Nutrition

IV. TITLE III PROGRAM ADMINISTRATION AND SERVICE DELIVERY

F. QUALITY OF PROGRAM SERVICES PROVIDED -- Part 1

The data collection effort included several different indicators of ENP service quality. In this section, we examine three important dimensions of quality:

1. The nutritional quality of meals offered

2. Participants’ satisfaction with meals and other program services

3. The safety and sanitation practices used in preparing and serving meals

1. Nutritional Quality of Meals Offered

The 1992 amendments to the OAA require program meals to (1) comply with the Dietary Guidelines for Americans, and (2) meet the Recommended Dietary Allowances (RDAs) for key nutrients (that is, a minimum of one-third of the RDA if the project provides one meal per day, two-thirds of the RDA if the project provides two meals per day, and 100 percent of the RDA if the project provides three meals per day).

Compliance with the Dietary Guidelines is a new requirement. For years, some states have encouraged projects to apply these recommendations to program meals, but these recommendations have never before been included in program requirements. Before the 1992 amendments, the OAA required that each meal contribute one-third of the RDA. Under the new requirements, in programs providing more than one eating occasion per day, the nutrient content of one meal can be below the RDA, if the other meals make up the difference and the appropriate total nutrient content is achieved for the day. On a per-meal basis, programs must average one-third of the RDA.

We have already reviewed participants’ dietary intake from program meals in Chapter III, where we saw that the program meals participants eat do indeed contribute at least one-third of the RDA for most nutrients. A more direct way of assessing the nutritional quality of program meals is to observe the meals offered at program sites and to analyze their nutritional content.

Methods. We randomly selected a meal from each eating occasion on two separate days for each of the congregate sites included in the in-person data collection. MPR data collectors recorded descriptions and amounts of the contents of the meals, using computer-assisted personal interviewing (CAPI) laptop computers. In addition, we randomly selected and analyzed a meal from each eating occasion on one day for the home-delivered meal programs, for each of the home-delivered meal routes whose meal participants were interviewed. More than 500 congregate and home-delivered meals were sampled and analyzed. The nutritional contents of the resulting food data were analyzed by the University of Minnesota, using essentially the same methods used in processing the 24-hour dietary recall intake data (see Volume III, Appendix E).

Nutrient Availability Relative to RDAs. Our conclusions are basically consistent with those reported from participants’ dietary recall of their intake from program meals--most programs provide meals that satisfy the RDA requirements. On average, both congregate and home-delivered meals supply at least one-third of the RDAs for virtually all nutrients (Table IV.31). The only exception is that the average zinc content of home-delivered meals falls just short of the RDA requirement for older males. For many of the nutrients studied, the nutritional content of the average meal was well in excess of the RDAs. For instance, the average nutritional content of Vitamin A, Vitamin B₁₂, phosphorous, and potassium was 70 percent or more of the daily female RDAs.

TABLE IV.31

MEAN NUTRIENT AVAILABILITY PER TITLE III PROGRAM MEAL

(As a Percentage of RDA)

	Title III Congregate Meals			Title III Home-Delivered Meals
Nutrient	Female RDA	Male RDA		Female RDA	Male RDA
Food Energy	43.6	36.0		44.7	36.9
Protein	74.8	59.3		81.6	64.7
Vitamin A	91.2	73.0		117.7	94.2
Vitamin C	70.3	70.3		60.7	60.7
Vitamin D	71.0	71.0		72.3	72.3
Vitamin E	51.5	41.2		50.0	40.0
Thiamin	67.2	56.0		66.5	55.4
Riboflavin	74.3	63.7		76.7	65.8
Niacin	67.2	58.3		77.3	67.0
Vitamin B6	47.5	38.0		55.4	44.3
Folate	58.6	52.7		57.8	52.0
Vitamin B12	112.2	112.2		89.2	89.2
Calcium	56.3	56.3		57.7	57.7
Iron	54.6	54.6		52.5	52.5
Phosphorous	75.6	75.6		77.7	77.7
Potassium	71.3	71.3		70.4	70.4
Magnesium	46.5	37.2		48.0	38.4
Zinc	41.2	33.5		40.8	32.6
Unweighted Sample Size	160	160		84	84

Source: Elderly Nutrition Program Evaluation, Meals Offered survey, weighted tabulations.

Note: Program requirement per meal is one-third of the RDA.

RDA = Recommended Dietary Allowance.

The data in Table IV.31 are also interesting in terms of what they show about the nutrient density of program meals, as measured by nutrients per kilocalorie of food energy. In general, the food energy content of the meals is lower, as a percentage of the food energy RDA, than the content of other nutrients, as measured against their RDAs. This pattern implies that the ENP meals are relatively "nutrient dense" and supply relatively high levels of nutrients per kilocalorie. [ Two other approaches to analyzing the nutrient content of program meals as offered were pursued. The first focused on median nutrient intakes, rather than means, while the second examined percentages of meals meeting one-third of the RDAs for various nutrients. An analysis of these two sets of variables produced results (shown in Appendix I) that are essentially consistent with those reported in Table IV.31. ]

Nutrient Availability Relative to the Dietary Guidelines and NRC Recommendations. Both congregate and home-delivered program meals, as offered, provide approximately 36 percent of food energy (calories) from total fat and about 12.5 percent of food energy from saturated fat (Table IV.32). These percentages exceed the recommendations in the Dietary Guidelines that total fat and saturated fat be 30 percent and 10 percent of food energy, respectively. [ However, as discussed in detail in Chapter III, there is some uncertainty in the scientific community as to whether the Dietary Guidelines are fully applicable to populations as old as the typical ENP participant.] About 47 percent of calories, on average, comes from carbohydrates. This is below the National Research Council (NRC) recommendation that carbohydrate equal or exceed 55 percent of total food energy. The program meals, however, are rich in protein. On average, protein is approximately 19 percent of total calories. Title III congregate and home-delivered meals contain about 1,400 mg of sodium chloride and between 100 and 110 mg of dietary cholesterol. The NRC recommends that the daily intake of sodium should not exceed 2,400 mg, and daily intake of cholesterol should not exceed 300 mg. Comparing the sodium and cholesterol content of program meals to one-third of these standards (800 mg and 100 mg, respectively) suggests that the program meals tend to be high in sodium and only somewhat elevated in dietary cholesterol.

TABLE IV.32

AVAILABILITY OF MACRONUTRIENTS, SODIUM, AND DIETARY CHOLESTEROL FROM TITLE III MEALS

(Per Program Meal)

Dietary Component	Title III Congregate Meals	Title III Home-Delivered Meals
Carbohydrate
Mean Percentage of Food Energy (Calories)	47.4	46.6
Median Percentage of Food Energy (Calories)	48.0	46.0
Distribution of Availability as a Percentage of Food Energy (Calories)
Less than 45 percent	37	41
45 to 55 percent	57	47
56 to 65 percent	6	9
More than 65 percent	*	4
Total Fat
Mean Percentage of Food Energy (Calories)	35.8	35.5
Median Percentage of Food Energy (Calories)	36.0	37.7
Distribution of Availability as a Percentage of Food Energy (Calories)
Less than 20 percent	*	6
20 to 30 percent	13	16
31 to 35 percent	33	14
36 to 40 percent	31	38
41 to 50 percent	22	25
More than 50 percent	*	1
Saturated Fat
Mean Percentage of Food Energy (Calories)	12.6	12.4
Median Percentage of Food Energy (Calories)	12.1	12.7
Distribution of Availability as a Percentage of Food Energy (Calories)
Less than 5 percent	*	2
5 to 10 percent	12	22
11 to 15 percent	70	57
16 to 20 percent	18	18
More than 20 percent	*	*
Protein
Mean Percentage of Food Energy (Calories)	18.2	19.3
Median Percentage of Food Energy (Calories)	17.8	18.7
Distribution of Availability as a Percentage of Food Energy (Calories)
Less than 5 percent	*	*
5 to 15 percent	6	17
16 to 25 percent	91	76
More than 25 percent	3	7
Sodium
Mean Availability (mg Per Day)	1,433	1,340
Median Availability (mg Per Day)	1,389	1,235
Distribution of Availability
Less than 800 mg per day	4	12
801 to 1,000 mg per day	13	8
More than 1,000 mg per day	83	80
Dietary Cholesterol
Mean Availability (mg Per Day)	102	109
Median Availability (mg Per Day)	96	111
Distribution of Intake
Less than 100 mg per day	58	46
101 to 134 mg per day	26	21
More than 134 mg per day	16	33
Unweighted Sample Size	160	84

Source: Elderly Nutrition Program Evaluation, Meals Offered survey, weighted tabulations.

Note: The Dietary Guidelines recommend that (1) total fat intake should be 30 percent or less of food energy intake, and (2) saturated fat should be 10 percent or less of food energy intake. The National Research Council recommends that the intake of (1) cholesterol should be less than 300 mg per day, (2) sodium chloride should not exceed 2,400 mg per day, and (3) carbohydrates should be at least 55 percent of food energy.

*= Less than 0.5 percent.

2. Participants’ Satisfaction with Meals and Other Program Services

Another indicator of program quality is whether participants are satisfied with program meals and other services. The participant interview included a series of questions about attitudes toward various aspects of the program. Most of the questions included a four-level response category, with the higher two (Per Program Meal)page 2page 3 levels indicating various degrees of positive satisfaction and the lower two categories indicating various degrees of dissatisfaction. The evidence from the participant survey suggests a high degree of satisfaction. As discussed in detail next, the majority of respondents report the highest level of satisfaction in response to most of the questions. Fewer than 10 percent indicated either of the two levels of dissatisfaction.

a. Congregate Participants’ Satisfaction with Meal Services

When asked about the safety of the meal site location, 68 percent of congregate participants rated the location as extremely safe (Table IV.33), while another 29 percent believed that the location was safe except at certain times. Only three percent described it as somewhat dangerous or usually unsafe. Eighty-five percent of respondents described their congregate sites as very pleasant, while most of the rest--14 percent overall--ranked their sites as fairly pleasant. Respondents who rated their sites as less than very pleasant were asked what aspects of the site they found unpleasant. Four percent of all respondents felt that the other participants were not pleasant, and two percent each rated the staff and the food in this way.

TABLE IV.33

CONGREGATE PARTICIPANTS’ SATISFACTION WITH MEAL AND OTHER PROGRAM SERVICES

Aspect of Service	Percentage of Title III Congregate Participants
Safeness of Meal Site Location
Extremely safe	68
Safe, except at certain times	29
Somewhat dangerous or usually unsafe	3
Pleasantness of Meal Site
Very pleasant	85
Fairly pleasant	14
Not too pleasant	1
Aspects of Meal Site that Are Not Pleasant
Other Participants	4
Staff	2
Food	2
Other	5
Get Enough to Eat from Program Meal
Always	93
Sometimes	7
Rarely or never	*
Number of Times Not Served Program Meal When Attended During Past Six Months
Never	96
Once	2
Two or more times	2
Satisfaction with How Food Tastes
Very satisfied	66
Somewhat satisfied	30
Not too satisfied	4
Not at all satisfied	*
Satisfaction with How Food Looks
Very satisfied	76
Somewhat satisfied	23
Not too satisfied	1
Not at all satisfied	*
Satisfaction with Temperatures of Meal/Food
Very satisfied	79
Somewhat satisfied	20
Not too satisfied	1
Not at all satisfied	*
Satisfaction with Variety of Food Served
Very satisfied	69
Somewhat satisfied	27
Not too satisfied	4
Not at all satisfied	*
Satisfaction with Getting Foods Personally Like
Very satisfied	60
Somewhat satisfied	35
Not too satisfied	4
Not at all satisfied	1
Satisfied with Degree to Which Special Dietary Needs Met
Very satisfied	70
Somewhat satisfied	24
Not too satisfied	4
Not at all satisfied	2
Perception of Suggested Meal Contribution Amounta
Too high	4
About right	85
Too low	11
What Participants Like About Meals Program
Participants	76
Meals	58
Supportive services	30
Unweighted Sample Size	1,040

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

Notes: Congregate participant tabulations are weighted to be representative of a cross-section of participants receiving Title III congregate meals on a given day. Calculated only for those congregate participants who typically make a voluntary contribution for program meals. Ninety-four percent of congregate participants report that they typically make a contribution.

^a Asked only of those participants who make contributions and whose project or site suggests an amount to contribute.

* = Less than 0.5 percent.

Most respondents are pleased with the portion sizes in the meals; 93 percent indicated that they always get enough to eat. In response to a question about whether program meals had been unavailable at their site at any time in the previous six months, most congregate participants (96 percent) said no. Only two percent reported meals being unavailable more than once.

The percentages of congregate participants who reported being very satisfied were 66 percent for how the food tastes, 76 percent for how the food looks, 79 percent for the food temperature, and 69 percent for the food variety. Most of the other respondents are somewhat satisfied with these characteristics of congregate meals. No more than four percent rated the food in one of the two lower satisfaction categories on any of these dimensions.

In general, congregate participants were also satisfied with the types of meals served. Sixty percent said they were very satisfied with getting foods they personally like, and 70 percent felt very satisfied that any special dietary needs they had were met. Most of the people who did not rate themselves as very satisfied indicated that they were somewhat satisfied.

In response to a question about what they particularly liked about congregate meals, 76 percent mentioned other participants, 58 percent mentioned the meals, and 30 percent mentioned supportive services. These responses suggest that, although participants are generally satisfied with the meals, the socialization aspect of the program is also very important.

Congregate respondents who make contributions for meals and attend sites that suggest a contribution amount were asked their perception of the suggested amount. Eighty-five percent rated it as about right. Interestingly, most of the remainder (11 percent of all respondents) thought the suggested contribution amount was too low. Only four percent thought it was too high.

b. Home-Delivered Meal Participants’ Satisfaction with Meal Services

Recipients of home-delivered meals are generally satisfied with them. Eighty-nine percent said that they get enough to eat from the program meals (Table IV.34). Only two percent indicated that they rarely or never get enough to eat. Interestingly, given the complicated logistics often involved in home-delivery systems, 82 percent of respondents said that their meals usually arrive at the proper temperature. Another 13 percent reported that the meals sometimes arrive at the proper temperature, while 5 percent said that their meals never arrive at the right temperature.

TABLE IV.34

HOME-DELIVERED MEAL PARTICIPANTS’ SATISFACTION WITH PROGRAM MEAL SERVICES

Aspect of Service	Percentage of Title III Home-Delivered Meal Participants
Get Enough to Eat from Program Meal
Always	89
Sometimes	9
Rarely or never	2
Meal Arrives at Proper Temperature
Usually	82
Sometimes	13
Never	5
Meal Arrives at Scheduled Time
Usually	84
Sometimes	14
Never	2
If Late, Meal Typically Arrives:
Less than 15 minutes late	19
15 to 30 minutes late	32
31 to 60 minutes late	25
More than an hour late	24
Satisfaction with How Food Tastes
Very satisfied	65
Somewhat satisfied	31
Not too satisfied	5
Not at all satisfied	*
Satisfaction with How Food Looks
Very satisfied	77
Somewhat satisfied	20
Not too satisfied	2
Not at all satisfied	1
Satisfaction with Temperatures of Meal/Food
Very satisfied	79
Somewhat satisfied	18
Not too satisfied	2
Not at all satisfied	1
Satisfaction with Variety of Food Served
Very satisfied	70
Somewhat satisfied	25
Not too satisfied	4
Not at all satisfied	1
Satisfaction with Getting Foods Personally Like
Very satisfied	61
Somewhat satisfied	33
Not too satisfied	4
Not at all satisfied	2
Satisfied with Degree to Which Special Dietary Needs Met
Very satisfied	77
Somewhat satisfied	20
Not too satisfied	2
Not at all satisfied	2
Perception of Suggested Meal Contribution Amounta
Too high	8
About right	85
Too low	7
Pleasantness of Delivery Person
Usually pleasant	98
Sometimes pleasant	2
Never pleasant	*
What Participants Like About Meals Program
Meals	80
Person who delivers meals	59
Other	24
Unweighted Sample Size	818

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

Note: Home-delivered meal participant tabulations are weighted to be representative of a cross-section of participants receiving Title III home-delivered meals on a given day.

^a Asked of only those participants who usually contribute and whose project suggests an amount to contribute.

* = Less than 0.5 percent.

A similar distribution of responses was observed for a question about whether meals arrive on time. Eighty-four percent of respondents said that they usually do, while only two percent reported that they never do. Among respondents who reported that their meals sometimes or always arrive late, the reported delays are often substantial. Nearly half of the people reporting late meals said that when the meals are late, they usually arrive more than half an hour late.

Satisfaction levels with various aspects of the food parallel those observed for congregate participants. Sixty-five percent are satisfied with how the food tastes, 77 percent with how the food looks, 79 percent with the temperature of the food, and 70 percent with the variety of the food. Most of the remaining responses expressed at least partial satisfaction, with no more that five percent ranking the food in one of the two lowest response categories for any given criterion.

Like congregate participants, home-delivered meal recipients are generally satisfied with the types of foods they receive. When asked about the suggested meal contribution amount, 85 percent thought it was about right, with the remainder about equally divided between the too high and too low categories. Ninety-eight percent of respondents indicated that their delivery person is usually pleasant, and most of the remainder rated him or her as sometimes pleasant.

When asked what they liked most about the program, 80 percent of respondents indicated that the meals themselves are important to them. However, 59 percent also mentioned the contact with the delivery person.

c. Participants’ Valuation of Services

To obtain additional information about the importance of the ENP and related services in participants’ lives, we asked respondents a series of questions about how they value various services or what they would do if the services were not available. The results suggest that substantial number of respondents find these services important and useful.

Twenty-six percent of congregate respondents said they use special transportation to and from the meal site (Table IV.35). More than a third of the respondents who indicated this (10 percent of congregate participants overall) indicated that they would not be able to attend the meal site at all without these services, and another 20 percent (5 percent of congregate participants overall) indicated that they would attend a lot less often. Similarly, of the 16 percent who said they use special transportation provided by the site for shopping or health care visits, about half said that, without it, they would either not make such trips at all or would make them a lot less often. The comparable numbers for the home-delivered participants are similar but indicate a somewhat higher degree of reliance on the program’s transportation services. Overall, only a minority of ENP participants use these transportation services, but a substantial number of those who use them feel very dependent on them.

TABLE IV.35

PARTICIPANTS’ VALUATION OF MEALS AND SUPPORTIVE SERVICES RECEIVED FROM THE MEAL PROGRAM IN PAST YEAR

(Percentages)

	Title III Congregate Meal Participants	Title III Home-Delivered Meal Participants
Used Special Transportation to and from Meal Site	26	NA
If Special Transportation Not Available, Would Go to Meal Site:
Not at all	10	NA
A lot less often	5	NA
Somewhat less often	4	NA
About the same	7	NA
Used Special Transportation for Shopping or Health Care Visits	16	19
If Special Transportation Not Available, Would Go Shopping or for Health Care Visits
Not at all	3	8
A lot less often	5	4
Somewhat less often	3	3
About the same	5	4
Participated in Recreation Activities at Congregate Meal Site	70	NA
Meal Site Recreation Activities Are:
Your only social activities	8	NA
A major source of your social activities	31	NA
One among other social activities	31	NA
Received Nutrition Education from Meal Program	68	34
To Improve Your Eating Habits, Nutrition Education from Meal Program Was:
Very useful	31	12
Somewhat useful	27	14
Not too useful	7	5
Not at all useful	3	3
Received Nutrition Screening and Assessment from Meal Program	43	36
In Helping Improve How and What You Eat, Nutrition Screening and Assessment from Meal Program Was:
Very useful	22	12
Somewhat useful	13	14
Not too useful	4	4
Not at all useful	3	6
Received Nutrition Counseling from Meal Program	18	12
In Helping Improve How and What You Eat, Nutrition Counseling from Meal Program Was:
Very useful	10	6
Somewhat useful	5	5
Not too useful	2	*
Not at all useful	1	1
Received Information and/or Referral Services from Meal Program	30	18
Information and/or Referral Services from Program Were:
Very helpful	17	12
Somewhat helpful	9	3
Not too helpful	2	2
Not at all helpful	2	1
Importance of Meal Program
Your only source of food	2	NA
A major source of your food	43	NA
One of several sources of your food	56	NA
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.

NA = Not applicable or not asked.

Reported degrees of dependency for congregate participants on recreation services are considerably lower. A substantial majority (70 percent) reported that they use recreational services, but only 8 percent reported that recreation at the meal site is their only social activity. However, another 30 percent of all congregate participants viewed the meal site as a major source of recreational activities.

Of the 68 percent of congregate participants who reported receiving nutrition education, most (58 percent of all recipients) reported that it has been very or somewhat useful in helping them improve their eating habits. Ten percent rated it as not too useful or not useful. Most home-delivered meal recipients who remembered receiving nutrition education also rated the information in one of the two useful categories.

Similar results were obtained for other services, including nutrition screening and assessment, nutrition counseling, and information and referral services. In each instance, between 15 and 45 percent of clients reported receiving the service. Of those clients who received the service, substantial majorities reported that it is very or somewhat useful.

Congregate respondents were also asked a question about the importance of the ENP meals in their overall diets. Approximately 2 percent indicated that the ENP was their only source of food, and 43 percent classified it as a major source of food. Thus, nearly half the participants view the program as a major source of nutrition. These responses are consistent with the dietary intake findings reported earlier, which showed that program meals account for substantial portions of many clients’ diets.

Last Modified: 1/15/2009 11:05:57 AM

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