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Nutrition

Evaluations Report

III. CONTRIBUTION OF THE TITLE III NUTRITION PROGRAM TO PARTICIPANTS’ 24-HOUR

DIETARY INTAKE AND SOCIAL CONTACTS

One of the goals of the Elderly Nutrition Program (ENP) is to improve the dietary intakes of program participants by directly providing them with nutritionally balanced meals. The Older Americans Act (OAA), as amended, specifies that nutrition projects are to provide at least one hot or other appropriate meal per day to participants, five or more days a week. [ In rural areas, if approved by the State Unit on Aging (SUA), the number of meals per week may be fewer than five, if this frequency is not feasible or for other reasons.] Furthermore, program meals must comply with the Dietary Guidelines for Americans, set forth by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (DHHS), and meet standards for food energy and selected nutrients based on the Recommended Dietary Allowances (RDAs) of the National Research Council (NRC). For congregate meals, another program goal is to attract isolated elderly people to the meal sites in order to facilitate social interaction and delivery of other nutrition and supportive services that they need.

This chapter presents evaluation findings on the contribution of the Title III meals program to participants’ daily intake of nutrients and opportunities for socialization. It has two sections. The first examines the contribution of the program to participants’ 24-hour dietary intakes and number of monthly social contacts, by presenting evidence on the fraction of participants’ daily dietary intake and monthly social contacts derived from program sources. In this section, we also compare participants’ dietary intake from program meals with the RDAs and other dietary recommendations. The second section examines the contribution of the program by estimating differences between the daily dietary intakes and number of monthly social contacts for program participants and eligible nonparticipants, controlling statistically for other participant characteristics related to these outcomes.

The evaluation found that Title III meal program participants’ average dietary intake from the program meal generally meets or exceeds the OAA requirement of one-third of the RDAs for most nutrients. Participants’ average intake from program meals of total fat and saturated fat as a proportion of total calories is slightly higher than the recommended levels. Intake of carbohydrates as a percentage of total food energy is below recommendations. Overall, more than 40 percent of the average participants’ total daily intake on a day that they attend or receive meals from the program is derived from program meals. Consistent with previous research, the evaluation found that program participants’ dietary intakes relative to the RDAs exceed those of eligible nonparticipants for the days on which participants receive a program meal. The dietary improvements were generally stronger for congregate than home-delivered meal program participants. Of the 18 nutrients studied, congregate participants’ average daily intakes of all nutrients except iron, folate, and Vitamin B12 are higher than those of congregate-eligible nonparticipants, at a statistically significant level. Home-delivered meal program participants’ average daily intakes of Vitamin A, Vitamin D, riboflavin, calcium, phosphorous, potassium, zinc, and magnesium are higher than those of home-delivered eligible nonparticipants, at a statistically significant level. The evaluation also found that program participants average more social contacts per month than eligible nonparticipants, using a broad definition of contacts that includes assistance from public or private home-and community-based long-term care service providers. Although methodological limitations make it impossible to attribute these differences definitively to causal effects of the program, as discussed more fully in the text, the differences are probably at least partially attributable to the ENP.

The remainder of the chapter describes these findings in greater detail.

A. DIETARY INTAKE AND SOCIALIZATION FROM PROGRAM SOURCES

1. Participants’ Dietary Intake from Program Meals
The in-person survey asked Title III meal program participants to recall all the foods they ate during the previous 24 hours. Participants were also asked the source of their meals. From these responses, weidentified all foods and beverages that came from the Title III program. For congregate participants, we included foods they consumed at the meal site, as well as any program foods taken home and eaten during the recall period.

Intake of Food Energy and Nutrients from Program Meals.
The OAA requires nutrition providers to serve meals that comply with the RDAs. Program meals must achieve a minimum of one-third of the RDA, if one meal is provided to participants per day; a minimum of two-thirds of the RDA, if two meals are provided per day; or 100 percent of the RDA, if three meals are provided per day. Thus, over a period of time, program meals for each eating occasion (breakfast, lunch, and dinner) are to average a minimum of one-third of the RDAs for specified nutrients. [ Chapter IV presents findings on the nutrient content of program meals as served or offered . It shows that the average program meal meets the explicit program target of providing at least one-third of the relevant RDAs. In this section, we address the issue of whether participants ' intake per program meal meets or exceeds one-third of the RDAs. Even though program meals as offered meet one-third of the RDAs, on average, participants ' average intake of nutrients from program meals may be less because they might not eat all of what is served to them.]

On the basis of an analysis of a single day’s 24-hour dietary recall, Title III congregate participants’ average intake of nutrients per program meal exceeds the one-third RDA requirement for all nutrients studied, often by substantial amounts (Table III.1). [ The majority of meal program participants receive just one program meal daily (88 percent of congregate participants and 87 percent of home-delivered participants). For participants who received more than one program meal during the recall period, we standardized their intake from program meals to a per-meal per-day basis, so it could be meaningfully compared to one-third of the RDA. For example, if a participant received two program meals daily, intakes from these two meals for each nutrient were summed and divided by two (the number of meals) to derive a measure of intakes on a per-meal basis.] For example, congregate participants’ average intake of protein from program meals is 58.4 percent of the daily RDA, or nearly twice the per-meal standard of 33.3 percent. The typical congregate participant’s intakes of the critical nutrients calcium, folate, and magnesium exceed one-third of the RDAs. Overall, for 10 of the 18 nutrients examined, two-thirds or more of Title III congregate participants’ intakes per program meal meet or exceed one-third of the RDAs.

TABLE III.1
PARTICIPANTS’ DAILY NUTRIENT INTAKE PER PROGRAM MEAL

(As a Percentage of RDAs)


Title III Congregate Meal Participants


Title III Home-Delivered Meal Participants

Nutrient

Mean

Median

Percentage Exceeding One-Third of the RDA


Mean

Median

Percentage Exceeding One-Third of the RDA

Food Energy

33.1

32.0

46


26.6

27.1

31

Protein

58.4

55.8

86


50.6

51.4

73

Vitamin A

69.6

43.0

62


66.6

41.3

59

Vitamin C

61.0

46.8

66


48.5

33.7

51

Vitamin D

46.9

47.4

60


47.0

50.0

61

Vitamin E

38.0

35.1

53


28.3

26.4

35

Thiamin

50.6

47.0

76


44.6

43.0

65

Riboflavin

54.4

52.9

78


48.8

48.6

71

Niacin

56.8

53.8

83


45.8

44.8

69

Vitamin B6

37.5

35.0

54


32.8

32.5

46

Folate

46.1

41.0

66


41.1

35.3

53

Vitamin B12

91.3

70.0

80


74.2

64.5

73

Calcium

40.5

40.5

56


39.1

42.6

58

Iron

45.2

43.5

72


36.9

36.6

58

Phosphorous

59.1

57.5

85


52.7

55.2

75

Potassium

57.5

56.7

86


47.8

48.7

72

Magnesium

35.2

33.6

51


29.4

29.4

41

Zinc

33.2

30.8

43


28.2

27.7

35

Unweighted Sample Size

1,039

1,039

1,039


815

815

815

Source: Elderly Nutrition Program Evaluation, Participant survey, weighted tabulations.

Notes: Includes 89 participants who received but did not consume a program meal during the 24-hour recall period (23 congregate participants who attended the meal site and usually eat a program meal but did not that day because of medical tests or other reasons; 66 home-delivered meal program participants who received a program meal but chose not to eat the meal during the recall period, saving it for another time). Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day. Persons who received more than one program meal during the recall period had their intakes summed and divided by the number of program meals received, so their intake could be compared to the one-third RDA standard.

RDA = Recommended Dietary Allowance.

For zinc and food energy, however, fewer than one-half of congregate participants attain one-third of the RDAs.

Title III home-delivered meal program participants’ average intakes per program meal meet or exceed the one-third RDA requirement for all nutrients except food energy, Vitamin E, Vitamin B6, magnesium, and zinc (Table III.1). The typical home-delivered meal program participant consumes 50.6 percent of the RDA for protein, 41.1 percent of the RDA for folate, and 39.1 percent of the RDA for calcium from a program meal. For significant percentages of home-delivered participants, however, intakes from the program meal do not attain the one-third RDA requirement for the nutrients examined. Fewer than half of home-delivered participants achieve one-third of the RDA for food energy, Vitamin E, Vitamin B6, magnesium, and zinc.

It is important to note that eight percent of Title III home-delivered participants (or 66 elderly people) did not report consuming any food items from a program meal during the recall period. These individuals received zeros in the calculation of the mean (median) intake from program meals for each nutrient. Since most Title III home-delivered participants receive five meals per week, most of these individuals probably received a program meal during the recall period, but (1) they chose not to eat it, either because they planned to eat it some other day, or because they did not like what was served; (2) they failed to identify food items consumed as coming from the program; or (3) interviewers failed to record properly foods coming from program sources when they were reported as such. Regardless of the reason, it is appropriate to include these individuals in the analysis of intake from program meals, because virtually all of them received a program meal. [ When these individuals are excluded from the analysis, the average daily intake from a home- delivered program meal relative to the RDA increases, as does the percentage of home-delivered participants obtaining at least one-third of the RDA from their intake of program meals (see Volume III, Appendix F).]

Macronutrient Content of Participants’ Intake from the Program Meal. The typical Title III congregate and home-delivered meal program participant’s intakes of total fat, saturated fat, and sodium per program meal exceed the levels recommended by the Dietary Guidelines, whereas the intake of carbohydrate from the program meal is somewhat below recommended levels. The intake of dietary cholesterol from the program meal is well within the recommended levels.

The mean intake of carbohydrate as a percentage of total food energy from a program meal is 49.4 percent for congregate participants and 48.6 percent for home-delivered participants (Table III.2). For both congregate and home-delivered participants, the mean percentages of food energy from carbohydrates are below the NRC’s recommendation of 55 percent. Both congregate and home-delivered participants’ intakes of total fat from program meals as a percentage of food energy are above the 30 percent recommended level (34.7 percent and 34.3 percent, respectively). Title III congregate and home-delivered meal program participants’ intake of saturated fat from program meals as a percentage of total calories is 12 percent, which is above the recommendation of 10 percent.

Title III congregate participants’ intake of dietary cholesterol per program meal is 87 mg. Intake of cholesterol per program meal for home-delivered participants is somewhat lower, at 71 mg. Congregate participants’ intake of sodium from program meals is, on average, 1,162 mg; sodium intake from program meals for home-delivered participants is considerably lower, at 951 mg. There are no federal ENP program regulations that quantify sodium or cholesterol contents per program meal. Applying the one-third RDA rule to the NRC recommendations as a desirable target for program meals for cholesterol and sodium indicates that participants’ intake of cholesterol from the program meal is below the maximum recommended level of 100 mg, but intake of sodium from the program meal is above the maximum recommended level of 800 mg.

TABLE III.2

PARTICIPANTS’ DAILY INTAKE OF MACRONUTRIENTS, SODIUM, AND DIETARY CHOLESTEROL PER PROGRAM MEAL

Dietary Component

Title III Congregate Meal Participants

Title III Home-Delivered

Meal Participants

Carbohydratea



Mean Percentage of Food Energy (Calories)

49.4

48.6

Median Percentage of Food Energy (Calories)

48.6

47.3

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



Less than 45 percent

39

44

45 to 55 percent

35

34

56 to 65 percent

17

13

More than 65 percent

9

9

Total Fata



Mean Percentage of Food Energy (Calories)

34.7

34.3

Median Percentage of Food Energy (Calories)

35.0

34.0

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



Less than 20 percent

9

11

20 to 30 percent

26

29

31 to 35 percent

19

20

36 to 40 percent

21

15

41 to 50 percent

18

18

More than 50 percent

6

8

Saturated Fata



Mean Percentage of Food Energy (Calories)

12.2

12.3

Median Percentage of Food Energy (Calories)

11.9

11.7

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



Less than 5 percent

4

5

5 to 10 percent

39

37

11 to 15 percent

39

37

16 to 20 percent

14

14

More than 20 percent

3

6

Proteina



Mean Percentage of Food Energy (Calories)

19.4

21.1

Median Percentage of Food Energy (Calories)

18.6

19.8

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



Less than 5 percent

*

*

5 to 15 percent

30

23

16 to 25 percent

58

55

More than 25 percent

12

21

Sodium



Mean Intake (mg Per Day)

1,162

951

Median Intake (mg Per Day)

1,062

901

Distribution of Intake



Less than 800 mg per day

29

43

801 to 1,000 mg per day

17

13

More than 1,000 mg per day

54

44

Dietary Cholesterol



Mean Intake (mg Per Day)

87

71

Median Intake (mg Per Day)

78

66

Distribution of Intake



Less than 100 mg per day

68

76

101 to 133 mg per day

17

14

More than 133 mg per day

16

10

Unweighted Sample Size

1,039

815

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 intake of (1) total fat should be 30 percent or less of food energy, and (2) saturated fat should be 10 percent or less of food energy. The National Research Council recommends (1) a carbohydrate intake of 55 percent or more of food energy, (2) a total sodium intake of 2,400 mg or less daily, and (3) a total cholesterol intake of 300 mg or less daily. Applying the one-third standard to the sodium and cholesterol recommendations implies that the intake per program meal should not exceed 800 mg of sodium or 100 mg of cholesterol.

aExcludes 89 participants who received but did not consume a program meal during the 24-hour recall period (23 congregate participants who attended the meal site and usually eat a program meal but did not that day because of medical tests or other reasons; 66 home-delivered meal program participants who received a program meal but chose not to eat the meal during the recall period, saving it for another time).

* = Less than 0.5 percent.

Percentage of Total Daily Dietary Intake Provided by the Program Meal. Participants consume substantial proportions of their total daily intake of nutrients from Title III program meals on days when they either attend the congregate meal site or receive home-delivered meals. Title III congregate and home-delivered participants’ average intake from program meals ranges between 36 and 51 percent of their total daily intake of the 18 nutrients examined (Table III.3). For example, the typical congregate participant gets 44 percent of his or her daily intake of food energy (calories) from the program meal; the comparable figure for home-delivered participants is 39 percent. Congregate participants, on average, get 49 percent of their total daily intake of protein from the program meal, compared with 47 percent for home-delivered participants. Averaging the mean percentages of intake from program meals across the 18 nutrients shows that, for congregate participants, approximately 45 percent of the total daily intake of these nutrients (not as a proportion of the RDAs) is derived from program meals. Home-delivered participants’ percentage of total daily intake of these nutrients from program food is slightly higher, at 47 percent.

These findings on mean percentage of daily intake from program meals suggest that program meals are an important part of daily nutrient intake for a large number of participants. This is confirmed by other evidence in the characteristics survey. For example, when asked how important the meal program is as a source of food, nearly half (45 percent) of congregate participants reported that the program is their major source of food.

TABLE III.3

PERCENTAGES OF PARTICIPANTS’ TOTAL DAILY INTAKE FROM ALL PROGRAM MEALS


Title III Congregate Meal Participants


Title III Home-Delivered Meal Participants

Nutrient

Mean

Median


Mean

Median

Food Energy

43.6

43.4


39.4

40.1

Protein

49.1

49.6


46.8

49.3

Vitamin A

50.3

49.0


48.7

51.4

Vitamin C

44.7

40.5


42.6

39.8

Vitamin D

46.9

45.8


44.5

43.9

Vitamin E

47.3

47.6


43.8

43.8

Thiamin

39.3

37.0


37.0

36.3

Riboflavin

41.5

40.0


39.1

38.4

Niacin

43.6

43.0


40.0

41.3

Vitamin B6

43.8

41.6


41.7

41.7

Folate

39.6

37.5


36.2

33.1

Vitamin B12

49.1

48.4


46.5

45.4

Calcium

45.7

45.3


44.6

45.1

Iron

40.2

39.0


35.6

34.9

Phosphorous

45.8

44.8


43.7

45.5

Potassium

46.3

45.6


43.3

44.4

Magnesium

42.9

41.5


39.8

40.2

Zinc

47.5

46.9


44.5

46.1

Sodium

47.6

46.2


42.5

42.6

Dietary Cholesterol

49.2

47.0


45.9

44.8

Unweighted Sample Size

1,039

1,039


815

815

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. Includes 89 participants who received but did not consume a program meal during the 24-hour recall period (23 congregate participants who attended the meal site and usually eat a program meal but did not that day because of medical tests or other reasons; 66 home-delivered meal program participants who received a program meal but chose not to eat the meal during the recall period, saving it for another time).

Comparisons with Previous Studies. The findings on dietary intake from program meals and the contribution of program meals to participants’ overall total daily intake summarized in the previous sections are consistent with those reported in earlier evaluations of the Title III meals program.

Using participants’ dietary intake between 11 am and 4 pm as a proxy for their intake from program meals, Kirschner et al. (1983) found similar percentages of participants consuming one-third of the RDAs for selected nutrients as the current evaluation. [ To be comparable to the Kirschner (1983) results, the results reported in Table III.4 for participants in the current evaluation include only those participants who consumed a program meal during the recall period. Thus, the unweighted sample sizes in Table III.4 are less than those reported in the previous tables of this chapter, which included participants who received but did not consume a program meal. ] For example, the current evaluation found that 88 percent of congregate participants who consumed a program meal had intakes per program meal that provided at least one-third of the RDA for protein, compared with 87 percent of congregate participants surveyed by Kirschner et al. in 1981 (Table III.4). The current evaluation found that 81 percent of home-delivered participants received one-third or more of the RDA for protein from a program meal, compared with 82 percent of home-delivered participants in the Kirschner et al. study.

Similar to the current evaluation, three previous studies found that Title III program meals contributed substantially to participants’ total daily dietary intake (Caliendo 1980; Harrill et al. 1981; and Kohrs et al. 1978). Similar to the current evaluation findings, all three studies indicated that congregate and home-delivered meal program participants consumed an average of 40 percent or more of their total daily nutrient intake during the program meal (results not shown). [ The studies cited involved single area or local sites. In addition, the tabulations in each of these studies were based only on samples of participants that ate a program meal during the 24-hour period, whereas the tabulations reported for the current evaluation also include participants who received a program meal but did not consume it during the 24-hour period.]

TABLE III.4

PERCENTAGE OF PARTICIPANTS WHOSE DIETARY INTAKES FROM PROGRAM MEALS PROVIDED AT LEAST ONE-THIRD OF THE RDA: COMPARISON BETWEEN CURRENT AND PREVIOUS NATIONAL EVALUATIONS

(Includes Only Participants Who Consumed a Program Meal)


Title III Congregate Meal Participants


Title III Home-Delivered Meal

Program Participants

Nutrient

Current

Evaluation a

Previous

Evaluation b


Current

Evaluation a

Previous

Evaluation b

Food Energy

49

53


36

48

Protein

88

87


81

83

Vitamin A

65

55


67

50

Vitamin C

68

59


56

52

Thiamin

78

70


71

67

Riboflavin

80

78


79

75

Niacin

85

73


77

66

Calcium

58

51


65

50

Iron

74

75


65

67

Unweighted Sample Size

1,016

800


749

340

Source: Elderly Nutrition Program Evaluation, Participant survey, weighted tabulations; Kirschner et al. (1983).

Note: Participant tabulations for the current evaluation are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

a Refers to the intake of nutrients from program meal sources during the 24 hours as reported by participants who ate a program meal during the recall period.

b Refers to the intake of nutrients during the 11 am to 4 pm period as reported by participants who ate a program meal during the recall period. Kirschner et al. used intake during the 11 am to 4 pm period as a proxy for intake from program meal sources because they did not ask participants about meal sources. They reported that all of the surveyed meal programs and a majority of programs in general served their meals during these hours.

2. Social Contacts and Activities from Meal Program Sources

In addition to providing nutritious meals, a major goal of the ENP is to reduce the social isolation of elderly persons. The congregate meals program, through provision of group dining, recreation, and other activities, affords opportunities for social interaction and companionship. Although much more limited, the home-delivered meals component also provides an opportunity for an important social contact: the contact between the participant and a staff person or volunteer who delivers the program meal to the participant’s home.

Under a broad definition of "social contacts," congregate participants average 95 social contacts per month, and home-delivered meal program participants average 100. [ Social contacts were defined to include talking on the telephone; visiting or being visited by relatives, friends, or neighbors; attending church or religious services; attending clubs or other organizations; attending congregate meal sites for meals and/or recreation services; receiving home-delivered meals from the meal program; and receiving other home or community-based long-term care services, such as personal care, homemaker, home health, and attending adult day care programs. ] Program sources represent, on average, approximately 25 percent of Title III congregate and home-delivered participants’ total social contacts per month (Table III.5). [ Program sources of social contacts refer to attending congregate meal sites for meals or recreation, and having contact with staff or volunteers who deliver the home-delivered meal.] For 11 percent of congregate participants and 13 percent of home-delivered participants, social contacts afforded by the meals program account for 50 percent or more of their total monthly activities and social contacts.

For home-delivered participants, social contacts from program sources are exclusively contacts they have with program staff when the meal is delivered to them. These contacts tend to be limited: 75 percent of home-delivered meal program participants reported that the delivery person leaves immediately, whereas 25 percent reported that the delivery person spends some time to talk with or check on them (not shown). Regardless of the length of the contact, home-delivered meal program participants value it highly. For example, when asked to mention the things they like about the meals program, 59 percent of home-delivered participants reported that they like the contact with the delivery person, and 98 percent reported that the meal delivery person is usually pleasant.

Congregate participants avail themselves of the opportunities for social interaction and activities provided by the meal program. Ninety percent reported that they typically spend more than one hour at the meal site when they attend. Forty-seven percent reported participating at least once a week in recreation activities provided at the meal program (not shown).

TABLE III.5

PARTICIPANTS’ TOTAL MONTHLY SOCIAL CONTACTS FROM PROGRAM SOURCES

(Percentages, Unless Stated Otherwise)

Social Contacts

Title III Congregate

Meal Participants

Title III Home-Delivered Meal Participants

Total Number Per Month from All Sources



Mean

95.4

100.5

Median

74.1

85.9

Proportion from Program Sources (Percent Distribution)



1 to 10 percent

16

11

11 to 20 percent

28

33

21 to 30 percent

21

21

31 to 40 percent

16

14

41 to 50 percent

9

8

51 to 75 percent

8

10

More than 75 percent

3

3

Mean

27.4

28.6

Median

22.6

23.6

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. Social contacts include talking on the telephone; visiting friends, relatives, or neighbors; attending church or religious services; attending clubs; attending congregate meal sites; and having contact with program person who delivers home-delivered meal and with providers of personal care services, such as home health, homemaker, and adult day care. Program social contact sources refer to attending congregate meal sites for meals or recreation, and having contact with the person who delivers the home-delivered meal.

This section examines the contribution of the Title III meal program to participants’ daily dietary intakes and social contacts by comparing participants and a matched comparison group of program-eligible nonparticipants on the mean values of these outcomes, using multivariate regression methods. [ Appendix F contains tables showing the simple differences in mean values of 24-hour dietary intakes and number of monthly social contacts for Title III congregate participants and congregate-eligible nonparticipants, as well as home-delivered participants and home-delivered eligible nonparticipants, controlling for race and ethnicity, gender, income, and disability via constructed weight variables. Two sets of nonparticipant weight variables were derived, one corresponding to each Title III participant group. Their derivation is described in Appendix C on weighting. The simple differences in mean values, controlling for participant-nonparticipant differences in the above-mentioned demographic characteristics via the weight variables, are essentially the same as the regression-adjusted results reported in the text.] As a context for assessing the findings, it is important to understand how the comparison group of eligible nonparticipants was identified, as well as how the statistical comparisons between participants and eligible nonparticipants were conducted.

1. Research Methods

Our objective in assessing the impacts of participation in the Title III program is to answer the question, "What would participants’ dietary intake and socialization be had these individuals never participated, and how do these outcomes compare with outcomes of participating?" The purpose of a comparison group of eligible nonparticipants is to represent what would happen to participants in the absence of the program. The comparison sample of nonparticipants should ideally be as similar as possible to the sample of participants, except for program participation and random variation.

The preferred type of comparison group is achieved under an experimental research (or random assignment) design. Under this design, program-eligible older individuals who want to participate in the program would be randomly assigned to either a "treatment" group, which receives nutrition services from the program, or to a "control" group, which does not. If the randomization of program eligibles is executedproperly, then at the time of the randomization, the control group would not differ in any systematic or unmeasured way from the treatment group, on average. Under this design, subsequent observed differences in the mean values of outcomes between participants and nonparticipants can be attributed to participation in the program with known statistical confidence.

Random assignment was not possible in the current evaluation. The absence of random assignment of individuals to "program participant" or "program nonparticipant" status created significant challenges in assessing the effects of the program. In response, we selected a sample, from the Health Care Financing Administration (HCFA) Medicare Beneficiary File, of nonparticipants in the same locations as participants, in which the nonparticipants were matched with participants in terms of key variables. This was the next best alternative to a randomized control group of nonparticipants. Multivariate regression techniques were then used to compare program participants and eligible nonparticipants on dietary intakes and social contacts, controlling for characteristics that could be related to both program participation and the outcomes studied.

a. Identifying Program-Eligible Nonparticipants

We used the HCFA Medicare Beneficiary File to identify program-eligible nonparticipants. [ During the design phase of the project, we considered using as the source of the comparison group eligible individuals who were on program waiting lists. Individuals on waiting lists, who would like to receive program services but cannot because of program resource constraints, seemed more likely to be similar to program participants on both measured and unmeasured characteristics than a nonparticipant group selected from the community. However, there are problems with using program waiting lists: (1) not all meal programs, particularly congregate ones, have waiting lists; and (2) individuals on waiting lists may be different from those receiving meals because of the criteria sites use to determine who gets on the list, and, once on the list, who gets served first. For these and other reasons, MPR and the evaluation 's technical advisory group concluded that using the Medicare Beneficiary File was preferable to a combined strategy of using program waiting lists when available and screening from the general population when not.] Samples of congregate- and home-delivered-eligible nonparticipants were selected from the file in the zip code areas covered by the meal sites and delivery routes selected for the participant samples. MPR requested andobtained from HCFA the names and addresses of all Medicare beneficiaries with addresses in these zip codes; the names of elderly beneficiaries were randomized within each zip code. Medicare beneficiaries were then selected for screening in the order in which they appeared on the sorted lists. Potential nonparticipants were screened by telephone for age, income, and disability status and for program participation to make sure they were not participating in either the congregate or home-delivered program. The screened sample was then stratified by income and disability status. Random samples were selected in a manner that ensured the participant and nonparticipant samples would have approximately the same distribution of income and disability status. [ The six income/disability cells were (1) poor, nonfrail; (2) near poor, nonfrail; (3) nonpoor, nonfrail; (4) poor, frail; (5) near poor, frail; and (6) nonpoor, frail. Poor refers to income less than 100 percent of the DHHS poverty guidelines; near poor refers to income between 100 percent and 200 percent of the DHHS poverty guidelines, and nonpoor refers to income greater than 200 percent of the DHHS poverty guidelines. Individuals were classified as disabled if they had either mobility or self-care impairments, and as not impaired if they did not. Cells 1 through 3 define congregate eligible, and cells 4 through 6 define home-delivered eligible older people.]

b. Multivariate Analysis of Differences Between Participants and Eligible Nonparticipants

Despite efforts to identify a group of eligible nonparticipants who were comparable to participants across several critical individual characteristics related to outcomes, the characteristics of the two samples differed. [ If we consider only the socioeconomic characteristics of the unweighted samples of participants and nonparticipants, Title III program participants tend to be older, to have completed fewer years of formal education, to be more racially mixed, and to be more likely to live alone and be female. Program participants ' incomes tend to be much lower than nonparticipants ' incomes, and a far greater percentage of Title III participants take part in other food assistance programs. That participants are, on average, older is partially a product of the study design: reflecting the age eligibility rules for receipt of Medicare, the Medicare Beneficiary File consists of elderly persons age 65 and older, whereas program participants are age 60 and older (and may be under age 60 if married to a participant age 60 or older). ] Consequently, our analyses used statistical methods to control for differences in the characteristics of participants and nonparticipants that affect outcomes and may be correlated with program participation.

Basic OLS Regression. The basic approach used for estimating differences in mean values on dietary intake and socialization outcomes between program participants and nonparticipants involves estimation of a linear model of the form:

(1)BOLD ITAL {Y SUB {i}~=~ b SUB {k}`` X SUB {ki}~ +~ c CMP SUB {i}~ +~ d HDMP SUB {i}~ +~ e SUB {i}``,}

where:

I="individuals"

Yi =the outcome of interest (for example, intake of food energy relative to the RDA)

Xki =a matrix of person-specific characteristics that are thought to affect the outcome of interest [ The following person-specific characteristics ( X ki ) were used in the OLS regressions: age; gender; minority status; mobility limitations, as measured by the number and types of activities of daily living and instrumental activities of daily living that the person had difficulty doing; income; self-reported health status; whether the person has hypertension, high blood cholesterol, or had a stroke; whether the person takes vitamin supplements; educational attainment; marital status; whether the person lives with other family members; physical activities in the prior month; self-reported appetite; and whether the person owns a microwave. We also included indicators for whether the person was on a general diabetic diet or one designed for low-salt, low-cholesterol, low-sugar, low-fat, high-fiber, or lactose-free intake.]

bk =a vector of unknown regression coefficients (parameters) to be estimated, each of which shows the change in the outcome variable resulting from a unit change in the corresponding regressor variable Xki

CMPi = a binary variable that equals "1" if the ith individual participates in the Title III congregate meals program, "0" otherwise

HDMPi = a binary variable that equals "1" if the ith individual participates in the Title III home-delivered meals program, "0" otherwise

NPi = a binary variable that equals "1" if the ith individual is a nonparticipant, "0" otherwise (omitted binary variable)

c = an unknown regression coefficient to be estimated that measures the difference in the outcome between congregate participants and the omitted category nonparticipantsd = an unknown regression coefficient to be estimated that measures the difference in the outcome variable between home-delivered meal program participants and the omitted category nonparticipants

ei = a stochastic error term

The combined unweighted sample of Title III congregate participants, home-delivered participants, and nonparticipants was used to get consistent estimates of the regression coefficients. This process was repeated separately for the 24-hour intake of food energy, for each of the other nutrients, and for the total number of social contacts per month. [ As will become apparent during the discussion of selection bias in the next section, estimation of the single linear equation implicitly assumes that any existing unmeasured differences between program participants and eligible nonparticipants do not systematically affect the outcomes being studied.]

The estimation results are summarized in Tables III.6 and III.7. Consider the comparisons for congregate and congregate-eligible nonparticipants first. For each outcome, we present the adjusted mean value for Title III congregate participants and then the adjusted mean value for congregate-eligible nonparticipants, as well as the difference in the mean values on the outcome between the two groups expressed as a percentage of nonparticipants’ mean outcome. We also indicate whether the difference is statistically significant at conventional levels, assuming a one-tailed test. [ One-tailed hypothesis tests are used in the analyses of all outcomes because the expectation a priori is that program participation improves dietary intake and socialization opportunities. The sharper hypothesis test in each case is that the differences in mean values between participants and nonparticipants are positive (or negative, in the case of dietary cholesterol, sodium, or fat intake, given meals are to conform to the Dietary Guidelines ), as opposed to the differences simply being different from zero.] , [ Standard errors and significance tests were adjusted to account for the complex sample design. There are two factors, working in opposite directions, that affect the adjustment. Because we are using a clustered sample in which individuals are selected from a limited set of nutrition projects selected at an earlier stage, there should be an upward adjustment in the standard errors. On the other hand, the sample is also stratified, in that a certain number of projects were selected in each census region on the basis of the elderly population in that region, which leads to a downward adjustment. A separate adjustment factor or "design effect " was calculated for the 18 nutrients studied and for congregate and home-delivered meal participation. The adjustments ranged from a 56 percent decline in variance to a 126 percent increase in variance, with the average adjustment being a 22 percent increase in variance. For the subgroup analysis, the design effect adjustments are somewhat smaller than the adjustments we obtained for the overall impact regressions. See also the discussion of design effects in Volume III, Appendix D.] The adjusted mean value for a particular outcome is calculated by inserting the weighted mean values of Title III congregate participants for the values of each covariate and multiplying the mean of each covariate by the corresponding estimated regression coefficient. The weighted mean values for congregate participants are used for deriving the adjusted mean outcomes for both congregate participants and congregate-eligible nonparticipants. The difference in mean values for a specific outcome is the estimated value of coefficient c in the linear model. A similar process is used to calculate the adjusted mean outcomes for home-delivered participants and eligible nonparticipants. The only differences are that the mean values for the covariates used in the equation are the weighted mean values of Title III home-delivered participants, and the difference in mean values for a specific outcome is the estimated value of the coefficient d in the linear model.

TABLE III.6

REGRESSION-ADJUSTED COMPARISON OF MEAN DAILY NUTRIENT INTAKES AS A PERCENTAGE OF THE RDA FOR PARTICIPANTS AND ELIGIBLE NONPARTICIPANTS

(Regression-Adjusted Means)


Title III Congregate Meal


Title III Home-Delivered Meal

Nutrient

Participants

Nonparticipants

Percent

Difference


Participants

Nonparticipants

Percent

Difference

Food Energy

78.8

71.6

10.0***


70.7

67.5

4.8**

Protein

122.7

111.9

9.6***


111.7

105.7

5.6**

Vitamin A

150.7

119.8

25.8***


141.8

117.6

20.6**

Vitamin C

165.7

140.3

18.1***


148.0

139.0

6.4*

Vitamin D

107.0

84.4

26.8***


109.4

83.5

30.9***

Vitamin E

91.0

76.5

19.0***


74.2

72.5

2.4

Thiamin

140.7

131.3

7.1**


129.8

126.4

2.7

Riboflavin

141.5

122.7

15.3***


137.5

119.3

15.3***

Niacin

139.5

129.4

7.8***


125.0

122.1

2.4

Vitamin B6

97.3

88.4

10.2***


89.8

84.1

6.8***

Folate

140.3

129.0

8.7***


131.1

122.6

6.9**

Vitamin B12

203.4

185.6

9.6


213.5

180.2

18.5***

Calcium

92.6

74.9

23.7***


91.1

72.8

25.1***

Iron

130.5

125.3

4.2*


124.5

119.6

4.1

Phosphorous

135.2

117.3

15.2***


126.6

112.5

12.6***

Potassium

130.7

112.1

16.6***


116.3

105.3

10.5***

Magnesium

87.3

75.4

15.8***


79.2

70.9

11.8***

Zinc

75.2

65.8

14.3***


67.9

62.8

8.1**

Unweighted Sample Size

1,040

841



818

841


Source: Elderly Nutrition Program Evaluation, Participant and Nonparticipant surveys.

* Significantly different from zero at the .10 level, one-tailed test.

** Significantly different from zero at the .05 level, one-tailed test.

*** Significantly different from zero at the .01 level, one-tailed test.

See the text and Volume III, Appendix G, for full description of the empirical model and variables used.

TABLE III.7

REGRESSION-ADJUSTED COMPARISON OF MEAN NUMBER OF SOCIAL CONTACTS FOR PARTICIPANTS AND ELIGIBLE NONPARTICIPANTS


Title III Congregate

Participants

Congregate-Eligible

Nonparticipants

Percent

Difference

Title III Home-Delivered Participants

Home-Delivered Eligible Nonparticipants

Percent

Difference

Mean

96.0

82.5

16.3**

98.6

83.3

18.4**

Unweighted Sample Size

1,040

841


818

841


Source: Elderly Nutrition Program Evaluation, Participant and Nonparticipant surveys, weighted tabulations.

Note: Social contacts include talking on the telephone; visiting friends, relatives, or neighbors; attending church or religious services; attending clubs; attending congregate meal sites; and having contact with program person who delivers home-delivered meal and with providers of personal care, home health, homemaker, and adult day care services. Tabulations are weighted to be representative of a cross-section of participants receiving Title III meals on a given day.

Note that some subgroup analyses were also conducted. This was accomplished by including interaction terms in the basic linear model. These interaction terms are the product of the various participation indicator variables and the variable defining the particular subgroup being considered. For example, to explore the possibility that the difference in outcomes between participants and nonparticipants is larger for low-income elderly people, we interact the variables CMPi and HDMPi with an indicator variable LIi, also included in the covariates Xi, that equals "1" if the person has low income, "0" otherwise. In other words, we replace CMPi with c 1CMPi × L I and c 2CMP I × (1-LI I), where c 1 represents the difference between low-income congregate participants and congregate-eligible nonparticipants, and c2 represents the difference between non-low-income congregate participants and congregate-eligible nonparticipants. Subgroups considered for this report include racial and ethnic minority, low income, and gender. The subgroup results are fully detailed in Appendix G.

Regressions Corrected for Selection Bias. The estimated OLS regressions control for several demographic, economic, health, function, and lifestyle variables that affect outcomes. Even after controlling for this extensive set of observed characteristics, it is still possible for program participants to differ systematically from eligible nonparticipants in ways that can confound the estimation results. This situation can arise if some determinants of program participation are not fully observed and are related tothe outcomes, resulting in misestimation of program effects because of the noncomparability of participants and nonparticipants (selection bias). For example, if participants in the meals program were more frail, on average, than nonparticipants in ways that could not be fully measured by the variables collected for the evaluation, this difference might lead them to consume less food or to have fewer monthly social contacts, independent of any program participation effects per se. The OLS regression analysis could show an apparent lack of program effects, even if impacts existed, because of difficulty in controlling for the frailty variable.

We estimated three statistical models that researchers have developed to control for this potential difficulty. These models essentially involve modeling the participation decision first, and then using information about each person’s likelihood of participating to correct for the selection bias. As discussed in greater detail in Volume III, Appendix H, our experience was that the resulting coefficient estimates of program impacts based on selection-bias correction approaches do not seem reliable.

Consequently, we present the estimates produced by OLS estimation of the outcome equations, not adjusting for selection bias. These estimates, however, cannot be considered estimates of program impacts but, rather, are suggestive of impacts.

2. Regression-Adjusted Mean Differences Between Participants’ and Nonparticipants’ 24-Hour Dietary Intakes

The regression-adjusted comparisons of dietary outcomes for Title III meal participants and eligible nonparticipants show that, for both congregate and home-delivered participants, nutrient intake as a percentage of the RDA tends to be higher for participants than for the comparison group. These results suggest that the program is increasing participants’ dietary intakes, although unmeasured differences between the groups may also play a role. [ Table III.6 summarizes the participant-nonparticipant differences in mean intakes of food energy and selected nutrients. See Volume III, Appendix G, for presentation of the complete results of the OLS regression estimates for selected dietary intake outcomes. ]

The mean nutrient intakes relative to the RDAs for congregate participants exceed those of nonparticipants for every nutrient studied, often by differences of 10 to 20 percent or more (Table III.6). For 16 of the 18 nutrients studied, the participant-nonparticipant differences in mean values are statistically significant at the 95 percent or higher level of confidence. In particular, congregate participants’ mean intakes relative to the RDAs of problem nutrients, such as calcium, magnesium, zinc, Vitamin B6, Vitamin D, and Vitamin E, are 14 to 27 percent higher than the mean intakes of these nutrients for congregate-eligible nonparticipants. For example, the mean daily intake of calcium relative to the RDA for congregate-eligible nonparticipants is 74.9 percent; congregate participants’ mean intake of calcium relative to the RDA is 92.6 percent--24 percent higher. Congregate participants’ mean intake of food energy relative to the RDA is 10 percent higher than the intake of eligible nonparticipants (78.8 percent versus 71.6 percent); furthermore, this difference is statistically significant.

Similarly, the mean intakes of nutrients relative to the RDAs of home-delivered participants exceed those of eligible nonparticipants for the 18 nutrients studied. For 12 of these nutrients, the differences are statistically significant at the 95 percent or higher level of confidence, with the increases ranging between 5 and 30 percent (Table III.6). Relative to program-eligible nonparticipants, mean nutrient intakes relative to the RDAs for the problem nutrients calcium, magnesium, zinc, Vitamin B6, and Vitamin D are between 7 and 30 percent higher. For these problem nutrients, the largest increase is for Vitamin D (30 percent), followed by calcium (25 percent), magnesium (12 percent), and zinc (8 percent). Home-delivered meal program participants’ mean intake of food energy relative to the RDA is 5 percent higher than eligible nonparticipants’ intake (70.7 percent versus 67.5 percent); however, this difference is marginally statistically significant (at the 90 percent level).

These patterns hold when participant-nonparticipant differences are examined for key subgroups, such as low income, minority, oldest old, and most disabled. In general, the largest differences observed between participants and eligible nonparticipants for these subgroups of both congregate and home-delivered participants are in intakes of calcium, Vitamin D, Vitamin B6, magnesium, and zinc (see Volume III, Appendix F).

The mean intake of macronutrients, sodium, and dietary cholesterol during the 24-hour period differed little between Title III participants and their nonparticipant counterparts (these data are displayed in Appendix F). Participants, on average, have a higher intake of carbohydrates as a percentage of calories and a lower mean intake of dietary cholesterol. These differences, however, are quite small (one to two percent) and are not statistically significant. Participants’ mean intakes of fat and saturated fat tend to exceed those of eligible nonparticipants, as do their intake of sodium; again the differences are small and statistically insignificant. An exception is home-delivered meal participants’ intake of total fat, which is lower than that of eligible nonparticipants--but the difference is not statistically significant.

3. Regression-Adjusted Mean Differences Between Participants’ and Nonparticipants’ Number of Monthly Social Contacts and Activities

Congregate participants average 96 social contacts per month. This is 13 more social contacts per month than the comparison group of congregate-eligible nonparticipants, or a 16 percent increase (Table III.7). This difference is statistically significant. Home-delivered participants average 99 social contacts per month, compared with 83 for home-delivered eligible nonparticipants. Home-delivered participants thus average 16 more social contacts per month than do eligible nonparticipants. This is an increase of 18 percent; the difference is statistically significant. The same caveats noted in the previous section also apply here, but this finding suggests that the program increases socialization opportunities for participants.

In interpretations of these results, it is important to note that direct program contacts--either attendance at a meal site or receipt of a meal delivery--are included in the estimates of contacts for participants. In the case of congregate site visits, this inclusion is clearly appropriate, because these contacts usually last for an hour or more and involve considerable social interaction. The home-delivery contacts are usually much shorter, but about 25 percent of the recipients (not shown) report that the ENP delivery person oftenspends at least some time in conversation with them. Even when conversation did not occur, the majority of home-delivered clients reported that the contact with the delivery person was important to them socially.

4. Conclusions

Two main areas in which the program seeks to provide direct benefits to participants are nutrient intake and opportunities for socialization. The available evidence suggests that the program makes substantial contributions in both areas. In particular, participants have a higher average daily intake of nutrients and a greater average number of social contacts per month than a matched comparison group. Methodological limitations make it impossible to attribute these differences formally to causal effects of the program, but it seems likely that these differences are at least partially caused by the ENP.

This view is supported by the very direct nature of the relationship between the program and the outcome variables examined. Our research verifies that the program provides nutritious meals to participants (see Chapter IV), as well as direct opportunities for socialization, either through contacts at the congregate sites or conversations with deliverers of program meals. Furthermore, we know from the interview data on dietary intake that, in general, participants eat the program meals and perceive the social contacts as meaningful. In light of this, it is reasonable to expect that the program is having positive impacts on participants, and our comparison group analysis supports this view.