Enriching nutrition programs to better serve the needs of a diversifying aging population

Abstract

Racial minorities experience a high burden of food insecurity relative to non-Hispanic Whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 are non-White, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on two programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

In the United States, nearly 8.6 million adults over the age of 65 experience food insecurity.¹ Food insecurity is associated with increased mortality, declines in functional status, impaired cognition, immune dysfunction, and higher hospital admission and readmission rates.² Food insecurity is especially pronounced among older adults from racial and ethnic minority groups who experience the threat of hunger at more than twice the rate of Whites.¹ Currently, 23% of older adults are racial/ethnic minorities, and by 2030 this proportion will grow to 28%.³ Reducing health disparities and advancing health equity in an aging population that is growing both in size and racial/ethnic diversity requires interventions that address their unmet needs for resources, including sufficient access to healthy foods.⁴

Nutrition programs at federal, state, and local levels, are designed with the goal of increasing food security and reducing hunger by providing low-income people access to healthy foods and nutrition education.⁵ These programs are critical in preserving older adults’ health and independence. Programs like the Older Americans Act (OAA) Home Delivered Meals Program, commonly known as Meals on Wheels, have profoundly positive effects on the health and well-being of those they serve.^6–8 Participation in nutrition programs has been associated with improvements in self-rated health, reductions in falls, and reductions in loneliness.⁸ Independent evaluations of the nationwide home-delivered meal program found that such programs reduce food insecurity, increase nutrient intake,⁹ and reduce healthcare utilization and institutionalization.¹⁰

In New York City, where nearly 60% of adults aged 65 and over identify as racial and ethnic minorities, older Latinos, Asians, and Blacks have higher rates of food insecurity than non-Latino Whites.¹¹ Among Latinos over the age of 65, for example, 18% report that they did not have enough food to eat, compared to just 3% of non-Latino Whites.¹² Title III C of the OAA requires that state and local agencies target services to older adults with high levels of social and economic need, specifically low-income racial/ethnic minorities.¹¹ However, the AARP, formerly known as the American Association of Retired Persons, has reported that nutrition programs for older adults are not fully engaging minorities, who make up a large component of the population that nutrition programs are meant to serve.¹² In 2018, the racial/ethnic make-up of New York City was as follows: White (32.1%), Black (24.3%), Hispanic (29.1%), and Asian Pacific/Islander (14.1%).¹¹ In the most recent data published, the racial/ethnic composition among New York City’s home-delivered meals program participants was 63% White, 29% Black, 11% Hispanic, and 1% Asian.⁶ In a scoping review summarizing studies examining senior center participation and racial/ethnic diversity, authors concluded that language and acculturation are the explanatory factors for differing rates in participation by ethnicity.¹³

Greater outreach and education for minority populations will increase the impact of these programs, particularly in major metropolitan regions that are home to diverse populations.¹⁴ In this commentary, we (1) highlight the nutrition programs available to older adults and (2) offer insights and concrete strategies, informed by research and interdisciplinary expertise, that such programs could use to increase their engagement of and clinical effectiveness with ethnically diverse older adults.

Overview of Nutrition Programs for Older Adults

Several benefit programs exist to provide low-income older adults and people with disabilities with access to nutritious foods, some of which are amplified through private partnerships.¹⁵ These are described in Table 1. We focus on two programs in particular— Older Americans Act (OAA) Congregate and Home-Delivered Meals Program and the Child and Adult Care Food Program (CACFP)—in order to draw from our experiences working in settings served by these programs.

Table 1.

Summary of Federal Nutrition Programs Serving Older Adults

Name of Program	Acronym	Population Served	Description
Older Americans Act (OAA) Home-Delivered Meals Program	HDMP	Home-bound seniors aged 60+	Meals delivered to an individuals’ home in addition to nutrition related services, such as screening, education, and counseling
Older Americans Act (OAA) Congregate Meals Program	CMP	Adults aged 60+	Meals and nutrition related services, such as screening and counseling, at a variety of sites including senior centers and community centers
Child and Adult Care Food Program	CACFP	Low-income children in day care programs or emergency shelters, & low-income disabled adults enrolled in day care facilities	Offers financial subsidies to day care centers that supply snacks or meals to low-income individuals
Supplemental Nutrition Assistance Program	SNAP	Low income households	Provides benefits to households through electronic cards that allow them to buy nutritious foods at participating stores
Commodity Supplemental Food Program	CSFP	Low-income adults aged 60+	supplements diets with nutrient-dense foods from the United States Department of Agriculture (USDA)
Senior Farmers’ Market Nutrition Program	SFMNP	Low-income adults aged 60+	Provides access to locally grown fruits and vegetables from local farmers’ markets and community-supported agriculture programs

The benefits of nutrition programs serving older adults are well-documented.^14–16 Among the many favorable outcomes are (1) improved nutritional intake, (2) more resources for health-promoting activities and medical care, and (3) support so that functionally impaired older adults can remain in their own homes. ^8,16–18 Research has specifically shown that OAA and CACFP meals can provide anywhere from one-third to two-thirds^16,18 of the recommended dietary allowance for energy and nutrients and participants who receive home-delivered meals are less worried about their ability to remain living at home independently.⁸

However, several barriers limit the uptake and effectiveness of these programs among older minorities. According to a 2015–2016 evaluation by Mabli et al.¹⁹ in a nationwide sample, 66% of Congregate Meal participants and 71.8% of home-delivered meal participants were non-Hispanic Whites. Just 0.3% of home-delivered meal participants were Asian, 8.7% were Hispanic, and 17.7% were Black. In one study, researchers surveyed staff and long-term volunteers of an OAA nutrition program, and conducted focus groups comprising professionals working with minority older adults in the Pacific Northwest.²⁰ Several reasons were cited for low levels of OAA meal program participation among older minorities, including misinformation due to language barriers, lack of menus that can accommodate dietary restrictions and cultural preferences, discomfort with staff due to cultural and linguistic differences, and inadequate transportation to congregate meal sites.²⁰ For CACFP sites, low rates of federal reimbursement (which average $2.25 for lunch nationally) and clerical burden (including weekly reconciliation and reporting of menus, meal components, invoices, receipts, head counts) are also barriers to participation for low-resource centers with limited staff.²¹

As the aging population in the United States becomes more ethnically diverse, social service providers—especially those overseeing nutrition programs for the aging—can be strong advocates for bridging cultural barriers and improving the capacity to offer culturally appropriate assistance to older adults of all backgrounds. We therefore explore opportunities and strategies for enhancing the reach and effectiveness of two programs—the OAA and the CACFP—in minority communities.

The OAA

The OAA Title III-C Nutrition Services Program (NSP), administered by the Administration on Aging (AoA), plays an important role in the health of the older adults who participate in the program. Specifically, the purposes of the NSP are to (1) reduce hunger and food insecurity; (2) promote socialization among older individuals; and (3) promote the health and well-being of older individuals by helping them access services that encourage proper nutrition, prevent disease, and promote health.¹² In 2017, approximately 1.5 million people were served congregate meals, and over 850,000 were served home-delivered meals.¹⁷ In addition to meals, the program provides nutrition-risk screening, nutrition counseling, and referrals to other services as needed through a case manager. Congregate and home-delivered meals must adhere to the 2015 Dietary Guidelines for Americans and provide a minimum of one-third of the Dietary Reference Intakes.²²

The 2015–2016 policy research evaluation referenced above demonstrated that the meals provided through the NSP make substantial contributions to older adults’ diets.¹⁹ On average, older adults who participated in the NSP obtained about 40% of their daily intakes of calories from a program meal, as well as 35 to 47% of their daily nutrient intakes, based on Healthy Eating Index 2010 scores.¹⁹ In addition, the program had positive effects on the participants’ nutrient intakes and overall quality of their diets, particularly among congregate meal participants.¹⁹ It is therefore imperative that the NSP make itself more accessible and appealing to racial, ethnic, and cultural minorities, who, as previously mentioned, have disproportionately low rates of NSP usage despite a greater predisposition to food insecurity and nutritional risk.

Since approximately 50% of older New Yorkers are foreign born, according to a recent Center for an Urban Future study,²³ OAA providers in New York City must provide meals that are culturally appropriate to an array of backgrounds. Providers are required to offer menus that are culturally appropriate and nutritious, but cost is a major impediment. In 2015, NYC’s Department for the Aging (DFTA) stated that, “in DFTA’s [Home Delivered Meals] network, each catered Kosher [meal] is on average $1.38 more than non-Kosher catered meals”.²⁴ Accommodating halal, gluten-free, low-sodium, vegetarian, vegan, or other special diets would have similar cost increases under the current system.²⁵

In addition to cost, OAA providers must have special diets approved by a nutritionist to assure the meals comply with the 2015 Dietary Guidelines for Americans (DGA).²⁶ A survey of over 2,000 congregate-meal-program participants identified different food preferences among African Americans compared with Whites.²³ Overall, participants reported that the menus could be improved by including more seafood, vegetables/salad, and poultry as well as a variety of meats such as steak, roast beef, and spare ribs.

Honoring culturally derived preferences and remaining compliant with the DGA are not mutually exclusive. Guidelines recommend replacing saturated fats with unsaturated fats; refined grains with whole grains; red meat with leaner meats, poultry, and seafood; and higher-fat dairy with fat-free or low-fat varieties.²⁸ For example, for both congregate and home-delivered meal participants, sandwiches are a leading contributor to all 4 dietary components.⁶ Modifying sandwich ingredients to include ingredients with less fat, less sodium, and more fiber could help recipients meet their dietary recommendations and fall in line with some of the stated preferences. For OAA participants who prefer rice or tortilla-based dishes to sandwiches, providing nutrient-dense sides could help to ensure that the participants are enjoying food with their peers and meeting dietary recommendations.

The Child and Adult Care Food Program

The Child and Adult Care Food Program (CACFP) is a federal nutrition program originally established in 1978 for children in child care settings, and subsequently expanded in 1987 to specifically include people over the age of 60 in adult day care (ADC) settings. The CACFP offers financial subsidies to ADCs that supply snacks or meals to low-income individuals. The nutrition-assistance-program meals are required to be aligned with the DGA’s specifications. Individuals are eligible if they are over the age of 60 or functionally impaired and reside in the community. There have been few evaluations of the ADC component of the CACFP; the most recent was conducted in 1993.²¹

ADCs, a form of community-based long-term care that have proliferated across the United States in the last 2 decades, service more than 260,000 community-dwelling chronically ill and functionally impaired individuals annually.²⁹ ADCs serve a greater proportion of aging minorities than any other category of long-term care provider; in New York, approximately 50% of ADC users are non-White, and the majority of users are economically disadvantaged.³⁰ Data indicate that ADC users are at high risk of poor nutritional outcomes: a study of racially diverse ADC users in California found that 65% of Blacks had high nutritional risk, as compared to 38.5% of Whites. In that study, 76.5% of Blacks ate < 5 servings of fruits, vegetables, or milk daily, and 21% reported eating fewer than 2 meals daily.³¹

In addition to meals and snacks, ADCs provide therapeutic services and often have registered nurses and social workers on-site.²⁹ They provide frail older adults with the opportunity to socialize in a supervised setting with their peers.²⁹ An integrative review of minority users’ experiences in ADCs found that access to regular meals at the ADC is a critical component of perceived health improvements.³² In a qualitative study of Cambodian American ADC users, participants remarked that regular meals at the center contributed to their longevity, saying they would not otherwise eat at all.³³

However, while ADCs are well-positioned to improve the nutritional status of ethnically diverse older adults, they are not fully taking advantage of the CACFP’s offerings. The last formal national evaluation of the ADC component of the CACFP revealed that only 43% of eligible ADCs participate in the program.²¹ CACFP usage was also low among certain minority groups. For example, only 7% of CACFP beneficiaries were Hispanic, compared to 22.7% of ADC users overall.²¹ In their review of federal food and nutrition programs, Gergerich et al. reported that despite a simultaneous 35% growth in the number of ADCs nationally, CACFP enrollment among ADCs began to plateau in 2011.³⁴

There is additional concern among ADC operators that older minorities who are currently receiving CACFP meals at their center may not be receiving the full caloric benefit of CACFP meals if the required components are not culturally appropriate. Changes to CACFP nutrition standards were made in April 2016, the first time since the program began in 1968.³⁵ These important changes centered on increasing fruits, vegetables, and whole grains and reducing sugar and saturated fats.³⁵ However, the United States Department of Agriculture (USDA) offers little guidance on how to make meals culturally relevant within the context of the program’s requirements or to make them appeal to diverse palettes. For example, if 8 ounces of milk (or 6 ounces of yogurt) must be offered at breakfast and lunch, how can ADCs support the preferences and calcium requirements of East Asians, 90% of whom are believed to have reduced ability to digest lactose?³⁶ CACFP administrators have offered little information on how to maximize program offerings to meet the unique nutritional needs of older adults, let alone ethnically diverse older adults.

Finally, many of the changes made to overall CACFP guidelines were intended to help the program better align with certain other government nutrition programs. For example, requirements for infants benefitting from the CACFP were better aligned with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), while the adult component was not aligned with the OAA or other nutrition programs focused on the aging population.³³ In addition, the CACFP, unlike the OAA, does not require that participants be screened and counseled regarding nutrition risk.³¹ This is an important inconsistency as nutritional risk is a commonly overlooked indicator of health. Finally, risk factors for poor nutrition, such as social isolation, provide insights into individuals’ social circumstances as well.³¹

Strategies to Improve the Reach and Engagement of Nutrition Programs among Diverse Older Adults

Several opportunities exist to strengthen these programs and support them in making an even greater impact than they already do. Overall, we recommend broad evaluation of these programs, with deep analysis into the diversity and needs of the populations they serve. In the case of the CACFP, the program may not be reaching ADCs serving ethnically diverse older adults. For OAA programs, greater attention is needed with respect to menu items that are both culturally appropriate and nutrient dense. We recommend nutrition programs targeting older adults incorporate the following strategies, to have a greater impact on ethnically diverse older adults who may be especially vulnerable to poor nutrition:

1. Conduct both national and state-level survey-based evaluations to examine ethnic, racial, and cultural minorities’ engagement with nutrition programs targeting older adults. This includes specifically evaluating the adult component of the CACFP and, across all programs, surveying minority stakeholders’ perceptions as to whether and how programs are meeting their participants’ needs.

2. Standardize and align the screening requirements and nutrition components across programs serving older adults. The programs all share the goal of optimizing nutrition for older adults; therefore, they should be unified in their approach to doing so, and OAA and CACFP guidelines should not drastically differ.

3. Provide NSP and CACFP providers with more guidance and funding to offer culturally appropriate meals to participants within the programs’ parameters and encourage them to hire staff who are ethnically and linguistically representative of minority communities. For example, some senior center partners in New York City are catering to their clients’ needs by hiring staff who speak Hindi or Urdu but lack the necessary funding to provide halal or vegetarian meals.²⁴ An alternative model for offering culturally competent meals that has been employed successfully in Montgomery County, MD, would be to contract with an ethnic organization that is interested in improving the quality of life for their elders in a cost-sharing model.³⁷ For example, a Korean church successfully contracted with the OAA to provide meals rich in fish, tofu, rice, and kimchi and a Vietnamese organization offered beef or chicken stews, noodles, and fresh fruit for dessert.³⁷

4. Recognize that taste and cultural food preferences are critically important in attracting and retaining racial, ethnic, and cultural minority populations. We recommend surveying these programs’ users on their preferences around meals and using these data to conduct a cost-benefit analysis on incorporating culturally appropriate meals into congregate-meal and home-delivered-meal programs. We also recommend providing greater choice with respect to meal offerings. We suggest developing a database of menus so that program participants have a central place to search for meals that adhere to their dietary preferences and needs and/or offering two menu options per day (e.g., a Spanish-style baked cod or quinoa with black beans).

Nutrition programs clearly play a powerful role in supporting the health and wellness of a rapidly growing aging population. Through further research and implementation of strategies that emphasize the diversity within the aging population, we believe such programs can provide more optimal support in meeting the nutritional requirements of a vulnerable, often overlooked subset of older adults.