The Crucial Role of Federal Nutrition Programs in Promoting Health Among Low-Income Older Adults

Abstract:

Food insecurity is an enormous problem in the United States, including in the older adult population, with notable negative health impacts such as malnutrition. Food insecurity has increased with the COVID-19 pandemic. Federal nutrition programs such as the Supplemental Nutrition Assistance Program and the Older Americans Act Nutrition Services Program can help alleviate food insecurity. These programs have had some issues, both pre- and post-pandemic, but have been able to adapt to meet the challenges they faced. Food insecurity must be tackled head-on to invest in better health for all older Americans.

Key Words:

food insecurity, nutrition, Older Americans Act, Supplemental Nutrition Assistance Program, malnutrition, COVID-19 pandemic

Food insecurity is a shockingly large problem in the United States, including in the older adult population. The rates of food insecurity and hunger among older Americans continue to climb, although the precise number of affected persons is difficult to determine given variations in surveys’ definitions and measures of food insecurity, as well as employed methodologies.

One report found that more than 10 million older Americans, representing 16 percent of older adults in the United States, are at risk for hunger (Lloyd, 2017). Using 2018 data, another report found that 5.3 million older adults, or 7.3 percent of the older population, were food insecure (Gundersen and Ziliak, 2020). The COVID-19 pandemic has only made matters worse; we do not yet have full data on the scope, but one estimate shows that 25 percent of all adults are now food insecure (Schanzenbach, 2020).

In this article, we discuss the prevalence and impacts of food insecurity and malnutrition in the older adult population, describe the federal nutrition programs that address food insecurity and the challenges they have faced pre- and post-pandemic, and provide thoughts on the ultimate role of federal nutrition programs in providing nutrition security to older adults.

The Prevalence and Impacts of Food Insecurity and Malnutrition

Food insecurity is an issue of equity—significant disparities exist in the nation’s older population’s access to food, particularly in terms of racial, economic, and disability status. Black and Hispanic older adults are more than twice as likely (15.1 percent and 14.8 percent) to be food insecure as White non-Hispanic older adults (6.2 percent) (Gundersen and Ziliak, 2020).

Gundersen and Ziliak also found that renters are a more vulnerable group; they are four times more likely (18.1 percent) to be food insecure than are homeowners (4 percent). Almost one in five grandparents raising grandchildren lives in a food insecure household. Older adults with disabilities are more than 2.5 times as likely to be food insecure (13.8 percent) than are those without disabilities (5.1 percent) (Gundersen and Ziliak, 2020).

Food insecurity, which can have negative consequences on individuals’ nutrition and physical and mental health, may be particularly deleterious for older adults, especially for those with chronic and/or disabling conditions. Gundersen and Ziliak (2015) found that “food-insecure seniors were 2.3 times more likely to report being in fair or poor health, compared to food-secure seniors.” Food-insecure older adults reported limitations in activities of daily living (ADLs) that were “roughly equivalent” to those in food-secure older adults who were fourteen years older. Food insecurity also recently has been “associated with lower cognitive function among older adults, which may translate into higher risk of cognitive impairment,” such as Alzheimer’s disease or other dementias (Portela-Parra and Leung, 2019).

Malnutrition is another significant consequence of food insecurity, as those experiencing food insecurity may have significant deficits in proper nutrients such as protein and calories. The World Health Organization (WHO) defines malnutrition as deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. While malnutrition can happen to persons of any age, older adults are particularly at risk—one in two older adults is either malnourished or at risk of malnutrition (The Malnutrition Quality Collaborative, 2020).

Hunger and lack of access to healthy foods may increase the risk of malnutrition, but chronic diseases such as cancer, diabetes, and dementia can impact one’s appetite, ability to chew or swallow, and metabolism. Malnutrition can weaken the immune system, making patients vulnerable to infection, slower recovery time, and slower wound healing. It can cause weight, as well as muscle and bone mass loss, which may lead to frailty, falls, broken bones, and disability.

Contrary to the common belief that malnutrition is a condition solely affecting underweight persons, it also can happen to people who are of average weight or overweight. As highlighted in the National Blueprint: Achieving Quality Malnutrition Care for Older Adults, 2020 Update, “For many older adults, lack of adequate protein and loss of lean body mass are particularly significant problems, including for those who may be overweight or obese. The importance of malnutrition prevention for older adults is magnified as it affects independent living, healthy aging, and the severity of chronic conditions and disabilities” (Malnutrition Quality Collaborative, 2020). The Alliance for Aging Research has described malnutrition as a “hidden epidemic.” Ultimately, malnutrition is costly for both the patient and the healthcare system at large; this issue is heightened when a low-income older adult is malnourished and might not have the resources to pay for medical expenses resulting from this condition.

Federal Nutrition Programs for Older Adults

The federal government funds several types of nutrition services for older adults who might be food insecure. The U.S. Department of Agriculture’s (USDA) nutrition programs are “means-tested” (provided only to older adults with lower incomes) while the U.S. Department of Health and Human Services’ (HHS) nutrition programs are open to all older adults, regardless of income level.

The USDA administers the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), which provides monthly benefits to low-income households to purchase food and is the largest USDA food assistance program, serving more than 5 million older adults annually (U.S. Government Accountability Office, 2019). SNAP is funded through “mandatory” federal funding, meaning that funding for the program is automatically expanded or contracted to meet demand.

Other USDA programs include the Commodity Supplemental Food Program (CSFP, also called the senior food box program), funded at $325 million in federal fiscal year (FY) 2021, which provides shelf-stable commodity foods delivered monthly to approximately 675,000 low-income older adults older than age 65, and the Senior Farmers’ Market Nutrition Program, funded at $21 million in FY 2021, which provides vouchers to approximately 835,000 low-income older adults older than age 65 to purchase fresh fruit and vegetables at farmers’ markets and roadside stands (U.S. Government Accountability Office, 2019).

Unlike most USDA programs, all older adults older than age 60 are eligible to participate in the HHS nutrition programs, regardless of income. The HHS nutrition programs, also called the Older Americans Act Nutrition Services Programs, were established in 1972 and are authorized through the Older Americans Act (OAA). They include the OAA Title III-C-1 congregate nutrition program (meals provided at senior centers and other group locations), funded at $515 million in FY 2021, and the OAA Title III-C-2 home-delivered nutrition program (commonly known as “Meals on Wheels”), funded at $276 million in FY 2021 (Colello, 2020).

A separate program under Title VI of the OAA provides nutrition services to older Native Americans through funding to tribes. The OAA is funded through “discretionary” federal funding, meaning the funding is provided through the annual congressional appropriations process and funding levels can change based upon the will of Congress, not upon demand for the program.

The OAA nutrition programs are statutorily required to provide meals, nutrition education, and socialization to all participants. In federal fiscal year 2018, the OAA congregate nutrition program served 1.5 million adults older than age 60 and the OAA home-delivered nutrition program served almost 900,000 adults older than age 60 (Colello, 2020). Meals served as part of the OAA nutrition programs must meet one-third of the daily recommended dietary reference intakes (DRIs), helping to ensure the nutritional quality of the food served (Colello, 2020).

Federal nutrition programs have historically played an important role in preventing and intervening in food insecurity among low-income older adults. For example, SNAP is reaching impoverished older adults; according to the Center on Budget and Policy Priorities (2017), in 2015, an average SNAP household with an older adult had a total monthly income of about $912 (not including SNAP)—about $10,940 per year. These households in 2015 received an average of $128 in monthly benefits, or about $1,500 per year, which raised their income by 14 percent (Center on Budget and Policy Priorities, 2017).

Further, because SNAP provides money specifically for food, these benefits free up money to be spent on other household needs such as medications or utilities. Through this “freeing-up” of money, SNAP also benefits the economy at large. One USDA study found that during a struggling economy, $1 billion in SNAP investment has a yield of $1.54 billion in Gross Domestic Product (GDP) (Canning and Morrison, 2019). The researchers state, “when the government spending targets low-income individuals, such as SNAP recipients, the multipliers tend to be larger. Low-income recipients of government assistance spend most, if not all, of the money they receive soon after receiving it. Higher income individuals, on the other hand, are more likely to save a substantial share of their increased income from the government spending” (Canning and Morrison, 2019).

SNAP benefits also may reduce nursing home admissions and hospitalization among older adults. In a 2017 study, researchers examined the 77,678 adults older than age 65 who were dually eligible for Medicaid and Medicare in Maryland between 2010 and 2012. They found that SNAP participants had a 23 percent reduced chance of nursing home admission as compared to non-participants. And, for SNAP participants, an additional $10 of monthly SNAP assistance was associated with lower odds of admission and fewer days’ stay among those who were admitted to nursing homes and other long-term care facilities (Szanton et al., 2017).

The same researchers also examined 68,956 Maryland residents older than age 65 who between 2009 and 2012 were dually enrolled in Medicare and Medicaid, and found that SNAP participation, and, among participants, a $10 increase in monthly SNAP assistance, were both associated with a reduced likelihood of hospitalization (Samuel et al., 2018).

The HHS nutrition programs also sustain older adults who are experiencing food insecurity. In a 2018 national survey of OAA nutrition program participants, 58 percent of respondents reported that the congregate nutrition program provided one-half or more of their daily food intake, as did 62 percent of home-delivered meals program participants who responded to the survey (Administration for Community Living, 2020a). Plus, 11 percent of congregate nutrition respondents and 19 percent of home-delivered nutrition respondents stated in survey responses that they had an annual household income of $10,000 or less, despite the programs not having an income requirement.

Federal Nutrition Programs and the Unmet Needs of Older Americans

Though SNAP is essential to many older adults’ nutrition security, millions of eligible older adults do not participate in the program. As of 2018, only 48 percent of eligible older adults participated in SNAP (National Council on Aging, n.d.). Some of the disincentives to older adult SNAP participation can include lack of ability to navigate the application process, including technology, mobility, and language barriers; perceived stigma about participating in government assistance programs; and pervasive myths about how SNAP benefits work and who might qualify (National Council on Aging, 2021).

OAA nutrition programs have a different challenge: millions of older adults who could participate in the program are unable to do so because of capacity issues. As noted earlier, funding for the OAA nutrition program is discretionary—it does not grow with demand or need for the program, it is subject to congressional decisions. Though discretionary funding for this program has increased significantly in dollar amounts in recent years, it still has not kept pace with the growth of the older adult population—nor with inflation.

One set of researchers found that “when adjusted for inflation, total funding appropriated for OAA nutrition services over the past 18 years fell by 8 percent, a decline of $80 million in 2019 value” (Ujvari, Fox-Grage, and Houser, 2019). Given significant growth projections of the older population in the coming years, even if the poverty rate remains the same, there will be an increase in the total number of older adults living in poverty. Thus, the issue of food insecurity will only grow in an increasingly diverse older population.

This lack of funding has led to lengthy waiting lists, particularly for home-delivered meals. In the Government Accountability Office (GAO)’s 2019 study of federally funded senior nutrition programs, one state’s officials told investigators that “in the absence of other changes, they will only be able to serve new people [in the state’s home-delivered meals program] through attrition of current program participants.” One provider told GAO investigators that their home-delivered meals program had a 12,000-person waiting list of older adults, and another said they were “serving about 10 percent of the older adult population in their area, although the need for these services is greater, and they have continually had a waiting list for their home-delivered meal program” (U.S. Government Accountability Office, 2019).

Other OAA nutrition program challenges reported to the GAO include lack of funding to tailor meals to older adults’ health needs (such as pureed meals or low-carbohydrate meals) or cultural preferences (such as kosher meals or regional dishes), lack of information on how they might tailor meals with limited resources, lack of resources to attract and retain staff through competitive wages and benefits, and lack of ability to reach rural and frontier-dwelling older adults (U.S. Government Accountability Office, 2019).

Impacts of the COVID-19 Pandemic

The COVID-19 pandemic has only exacerbated the challenges facing low-income older adults and the nutrition providers who support them. Many older adults have been mostly or entirely unable to leave their homes for the duration of the pandemic, which meant acquiring valuable sources of nutrition has been a bigger challenge.

In response, federal nutrition programs have had to pivot in unexpected ways. For example, in March 2020, OAA congregate nutrition providers were forced to quickly convert their in-person nutrition programs for older adults into programs serving “grab and go” meals and/or home-delivered meals. Many programs saw an enormous increase in demand overnight; in a January 2021 survey of members of the National Association of Nutrition and Aging Services Programs (NANASP, 2021), around 90 percent of respondents reported that they were still serving more meals now than they had been prior to the pandemic, with many of those stating that their demand had doubled or more. In response to this overwhelming demand, Congress appropriated $915 million in emergency funding for the OAA nutrition program over the course of 2020. Through the Families First Coronavirus Response Act and the Coronavirus Aid, Recovery and Economic Security (CARES) Act, by the end of March 2020, $750 million in total had been appropriated for the OAA Title III-C and Title VI nutrition programs (Administration for Community Living, 2020b). Another $175 million followed in December 2020.

The CARES Act also provided several key flexibilities for Title III-C nutrition programs: it allowed all funding from these two emergency bills to be transferred freely between the congregate and the home-delivered nutrition programs (regularly, only 40 percent of each “pot” of money could be transferred); it waived the dietary reference intakes requirements for meals provided using this funding; and, it stated that regardless of state policies, all older adults who were socially distancing could be considered “homebound” for the purposes of receiving home-delivered meals (Administration for Community Living, 2020b). The December 2020 funding carried the same flexibilities. This allowed programs to spend all available funding on home-delivered meals, work with non-traditional meal partners to address food shortages, and dramatically expand their home-delivered meals rosters.

With their newfound funding and flexibility, innovation has flourished among OAA nutrition programs. From providing drive-up “grab and go” meals to “contactless” home-delivered meal deliveries to outdoor, socially distanced meals, programs have found many new ways to get meals to older adults on the edge of hunger. When the traditional senior nutrition food distribution channels were overwhelmed, providers found new corporate partners. One example: members of NANASP and the National Association of Area Agencies on Aging (n4a) partnered with Tivity Health to provide Nutrisystem and South Beach Diet frozen home-delivered meals to older adults in areas with these food shortages. The net result of these flexibilities has meant more meals for more older Americans in need.

SNAP has also been able to serve more people, including older adults, during the pandemic. Through the Families First Act, states can give SNAP participant households emergency supplementary benefits to bring a household up to the maximum benefit a household can receive (Center on Budget and Policy Priorities, 2021). (All states have exercised this option.) The December 2020 COVID-19 relief package also included a 15 percent increase in SNAP’s maximum benefit for January through June 2021.

A somewhat obscure SNAP pilot also became very popular during the pandemic. The 2014 Farm Bill authorized a SNAP Online Purchasing Pilot to allow SNAP participants the option of grocery shopping online. Until the pandemic, the adoption of this program by states was very slow; only two states (New York and Washington) were participating prior to March 2020. However, as of February 2021, 46 states and the District of Columbia are participating (the exceptions being Louisiana, Alaska, and Montana; Maine’s application is pending) (U.S. Department of Agriculture, 2021).

This program, though welcome for older adults who may not be able to leave their homes, comes with challenges for SNAP participants. As the Food Research & Action Center (2020) noted, “Only a limited number of food retailers are able to participate in online SNAP purchasing . . . . [I]t may be difficult for shoppers to find participating retailers with available online ordering slots. Furthermore, participants may face challenges with . . . transportation to pick up online purchases.” Other challenges for older adults might include “digital divide” issues, such as lack of internet access, lack of knowledge about ordering options, and/or lack of ability to use the necessary technology.

Assuming older SNAP participants can overcome these barriers, delivery fees, tips, or other service fees (which are not covered through SNAP) may prove to be too expensive, or the participant may be unable to afford an order that meets the threshold to qualify for free home delivery or curbside pickup. To assist these participants, in the 116th Congress, U.S. Reps. Jahana Hayes (D-CT) and Joe Neguse (D-CO) and U.S. Sen. Bob Casey (D-PA) introduced the Food Assistance for Kids and Families During COVID-19 Act, which would have authorized $500 million for state agencies to reimburse retailers for SNAP participants’ grocery delivery fees (Food Research & Action Center, 2020). The legislation expired at the end of the 116th Congress in December 2020, and as of May 2021, it has not been reintroduced.

Conclusion

One of the more important realities finally realized in recent years is that there is a vital link between nutrition and health, especially for older adults. The increases in hunger and food insecurity among older adults, especially those with low incomes, are incredibly alarming. Even more disturbing is the threat that malnutrition is to health and that today one of two older adults are at risk (Malnutrition Quality Collaborative, 2020). These were all realities before the pandemic. How much more serious these problems might become after a year of the pandemic remains to be seen.

However, the federal government response to date in providing funding for nutrition programs for low-income older adults seems to be a recognition that good nutrition is a critical intervention needed to promote health. Why else would Congress in 2020 provide more than $900 million in emergency funding for the Older Americans Act nutrition program, an amount higher than its regular annual funding? Why else would Congress also increase the SNAP benefit by 15 percent in 2020 and allow those most in need to gain greater access to the program?

Looking forward, a national goal for all low-income Americans, especially older adults, is to achieve full nutrition security. This means first and foremost that all low-income individuals who are eligible for federal nutrition programs become enrolled. Second, the nation needs to view spending on nutrition programs as investments in promoting better health. It is time to move away from the siloed approach when determining funding for individual programs and instead view things more holistically. A home-delivered meal for a low-income older adult can avert being sent to a nursing home or a hospital, at a much higher cost to the federal government. Giving low-income older adults access to fresh fruits and vegetables and other nutritious foods can prevent disease-associated malnutrition, which can cost as much as $51.3 billion per year (Malnutrition Quality Collaborative, 2020).

Today, federal nutrition programs play a crucial role in promoting health among low-income older adults. However, it took too long to fully recognize this. It must not take that long before our country makes the kind of commitment at the federal level that allows us to achieve nutrition security, which in turn ensures a better quality of life for low-income older adults.

Robert Blancato, MPA, is president of Matz, Blancato and Associates in Washington, DC, and may be contacted at rblancato@matzblancato.com. Meredith Whitmire, JD, is vice president of Matz, Blancato and Associates, and may be contacted at mponder@matzblancato.com.

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