered participants are unable to perform one or more Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) without the assistance of another person or the use of physical devices; 77 percent are either unable to perform or have much difficulty performing one or more ADLs or IADLs without assistance (results not shown).

The remainder of this section defines participants as impaired in a particular ADL or IADL if they report that they are either unable to perform or have much difficulty performing the activity. Table II.3 shows that, for any particular ADL category, most Title III congregate participants do not report a functional impairment. In contrast, 37 percent of Title III home-delivered meal program participants are unable to walk or have much difficulty walking without assistance. Similarly, 36 percent are unable to take a bath or shower or have much difficulty doing so without assistance. One-quarter of home-delivered participants are either unable to dress themselves or have much difficulty doing so without assistance. Regarding IADLs, the majority (64 percent) of home-delivered meal program participants are unable to shop or have much difficulty shopping for groceries without assistance, and 59 percent are unable or have much difficulty doing household chores without assistance. More than 40 percent of home-delivered participants are unable to prepare or have much difficulty preparing meals without assistance. Home-delivered meal participants, on average, are impaired on two ADLs and two IADLs. Overall, they are impaired on 4 ADLs/IADLs, and 20 percent of home-delivered meal participants are impaired on 7 or more of the 14 ADLs and IADLs.

TABLE II.3

PREVALENCE OF FUNCTIONAL LIMITATIONS IN THE MEAL PROGRAM PARTICIPANT POPULATION

(Percentage, Unless Stated Otherwise)


Much Difficulty Performing or Unable to Perform

Activity Without Assistance

Functional Activities

Title III Congregate

Meal Participantsa

Title III Home-Delivered

Meal Participantsa

Elderly (65+)

Medicare Beneficiariesb

Activities of Daily Living




Personal Grooming

1.6

18.7

N.A.

Eating

0.6

7.3

0.6

Getting In and Out of Bed

1.9

15.0

3.8

Walking

4.7

37.4

10.7

Taking a Bath or Shower

4.2

35.7

6.4

Using the Toilet

0.7

12.3

2.4

Dressing

2.8

25.3

2.1

Maintaining Continence

1.5

15.9

3.8

Average Number of ADLs Have Difficulty Performing or Unable to Perform Without Assistance

0.2

1.7

--

Percentage with Difficulty Performing or Unable to Perform One or More ADLs Without Assistance

9

52

--

Instrumental Activities of Daily Living




Using the Telephone

3.1

9.9

3.0

Taking Medication

2.1

9.3

N.A.

Managing Money

6.3

23.7

5.1

Preparing Meals

7.5

41.3

6.6

Doing Housework c

11.9

59.1

7.8

Grocery Shopping

12.8

63.9

11.5

Average Number of IADLs Have Difficulty Performing or Unable to Perform Without Assistance

0.4

2.1

--

Percentage with Difficulty Performing or Unable to Perform One or More IADLs Without Assistance

21

76

--

Unweighted Sample Size

1,040

818

3,485

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of program participants receiving Title III meals on a given day.

  1. In the current evaluation, the questions were: "Now I am going to read a list of activities. Please tell me how much difficulty you have doing these things without the use of aids or another person. What about . . . ? Do you have no difficulty, some difficulty, much difficulty, or are you unable to . . . at all by yourself?"
  2. In the National Survey of Self-Care and Aging, the questions were: "Because of a health or physical problem, do you have difficulty . . . ?" If response was "yes," the subject was asked: "Do you have some difficulty, a lot of difficulty, or are you unable to . . . ?"
  3. Refers to "doing light housework" in the National Survey of Self-Care and Aging.

N.A. = Not asked.

Title III home-delivered meal program participants are considerably more functionally impaired than congregate participants. After examining each ADL category separately, we found that home-delivered meal program participants are approximately 7 to 18 times more likely than congregate participants to be impaired in ADLs. For example, 37 percent of home-delivered participants are unable to walk or have much difficulty walking without assistance, compared with five percent of congregate participants. Home-delivered participants are three to six times more likely than congregate participants to be impaired in IADLs. Sixty-four percent of home-delivered meal program participants are unable to shop or have much difficulty shopping for groceries without assistance, compared with 13 percent of congregate participants; 41 percent of home-delivered participants are unable to prepare or have much difficulty preparing meals without assistance, compared with 7 percent of congregate participants. Home-delivered meal participants, on average, are impaired in 2 ADLs and 2 IADLs, compared with 0.2 and 0.4 for congregate participants, respectively. Overall, home-delivered meal participants, on average, are unable to perform or have much difficulty performing four ADLs and IADLs, compared with less than one for congregate participants.

A comparison of Title III participants with the Medicare beneficiary population age 65 and over on their ability to perform ADLs and IADLs shows that home-delivered meal participants are considerably more impaired in both ADLs and IADLs (Table II.3). In general, Title III congregate participants are somewhat more impaired in IADLs, but somewhat less impaired in ADLs, than elderly Medicare beneficiaries.

Mobility and Leisure Time Physical Activity. Title III congregate participants as a group are very mobile and physically active, and they are considerably more mobile and physically active than Title III home-delivered meal participants. Ninety-one percent of congregate participants report getting out of their homes at least once per week; 73 percent report getting out of the house five or more times per week (Table II.4). In contrast, 46 percent of home-delivered participants report getting out of the house at least once per week, and only 15 percent get away from their home five or more times per week. About 70 percent of Title III congregate participants report that they participated in leisure time activities during the past month. These activities include walking, other forms of exercise, gardening, or other physical activities. Congregate participants report, on average, 21 leisure time physical activities during the past month (the median number is 13). In contrast, less than half (42 percent) of home-delivered meal program participants report any leisure time physical activities during the past month. Home-delivered meal participants report an average of 10 leisure time physical activities during the past month (the median is zero).

TABLE II.4

MOBILITY AND LEISURE TIME PHYSICAL ACTIVITY OF MEAL PROGRAM PARTICIPANTS

(Percentages, Unless Stated Otherwise)


Title III Congregate Meal Participants

Title III Home-Delivered Meal Participants

Unable to Walk or Have Much Difficulty Walking Without Assistance

5

37

Get Out of the House At Least Once Per Week

91

46

Get Out of the House 5 or More Days Per Week

73

15

Some Leisure Time Physical Activity During the Past Month

72

42

Number of Leisure Time Physical Activities During the Past Month



Mean

21

10

Median

13

0

Unweighted Sample Size

1,040

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

Summary. In summary, both Title III congregate and Title III home-delivered meal participants appear to have significant numbers of health problems, based on self-reports of health history and health status. However, health problems are somewhat more prevalent among the home-delivered meal group. When ADL and IADL indicators and direct measures of mobility are considered, the picture that emerges is that most congregate meal participants retain relatively high degrees of functional ability, but the typical home-delivered meal recipient has significant limitations in functional status.

3. Food and Dietary Behaviors, Nutritional Risk, and Food Insecurity

Food and Dietary Behaviors. Most Title III congregate and home-delivered meal participants report consuming about three meals a day, including daily breakfast (Table II.5). About half of congregate participants and nearly two-thirds of home-delivered meal participants usually eat alone when they consume meals at home. The vast majority (95 percent) of congregate participants and the majority (67 percent) of home-delivered participants can prepare hot meals if they absolutely have to. Yet, fully one-third of home-delivered meal participants are unable to prepare hot meals for themselves. A minority (15 percent) of congregate participants report their current appetite as "poor" or "fair," compared with 36 percent of home-delivered meal program participants. More than 20 percent of congregate participants and 31 percent of home-delivered meal program participants are on special diets, most commonly to lower blood cholesterol levels. About half of those on special diets are on two or more special diets concurrently. About one-third of Title III meal program participants have an illness or condition that has changed the kind or amount of food eaten. About 40 percent of congregate and home-delivered participants report taking vitamin supplements daily; half of these persons report consuming two or more supplements daily.

TABLE II.5

SELECTED DIETARY CHARACTERISTICS AND BEHAVIORS OF MEAL PROGRAM PARTICIPANTS

(Percentages)

Characteristic

Title III Congregate

Meal Participants

Title III Home-Delivered

Meal Participants

Eat Fewer than Three Meals Per Day

22

29

Rarely or Never Eat Breakfast

7

11

Cannot Prepare Hot Meals if Need to

6

33

Usually Eat Alone

51

61

Current Appetite Is Fair or Poor

15

36

Have Illness or Condition that Has Changed Eating Habits

30

34

Eat Few Fruits Daily

24

35

Eat Few Vegetables Daily

17

27

Consume Few Milk Products Daily

32

38

Regularly Take Vitamin or Mineral Supplements

41

40

Currently on Special/Therapeutic Diet

22

31

Unweighted Sample Size

1,040

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

Title III congregate and home-delivered meal recipients differ in several important characteristics related to their nutrition habits. Home-delivered meal recipients are far less likely to be able to prepare a hot meal if they have to and are far more likely not to cook. They are more likely to report their appetites as "fair" or "poor," more likely to be on medically prescribed therapeutic diets, and more often on multiple concurrent prescriptions. They are slightly more likely to eat alone or to have a current illness that interferes with eating.

Characteristics and Behaviors Suggestive of Increased Nutritional Risk. As shown in Table II.6, 22 percent of congregate participants and 48 percent of home-delivered participants report a combination of characteristics or behaviors that place them at high risk for nutritional problems, as measured by an approximation of the NSI Checklist (Nutrition Screening Initiative 1991). These characteristics increase the likelihood of risk for nutritional problems (Posner et al. 1994), as indicated by a score of 6 or more on our approximation of the NSI Checklist. Scores for about 40 percent each of congregate and home-delivered meal program participants ranged from 3 to 5, suggesting moderate nutritional risk. Overall, 64 percent of congregate and 88 percent of home-delivered participants have characteristics associated with moderate to high nutritional risk.

Food Insecurity. Food insecurity is a condition in which the household in which the individual resides does not always have adequate food, the individual cannot always afford to buy enough food and/or cannot always get to markets or food programs to obtain food, or the individual cannot prepare and gain access to the food available in the household (Burt 1993). Food insecurity was operationalized in the current evaluation using four questions about household circumstances that several researchers recently used to assess the degree of food insecurity in the United States (Burt 1993; Cohen and Young 1993; and Food Research and Action Center 1987). These household circumstances refer to one or more of the following during the past month: (1) on one or more days the participant had no food in the house and no money or food stamps to buy food; (2) the participant had to choose between buying food and buying medications; (3) the participant had to choose between buying food and paying rent or utility bills; or (4) the participant skipped one or more meals because he or she had no food in the house and had no money or food stamps to buy food.

TABLE II.6

NUTRITIONAL RISK OF MEAL PROGRAM PARTICIPANTS, BASED ON NUTRITION SCREENING INITIATIVE CHECKLIST

(Percentages, Unless Stated Otherwise)


Title III Congregate Meal Participants

Title III Home-Delivered Meal Participants

Components of Index (Score)



Have Illness or Condition that Changed the Kind and/or Amount of Food Eaten (2)

30

34

Eat Fewer than Two Meals Per Day (3)

2

4

Eat Few Fruits, Vegetables, or Milk Products (2)

48

58

Consume Three or More Drinks of Beer, Liquor, or Wine Almost Every Day (2)

2

1

Have Tooth or Mouth Problems that Make Eating Hard (2) a

--

--

Don’t Always Have Enough Money to Buy Food (4)

12

18

Eat Alone Most of the Time (1)

51

61

Take Three or More Different Prescription or Over-the-Counter Drugs a Day (1)

40

61

Without Wanting to, Have Lost or Gained 10 Pounds in the Past Six Months (2)

18

30

Not Always Physically Able to Shop, Cook, and/or Feed Self (2)

12

65

Nutritional Health Index Score



0 to 2 (Good)

36

11

3 to 5 (Moderate Risk)

42

40

6 or More (High Risk)

22

48

Mean

3.7

5.6

Median

3.0

5.0

Unweighted Sample Size

1,040

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

a.Question not asked.

Most Title III meal program participants report having enough food to eat. Relatively small but meaningful proportions of congregate and home-delivered participants, however, report one or more circumstances of food insecurity during the past month. Ten percent of congregate participants and 16 percent of home-delivered meal program participants mentioned experiencing one or more of these instances of food insecurity during the past month (Table II.7). Note that while the percentages appear relatively modest, they mean that, within the 30 days preceding the interview, approximately 237,000 congregate participants and 127,000 home-delivered participants experienced food insecurity. Food insecurity is somewhat higher for home-delivered meal participants than for congregate participants (16 percent versus 10 percent).

TABLE II.7

FOOD INSECURITY EXPERIENCED BY MEAL PROGRAM PARTICIPANTS IN A ONE-MONTH PERIOD

(Percentages)

All Eligible Elderly


Title III Congregate Meal

Eligible Elderly


Title III Home-Delivered Meal

Eligible Elderly

Elderly Target Group

Program

Participantsa

Elderly

Populationb


Program

Participantsc

Elderly

Populationd


Program

Participantse

Elderly

Populationf

Non-Hispanic Blacks

15.68

8.21


10.69

7.25


18.72

12.81

Non-Hispanic American Indians, Eskimos, or Aleuts

1.18

0.40


1.22

0.36


1.16

0.56

Non-Hispanic Asians or Pacific Islanders

0.38

1.58


0.99

1.56


0.01

1.68

Hispanics

5.31

3.90


6.70

3.68


4.47

4.93

All Racial and Ethnic Minorities

22.89

14.12


19.92

12.88


24.69

20.03

All Low-Income Elderly

41.16

14.58


33.78

12.54


45.79

24.34

Low-Income Racial and Ethnic Minorities

13.52

4.10


11.05

3.36


15.07

7.62

Low-Income Nonminorities

27.63

10.49


22.68

9.18


30.74

16.72

Rural Elderly

25.51

25.36


39.57

25.54


16.97

24.48


SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

a Percentage of participants who experienced one or more of the four preceding food insecurity circumstances during the past month.

Examining the individual food insecurity indicators shows that the most frequently mentioned circumstances involve a choice of how to spend scarce household resources--whether to buy food or pay for rent, utility bills, or needed medicines. Ten percent of home-delivered meal program participants said that they had to choose between buying food and medicines during the past month; 10 percent also reported having to choose between buying food and paying rent or utility bills. The percentages for congregate participants are lower, at seven percent and five percent, respectively. Smaller percentages of home- delivered and congregate participants report having no food in the house or skipping meals because they had no food or resources to buy food during the past month. Approximately five percent each of congregate and home-delivered participants report these circumstances.

Title III participants are much more likely to experience food insecurity than elderly persons in the overall U.S. population. Using the same four questions, but using the preceding six months as a reference period, Burt (1993) found that five percent of elderly persons age 65 and older in the overall population experienced one or more of the four food insecurity circumstances. Thus, 1 in 10 congregate participants and 1 in 6 home-delivered participants experienced food insecurity during the preceding month, compared with 1 in 20 elderly persons in the overall U.S. population who experienced food insecurity in the preceding six months. The differences between Title III participants and the overall elderly population would probably be even larger if the current evaluation had used a six-month reference period.

4. Overall 24-Hour Dietary Intake

Program participants, on average, have daily nutrient intakes that meet or exceed the Recommended Dietary Allowances (RDAs) of the National Research Council (NRC) for most nutrients. However, significant numbers of participants fail to attain the RDAs. When a more conservative, albeit somewhat arbitrary, target criterion of meeting two-thirds of the RDAs is used, the percentage of Title III participants meeting the RDA targets, based on analysis of a single day's intake, is considerably higher. The appropriateness of the RDA for the older population is controversial. These recommendations are designed to meet the needs of healthy persons, but do not consider increased nutrient requirements that may be introduced by chronic health problems, medications that interfere with nutrient utilization, physiological changes with advanced age, and so forth. The interpretation of these findings, particularly in reference to the two-thirds RDA benchmark, must be done cautiously. Our examination of total intake of macronutrients, sodium, and dietary cholesterol over the 24-hour period shows that participants' intake of total fat and saturated fat as a percentage of total calories and the intake of sodium are somewhat higher than recommended daily levels, and that the intake of carbohydrate as a percentage of total calories is lower than the recommended level. When interpreting the findings on the macronutrient content of participants' overall diets, it should be noted that some nutrition experts believe the recommended levels of total fat and saturated fat as a percentage of calories for elderly people may be overly stringent. The argument is that the full implications of lowering total and saturated fat intake on longer-term health outcomes in the elderly are unknown. Furthermore, reducing total and saturated fat intake may result in lowering the intake of much needed calories and other essential nutrients for this population, and this intake needs to be carefully managed to preserve the nutrient density of the diet.

As a context for assessing participants' 24-hour nutrient intake, it is important to describe the requirements used to assess the adequacy of participants' diets first. This information is provided next.

a. Description of Dietary Requirements Used to Assess Participants' Diets

The 1992 amendments to the Older Americans Act require the meals served by the program to comply with the Dietary Guidelines for Americans, published by DHHS and the U.S. Department of Agriculture (USDA), and to meet the RDAs. We used these recommendations to assess the dietary adequacy of all meals eaten by program participants during the 24 hour period, inclusive of program and nonprogram meals.

The Dietary Guidelines make several recommendations about how Americans should eat; however, most of the recommendations are not specified in quantitative terms. The following specific quantitative recommendations, are provided for total fat and saturated fat in an individual's overall diet:

  • Intake from total fat should not exceed 30 percent of total food energy (calories).
  • Intake from saturated fat should not exceed 10 percent of total food energy (calories).

The NRC does provide some quantitative benchmarks for some of the recommendations in the Dietary Guidelines:

  • Intake from carbohydrates should exceed 55 percent of total food energy (calories).
  • Intake of dietary cholesterol should not exceed 300 mg per day.
  • Intake of sodium should not exceed 2,400 mg per day.
  • Intake of protein should not exceed twice the RDA for protein.

The NRC recommendations are used in the current evaluation to operationalize the nonquantitative recommendations of the Dietary Guidelines and to provide additional quantitative measures for assessing the adequacy of participants' diets.

b. 24-Hour Intake of Food Energy and Nutrients

Program participants, on average, have daily nutrient intakes that meet or exceed the RDAs for most nutrients. The mean intakes of both congregate and home-delivered meal program participants meet or exceed the RDAs for protein, Vitamin A, Vitamin C, Vitamin D, thiamin, riboflavin, niacin, folate, Vitamin B12 , iron, phosphorous, and potassium (Table II.8). Participants' average intake of food energy (calories) is below the RDA, equaling 79 percent for congregate participants and 71 percent for home-delivered participants. Mean intakes are below the RDAs for only five nutrients other than food energy: (1) Vitamin E; (2) Vitamin B6; (3) calcium; (4) magnesium; and (5) zinc. However, the average intake of Vitamin E, Vitamin B6, and calcium are close to the RDAs--the mean intake of each exceeds 90 percent. The findings on 24-hour nutrient intake indicate that, on average, participants consume nutrient-dense diets: their intake of food energy is below the RDA, but their intake of most nutrients meets or exceeds the RDAs.

TABLE II.8

MEAL PROGRAM PARTICIPANTS' 24-HOUR NUTRIENT INTAKE

(As a Percentage of the RDAs)

Title III Congregate Meal Participants


Title III Home-Delivered Meal Participants

Nutrient

Mean

Median

Percentage Attaining Two-Thirds of the RDA


Mean

Median

Percentage Attaining Two-Thirds of the RDA

Food Energy (Calories)

79

76

66


71

70

56

Protein

124

117

94


111

105

86

Vitamin A

146

103

73


136

105

68

Vitamin C

167

144

80


144

110

69

Vitamin D

108

100

72


109

101

71

Vitamin E

92

77

62


73

64

46

Thiamin

141

128

93


128

121

89

Riboflavin

143

131

95


135

124

91

Niacin

141

130

95


122

113

88

Vitamin B6

99

87

71


88

81

64

Folate

140

121

86


125

108

79

Vitamin B12

205

165

91


192

147

87

Calcium

94

87

68


91

83

66

Iron

131

113

89


123

103

84

Phosphorous

137

129

95


126

122

89

Potassium

131

125

95


115

111

88

Magnesium

88

83

73


78

74

60

Zinc

76

69

53


69

62

44

Unweighted Sample Size

1,040

1,040

1,040


818

818

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTE: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

RDAs = Recommended Dietary Allowances.

Although the typical congregate and home-delivered participant's intake of nutrients meets or exceeds the RDAs for most nutrients, significant numbers of participants fail to attain 100 percent of the RDAs (results not shown). While the RDA meets the needs of most healthy adults, they may underestimate the nutritional needs of those with multiple chronic diseases and medications that may compromise nutritional status. When a target criterion of two-thirds of the RDA is used, the percentage of participants meeting the target, based on analysis of a single day's intake, is considerably higher.

c. 24-Hour Intake of Macronutrients, Sodium, and Dietary Cholesterol
The typical Title III congregate and home-delivered meal program participants' diets tend to have too much fat and sodium and too little carbohydrates. On the other hand, intake of dietary cholesterol is well below the daily maximum.

Congregate and home-delivered participants, on average, consume 53 percent of their food energy in carbohydrates, somewhat below the 55 percent level recommended by the NRC (Table II.9). About 40 percent of congregate participants and 36 percent of home-delivered participants meet or exceed the minimum 55 percent recommended level. For nearly one-quarter each of congregate and home-delivered participants, the carbohydrate content of their diets is below 45 percent of food energy (10 percentage points below the recommendation).

TABLE II.9

MEAL PROGRAM PARTICIPANTS' 24-HOUR INTAKE OF MACRONUTRIENTS, SODIUM, AND CHOLESTEROL

Dietary Component

Title III Congregate

Meal Participants

Title III Home-Delivered

Meal Participants

Carbohydrate



Mean Percentage of Food Energy (Calories)

53

53

Median Percentage of Food Energy (Calories)

53

52

Distribution of Intake as a Percentage of Food Energy (Calories)



Less than 45 percent

21

25

45 to 55 percent

40

39

56 to 65 percent

33

27

More than 65 percent

6

9

Total Fat



Mean Percentage of Food Energy (Calories)

32

32

Median Percentage of Food Energy (Calories)

32

32

Distribution of Intake as a Percentage of Food Energy (Calories)



Less than 20 percent

6

8

20 to 30 percent

34

34

31 to 35 percent

26

25

36 to 40 percent

22

19

41 to 50 percent

11

13

More than 50 percent

1

1

Saturated Fat



Mean Percentage of Food Energy (Calories)

11

12

Median Percentage of Food Energy (Calories)

11

12

Distribution of Intake as a Percentage of Food Energy (Calories)


Less than 5 percent

2

5

5 to 10 percent

41

35

11 to 15 percent

44

44

16 to 20 percent

12

15

More than 20 percent

1

2

Protein



Mean Percentage of Food Energy (Calories)

17

17

Median Percentage of Food Energy (Calories)

17

16

Distribution of Intake as a Percentage of Food Energy (Calories)



Less than 15 percent

41

40

16 to 25 percent

55

55

More than 25 percent

4

5

Sodium



Mean Intake (mg Per Day)

2,568

2,352

Median Intake (mg Per Day)

2,363

2,200

Distribution of Intake (Percentage)



Less than 2,400 mg per day

51

56

2,401 to 3,000 mg per day

20

21

More than 3,000 mg per day

29

23

Dietary Cholesterol



Mean Intake (mg Per Day)

210

196

Median Intake (mg Per Day)

169

149

Distribution of Intake (Percentage)



Less than 300 mg per day

80

83

300 to 400 mg per day

10

7

More than 400 mg per day

10

10

Unweighted Sample Size

1,040

818

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations.

NOTES: Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day. The Dietary Guidelines recommend that (1) total fat intake should be 30 percent or less of food energy intake, and (2) saturated fat should be 10 percent or less of food energy intake. The NRC recommends that (1) the intake of cholesterol should be less than 300 mg per day, (2) the intake of sodium should not exceed 2,400 mg per day, and (3) the intake of carbohydrates should be at least 55 percent of food energy.

The typical congregate and home-delivered participant consumes 32 percent of his or her diet as fat, somewhat above the guideline of 30 percent. About 40 percent in each group are below the 30 percent guideline. A significant minority of participants (approximately 15 percent in each group) exceed the guideline by 10 percentage points or more, consuming more than 40 percent of their food energy as fat. Similar patterns were found for saturated fat intake.

Congregate and home-delivered participants, on average, consume 2,568 mg and 2,352 mg of sodium daily, respectively (Table II.9). Congregate participants' daily intake of sodium exceeds the 2,400 mg level suggested by the NRC by about seven percent, whereas home-delivered participants consume somewhat less than this level. About one-quarter each of congregate and home-delivered participants consume more than 3,000 mg of sodium daily, exceeding the suggested daily recommendation by more than 25 percent.

Intake of dietary cholesterol, in general, is not a problem for Title III meal program participants. The mean daily intake of cholesterol is 210 mg for congregate participants and 196 mg for home-delivered meal participants--well below the 300 mg suggested recommendation. About 20 percent of congregate and home-delivered participants consume more than 300 mg of cholesterol per day.

As stated earlier, some nutrition experts suggest that the recommended maximum levels of total fat and saturated fat as a percentage of calories for elderly people are overly stringent. Thus, these slightly higher-than-recommended daily intakes of total fat and saturated fat need to be interpreted cautiously, because reducing total and saturated fat intake, unless carefully managed, may compromise the nutrient density of their diets.

d. Comparisons with the Overall Elderly Population

To get a sense of how Title III participants fare relative to the overall elderly U.S. population, Tables II.10 and II.11 compare the 24-hour dietary intakes of Title III congregate and home-delivered participants with those of the overall U.S. elderly population age 60 and older, separately for females and males. For elderly females, female congregant participants' mean intake of food energy and nutrients generally exceeds the mean intake for the overall female elderly population (Table II.10). Also, on the positive side, their intake of sodium and dietary cholesterol is more favorable, being less, on average, than the intake for the overall elderly female population. In general, the average intake of food energy and all other nutrients for female home-delivered meal program participants is less than the intake for the overall elderly female population. Again, female home-delivered meal participants' average intake of sodium and dietary cholesterol is lower than that for the overall elderly female population. The pattern is somewhat different for elderly males. Table II.11 shows that, for virtually all nutrients, the average intake for the overall elderly male population exceeds the intake for both Title III congregate and home-delivered meal program male participants. Exceptions are for carbohydrates, total fat, and dietary cholesterol.

TABLE II.10

AVERAGE DAILY NUTRIENT INTAKE OF FEMALE MEAL PROGRAM PARTICIPANTS AGE 60 AND OLDER, COMPARED WITH OVERALL U.S. ELDERLY FEMALE POPULATION

Nutrient

Title III Congregate

Meal Participants

Title III Home-Delivered Meal Participants

U.S. Elderly

Population (60+)

Recommended Daily

Allowance

Food Energy (Kcal)

1,512

1,365

1,482

1,900

Protein (g)

64

57

60

50

Vitamin A (RE)

1,215

1,130

1,114

800

Vitamin C (mg)

100

84

105

60

Vitamin D (µg)

5.2

5.2

NA

5.0

Vitamin E (mg •-TE)

7.6

5.8

7.9

8.0

Thiamin (mg)

1.4

1.3

1.4

1.0

Riboflavin (mg)

1.7

1.6

1.6

1.2

Niacin (mg)

18.4

15.6

18.3

13.0

Vitamin B6 (mg)

1.6

1.4

1.6

1.6

Folate (µg)

253

218

272

180

Vitamin B12 (µg)

3.9

3.7

3.8

2.0

Calcium (mg)

716

708

669

800

Iron (mg)

12.4

11.5

12.7

10.0

Phosphorous (mg)

1,048

960

987

800

Potassium (mg)

2,542

2,233

2,427

2,000

Magnesium (mg)

255

223

246

280

Zinc (mg)

9.4

8.3

9.0

12.0

Carbohydrate (g)

200

180

190

NA

Total Fat (g)

54

49

55

NA

Saturated Fat (g)

19.3

18.1

18.6

NA

Cholesterol (mg)

188

177

197

300a

Sodium (mg)

2,411

2,258

2,459

2,400a

Carbohydrate as Percentage of Food Energy

53.1

53.3

52.2

55.0a

Protein as Percentage of Food Energy

17.1

17.0

16.5

15.0a

Total Fat as Percentage of Food Energy

31.5

31.4

32.3

30.0a

Saturated Fat as Percentage of Food Energy

11.3

11.6

10.9

10.0a

Unweighted Sample Size

701

564

1,280

NA

SOURCE: Elderly Nutrition Program Evaluation, participant survey, weighted tabulations; National Center for Health Statistics 1994.

NOTES: Tabulations are weighted to be representative of a cross-section of female participants receiving Title III meals on a given day. Participant tabulations in this table are for Title III participants age 60 and older. Figures for U.S. elderly population are authors' tabulation of published NHANES III data cited under source.

  • a Recommended levels based on Dietary Guidelines and NRC recommendations.
  • NA = not available.
  • g = grams.
  • mg = milligrams.
  • Tg = micrograms.
  • RE = retinol equivalents.
  • mg I-TE = milligrams alpha-tocopherol equivalents.

TABLE II.11

AVERAGE DAILY NUTRIENT INTAKE OF MALE MEAL PROGRAM PARTICIPANTS AGE 60 AND OLDER, COMPARED WITH OVERALL U.S. ELDERLY MALE POPULATION

Nutrient

Title III Congregate

Meal Participants

Title III Home-Delivered Meal Participants

U.S. Elderly

Population (60+)

Recommended Daily

Allowance

Food Energy (Kcal)

1,786

1,591

1,989

2,300

Protein (g)

73

68

79

63

Vitamin A (RE)

1,323

1,281

1,296

1,000

Vitamin C (mg)

101

94

104

60

Vitamin D (µg)

5.9

6.1

NA

5.0

Vitamin E (mg •-TE)

8.7

7.4

9.4

10.0

Thiamin (mg)

1.7

1.5

1.7

1.2

Riboflavin (mg)

2.0

1.9

2.1

1.4

Niacin (mg)

21.0

19.3

23.7

15.0

Vitamin B6 (mg)

1.8

1.7

2.0

2.0

Folate (µg)

278

267

318

200

Vitamin B12 (µg)

4.5

4.1

5.8

2.0

Calcium (mg)

815

806

830

800

Iron (mg)

14.8

13.6

16.3

10.0

Phosphorous (mg)

1,183

1,129

1,296

800

Potassium (mg)

2,800

2,518

2,964

2,000

Magnesium (mg)

283

261

311

350

Zinc (mg)

10.8

10.1

12.4

15.0

Carbohydrate (g)

230

203

242

--

Total Fat (g)

67

58

76

--

Saturated Fat (g)

24.1

21.5

25.8

--

Cholesterol (mg)

260

235

289

300a

Sodium (mg)

2,914

2,555

3,241

2,400a

Carbohydrate as Percentage of Food Energy

51.7

50.8

49.3

55.0a

Protein as Percentage of Food Energy

16.8

17.5

16.2

15.0a

Total Fat as Percentage of Food Energy

32.9

32.7

33.5

30.0a

Saturated Fat as