Risk and Presence of Food Insufficiency Are Associated with Low Nutrient Intakes and Multimorbidity among Homebound Older Women Who Receive Home-Delivered Meals

Patterns of food insecurity and participation in food assistance programmes over time in the elderly

OBJECTIVE

The present study aimed to understand the relationship between need and help-seeking behaviour in older adults by examining the patterns of food insecurity and participation in food assistance programmes (FAP), i.e. the Food Stamp Program and home-delivered meals.

DESIGN

Data from two longitudinal studies were used. The studies were designed to obtain nationally representative information on health, insurance coverage, financial status, family support systems, labour market status and retirement planning, every two years: the Health and Retirement Study (HRS, 1996-2002) and Asset and Health Dynamics Among the Oldest Old (AHEAD, 1995-2002).

SETTING

USA.

SUBJECTS

There were 7623 participants for HRS and 3378 for AHEAD.

RESULTS

The older adults appeared to have persistent patterns between food insecurity and participation in FAP, especially in the Food Stamp Program. More persistently food-insecure older adults had higher participation in FAP (P < 0.001). Food-insecure older adults at one time were more likely to shift from non-participation to participation in FAP the next time than food-secure older adults (P < 0.001). Regardless of previous food insecurity status, previous participants in FAP were more likely to participate subsequently.

CONCLUSIONS

The relationship between need and help-seeking behaviour in older adults was found to follow a persistent positive pattern, determined by looking at the patterns of food insecurity and participation in FAP. Although food insecurity as a need is a good predictor of participation in FAP, it is not enough to fully predict participation in FAP. Help-seeking behaviour (i.e. previous programme participation) is also important in predicting participation in FAP.

Height differences and the associations between food insecurity, percentage body fat and BMI among men and women

OBJECTIVE

The present study examined the associations between adult food insecurity (FI) and percentage body fat (%BF) and BMI, stratified by height (HT).

DESIGN, SETTING AND SUBJECTS

%BF, HT and BMI of 2117 men and 1909 women in the National Health and Nutrition Examination Survey 1999-2002 were analysed in relation to adult food security status using multiple regression procedures.

RESULTS

Compared with the fully food-secure, men's %BF, BMI and HT were lower as FI intensified. Marginal food security among women was associated with 1.3 cm shorter HT, P = 0.016. Marginal food security among women who were below median HT was associated with about 2.0 kg/m2 higher BMI, P = 0.042. %BF was not associated with FI among women.

CONCLUSIONS

FI is associated with shorter HT and lower %BF and BMI in men. Women's HT should be considered in the reported associations between FI and higher BMI.

Increased energy density of the home-delivered lunch meal improves 24-hour nutrient intakes in older adults

As food intake declines with aging, older adults develop energy and nutrient inadequacies. It is important to design practical approaches to combat insufficient dietary intakes to decrease risk for acute and chronic diseases, illness, and injury. Manipulating the energy density of meals has improved energy intakes in institutional settings, but the effects on community-residing older adults who are at nutrition risk have not been investigated. The aim of this study was to determine whether enhancing the energy density of food items regularly served in a home-delivered meals program would increase lunch and 24-hour energy and nutrient intakes. In a randomized crossover counterbalanced design, 45 older adult Older American Act Nutrition Program participants received a regular and enhanced version of a lunch meal on alternate weeks. The types of foods, portion sizes (gram weight), and appearance of the lunch meal was held constant. Consumption of the enhanced meal increased average lunch energy intakes by 86% (P<0.001) and 24-hour energy intakes by 453 kcal (from 1,423.1+/-62.2 to 1,876.2+/-78.3 kcal, P<0.001). The 24-hour intakes of several key macronutrients and micronutrients also improved. These data suggest that altering the energy density of regularly served menu items is an effective strategy to improve dietary intakes of free-living older adults.

Targeting of home-delivered meals programs to older adults in the United States

The Home-Delivered Meals Program (HDM) is an essential component of home-and community-based services available through the National Aging Service Network in the United States. It has the potential to help delay institutionalization and stem rising health care costs for older Americans; little is known, however, about the targeting practices used for HDM. A nationally representative telephone survey of state and local program providers showed that a variety of outreach measures were being employed, but challenges such as inadequate resources, waiting lists, rural delivery, and misconceptions about the program require resolution to ensure optimal service outcomes.

Food security in older adults: community service provider perceptions of their roles

Food insecurity in older adults is influenced by financial constraints, functional disability, and isolation. Twenty-eight social- and community-service providers participated in four focus groups to report (a) perceptions and experiences with food insecurity in their older clients, (b) beliefs about their potential role(s) in promoting food security, and (c) opinions about constraints that influenced these roles. A constant comparison analysis identified key themes. The formal caregivers reported six roles for improving food security: (a) monitoring, (b) coordination, and (c) promoting services, (d) education, (e) advocacy, and (f) providing a social environment. The final theme summarizes these roles as "the need for personalization of service". Social and community service providers are involved in roles that can promote the health of older adults by addressing their food insecurity. Social service providers need to be acknowledged and supported in this health promotion role.

A multidimensional approach to understanding under-eating in homebound older adults: the importance of social factors

PURPOSE

The purpose of this study was to identify relationships between medical, functional, economic, oral health, social, religious, and psychological factors and under-eating in homebound older adults. The focus of the study was on identifying potentially modifiable factors amenable to social and behavioral interventions.

DESIGN AND METHODS

A total of 230 homebound older adults who were currently receiving home health services participated in interviews in their homes using a questionnaire to assess eating behaviors and factors that could possibly affect those eating behaviors. Interviewers measured height and weight, and participants completed three 24-hr dietary recalls.

RESULTS

The mean age of participants was 79.1 years. The sample comprised 78% women and 38% African Americans. We found that 70% of participants were under-eating, defined as not consuming enough calories to maintain their current body weight. Participants who were at higher risk of under-eating included men, those receiving either infrequent care or very frequent care by a caregiver, those who had been hospitalized prior to receipt of home health services, and those with a higher body mass index.

IMPLICATIONS

Findings from the study have implications for both practice and policy. Experts must develop evidence-based interventions targeted at under-eating in this particularly vulnerable and growing population of homebound older adults. This study provides an initial foundation for the development of targeted evidence-based behavioral nutritional interventions that are noninvasive and cost effective.

Health-related quality of life among Mexican Americans living in colonias at the Texas-Mexico border

Understanding influences on health-related quality of life (HRQL) is critical in order to track and improve the health of poor, vulnerable populations and reduce health disparities. However, studies assessing HRQL of minorities are relatively scarce. The purpose of this study was to document personal and socioenvironmental correlates to HRQL. The study population is Mexican Americans in the Texas-Mexico border region living in colonias - unincorporated, impoverished settlements with substandard living conditions along the U.S.-Mexico border. Mexican Americans living in colonias are one of the most disadvantaged, hard-to-reach minority groups in the United States. We used data from the Integrated Health Outreach System Project collected in 2002 and 2003. Our sample included 386 participants randomly selected and interviewed face-to-face with a structured survey. We measured HRQL and examined personal and socioenvironmental correlates. Unadjusted and adjusted (multivariate) logistic regression models were used for data analyses. We found that border Mexican Americans living in colonias were of similar mental health status compared to the general population of the United States, but worse off in terms of physical health. Poor education and long-term residency in colonias were predictors of lower physical health. Women reported worse mental health than men. Length of time living in a colonia, co-morbidity status, and perceived problems with access to healthcare was associated with poorer mental health status. This study provides information for health professionals and policymakers and underscores the need to provide better preventive and medical services for underserved populations. Major findings indicate the need for additional research centered on further exploration of the impact of economic, cultural, and social influences on HRQL among severely disadvantaged populations.

The effects of nutrition-related factors on four-year mortality among a biracial sample of community-dwelling elders in the North Carolina piedmont

The purpose of this epidemiological study was to estimate mortality risk associated with poor diet quality (consumption of five food groups), extremes of body mass index (BMI), waist circumference, and impaired food-related activities of daily living among community-dwelling older Black and White men and women. The design of the current study was a retrospective-prospective cohort study. The sample included residents (n = 1920) of five North Carolina Piedmont counties. The dependent variable was four-year all-cause mortality. Analyses were stratified by gender and race, and controlled covariates included: age, living with others, income, smoking and alcohol use, cognitive status, and overall self-rated health. Data were self-reported to interviewers, except BMI and waist, which were measured by trained interviewers. Difficulty in fixing meals elevated the risk of mortality between 2.7 and 6.5 times across the four gender-race groups. Among older adults, inability to fix a meal conferred more risk of mortality than did lack of financial means. Adequate servings of vegetables were uniformly protective, although significant only among Black males. Neither BMI nor waist circumference conferred significant mortality risk. These population-based findings suggest relationships between nutrition risk factors and mortality that are unique and require further focused studies.

Obesity is a risk factor for reporting homebound status among community-dwelling older persons

OBJECTIVE

To test the a priori hypothesis that obesity is a predictor of risk for reporting homebound status.

RESEARCH METHODS AND PROCEDURES

A longitudinal cohort study was conducted with 21,645 community-dwelling men and women 65 to 97 years old. A nutrition risk screen was administered baseline between 1994 and 1999 and again 3 to 4 years later. Univariate analyses identified baseline variables associated with subsequent reporting of homebound status. Multivariable logistic regression models were created to identify baseline variables that were significant independent predictors of reporting homebound status.

RESULTS

At baseline, 24% of the cohort had BMI > or = 30. There were 12,834 (45% men) respondents at follow-up (68% response). Non-responders at follow-up differed little from responders except for greater baseline age (72.2 +/- 6.2 vs. 71.4 +/- 5.6 years, p < 0.001) and reporting of any functional limitations (9.2% vs. 4.9%, p < 0.001). At follow-up, those who reported homebound status (n = 169) were significantly (p < 0.001) older (80.3 +/- 7.3 vs. 75.1 +/- 5.5 years) and more likely to report functional limitations (83.4% vs. 10.8%). Univariate analyses identified 16 baseline variables that were eliminated stepwise until five significant independent predictors remained: age > or = 75 years (2.21, 1.55 to 3.15/odds ratio, 95% confidence interval), BMI > or = 35 (1.75, 1.04 to 2.96), poor appetite (2.50, 1.29 to 4.86), low income (1.59, 1.00 to 2.56), and any functional limitation (10.67, 7.36 to 15.46).

DISCUSSION

Obesity remained a significant independent predictor for reporting homebound status and should be considered in screening of older populations and in the planning, implementation, and evaluation of services for homebound older persons.

Longitudinal Examination of Homebound Older Adults Who Experience Heightened Food Insufficiency: Effect of Diabetes Status and Implications for Service Provision

PURPOSE

Healthful eating is important for optimal diabetes self-care. However, the level of food sufficiency may influence the degree of adherence to dietary self-care behaviors through the affordability of nutritionally appropriate food. This study examines whether homebound older adults with diabetes were at greater risk for heightened food insufficiency over 1 year, despite regular receipt of home-delivered meals.

DESIGN AND METHODS

This was a longitudinal study of a randomly recruited sample of 268 homebound older adults in the Nutrition and Function Study (NAFS) who regularly received home-delivered meals and completed baseline and 1-year in-home assessments. Based on an economic context model, self-reported data were collected on fundamental and proximate factors, food-sufficiency status, and intervening events. Determinants of heightened food insufficiency were examined with multivariate logistic regression models.

RESULTS

Not only did food-sufficiency status diminish over time in this sample, but it became or remained worse for older adults with diabetes. In addition to diabetes status, heightened food insufficiency was associated with perceived inadequacy of economic resources.

IMPLICATIONS

Health care providers and nutrition programs should attempt to identify high-risk older adults - those who have diabetes and are at risk of food insufficiency - and develop community linkages and strategies that integrate nutrition with diabetes care plans, thus supporting a multidisciplinary, chronic care model to improve diabetes management and outcomes.

Obesity and functional decline: epidemiology and geriatric consequences

Obesity is growing in prevalence among older Americans and is accompanied by an unfortunate burden of chronic disease, functional decline, and poor quality of life. Elevated past or current body mass index (BMI) is strongly associated with increased self-reported functional limitations. Supportive findings have also related decreased physical performance test scores with elevated BMI. Body composition analyses have explored which body compartment is most strongly associated with obesity-related functional impairments. Studies have suggested possible contributions of decreased muscle mass and increased fat mass. Weight reduction intervention studies that have examined functional outcomes among older persons are limited.

Prospective study of black-white differences in food insufficiency among homebound elders

OBJECTIVE

This study examines race differences in the association of sociodemographic and health-related characteristics with change in food sufficiency status over 1 year in homebound older adults.

METHOD

Using sociodemographic and health-related data collected during two in-home assessments as part of the North Carolina Nutrition and Function Study, logistic regression models (binary and nominal outcomes) adjusted for covariates and examined the characteristics associated with 1-year change in risk (RFI) and presence (FI) of food insufficiency among a random sample of 268 home-delivered meals participants.

RESULTS

Not having enough money for food and having to prepare cheaper and smaller meals was associated with increased RFI and FI at 1 year; having to borrow money for food, loss of food stamps, and inadequate income increased the odds among Whites, and increased medication use among Blacks.

DISCUSSION

The findings suggest that race, independent of other characteristics, is associated with diminished food sufficiency over 1 year.

Inadequate Intakes of Indispensable Amino Acids Among Homebound Older Adults

Adequate dietary intakes of all indispensable amino acids are vital to optimal health. Using three random 24-hour dietary recalls and the newly released Dietary Reference Intakes (DRIs), we examined the extent and correlates of inadequate dietary intakes of indispensable amino acids among 323 homebound older adults who received home-delivered meals. Despite regular receipt of home-delivered meals and controlling for other sample characteristics, three factors were independent ly associated with usual dietary intake below the Estimated Average Requirement (EAR) for at least one indispensable amino acid-not regularly eating a breakfast meal, having a diminished sense of taste, and consuming less than 65% of total protein from animal sources. With the greater vulnerability for poor nutritional health among homebound older individuals, policymakers and service providers should strengthen efforts to target the type and amount of protein and tailor programs that address a variety of influences on the adequacy of protein intake.

Determinants of Self-Management Strategies to Reduce Out-of-Pocket Prescription Medication Expense in Homebound Older people

OBJECTIVES

To determine the extent to which homebound older people adopt strategies to reduce out-of-pocket prescription medication cost and the factors associated with level of cost-related medication management.

DESIGN

Cross-sectional study.

SETTING

Home-delivered meals programs in four North Carolina counties.

PARTICIPANTS

Random sample of 222 home-delivered meal recipients aged 60 and older.

MEASUREMENTS

The use of six different management strategies to reduce medication expenses was reported at the in-home assessment. Associations between level of cost-related medication management and sample characteristics, drug coverage, behaviors to cope with out-of-pocket medication expense, and payment difficulty were examined.

RESULTS

Forty-five (20.3%) participants used one or more behaviors that restricted medication use; another 47 (21.2%) used one or more strategies to reduce out-of-pocket medication cost. Using medication restriction to reduce medication expense was more likely in older people who had difficulty paying for medications (odds ratio (OR)=8.2, 95% confidence interval (CI)=1.4-50.3), or used a strategy to cope with out-of-pocket expenses (choose food or medications (OR=5.1, 95% CI=1.7-15.7) or borrowed money or had another person pay for medications (OR=5.5, 95% CI=2.6-11.6)). Income, drug coverage, and medication use (prescribed and over-the-counter) increased the likelihood of having increased difficulty paying for medications.

CONCLUSION

Clinicians should attempt to identify patients who are at risk for medication restriction and develop strategies for minimizing any unintended consequences of cost-related medication management behaviors. Provider-patient communication should include discussion of medication cost and appropriate medication management strategies.

Patterns of therapeutic prescription medication category use among community-dwelling homebound older adults

PURPOSE

The measurement of prescription medication use is usually through a simple count of medications, which tends to ignore therapeutic categories. This research investigated prescription medication use among homebound older adults, by documenting the therapeutic prescription medication categories used by these individuals and identifying the factors associated with use of multiple therapeutic categories.

METHODS

Baseline Nutrition and Function Study (2000-2001) data from 326 homebound older persons who completed the medication review component (visual inspection of medications) of the baseline in-home interview and used > or =1 prescribed medication were included in this analysis.

RESULTS

More than 40% (n = 133) regularly took medications from three to four different therapeutic categories and 31.6% (n = 103) used > or =5 different therapeutic categories. The use of respiratory medications declined with increasing age, and more women than men used diuretic and thyroid replacement medications. Independent of other factors, increased use of multiple therapeutic categories was associated with sociodemographic characteristics (gender, age, living arrangement, marital status and medication coverage), medical conditions (diabetes, heart problems and lung disease) and inability to self-manage medications.

CONCLUSIONS

Our findings suggest that individual characteristics and medical conditions may help identify homebound elders at high risk for using prescription medications from an increased number of different therapeutic categories. This observation may help clinicians and community-based providers of services to older persons to be aware of differences in therapeutic medication use within an older population, and how patterns of use may alter service needs.

Nutrition risk screening: the interrelationship of food insecurity, food intake, and unintentional weight change among homebound elders

Nutrition risk screening is a key component of the homedelivered meals program. To examine direct and indirect relationships among individual components of nutrition risk, path analysis was conducted on routinely collected data from 908 homebound elders who received home-delivered meals. The good fit of the model revealed that specific nutrition risk factors and indicators of nutritional risk were directly and indirectly associated with meal frequency and unintended weight change. With the heightened vulnerability for poor nutritional health among homebound elders who report food insecurity, policymakers and service providers should strengthen efforts to target individual components of nutrition risk rather than aggregate scores or categorical measures.

Prevention of food-drug interactions with special emphasis on older adults

PURPOSE OF THE REVIEW

Adverse drug interactions may be the fourth leading cause of death in hospitalized patients. In children and older adults undetected food-drug interactions may lead to serious morbidity and mortality and be misdiagnosed as chronic disease progression. Recent recognition of the effects of certain foods on many drugs metabolized by CYP450 families or drugs susceptible to chelation and adsorption have increased awareness for prevention of food-drug interactions.

RECENT FINDINGS

Polypharmacy, self-medications with non-prescription drugs including herbal remedies, dietary/nutritional supplements, fortified foods, and polymorphism in drug metabolism increase the need to consider food-drug interactions. Improved food processing and analysis have led to overall decreased risk in monoamine oxidase inhibitor regimens with counseling. Drugs may create submarginal nutrient deficiencies with serious consequences, such as diuretics contributing to thiamin deficiency and further cardiac failure. Foods may contain compounds that lead to therapeutic failure, such as calcium-fortified foods producing therapeutic failure and promoting resistance in antibiotic therapy. Poor nutritional status can lead to poor health outcomes.

SUMMARY

Prevention of adverse events from food-herb-drug interactions requires clinical monitoring in high-risk regimens and populations. Nutritional status has an important impact on the quality of life as well as appropriate responses to drug therapy. Both diet-drug histories and counseling are needed. As new foods and drugs emerge and more self-medication is promoted, research in the prevention of food-drug interactions is needed.