Food Is Medicine

By 2050, the majority of older Americans will have at least one chronic disease or condition, many of which are diet-related, with important health and economic implications. Diet-related chronic diseases are among the leading causes of death and disability in the United States, intensifying the interest in food is medicine (FIM) interventions.

Malnutrition and increasing food insecurity are also concerns in for older adults. New data from the 2022 National Survey of Older Americans Act Participants report that up to 20% of Older Americans Act Nutrition Program (OAANP) participants are at high risk for malnutrition, as defined by unintended loss of weight and poor appetite. And a majority of OAA participants report at least one chronic disease.

Yet, lack of infrastructure linking community-based food programs to clinical and other supportive services often makes it difficult for older adults to obtain the care they need in the place they live—the community. Older adults have the highest rate of dietary supplement use and may turn to condition-specific dietary supplements of unproven efficacy to help prevent or treat disease, potentially delaying more effective care and increasing risks of polypharmacy-related adverse reactions.

Congress recently required reducing malnutrition be a part of the OAA Title III Nutrition Services Program’s purpose and the Administration on Community Living (ACL), which administers OAA programs, has required OAA state and area plans to include addressing malnutrition.

Malnutrition’s causes are many and include inadequate intake, disease, or a combination of these and other factors. It occurs in those who are under- as well as overweight. The OAANP helps to combat older adult malnutrition. The U.S. Community Services Preventive Task Force (CPSTF) recommends “home-delivered and congregate meal services for older adults living independently (i.e., not residents of senior living or retirement community centers) based on sufficient evidence of effectiveness showing reductions in malnutrition.” For home-delivered meal services, CPSTF found sufficient evidence of effectiveness for increasing energy intake and improving health-related quality of life and well-being.

The OAA’s national network of community nutrition programs is vital for ensuring that older adults receive the nutrition-related supportive services and information necessary to better deal with their health conditions. Further, the OAANP provides a strong foundation to support FIM for older adults in the community and it aligns with U.S. Department of Health and Human Services (HHS) FIM principles.

OAANP Exemplifies FIM and Aligns with HHS FIM Principles

The most expedient approach to building a viable and accountable community-based services infrastructure for FIM is to leverage the OAANP’s broad expertise and network. The OAANP reaches and serves Americans in all locales and from all socioeconomic and racial/ethnic backgrounds. It has the technical knowledge and federal/state administrative experience with local programs to ensure federal and state monies are spent in a cost-effective and accountable manner. In addition, through serving nearly 1 million meals a day and regularly forging links with clinical providers to combat malnutrition/diet-related diseases, the OAANP’s capability is invaluable for guiding FIM services in collaboration with the private sector, including foundations, universities and research institutions, employers and others.

Greater prevalence of diet-related chronic disease and increasing food insecurity—including in U.S. households with older adults—were driving factors leading to the 2022 White House Conference on Hunger, Nutrition, and Health, and the resulting National Strategy on Hunger, Nutrition and Health. Interest in and actions related to the FIM approach continue to grow in the United States, with support from a variety of private and public sector funding streams, including new Centers for Medicare & Medicaid Services (CMS) initiatives.

The HHS Office of Disease Prevention and Health Promotion’s framing language describes FIM as encompassing a broad range of approaches that “promote optimal health and healing and reduce disease burden by providing nutritious food—in conjunction with human services, education, and policy change—through collaboration at the nexus of healthcare and community.”

Five FIM principles are defined in the framing language. The OAANP shares these goals and offers the benefit of federally required oversight and quality assurance, providing a framework to support these principles in community-dwelling older adults in the following ways:

1. Recognizes that nourishment is essential for good health, well-being and resilience.
   
   Nutrition is a fundamental health issue for older adults because poor nutrition—particularly protein-calorie malnutrition—can lead to poorer health outcomes and risks for other health conditions, including frailty and disability, as well as increased healthcare costs. The ACL requires OAA state plans to include addressing malnutrition, based on the OAA intent for the nutrition program to reduce hunger, food insecurity and malnutrition; promote socialization; and enhance well-being via improved access to nutrition and other disease prevention/health promotion services.
   
   The National Survey of Older Americans Act participants indicates that 70% or more of OAANP participants have reported eating healthier foods because of the program and more than 80% report that OAANP meals help them remain independently in the community. A programmatic evaluation found congregate meal program participants had less likelihood of a hospital/nursing care facility admission or an emergency department visit.
   
   A recent U.S. Senate Special Committee on Aging report detailed the “OAA Nutrition Program has increased access to healthy and affordable food for older adults, helping to combat hunger, foster social connectedness, promote healthy aging, and prevent adverse health outcomes.”
    
2. Facilitates easy access to healthy food across the health continuum in the community.
   
   While the OAANP may often be overlooked as a critical food access resource, it plays a significant role in providing nutritious meals to community-based older adults. In 2019, the OAANP delivered 223 million meals to 2.4 million older adults through 5,000 community providers across the country. While many are familiar with hospitals referring patients to “Meals on Wheels” after hospital discharge to help with recuperation, the OAANP is modernizing its approaches to meet the needs of current and future older adult populations with a particular focus on underserved communities. By offering online nutrition education, food truck meals and pop-up meal sites in under-resourced areas, culturally appropriate meals, and restaurant partnerships, OAANP innovations help reduce barriers to accessing OAANP nutritious meals and other services.
    
3. Cultivates understanding of the relationship between nutrition and health.
   
   OAANP services not only include meals but also nutrition education, nutrition assessment and screening, and additional supports like supplemental foods. And appropriate social services and healthcare referrals are offered based on person-centered needs. OAANP providers have solid foundations with registered dietitian nutritionists (RDNs) as staff who can ensure nutrition quality, food safety, and provide nutrition education. In some settings, and when funds and nutrition care pathways are in place, RDNs also provide medical nutrition therapy to OAA participants. Plus, OAANP providers work closely with other medical professionals, hospital discharge staff and community care coordinators during care transitions. The OAANP draws on objective, evidence-based nutrition research and information from multiple federal agencies including the National Institutes of Health Institute of Aging and Office of Dietary Supplements, the Food and Drug Administration, U.S. Department of Agriculture (USDA), the Veteran’s Administration, the ACL Nutrition and Aging Resource Center, as well as from other organizations.
    
4. Unites partners with diverse assets to build sustained and integrated solutions.
   
   The OAANP operates across all states. Its strength lies in its ability to provide critical services that address numerous issues faced by older adults, including malnutrition, food insecurity, chronic disease and social isolation. The OAANP is positioned to act as a vital link connecting older adults with help from other organizations, such as health clinics, food banks and the USDA’s Supplemental Nutrition Assistance Program, Senior Farmers Market Nutrition Program and Commodity Supplemental Food Program.
   
   As one example, the Massachusetts OAANP was identified as the Commonwealth’s largest provider of nutrition and health services according to a FIM community inventory. The OAANP encourages the use of locally grown foods and arrangements with schools and other facilities serving meals to children to promote intergenerational meals. It also serves as a lead agency in developing protocols to procure qualified providers and hold vendors accountable to ensure nutrition and food safety standards are followed.
    
5. Invests in the capacity of under-resourced communities.
   
   The OAANP focuses on underserved communities, including persons with the greatest social and economic needs, those who are lower income, live in rural areas, and/or are members of minority communities. It also has the capability of expanding service delivery models to support state/community waivers and FIM initiatives.

OAANP Fits Well in the Strategic Framework for a National Plan on Aging

The U.S. Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities recently released the HHS plan, Aging in the United States: A Strategic Framework for a National Plan on Aging. It raised awareness of key aging issues and outlined goals for supporting older adult health and well-being. Nutrition is included as one of the healthcare/supportive services older adults need to improve “health and well-being across the lifespan,” “age well in the community,” and “advance their quality of life.” Further, nutrition is among the important services listed as helping older adults remain in their “desired homes in the community.”

The OAA is identified in that document as a “major vehicle for the organization and delivery of social and nutrition services.” As states move to develop and implement their own OAA and multisector plans for aging, policymakers and stakeholders will benefit from engaging with the OAANP and its experienced staff, to maximize the health and well-being of older Americans.

Conclusion

The OAANP is holistic in scope and national in scale and is experienced in providing FIM-aligned interventions to older adults in the community. Building on its proficiency in collaborating and linking with community-level programs/providers and its existing framework for standards, monitoring, and enforcement, local providers can help ensure an accountable and scalable community services infrastructure for broader and widely impactful FIM initiatives.

The OAANP also has data, evaluation, and research expertise that could benefit FIM studies with older adults. Finally, policymakers can look to the OAANP as a valuable partner for helping develop and implement federal and state plans and legislation that support older adults in aging well and for helping communities employ successful nutrition and health initiatives now and into the future.

Shirley Chao, PhD, RDN, LDN, FAND, is the principal at FoodPolicy Insights; Judy Simon, MS, RDN, is a consultant with the National Association of Nutrition and Aging Services Programs and Defeat Malnutrition Today; Laura Borth, MS, RDN, CD, is director of policy with the National Association of Nutrition and Aging Services Programs and Defeat Malnutrition Today. Lydia McGrath, MS, RD, LDN, is a clinical dietitian at Brigham and Women’s Hospital; Jaime Gahche, MPH, PhD, is director of the population studies program with the National Institutes of Health (NIH) Office of Dietary Supplements; Mary Beth Arensberg, PhD, RDN, FAND, is director of health policy and Programs at Abbott Nutrition, a division of Abbott, and Johanna T. Dwyer, DSc, RDN, is senior nutrition scientist, ICF (contractor to the NIH Office of Dietary Supplements), professor of Medicine and Community Health at the Schools of Medicine and Nutrition and senior scientist at the Jean Mayer USDA Human Nutrition Research Center at Tufts University.

Photo credit: Shutterstock/margouillat photo

Note: more detail on how OAANP benefits HHS FIM principles and the U.S. Strategic Framework for a National Plan on Aging is provided in the table below.

Table: Unique strengths and supporting characteristics of the OAANP that benefit HHS FIM principles and the U.S. Strategic Framework for a National Plan on Aging