Nutrition

Volume I: Chapter 1

I. INTRODUCTION

With the aging of the U.S. population, increased attention has been given to designing efficient and effective systems for delivering health and related services to older people. Of particular concern is the development of service networks that can provide elders with a continuum of home and community-based long-term care, to allow them to avoid unnecessary and costly institutionalization.

One very important component of any overall package of home- and community-based services for elderly people is the provision of comprehensive nutrition services. Adequate nutrition is critical to health, functioning, and quality of life for people of all ages. For elderly people, nutrition can be especially important, because of their vulnerability to health problems and physical and cognitive impairments. Key nutrition services include nourishing meals, as well as nutrition screening, assessment, education, and counseling, to ensure that older people achieve and maintain optimal nutritional status.

This report summarizes the results of a comprehensive evaluation of the largest U.S. community nutrition program for older persons, the Elderly Nutrition Program (ENP). The ENP, which serves the general elderly population under Title III of its authorizing legislation and Native Americans under Title VI, is authorized under the Older Americans Act and is administered by the U.S. Department of Health and Human Services (DHHS), Administration on Aging (AoA). The evaluation was conducted by Mathematica Policy Research, Inc., (MPR) in conjunction with MPR's subcontractor, the University of Minnesota. It was directed by three principal investigators, Michael Ponza and James Ohls of MPR and Barbara Millen, Associate Director for Research, Boston University Schools of Public Health and Medicine.

The remainder of this chapter provides an overview of the ENP and summarizes the research objectives of the evaluation.

A. OVERVIEW OF THE ELDERLY NUTRITION PROGRAM

The ENP is authorized under Title III and Title VI of the Older Americans Act (OAA). Through Title III, State Units and Area Agencies on Aging implement a system of coordinated, community-based services targeted to older individuals. Title III authorizes the provision of nutrition and supportive services, such as meals, nutrition education, transportation, personal and homemaker services, and information and referral. Similar nutrition and supportive services for elderly American Indians, Alaskan Natives, and Native Hawaiians are authorized separately under Title VI. The OAA has been amended frequently since the creation of the ENP in 1972. These amendments have added new responsibilities for agencies in the aging network and clarified responsibilities that were to have been performed under the original legislation.

1. Title III Nutrition Services

Under Title III-C of the OAA, the AoA provides grants to State Units on Aging (SUAs) to support the provision of daily meals and related nutrition services in either group (congregate) or home settings to persons age 60 and older. The program specifically targets older people with the greatest economic or social need. In fiscal year (FY) 1994, OAA Title III-C funding for the ENP was nearly $470 million. In that year, 127 million meals were served to 2.3 million people at congregate sites, and more than 113 million home-delivered meals were provided to 877,000 homebound elderly people.

Administration and Funding. Under Title III, SUAs receive federal grants for provision of congregate nutrition services (authorized under Part C-1), home-delivered nutrition services (authorized under Part C-2), and supportive services (authorized under Part B) from DHHS. Funds are allocated to states and territories according to a formula that is based on the state's or territory's share of the population aged 60 or older (as compared with all states and territories). The OAA also requires the U.S. Department of Agriculture (USDA) to provide SUAs with commodities or cash in lieu of commodities, the value of which is based on the annual number of meals served. (In FY 1994, USDA provided approximately $150 million in cash and commodity assistance to the ENP.) In the annual appropriations process, Congress allocates separate amounts under Title III for congregate nutrition services, home-delivered nutrition services, and supportive services. However, the actual amounts available differ from the initial appropriations because states are allowed, within limits, to transfer funds among various Title III components.

SUAs distribute the funds to Area Agencies on Aging (AAAs), which administer the nutrition services program within their respective planning and service areas. AAAs receive funds from SUAs on the basis of state-determined formulas that reflect the proportion of older people in their planning and service areas (PSAs) and other factors. The AAAs award grants to and contract with nutrition projects to provide nutritional and supportive services in their planning areas. AAAs are often direct providers of nutrition services as well. In addition to receiving AoA funds, AAAs and nutrition projects receive financial support from state and local government, in-kind contributions, private donations, and voluntary contributions from participants. Congregate meals and supportive services are provided at nutrition projects' meal sites (such as senior centers, religious facilities, schools, public or low-income housing, or residential care facilities). Home-delivered meals are provided to homebound clients, either by the congregate meals sites, affiliated central kitchens, or nonaffiliated food service organizations.

AoA program data collected during the past 15 years show an increase in the number of Title III-C meals served. Most of this growth, however, occurred in the early 1980s. The total number increased by 43 percent during the entire period between FY 1980 and FY 1994 (from 168 million to 240 million meals), but increased by only 7 percent between FY 1985 and FY 1994. There has been a continuing shift in services over time from congregate to home-delivered meals. Most of the program growth during the past 15 years can be attributed to the substantial increase in the number of home-delivered meals. The number of congregate meals served during FY 1994 was four percent less than the number served in FY 1980 (126.7 million and 132.0 million meals, respectively). In contrast, the number of home-delivered meals increased 210 percent during that time, from 36.4 million to 113.1 million. The percentage of total meals served as home-delivered increased steadily, from 22 percent in FY 1980 to 47 percent in FY 1994.

Eligibility. Persons aged 60 and older, and their spouses of any age, may participate in the Title III congregate program. In addition, the following groups may also receive meals: (1) disabled persons under age 60 who reside in housing facilities, occupied primarily by elderly people, in which congregate meals are served; (2) disabled persons who reside at home with, and accompany, older persons to meal sites; and (3) nutrition service volunteers. Title III home-delivered meals are available to homebound persons 60 years of age or older and their spouses (who may be younger than age 60) and disabled persons younger than age 60 living with elderly persons. Persons eligible for the home-delivered meal program may be homebound as a result of disability, illness, or isolation. The ENP does not have a means test, but services are targeted at older persons with the greatest economic or social need. Participants are not charged for meals but are encouraged to contribute toward the meal costs. However, participants cannot be denied meals or other services because of inability or an unwillingness to contribute.

Benefits and Participation. Congregate and home-delivered nutrition projects must offer at least one meal per day, five or more days per week (except in rural areas). Each meal must provide a minimum of one-third of the daily Recommended Dietary Allowances (RDAs) established by the Food and Nutrition Board of the National Academy of Sciences National Research Council. The meals must also comply with the Dietary Guidelines for Americans, published by the Secretaries of DHHS and USDA. In addition to meals, nutrition service providers offer a variety of nutrition-related services, such as nutrition education and screening, shopping assistance, and health promotion activities.

2. Title VI Nutrition Services

ENP services are also authorized under Title VI of the OAA. The AoA awards Title VI funds directly to Indian Tribal Organizations (ITOs) from federally recognized tribes and organizations serving Native Hawaiians. Title VI has two parts: (1) Part A--American Indian and Alaskan Native Program; and (2) Part B--Native Hawaiian Program.

Administration and Funding. Title VI of the OAA established a grant program directly from the federal government to tribal organizations and other organizations to promote the delivery of nutrition and supportive services for older American Indians, Alaskan Natives, and Native Hawaiians. These services are to be comparable to those provided under Title III. ITOs and agencies serving Native Hawaiians receive grant awards directly from the AoA. These agencies typically administer the program as well as provide the services.

Grants are awarded to ITOs and other organizations on the basis of the number of elderly American Indians and Native Hawaiians represented by their respective agencies. In FY 1994, Title VI grants were awarded to 226 ITOs; one grant was awarded under Title VI-B, where the overall grants totaled $17 million. OAA provisions permit nutrition programs funded under Title VI to also receive donated dairy products and food commodities or cash in lieu of commodities from USDA. In FY 1994, Native American and Native Hawaiian grantees provided 1.3 million meals to 41,000 American Indian and Native Hawaiian congregate participants and 1.5 million meals to 47,500 American Indian and Native Hawaiian home-delivered participants.

Eligibility. Only federally recognized tribal organizations and nonprofit private organizations serving native Hawaiians are eligible for funding under Title VI. Additionally, to receive funding, ITOs and agencies representing Native Hawaiians must represent at least 50 individuals who are 60 years of age or older. They must also demonstrate the ability to deliver nutrition and supportive services. Spouses of eligible American Indians, Alaskan Natives, and Native Hawaiians may participate, regardless of age. Unlike Title III, which requires participants to be at least 60 years old to receive services, Title VI allows ITOs and agencies serving Native Hawaiians to specify the minimum age (which generally ranges between 45 and 60) for participants to receive nutrition and support services.

Benefits and Participation. Title VI nutrition programs may provide congregate meals, home-delivered meals, or both. A hot or otherwise appropriate meal must be provided at least five days a week, unless the tribal organization can justify, on the basis of its needs assessment, fewer than five days a week. The meals may consist of cold, frozen, dried, canned, or supplemental foods. On average, each meal must provide a minimum of one-third of the daily RDAs established by the Food and Nutrition Board of the National Academy of Sciences National Research Council. The meals must also comply with the Dietary Guidelines for Americans, published by the Secretaries of DHHS and USDA. In addition to meals, nutrition service providers offer a variety of supportive services, such as nutrition education and screening, shopping assistance, and health promotion activities.

3. ENP Nutrition Requirements

The 1992 amendments to the Older Americans Act (P.L. 102-375, Section 339) require that meals provided through the ENP comply with the Dietary Guidelines for Americans, published by DHHS and USDA, and meet the Recommended Dietary Allowances (RDAs) as established by the Food and Nutrition Board of the National Research Council (NRC) of the National Academy of Sciences.

a. Dietary Guidelines

The Dietary Guidelines for Americans make seven broad dietary recommendations for persons age two and older to help them choose food for a healthful diet:

1. Eat a variety of foods

2. Maintain healthy weight

3. Choose a diet with plenty of vegetables, fruits, and grain products

4. Choose a diet low in fat, saturated fat, and cholesterol

5. Use sugars only in moderation

6. Use salt and sodium only in moderation

7. If you drink alcoholic beverages, do so in moderation

In some of these recommendations, the Dietary Guidelines provide specific quantitative standards. In particular, the recommendation for the consumption of a variety of foods is specified in terms of a suggested number of daily servings from each of five basic food groups:

1. 3 to 5 servings of vegetables

2. 2 to 4 servings of fruits

3. 6 to 11 servings of breads, cereals, rice, and pasta

4. 2 to 3 servings of milk, yogurt, and cheese

5. 2 to 3 servings of meats, poultry, fish, dry beans and peas, eggs, and nuts

The Dietary Guidelines also make specific quantitative recommendations for the amount of total and saturated fat in diets:

• Intake of total fat should not exceed 30 percent of food energy (calories)
• Intake of saturated fat should be less than 10 percent of food energy (calories)

However, the Dietary Guidelines do not provide quantitative benchmarks for the intake of cholesterol, sugar, or sodium.

Compliance with the Dietary Guidelines is a new requirement for states, although some have encouraged nutrition projects to incorporate them for several years. The Dietary Guidelines have never before been included in program requirements, however.

b. Recommended Dietary Allowances (RDAs)

The NRC defines the RDAs as the levels of intake for essential nutrients that, on the basis of scientific knowledge, are judged by the Food and Nutrition Board to meet the known nutrient needs of practically all healthy persons (NRC 1989a, p. 10). The NRC sets age- and gender-specific RDAs for each nutrient. The RDAs are based on the needs of an average person of median height and weight within the specific age and gender population group.

The most recent RDAs provide guidelines for assessing the intake of energy and specified nutrients for adults up to age 50 and for those 51 years or older. Age- and gender-specific recommendations exist for the following essential nutrients: energy (calories); protein; vitamins A, D, E, K, C, B6, B12, thiamin, niacin, riboflavin, and folate; and the minerals calcium, phosphorus, magnesium, iron, zinc, iodine, and selenium. Guidelines on safe and adequate daily levels of other vitamins (biotin and pantothenic acid) and trace mineral elements (copper, manganese, fluoride, chromium, and molybdenum) are also provided.

ENP meals are required to meet the RDAs. Specifically, program meals provided to each participating older person must provide:

• A minimum of 33 1/3 percent of the RDAs if the nutrition project provides one meal per day
• A minimum of 66 2/3 percent of the RDAs if the nutrition project provides two meals per day
• 100 percent of the RDAs if the nutrition project provides three meals per day

Before the 1992 amendments, the ENP required that each meal contribute one-third of the RDA. For nutrition projects that provide more than one meal or eating occasion daily, the requirements now focus on the nutrient content of the total meal package rather than on each individual meal.

B. EMERGING ISSUES IN THE ENP

Older persons constitute a significant, growing percentage of the United States population. Currently, 17 percent of the population--or 42 million people--are age 60 or older (U.S. Bureau of the Census 1993). This percentage is expected to increase to approximately 25 percent (89 million people) by the year 2030 (Day 1993). The "oldest old"--those 85 years and older--and elderly nonwhites and Hispanics are expected to be the most rapidly growing segments of the elderly population in the next several decades. Between 1990 and 2030, the oldest old and the elderly Hispanic populations will nearly triple in size, and the elderly African American and other nonwhite populations will double.

Despite overall improvements in the economic status of elderly people in the past two decades, a substantial number of these people are poor--12 percent, or 4,901 million people in 1991 have cash income below 100 percent of the U.S. poverty threshold (U.S. Bureau of the Census 1993). A disproportionate number of the poor and near-poor elderly are women, minorities, those who live alone, and the oldest old. Moreover, these groups are expected to continue to have poor economic status for the next several decades (U.S. General Accounting Office 1986).

Proper nutrition is very important for elderly people. Nutritional status has been shown to affect the age-related rate of functional decline for many organs and to be a determinant of changes in body composition associated with aging, such as loss of bone and lean body mass (U.S. Department of Health and Human Services 1988). Furthermore, diet and nutrition have been related to the etiology of many chronic diseases affecting elderly people, such as osteoporosis, atherosclerosis, diabetes, hypertension, and certain forms of cancer (National Research Council 1989b). A 1991 study showed that about 85 percent of older persons suffered from one or more of these nutrition-related chronic conditions; chronic disease risk is particularly pronounced in black and Hispanic elderly persons (Dwyer 1991). These chronic diseases have been shown to cause physical and mental impairments in elderly persons that threaten their independence, well-being, and quality of life.

The last reauthorization legislation for the OAA was signed into law in September 1992 (P.L.102-375). This authorization of the OAA programs expired at the end of FY 1995, but the appropriation is still being maintained. The following emerging and recurring issues make the current ENP evaluation particularly timely:

• Targeting program services to older persons most in need--especially the lower-income elderly and groups that tend to have high proportions of low-income members, such as racial/ethnic minorities and socially isolated individuals
• The impacts of program components on participants' nutrition and socialization
• Program linkages with the long-term care system
• Efficient and cost-effective program administration and service delivery
• Nutrition quality assurance of the program--service quality and promotion of food sanitation and safety
• Fund transfers between Title III congregate and home-delivered nutrition services, as well as between nutrition services and supportive services--to assess their impact on program operations and participants
• The adequacy of the Dietary Guidelines and the RDAs

1. Targeting

The ENP authorizing legislation stated that services were to be targeted to those with the "greatest economic or social need." Over the years, several amendments to the OAA have tried to strengthen the program's ability to provide nutrition and supportive services to this group of older people. These amendments have also attempted to help nutrition projects target services more effectively and implement appropriate outreach activities. Yet, studies examining the effectiveness of program targeting have reported conflicting results (O'Shaughnessy 1990; Ponza et al. 1994; Posner, 1979; and Kirschner et al. 1983).

Both Title III and Title VI provide nutrition services to elderly American Indians. Title III programs provide services to American Indian and Alaskan Native elderly people living in urban areas, as well as to state-recognized tribes and others who are not members of federally recognized tribes; Title VI provides nutrition services only to federally recognized tribes. Although Title VI was specifically established to provide services to American Indians, elderly Native Americans receive most nutrition services through Title III (Jackson and Godfrey 1990).

The current ENP evaluation has provided national estimates of the levels of program participation for low-income and minority elderly people and other elderly subgroups. In addition, the two main program components, congregate and home-delivered meals, are designed to serve somewhat different groups. In particular, recipients of home-delivered meals may be bedridden or homebound or generally too frail to leave their homes to obtain meals in a congregate setting. The evaluation data facilitate comparisons of home-delivered and congregate participants' characteristics along such dimensions as age, health, functional capabilities, and nutritional risk.

2. Program Impacts on Participants' Nutritional Intake and Socialization

To date, few studies of the ENP have provided reliable estimates of program impacts on participants' nutritional intake and socialization. The current evaluation assesses the impact of the program's nutritional components on participants. This assessment, which is based on comparisons of nutritional and other outcomes for participants and nonparticipants, after controlling for other factors, represents the most rigorous analysis to date of program impacts.

3. Linkages with the Long-Term Care System

As the older population grows--especially those over 85 years of age, who are most likely to be frail and at risk of losing their independence--the availability and accessibility of a well-managed system of home- and community-based services to assist these people with activities of daily living will play a greater role in delaying or preventing institutionalization for acute or long-term care (that is, hospitals, rehabilitation facilities, and nursing homes). Service planners have increasingly emphasized the importance of developing a continuum of services, including geriatric assessment, acute care, home care, assisted living, adult day care, respite services, hospice care, and community-based services such as transportation, nutrition, and so forth. Any gap in the continuum will tend to increase the individual's level of dependence and need for more costly services and, possibly, unnecessary or premature institutionalization.

The nutrition and supportive services offered under Title III and Title VI, which are a critical component of this continuum in any locality, are interconnected. For example, transportation is available through Title III and Title VI to ensure that clients can attend congregate sites or receive home-delivered meals; shopping assistance may be provided so that clients can have access to food at times when program meals are unavailable. However, it is likely that Title III and Title VI services are most effective when they are integrated with other community services, to ensure that service gaps are closed and to prevent service duplication. This evaluation has provided an opportunity to examine how well the ENP is integrated with other types of home- and community-based care (such as geriatric case management, local health agencies and providers, discharge planning units of hospitals, and other local formal outreach programs).

4. Efficient and Cost-Effective Administration and Service Delivery

The environment in which the ENP operates today is substantially different from the one that the program faced 15 years ago. The program must provide services to a targeted population that is growing dramatically at the same time that federal resources are decreasing. In this challenging environment, the efficiency of program administration and operations must continually improve. The current evaluation includes a comprehensive set of analyses designed to provide information about ways to reduce program costs and improve productivity, as well as a detailed analysis of meal and other program costs. In addition, information on contracting and purchasing practices, use of USDA commodities, use of volunteers, and coordination with agencies within and outside the aging network has been obtained to inform strategies for program improvement.

5. Quality of Program Services

To ensure service quality, Congress has required the ENP to meet several criteria related to nutrition services. These include meeting nutritional requirements for meals, providing nutrition education to participants, and conforming with state and local laws for food sanitation and safety. By collecting and analyzing data on the nutritional content of meals offered, procedures and policies for food sanitation and safety, and other aspects of the program, the evaluation has obtained data with which to determine the extent to which nutrition projects and sites meet these criteria. Data on participants' perceptions of the quality and other aspects of program services are included.

6. Effects of Funds Transfers

A series of amendments to the authorizing legislation for Title III during the 1970s and 1980s defined and augmented the program's flexibility to transfer funds between home-delivered and congregate meals and between nutrition and supportive services. Since the vast majority of transfers historically involved moving resources out of the congregate program and into the home-delivered one, and to a lesser extent, into supportive services, the limitations adopted in the 1992 amendments are an effort to moderate the reduction of funds for congregate nutrition services that has been occurring. There is considerable debate about the need for further legislative action to impose additional constraints on how agencies in the aging network use AoA funds. On one hand, some argue for greater flexibility--that the transfers enable the program to better serve those most in need of nutrition services. Others argue that the practice erodes the effectiveness of the congregate program--the very foundation on which nutrition and supportive services provided in the community are built. The evaluation has provided an opportunity to investigate the extent and nature of funds transfers and the resulting variation in services for different areas. It has also assessed why program administrators make transfers and the effect of resulting service adjustments on the types of clients served and the program's ability to meet their needs.

7. Appropriateness of the RDAs and the Dietary Guidelines in Program Administration

The most commonly used guidelines on the nutritional requirements of elderly people are the Recommended Dietary Allowances (RDAs) determined by the National Research Council (NRC), Food and Nutrition Board. The RDAs provide recommendations for the intake of vitamins, minerals, protein, and food energy. Other important recommendations include the DHHS and USDA Dietary Guidelines for Americans and recommendations of the NRC. ENP regulations require that program meals meet the RDAs and comply with the Dietary Guidelines. However, there is uncertainty about the appropriateness of the RDAs and the Dietary Guidelines for elderly ENP participants, especially the oldest old. These issues are described next.

a. Recommended Dietary Allowances

The RDAs are recommendations established and revised periodically by the NRC's Food and Nutrition Board for planning diets and evaluating the adequacy of the population's nutrient intake. The RDAs reflect experts' current opinions on safe and adequate nutrition allowances for the maintenance of good health among relatively healthy people. The RDAs exceed minimum nutrient requirements and are estimated to cover the needs of nearly all healthy persons in the population. Thus, intakes below the recommended levels are not necessarily inadequate for all individuals but are said to increase the "risk" of deficiency. In addition, the RDAs are defined in terms of the average, or usual, consumption of nutrients. Good health does not necessarily require that a person consume nutrients at the RDA levels each day; rather, the RDAs are general goals to be achieved over time. As a result, the RDAs reflect experts' opinions on the intake levels needed to prevent deficiencies and maintain existing health. Adjustments are not made for health problems that may alter nutrient requirements. Thus, persons with major health problems may require considerably higher nutrient intake levels.

The RDAs as applied to elderly persons have some other important limitations:

• The RDAs Are Not Based on Direct Study of Older People. The RDAs are largely extrapolations of data from studies of the needs of healthy young adults, supplemented by a limited amount of data from available studies of older persons. However, direct studies of the elderly are now accumulating. Some researchers have argued that the RDAs for some nutrients for the elderly (for example, riboflavin, Vitamin B6, Vitamin D, and Vitamin B12) should be increased.
  
• The RDAs Do Not Take into Account the Physiological Changes Associated with Aging, the Degenerative Changes Related to Chronic Disease, or Pharmacologic or Other Interventions that Can Influence Nutrient Absorption, Utilization, or Excretion. The RDAs for elderly people encompass a single group of persons age 51 and older. Many researchers argue that this age group is far too broad to allow a single nutrient level to reflect the heterogeneous needs of all its members adequately.
  
• The RDAs Focus on Preventing Nutrient Deficiencies or Maintaining Existing Health, Rather than Preventing Chronic Disease. RDAs are set on the basis of nutrient levels that are necessary to correct or prevent nutrient deficiencies. This criterion may not be appropriate for elderly people, because the predominant health concern for this population group is prevention of chronic disease, not elimination of nutrient deficiencies.

Opinions differ about developing RDAs specifically for the older population and for specific subgroups within this population. Some have suggested developing two sets of recommendations: one for healthy elderly people, and the other for those with chronic disease. On the other hand, some researchers have cautioned against premature establishment of separate standards for the elderly, because they do not believe that the degree to which nutrient requirements change with advancing age has been demonstrated. The process is confounded by the difficulties inherent in distinguishing between changes in nutrient requirements resulting from normal, healthy aging and those arising from social, psychological, and physical factors that could alter health status.

Clearly, the process of determining the appropriateness of the current RDAs for older people and of developing, as needed, separate recommendations for those of advancing age is complex. Consideration must be given to the heterogeneity of the older adult population. Research has not yet differentiated nutritional status and its determinants among widely differing older populations, including older persons institutionalized in acute or long-term care settings; ambulatory, independently living, relatively healthy elderly people; and the frail, homebound, older population. The impact of normal, progressive aging on nutrient requirements must be evaluated in both cross-sectional and longitudinal studies of well-characterized cohorts of middle-aged and older adults. Studies must also clarify the degree to which nutrient requirements change as relative health is maintained but chronic conditions progress. Furthermore, it may be desirable for research to guide the development of dietary recommendations that are consistent with the promotion of healthy aging and the optimal management of chronic disease.

Despite these limitations, researchers seem to agree that, until more appropriate age-specific RDAs are established, the 1989 RDAs should be used as recommended levels for judging the nutritional adequacy of the diets of older people and the nutrient content of meals provided by federal food and nutrition programs.

b. Dietary Guidelines

Although the risk of nutrient deficiencies is of particular concern for certain high-risk groups of older persons, excessive food intake and diet-related chronic disease appear to be more prevalent diet-related problems among elderly persons. Today, chronic conditions, such as cardiovascular heart disease, strokes, and cancer, are the most predominant health problems for elderly people, many of whom consume excessive amounts of food energy (calories), fat (especially saturated fat), cholesterol, and sodium, and insufficient complex carbohydrates and dietary fiber. Genetic components are important determinants of many chronic diseases, but there is consensus that dietary factors play a significant role in the cause, prevention, and treatment of these diseases (National Research Council 1989b).

The Dietary Guidelines are intended to be the basis of menu planning in federal food and nutrition programs and homes. They provide advice about food choices that will meet nutrient requirements, promote health, and reduce chronic disease risks (see Section I.A.3 for the Dietary Guidelines recommendations). Diets with the majority of calories from grains, vegetables and fruits, low-fat dairy products, lean meats, fish, and poultry, and the minority of calories from fats and sweets, meet the recommendations of the Dietary Guidelines.

The Dietary Guidelines provide specific quantitative recommendations about food variety and the amount of fat in diets. However, they do not provide quantitative recommendations for cholesterol, sugar, or sodium, or other dietary components.

The Dietary Guidelines recommend that intake from total fat should not exceed 30 percent of total food energy (calories), and intake from saturated fat should not exceed 10 percent of total food energy (calories). However, some nutrition experts believe the recommended maximum levels of total fat and saturated fat as a percentage of calories for elderly people may be overly stringent, especially for the oldest old. The argument is that the full implications of lowering total and saturated fat intake on longer-term health outcomes in elderly people are unknown. Furthermore, reducing total and saturated fat intake may lower 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 this population's diet.

C. OBJECTIVES OF THE EVALUATION

Although established in 1972, there has been only one national evaluation of the OAA Title III nutrition program. That evaluation was completed more than 10 years ago (Kirschner et al. 1983 and 1981). Similarly, the last, and only, major evaluation of the Title VI nutrition program was in 1983 by Native American Indian Consultants, Inc. (Lustig 1983). The Title VI program was in its third year of operation then; at that time, 83 ITO grantees were participating. When Congress authorized the OAA in 1991, it recognized that comprehensive data on the Title III and Title VI nutrition programs were not available. As part of the 1992 amendments, Congress included two mandates to ensure that current and comprehensive data would be available to policymakers. One of the mandates called for a national evaluation of the nutrition services program.

In order to address the policy issues summarized here, Congress, in authorizing the current evaluation, identified 19 specific objectives for the research. These 19 objectives fall into four general categories:

1. To evaluate who is using the program and how effectively the program reaches targeted groups

2. To evaluate the program's effects on participants, relative to eligible nonparticipants

3. To assess how efficiently and effectively the program is administered and delivers services

4. To clarify program funding streams and allocation of funds among program components

The following sections discuss the specific research objectives, classified according to these categories.

1. Program Participation and Targeting

AoA requires up-to-date information on the characteristics of current participants to have an accurate picture of program participants and to target services more effectively. Four of the questions in the legislation relate to characteristics of program participants and targeting:

1. Describe the Characteristics of Participants. The logical starting point for an overall assessment of the program is to determine who the program is serving. An understanding of participant characteristics can help program administrators and Congress assess the degree to which those served by the program are in need of services provided. Information on both demographic and economic characteristics is necessary, as are indicators of nutritional, physical, social, and psychological status and well-being.

2. Describe Differences Between Participants in Congregate and Home-Delivered Meal Programs. The two main components of the program--congregate and home-delivered meals--are designed to serve somewhat different groups. The expectation is that recipients of home-delivered meals are generally less able to leave their homes to obtain meals in a congregate setting. To evaluate whether the program is working as intended, the evaluation compared the characteristics of participants in the two program components.

3. Describe Changes Over Time in Participants and Program Services. It is important to analyze the current characteristics of program participants, as well as changes in these characteristics over time. Tracking changes can provide important clues about the direction in which the program is moving, thus making it possible to predict future participation patterns under various policy scenarios, and to refine targeting objectives.

4. Describe Program Effectiveness in Reaching Special Populations of Older Individuals. Although all older Americans are eligible for program services, the authorizing legislation emphasizes a number of special populations for whom services are believed to be particularly important. Accordingly, the evaluation has examined the program's effectiveness in reaching American Indians, Native Hawaiians, Alaskan Natives, Asians/Pacific Islanders, African Americans, Hispanics, frail/disabled individuals, residents of rural areas, low-income nonminority people, and low-income minority people. This assessment has compared data on the number of participants and program eligibles by race/ethnicity, income, functional status, and residential location.

2. Program Impacts

A second set of research questions relates to direct program impacts--the ways in which the program affects participants:

• Identify Impacts on Dietary Intake and Opportunities for Socialization. Given the structure of the program, the outcomes of particular and direct importance are dietary intake (in relation to recommendations and guidelines for nutrient intake) and opportunities for socialization. Effects of the program on these outcomes have been addressed, both for all participants as a group and for various subgroups, defined by race/ethnicity, income levels, and other factors.
  
• Identify Impacts of Recent Increases in the Proportion of Home-Delivered Meals Provided Under the Program. An important program trend in recent years has been a shift in resources toward home-delivered meals. The evaluation has assessed the impacts of this shift on participants and program operations, and whether it should be altered. Related shifts in the provision of supportive services have also been considered.

3. Program Administration and Service Delivery

As concern about large federal budget deficits continues to increase, all public programs are under scrutiny to assess whether their operations are as efficient as possible. Accordingly, a number of questions specified in the authorizing legislation pertain to this area:

• Describe the Efficiency of Program Administration and Service Delivery. The evaluation has described program operations and service delivery at all levels of program administration, including the state, AAA (or ITO), nutrition project, and meal site levels, in order to examine the efficiency of program operations. This process has involved assessing the inputs--including staff time, food, space, and other factors--that are used in producing program services. It has also involved obtaining information on different procedures used by agencies in delivering program services.
  
• Describe the Costs of Program Administration and Service Delivery. Measures of program costs provide a particularly important dimension for assessing the efficiency of program delivery, because they offer a way of combining information on individual inputs into an overall index of resource use. As a result, part of the evaluation computes the average costs of providing program meals.
  
• Describe Changes in Program Administration and Service Delivery Over Time. It has been important for the evaluation to examine changes in program administration and service delivery characteristics over time. Highlighting changes in recent years may make it possible to identify probable future trends, which can then be examined to determine whether they appear to be in the public interest.
  
• Describe Commodity Usage and Limitations on Commodity Usage. Most nutrition projects are not making direct use of USDA commodities available to them. Instead, they are taking advantage of an option that allows them to receive cash equal to the value of their basic commodity allotment, even though extra commodities are available to projects that take at least 20 percent of their commodities allotment in the form of actual commodities. As part of an overall assessment of the efficiency of program operations, the evaluation has examined both the degree to which commodities are used in the program and reasons why they are not used more.
  
• Assess the Quality of Services Provided. A full assessment of program efficiency must consider not only the quantity and cost of services (for example, meals) produced but also their quality. Various quality measures have been included in the evaluation: the degree to which program meals meet programmatic requirements of nutrient intake including Recommended Dietary Allowances (RDAs) and the USDA/DHHS Dietary Guidelines for Americans, the degree to which accepted sanitation and food handling standards are met at program sites, and participants' subjective evaluations of the services they receive.
  
• Describe the Levels of Nutritional Expertise of Staff Involved in Program Administration. The efficiency and quality of program operations are also reflected in the qualifications of staff involved in the program. The evaluation has examined the nutritional expertise of program staff, including consultants, at all levels of program administration. Both educational background and registration status were considered.
  
• Determine the Applicability of Health and Safety Standards. The success of the program in accomplishing its nutritional objectives requires that meals served meet high standards for compliance with health and sanitation standards. The evaluation has obtained information on the methods used in meal production and delivery, to determine whether appropriate health and safety precautions are being taken. Information on the applicability of state and local food service inspection requirements has also been obtained.
  
• Describe the Integration of Program Services with the Long-Term Care System. Because of the aging of the U.S. population and heightened concern about health care costs, increasing emphasis has been placed on developing long-term and case-managed systems that make it possible for elderly people to remain in their communities and avoid institutionalization for as long as possible. The ENP has the potential for contributing significantly to this objective by providing a means for elderly people to obtain nutritious meals and related services, and by identifying older persons who are in need of nutrition and support services. The trend toward home-delivered meals noted earlier may in part reflect pressures to provide program services to persons who need them as part of explicit long-term care plans. Given these factors, the evaluation has examined linkages between the ENP and the home and community based long-term system. These linkages might involve (1) funding mechanisms, such as Title XIX waivers; (2) referral systems, such as hospitals that refer patients who need meal services as part of their discharge plans; or (3) other types of linkages.
  
• Assess the Appropriateness of RDAs and Dietary Guidelines in Program Administration. Nutritional goals for the program are stated, in part, in terms of the RDAs for key nutrients, as established by the National Research Council of the National Academy of Sciences. However, these allowances are the same for all persons 51 years old and older, regardless of age differences and health factors. As a result, some observers have questioned whether the current RDAs are appropriate for ENP program administration. The evaluation has addressed this issue.

4. Program Funding

Nutrition projects operating under the ENP often draw on a broad array of funding sources in order to maximize the services they can provide. Understanding where funding comes from, how it meshes together to provide integrated program services, and what constraints funding sources introduce into the overall system is crucial for developing a comprehensive understanding of program operations. Two questions address this concern:

1. Describe Sources and Uses of Funds. At each level of program administration, the evaluation has examined funding sources and the degree to which monies from specific sources are linked to specific uses. In addition to OAA funds, the following funding sources have been examined: other federal sources (such as USDA); state and local governments; participant contributions; donations of labor; and donations of other resources.

2. Describe Transfers of Funds Between Components of the Program. As noted, the provision of home-delivered meals under the program has increased substantially. One of the administrative mechanisms through which this increase has been accomplished is the transfer of funds away from congregate meals. Funds have also been transferred from congregate meals to provide more supportive services under Title III-B. The evaluation has documented the degree of funding shifts and examined reasons for the shifts.

Note that not all the programmatic issues and, hence, study objectives, discussed previously are of relevance to the Title VI component of the ENP. In particular, transfers of funds among program components and some aspects of program targeting are not applicable to the Title VI program. In addition, because it was not feasible to identify a comparison group, no separate "impact" analysis of program components on participants' dietary intake and socialization was conducted for the Title VI program.

D. STUDY METHODS

Many of the evaluations's analytic objectives were descriptive in nature and required compiling detailed information about the organizations and persons involved with the program. To address these descriptive issues, interviews and/or observations were conducted with program participants and with personnel from organizations at all levels of the program hierarchy, including:

• AoA central office
• SUAs
• AAAs
• ITOs
• Nutrition projects
• Congregate sites
• Meal production facilities

Data on the contents of meals served in the program were also obtained, and program administrative data were reviewed.

Interviews were also conducted with program participants. In addition, in order to examine program impacts, it was necessary to obtain data on a set of persons who were similar to program participants but were not participating in the program. For the Title III program, a comparison group of eligible nonparticipants was identified for this purpose by screening a sample of persons receiving Medicare that was supplied by the Health Care Financing Administration (HCFA) of DHHS.

Much of the analysis was done using descriptive tabular methods. However, regression techniques were used in the impact analysis, in order to attempt to control for differences between the participant and nonparticipant samples.

Details concerning study methods are presented in Volume III of this final report. Among the topics covered there are sampling, telephone and in-person data collection, response rates, and weighting the data.

E. STUDY LIMITATIONS

This study represents the most comprehensive evaluation of the ENP conducted in the past 15 years. It provides important information about program operations and funding, participants in the program, and the impacts of the program on participants. However, interpretations of the results summarized here must be made in light of the study's limitations. Four of the most important of these limitations are highlighted next.

1. Lack of Random Assignment. The strongest evaluation design for measuring the effects of the ENP on participants would have randomly assigned potential participants to the program or to a control group that did not receive program services. Random assignment was not possible in the current evaluation. Instead, MPR selected a sample of nonparticipants in the same locations as participants, from HCFA's Medicare Beneficiary File, in which the nonparticipants were matched with participants in terms of key variables. Without random assignment, underlying differences between the participant and nonparticipant groups might confound the comparisons made in the impact analyses. MPR minimized this possibility, however, by matching the comparison group to the participant group as closely as possible, and by using statistical techniques to control for the effects of observable differences.

2. Sampling Error. With the exception of the data collection from SUAs, all of the surveys in this study were based on samples of agencies or respondents. As a result, the numerical estimates reported here are subject to possible error resulting from random statistical variation. In general, however, our sample sizes are large enough that sampling error, while present, is probably not large enough to affect the overall conclusions.

3. Potential Measurement Error in Nutrition Project Meal Cost Estimates. Many nutrition projects in the ENP do not keep sufficiently detailed cost records to provide consistent cost information across projects. Accordingly, MPR "built up" cost estimates on the basis of detailed information from the projects about local operations, staff wage rates, and other factors. This process may have introduced some measurement error into the detailed cost estimates, but MPR is confident that the overall order of magnitude of the cost estimates is correct.

4. Difficulties in Allocating Funding by Source. The agency surveys asked respondents to provide data on total funding and funding by source, separately for congregate meals, home-delivered meals, and supportive services. Because meals and supportive services are closely intertwined in many projects, it was often not possible to link services with specific funding sources. As a result, much of the analysis of program funding sources relied on aggregate program data.

These limitations should be kept in mind in assessments of the study's overall findings, as they may affect some details of the findings. Despite these limitations, however, the basic conclusions drawn here are strongly supported by the information collected in the study.

F. ORGANIZATION OF THE REPORT

Volume I of the final report on the evaluation presents the results pertaining to Title III of the program. Volume II presents parallel findings for Title VI. Details of the methodologies used are included in Volume III.

In the remainder of Volume I of this report, we examine the Title III program as it operates currently. Chapter II describes the characteristics of Title III meal program participants, highlighting similarities and differences between congregate and home-delivered participants, and comparing Title III participants with the overall elderly population. It also examines the extent to which the two meal program components successfully target program services to priority subgroups of elderly people, such as minority and low-income elders. Chapter III describes Title III participants' dietary intakes from program meals and assesses the contribution of the nutrition program to participants' dietary intakes and opportunities for socialization. It also compares the daily dietary intakes and socialization of Title III participants with those of nonparticipants. Chapter IV examines the Title III ENP and its operations, including the array of nutrition and supportive services provided, the nutritional expertise of program staff, and the quality of program services. Chapter V looks at the costs of providing Title III meals, funding sources and amounts, and program efficiency.

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