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

Effect of Social Determinants of Health Interventions on Adults Living with Disabilities: A Scoping Review

OBJECTIVE

To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings.

DATA SOURCES

A review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020.

STUDY SELECTION

Search terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS.

DATA EXTRACTION

During Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review.

DATA SYNTHESIS

Studies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE.

CONCLUSIONS

The preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.

Food Insecurity in Older Adults in Canada and the United States: A Concept Analysis

A concept analysis using the method of Walker and Avant was undertaken to clarify the concept of food insecurity in older adults in Canada and the United States. A literature review was undertaken to conduct a concept analysis of food insecurity in older people. Food insecurity is associated with multiple negative health outcomes and may be experienced differently by older adults as compared to younger adults. It is therefore important to understand the concept of food insecurity as is relates to older adults. Four defining attributes of food insecurity in older adults in Canada and the United States were identified: (i) inability to acquire or prepare enough food, (ii) compromising on food quality or preference, (iii) uncertainty or anxiety around the ability to acquire or prepare food, and (iv) socially unacceptable or non-normative practices. These attributes may allow for improved policies and programs aimed at addressing food insecurity in older adults by better meeting the needs of older individuals. Additional research into food insecurity as experienced by Canadian and American older adults could help to further clarify the concept.

Food Insecurity and Aging: A Scoping Study of the Literature

Literature on food insecurity (FI) and aging is limited and scattered across disciplines, the reasons for which include the nascence of the study of "hunger" more generally, and relatively lower rates of FI among older people. This scoping review synthesized and characterized the current research to prompt a more critical examination of food insecurity and aging. Data extraction included reviewing and characterizing the empirical, methodological and conceptual contributions of each study, accessed from selected health sciences and social sciences databases. Thirty-eight studies were included from 2,041 titles. Different methods and operationalizations of FI and age were found to be used across studies. Thematic analysis revealed, with few exceptions, consistent tendencies towards the biomedicalization of the FI issue alongside aging. These findings reinforce the value of population-level monitoring of FI and uptake of standard measures. Moving forward, the issue of FI and aging is an opportune topic for critical social analysis.

"I Try to Keep That Sugar Down." Experiences of Homebound Older Adults With Type 2 Diabetes: Barriers to Self-Management

Objectives: To study the experiences and challenges of type 2 diabetes (T2D) self-management among homebound older adults who regularly receive home-delivered meals and services.Methods: Participants (n = 31) were recruited by telephone screening and were selected by purposive sampling. Semi-structured interviews were subsequently conducted within participants' homes. The interpretive methodology utilized in this study was developed to systematically assess T2D self-management.Results: Thematic analysis shows that participants felt mostly responsible for their health status, but attributed any noncompliance to lack of social and economic assistance. Most of the seniors in this study felt competent, but often did not have the opportunity to engage in protective measures due to a number of economic, physical, and social barriers.Conclusions: These results contribute to a better understanding of how to approach, support, and motivate homebound older adults with T2D while addressing challenges. Findings offer insight into the development of diabetes self-management education (DSME) and interventions for this population.

Food security for community-living elderly people in Beijing, China

Food security has been identified as an important issue for elderly people's quality of life and ageing in place. A food security index composed of three indicators (food intake, food quality and food affordability) was developed to measure the food security status of community-living elderly people. Food security was then examined among community-living elderly in the central urban districts of Beijing, China. Data were collected by a questionnaire survey in the summer of 2013 and the response rate was 78.5%. Descriptive statistics and binary logistic regression were applied to analyse food security and the associations between food security and demographic and socioeconomic factors. The results showed that 54.2% of the surveyed elderly experienced food security. Participants with better education (OR = 1.68) and better health (OR = 1.47) were more likely to experience food security. The young-old were less likely to experience food security than the older old (OR = 0.94). Elderly people who lived with their children were less likely to experience food security than those who lived alone (OR = 0.43). The results of impact factors on food security highlight both similarities with studies from more developed countries and the unique challenges faced in a rapidly changing China with its unique social, cultural and political systems. The food security index we developed in this study is a simple and effective measure of food security status, which can be used in surveys for evaluating the food security status of elderly people in the future.

Does Participation in Home-Delivered Meals Programs Improve Outcomes for Older Adults? Results of a Systematic Review

Participation in home-delivered meals programs may contribute to the health and independence of older adults living in the community, especially those who are food insecure or those who are making transitions from acute, subacute, and chronic care settings to the home. The purpose of this study was to conduct a comprehensive and systematic review of all studies related to home-delivered meals in order to shed light on the state of the science. A complete review of articles appearing in PubMed using the keyword "Meal" was conducted; and titles, abstracts, and full-texts were screened for relevance. Included in this review are 80 articles. Most studies are descriptive and do not report on outcomes. Frequently reported outcomes included nutritional status based on self-reported dietary intake. Additionally, most studies included in this review are cross-sectional, have a small sample size, and/or are limited to a particular setting or participant population. More rigorous research is needed to (1) gain insight into why so few eligible older adults access home-delivered meals programs, (2) support expansion of home-delivered meals to all eligible older adults, (3) better identify what home-delivered meals models alone and in combination with other services works best and for whom, and (4) better target home-delivered meals programs where and when resources are scarce.

The Intersection between Food Insecurity and Diabetes: A Review

Access to sufficient, safe, and nutritious food not only affects the health of people who experience food insecurity, but also their ability to manage health conditions, such as diabetes. When people find it difficult to access sufficient food, tailoring their food selection to a diabetes regimen is even more difficult. Food insecurity in North America is consistently more prevalent among households with a person living with diabetes, and similarly, diabetes is also more prevalent in food-insecure households. Diabetes management can be stressful due to the many required responsibilities; when compounded with food insecurity, it becomes an even greater challenge. As a result, many food-insecure diabetics find themselves caught between competing priorities such as procuring food, prescribed medications and supplies for diabetes, and managing other living expenses, potentially worsening their condition and overall health. Healthcare providers should be aware and informed about the significant role that food security can play in the prevention and management of diabetes.

Nutrition risk factors among home delivered and congregate meal participants: need for enhancement of nutrition education and counseling among home delivered meal participants

OBJECTIVE

The short-term impact of nutrition education and counseling intervention on nutrition risk factors among home delivered (HDM) and congregate (CGM) meal participants using Nutrition Survey Risk Screening was studied.

DESIGN

A two-year intervention was conducted with 355 participants (n=259 CGM, n=96 HDM). Various nutrition behaviors that affect the nutrition risk score were compared.

SETTING

Congregate and home delivered meal locations in a northern county of New Jersey.

PARTICIPANTS

CGM and HDM participants in a northern county of New Jersey age 60 and older.

INTERVENTION

CGM participants received regular topical nutrition education and counseling in a classroom format with cooking demo, discussion, and handouts. The HDM participants only received the printed material (same handouts) and counseling by telephone.

MEASUREMENTS

Demographics, medical condition, risk factors data were collected. All participants completed the 12 items checklist Nutrition Survey Risk Screening. Nutritional behaviors assessed include number of meals eaten per day, servings of fruits and vegetables and nutrition risk score. A score of 6 or more points was defined as persons at high risk nutritionally. The impact of the intervention was evaluated using ANOVA/chi-square on Nutrition Survey Risk Screening.

RESULTS

Nutrition education and counseling intervention improved nutrition risk scores; 5.76 to 5.32 (p=0.14) in CGM, 8.1 to 6.1 (p<0.01) in HDM. A slight improvement in nutrition behaviors was noted: eating ≥ 2 meals in HDM (76 to 81.6 %, p= .310), eating ≥ 5 servings of fruits and vegetables in CGM (38 to 41.4 %, p=. 398).

CONCLUSION

Appropriate nutrition intervention for both HDM and CGM participants can improve health condition and delay chronic diseases. HDM participants need to be a primary focus for more effective nutrition education and counseling.

Food insecurity is associated with social capital, perceived personal disparity, and partnership status among older and senior adults in a largely rural area of central Texas

This study examined the association of compositional measures of collective social functioning, composed of community and familial social capital and perceived personal disparity, with food security among older (aged 50-59 y) and senior (aged ≥ 60 y) adult residents of the largely rural Brazos Valley in Central Texas using data from the 2006 Brazos Valley Community Health Assessment (analytic N = 1059, 74% response rate). Among older adults and seniors, 18.6% reported food insecurity (5.5% often and 13.1% sometimes), defined as running out of food and not having money to buy more. Low community social capital was reported by 22.4% of participants, and 30.8% indicated they were single, widowed, or divorced, an indicator of limited familial social capital. A robust multinomial regression model found the odds of reporting greater food insecurity increased for individuals who were women, African American, residents of a household with a low or poverty-level income, individuals who perceived themselves to be worse off than others within their community, and those who had low social capital. The odds of being food insecure decreased for older respondents, partnered respondents and persons with more education (pseudo r(2) = 0.27, p < 0.0000). Compositional level measures of collective social functioning are important associates of food insecurity among older adults and seniors, regardless of severity.

Indicators of material hardship and depressive symptoms among homebound older adults living in North Carolina

This study used the concept of material hardship to understand how unmet needs related to food, housing, and health influence depressive symptoms among homebound older adults (N = 345) in North Carolina. Using data from the Nutrition and Function Study, 37% reported high levels of depressive symptoms and 17.4% indicated not receiving needed health care. Approximately 10% of respondents were food insecure; 30.7% were at risk for food insecurity; and 39.7% reported having to choose between either food and medication or food and paying bills. Adjusted logistic regression model revealed that food insecurity status (OR = 4.9) and age 60-74 y (OR = 2.4) were significantly associated with a greater number of depressive symptoms. Other indicators of material hardship, such as having a major financial difficulty, unmet health need, and inadequate housing, were not significant. By far, food insecurity was the most salient influence on depressive symptoms. These findings have important implications for service providers, researchers, and policymakers.

Food insecurity, social capital and perceived personal disparity in a predominantly rural region of Texas: an individual-level analysis

Few studies have addressed the association of food insecurity with place of residence and perceptions of collective social functioning such as perceived social capital and perceived personal disparity. This study assessed the association between food insecurity and measures of perceived personal disparity and perceived social capital in a region of Central Texas, USA comprised of one urban and six rural counties. Food insecurity, perceived social capital, perceived personal disparity, and sociodemographic control measures were derived from the 2006 Brazos Valley Community Health Assessment on an analytic sample of 1803 adult participants (74% response rate). Robust multinomial regression models examined associations between food insecurity and perceived personal disparity, perceived social capital, education, age, residence in a poor or low-income household, minority group membership, and rural residence. A model was estimated for food insecurity (n = 1803, p < 0.0001). Residents with low social capital, higher levels of perceived personal disparity, rural residence, residence in a low-income or poor household, minority group membership, and lower levels of educational attainment were more likely to experience food insecurity. Rural residence (p = 0.021) was significant only for the comparison between those who never, and those who often experienced food insecurity, and findings for the stratified rural and urban samples were roughly equivalent to the combined sample. Individual level measures of collective social functioning are important correlates of food insecurity. In this study, both perceived personal disparity and perceived social capital play an important role, regardless of rural or urban residence.

Country of birth is associated with very low food security among Mexican American older adults living in colonias along the south Texas border with Mexico

The availability of an adequate household food supply is critical for the older population. There is little work that has examined food security and the influence of nativity on food security among older Mexican Americans living along the Texas-Mexico border. Using data from 140 older women (age ≥ 50 y) who participated in the 2009 Colonia Household and Community Food Resource Assessment (C-HCFRA), we examined demographic characteristics, health characteristics, food access and mobility, federal and community food and nutrition assistance programs, quality of food environment, food security, eating behaviors, and alternative food sources. 77% of participants experienced food insecurity, with 68% experiencing very low food security. Very low food security was associated with being born in Mexico, adjusting for household income and food assistance program participation. This article provides compelling evidence for enhanced research efforts that will better understand coping strategies and the use of food and nutrition assistance programs for reducing hardship associated with very low food security among older U.S.- and Mexico-born Mexican American women.

Food insecurity and food choices in rural older adults with diabetes receiving nutrition education via telemedicine

OBJECTIVE

To evaluate differences between rural older adults with diabetes reporting the presence or absence of food insecurity with respect to meal planning, preparation, shopping, obesity, and glycemic control after receiving nutrition counseling through telemedicine.

METHODS

Food insecurity data were obtained by telephone survey (n=74). Group differences for continuous variables were measured by t tests; categorical variables by Pearson chi-square tests.

RESULTS

Participants reporting mild food insecurity (23%) had higher body mass index (35.5±7.1 kg/m2 vs 30.5±6.0 kg/m2, P=.01) and lower household incomes (P=.03) and were more likely to consider cost of ingredients in food preparation compared to food-secure participants (P=.03). Most purchased fresh produce (97%) and considered the dietitian's advice when purchasing food. Both groups report similar adherence to dietitians' advice and had similar glycemic control.

CONCLUSIONS AND IMPLICATIONS

Strategies to address higher levels of obesity associated with food insecurity are needed.

Environmental influences on food security in high-income countries

Food security is a fundamental human right yet many people are food insecure, even in high-income countries. Reviewed here is the evidence for the physical, economic, sociocultural, and political environmental influences on household food security in high-income countries. The literature was evaluated using the ANGELO framework, which is a lens developed for understanding the environmental factors underpinning the obesity pandemic. A review of the literature identified 78 articles, which mostly reported on cross-sectional or qualitative studies. These studies identified a wide range of factors associated with food security. Foremost among them was household financial resources, but many other factors were identified and the complexity of the issue was highlighted. Few studies were prospective and even fewer tested the use of interventions other than the supplemental nutrition assistance program to address food security. This indicates a solution-oriented research paradigm is required to identify effective interventions and policies to enhance food security. In addition, comprehensive top-down and bottom-up interventions at the community and national levels are urgently needed.

Depressive symptoms and suicidal ideation among older adults receiving home delivered meals

OBJECTIVE

Homebound older adults may be vulnerable to the deleterious impact of untreated depression. Yet because these elders are difficult to reach, there is little data on the rates of depressive symptoms and suicidal ideation among this group. The objective of this study is to document the rates of depression and correlates among a population of homebound elders.

METHODS

Using a community based participatory research partnership, we implemented a routine screening for depressive symptoms and suicidal ideation among older recipients of Westchester County's home meal program. Older adults enrolled in the home delivered meal program were administered the Physician Health Questionnaire-9 (PHQ-9), and questions to assess pain, falls, alcohol abuse and perceived emotional distress.

RESULTS

In our sample of 403 meal recipients, 12.2% of older adults reported clinically significant depression (PHQ-9 > 9) and 13.4% reported suicidal thoughts. One-third of recipients with significant depressive symptoms were currently taking an antidepressant. Almost one-third of older adults who endorsed suicide ideation did not report clinically significant depressive symptoms. Among men, suicidal thoughts were associated with chronic pain and greater depression severity, whereas pain was not a predictor of suicidal thoughts among women.

CONCLUSION

More than one in nine elders suffer from depression; most are untreated with one-third undertreated. Through partnerships between public agencies that provide age related services and academic investigators there is an opportunity for improved detection of unmet mental health needs. Future research should explore innovative models to improve access to mental health services once unmet need is detected.