1. Introduction
Good nutrition is vital in maintaining the health and independence of vulnerable, older adults who are in social and economic need [
1]. The Older Americans Act (OAA) requires that Nutrition Programs provide meals and related nutrition services that promote health and help manage chronic disease [
2]. The initial OAA was enacted in 1965 by President Johnson, and was reestablished in 2016 as the Older Americans Act Reauthorization Act, S.192 by President Obama (National Committee to Preserve Social Security and Medicare [
3]). Formally under the Agency of Aging, it is now part of the Administration for Community Living (ACL) within the Department of Health and Human Services (DHHS). OAA funding is for 56 state agencies, and is distributed to over 200 tribal organizations, two native Hawaiian organizations, more than 600 area agencies on aging and 20,000 local service providers [
3]. Nutrition programs (congregate meals and/or home-delivered meals) are for adults 60 and older; however, they concentrate assistance to persons with the greatest social or economic need, such as low-income or older adults living in rural areas [
3].
Congregate meals are required to provide one-third of the necessary dietary requirements per day in accordance with the Dietary Guidelines, and are served five days a week [
4]. The type of food varies by location; however, it must be deemed safe and sanitary by meeting state and local foodservice codes. In addition, older adults provided feedback concerning the types of meals so that they are made appetizing to the demographic [
4]. Thus, variety depends on local availability, budget, and food preferences. The purpose of OAA nutrition programs are to: (1) reduce hunger and food insecurity; (2) promote socialization; and (3) promote health and wellness [
4]. Each state has flexibility with extra services, but all provide transportation, some form of nutrition education (web links, flyers, counselling), and either fitness services or information on neighboring older adult fitness programs [
4]. The overall goal of the congregate meal program is to help older adults remain independent through nutrition, socialization, and exercise [
4]. Of the sites that offer fitness classes, many contain an aerobic component geared toward improving balance, strength, and mobility.
Mobility is essential to independent living, and diets high in fruits and vegetables provide antioxidants and vitamins, which are key nutritional determinants of mobility in older adults [
5]. In addition, moderate physical activity reduces mobility impairment, and higher levels of physical activity are associated with lower mobility dysfunction in older adults [
6]. However, older adults are not meeting nutritional guidelines on fruit and vegetable intake, and are not following physical activity recommendations, both of which are related to physical function, mobility and independence [
7]. Less than one-third of older adults consume the recommended 3 or more servings of vegetables, and 31.4% report no physical activity in the past month [
7].
The issue of poor nutrition and low levels of physical activity is likely to be even more prominent among older adults who attend congregate meal sites, due to their low socio-economic status and limited access to high nutritional value foods. Some findings indicated that older adults attending congregate meals are older, have poorer health, and are more-likely to have difficulties in activities of daily living than their counterparts, who do not go to congregate meal sites [
1]. Despite the public health and clinical significance of government feeding programs, there is limited information concerning nutrition-related health characteristics of older adults who attend congregate meal sites in the United States [
8]. Investigators reported lower than recommended intakes of all food groups, particularly dairy, and a decrease of 0.038 cups of vegetables per day for each year in age for Kansas congregate meal attendees, who were 80 years and older [
9]. Assessing the health status and health characteristics of the vulnerable population who reported eating at congregate meal sites is necessary in order to guide the development of interventions tailored for community-dwelling, vulnerable, older adults. Therefore, the objectives of this study were to (1) determine health-related characteristics of a representative sample of older adults who attend congregate meal sites in the United States; and (2) assess differences among these characteristics by sex and race/ethnicity.
3. Results
Demographics of the study population are presented in
Table 1 with weighted and unweighted frequencies. Most participants were between 65 and 84 years old, female, White non-Hispanic with high school or some college education, an income at or below the poverty level, single, and lived in either a rural or urban area.
The participants’ health indicators are presented in
Table 2. There were similar proportions of participants across levels of self-rated health and with/without mobility impairments; 44% had difficulties with activities of daily living. Most participants reported having enough money to buy food. About one third of the participants had diabetes. Eighty percent thought the congregate meals helped them to eat healthier and two thirds thought they help them to be more independent. A higher proportion of the participants said they eat 3 or less servings of vegetable per day. The majority (95%) said they eat vegetables at the congregate meal site, but only 36% said they exercise at the site. Less than 40% of the participants did health screenings at the site and only 12% reported having received nutrition education though the program; yet, some form of nutrition education (pamphlets, web-links, or counselling) is made available through every OAA program.
Health-related factors presenting significant differences in proportions among races/ethnicities are presented in
Table 3. Mobility impairments were most common among White non-Hispanics, but Hispanics reported poor or fair health at much higher proportion than the White non-Hispanics, and they also were the group with higher proportion of food insecurity, diabetes and poverty as compared to White non-Hispanics.
Health-related factors presenting significant differences in proportions between sexes are presented in
Table 4. A higher proportion of males had more than half of their daily calories coming from the congregate meals, and considered that they ate heathier because of the congregate meals; whereas, a higher proportion of females exercised at the congregate meal sites and were poor.
Health-related factors presenting significant differences in proportions among self-rated health classifications (poor/fair, good, or very good/excellent) are presented in
Table 5. A significantly lower proportion of the participants that reported having very good/excellent health considered that the congregate meals helped with their independence, had diabetes, considered that they were eating healthier because of the meals, were poor, and had difficulties in at least two activities of daily living. At the opposite end, a significantly higher proportion of the participants that reported having poor/fair health had diabetes and difficulties in at least two activities of daily living.
Health-related factors were compared to reporting that congregate meals helped maintain independence by complex logistic regression (
Table 6). Odds of reporting that meals helped maintain independence were higher for persons with food insecurity (reporting fear of food running out) (OR = 2.67 (1.05, 6.80)) and those persons who reported eating half or more of their calories from the site (OR = 5.78 (2.36, 14.30)). Demographics, SRH, mobility, and reporting eating vegetables at the site were not significant for independence in the model.
4. Discussion
Mobility impairments and difficulties with activities of daily living were common among older adults going to congregate meal sites; almost half of the participants reported one of these issues. Exercise can reduce mobility impairments and improve function [
6,
14]. One third of the participants said they exercise at the sites (22% of men and 43% of women). A needs assessment for the types of exercise programs preferred by sex should be performed, since the literature is lacking this information [
15], and fewer men participated in exercise programs at congregate meal sites compared to women. Molanorouzi, Khoo, and Morris [
15] reported differences in the factors that motivate people to engage in physical activity, as well as in the preferred type of activity based on age and sex. Congregate meal sites need to consider people’s preferences when developing exercise programs. For example, an exercise program initiated in two congregate meal sites in Georgia recruited male and female volunteers for an aerobic program; 27 out of the 31 people who volunteered were female [
16]. According to our results, exercise programs in congregate meal sites are being attended predominately by females. Exercise programs targeting males and considering their preferences are needed.
In addition to physical activity, nutritional factors also affect older adult mobility [
5]. However, only 12% of the participants said they had taken part in nutrition education to them at the site. Given the importance of proper nutrition for optimal health, availability of nutrition education at the sites and encouragement to participate are warranted. Nutrition education in congregate meal sites has been found to improve attendee’s knowledge of healthy eating [
17]; however, interventions that successfully change eating behavior have not been reported to date. If nutrition education were available on a continuous basis at congregate meal sites with strategies to reach diverse attendees, longitudinal measures of fruit and vegetable consumption may be more promising. Community interventions to increase fruit and vegetable intake by older adults have been successful, particularly those that consider age-specific barriers in access or knowledge [
18].
Congregate meal sites provide an opportunity for community-based, college internship programs with registered dietitians and physical therapy students, for example. Intern dietitians could provide ideas for low-cost, easy to prepare, healthy meals and intern physical therapy students could provide exercises to reduce mobility disability. Also, community-based agencies in South Florida were successful in training lay people and professionals to conduct evidence-based physical activity for seniors in churches, senior housing, senior centers, community centers, and parks [
19]. The feasibility of implementing evidence-based physical activity programs at congregate meal sites has been established in the Midwest and in two Georgia counties [
16,
20]. However, dissemination and wide implementation still needs to be accomplished. The findings of our study further demonstrate the importance and urgency of implementing such programs.
There were significant differences between sexes and among races/ethnicities in the health-related characteristics of older adults going to congregate meal sites in the United States. These differences may need to be considered when developing meals, nutrition education, and exercise classes at the site. All racial/ethnic minorities 45–64 years old from a large population sample of California were significantly less likely to engage in vigorous physical activity compared to White non-Hispanics; however, this difference was no longer significant for older adults [
21]. Instead, the investigators found that chronic disease was a motivating factor in participation in physical activity. Differences in food preference by race/ethnicity and sex were reported for older adults in nutrition programs [
15]. These findings suggest that strategies to help engage participants receiving congregate meals to eat healthy and exercise at the site need to consider food preferences, and education should be aimed at lowering the risk of chronic diseases and their complications. Approaches to engaging older adults, particularly those who are frail, in exercise classes should consider that the social norms concerning vulnerability differ by sex [
22].
Programs to improve mobility and activities of daily living, particularly for White non-Hispanics, are needed. Efforts to reach more older Hispanics and encourage them to attend congregate meal sites are particularly important, because this is a highly vulnerable population that reports poor/fair health at a much higher proportion than other groups, and has the highest proportion of food insecurity, diabetes and poverty. Poor/fair self-rated health was associated with low income, food insecurity, having difficulty with activities of daily living, having diabetes, and not participating in social activities. Higher education levels, not self-rated health, was associated with a higher proportion consuming the recommended five or more servings of fruits and vegetables.
The study has several limitations to note. Although this was a representative sample of persons attending congregate meal sites across the United States, the demographics are continuously changing. The study was cross-sectional, and causality cannot be determined. Health-related factors were assessed based on self-reporting; some behaviors, such as diet, could be biased by sex or race; however, the trained staff used techniques to assess portions of foods consumed at the site and at home. Participation in exercise was only considered at the site, and some participants may have attended fitness activities in other facilities. Moreover, some congregate meal sites may not have exercise facilities or classes. The sample was not big enough to determine relationships among races/ethnicities by sex. There was uneven distribution across variables, and the attendees were primarily White non-Hispanic females.