2
Size and Demographics of Aging Populations

Following opening remarks by moderator Pamela Starke-Reed of the National Institutes of Health (NIH) Division of Nutrition Research Coordination, Bethesda, Maryland, two speakers addressed the changing size and demographics of the nation’s aging populations. First, Kevin Kinsella of the National Institute on Aging (NIA), Bethesda, Maryland, described the tremendous heterogeneity in U.S. aging populations and identified key health and socioeconomic trends among these populations (e.g., less institutionalization than in the past and existence of sensory impairment concerns about oral health). Then, Nancy Wellman of the Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, discussed food shopping, preparation, and consumption habits of older adults, as well as food insecurity trends among older adults. She emphasized that most Americans age 65 years and older live not in nursing homes or other institutional settings but in the community and that most food and nutrition programs aimed at providing services for these community-dwelling older adults are under-funded or disregarded. The presentations provided a wealth of background information on aging populations and served as a point of reference for the remainder of the workshop presentations and discussions. Both Kinsella’s observations about the heterogeneity among aging populations and Wellman’s remarks about the need to provide better food and nutrition services to community-dwelling older adults resurfaced many times during later discussions.



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2 Size and Demographics of Aging Populations F ollowing opening remarks by moderator Pamela Starke-Reed of the National Institutes of Health (NIH) Division of Nutrition Re- search Coordination, Bethesda, Maryland, two speakers addressed the changing size and demographics of the nation’s aging populations. First, Kevin Kinsella of the National Institute on Aging (NIA), Bethesda, Maryland, described the tremendous heterogeneity in U.S. aging popula- tions and identified key health and socioeconomic trends among these populations (e.g., less institutionalization than in the past and existence of sensory impairment concerns about oral health). Then, Nancy Wellman of the Friedman School of Nutrition Science and Policy, Tufts University, Bos- ton, Massachusetts, discussed food shopping, preparation, and consump- tion habits of older adults, as well as food insecurity trends among older adults. She emphasized that most Americans age 65 years and older live not in nursing homes or other institutional settings but in the community and that most food and nutrition programs aimed at providing services for these community-dwelling older adults are under-funded or disregarded. The presentations provided a wealth of background information on aging populations and served as a point of reference for the remainder of the workshop presentations and discussions. Both Kinsella’s observations about the heterogeneity among aging populations and Wellman’s remarks about the need to provide better food and nutrition services to community-dwell- ing older adults resurfaced many times during later discussions. 

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE OUR AgINg POPULATION Presenter: Kevin Kinsella Kinsella remarked that he would be describing growth in what he called the “older population” (i.e., people age 65 years and older), not just in terms of numbers but also with respect to socioeconomic trends, which he noted as relevant when thinking about food safety and other food concerns. growth of the Older Population Today, there are about 39.5 million people in the United States over the age of 65, including 5.6 million people over 85. While these numbers appear high, if they are considered in a historical context, starting in 1910 up until 2050 (using projected numbers for the population size from the present year until 2050), it is very clear that the current growth rate of both the 65-and-older and 85-and-older is in fact lower than it has ever been in the past century (Figure 2-1). But this is about to change. In the FIgURE 2-1 The U.S. populations, over time, of people more than 65 and 85 years of age. NOTE: These data refer to the resident population; data for years 2010–2050 are projections of the population. SOURCE: U.S. Census Bureau, Decennial Census, Population Estimates and Projec- tions, 2008.

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS next one or two years and continuing over the course of the next 20 years, the growth rate of the older population is going to dramatically increase to nearly double what it is today (Figure 2-2). This steep incline reflects aging of the baby boomer generation, with about 75 million people moving into the ranks of the older population during the next 20 years. Kinsella noted that the projected future growth of the 85-and-older population in particular has taken demographers and social scientists by surprise. By 2050, there will be an estimated 19 million people in the United States age 85 and older. In the past, statisticians have tended to underesti- mate improvements in mortality. If one were to examine these same pro- jected numbers 20 years ago, the numbers would be a lot lower than they are today. But with improvements in mortality that have taken place over the past 40 or so years, by all accounts it appears that in fact this “oldest old” population (i.e., people age 85 and older) will grow tremendously over the next few decades. Moreover, given that these projected numbers are official U.S. Census Bureau numbers, Kinsella suspects that they may be conservative and that the real numbers could be even higher. Referring to discussion in the previous session about the legibility of food labels, Kinsella observed that this is an important trend to keep in mind, given the high prevalence of vision problems in the oldest old. Kinsella discussed some key trends in the aging population in more detail. For example, geographically, the 65-and-older population is con- centrated in the upper Midwest and parts of Florida. The 85-and-older population is concentrated in the upper Midwest, Florida, and New Eng- land. When categorized by race, from 2006 and projected to 2050, the FIgURE 2-2 The changing growth rate of the U.S. population age 65 years and older. SOURCE: U.S. Census Bureau, 2003. Figure 2-2, fixed image

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0 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE non-Hispanic white population will become a much smaller percent of the total in the future (61 percent in 2050) than it is today (81 percent in 2006). Conversely, the Hispanic population will occupy a much larger proportion of the 65-and-older age group in the future (18 percent in 2050) than it does today (6 percent in 2006). Kinsella explained how immigration is likely to impact the age struc- ture of the U.S. population. Compared to other developed countries, the United States is a fairly young country in the sense that the proportion of the U.S. population that is 65 and older is fairly low and will remain fairly low in the future. The United States does not even rank among the top 20 countries with respect to the percentage of the population age 65 years or older because, although fertility rates in the United States tend to be slightly higher than in other developed countries, so do immigration rates. Every year, there is an influx of mostly young and middle-aged adults, with the bulk of the foreign-born U.S. population between the ages of 25 and 45 (Figure 2-3). Just as life expectancy at birth has been increasing over the past cen- tury, so too has life expectancy at the ages of 65 and 85 (Figure 2-4). Kinsella explained that another way to examine this trend is to consider survivorship. Survival at every age has increased over the past century as well (Figure 2-5). In 1901, there was a large drop-off early in life because of infant mortality. Many people (up to about 20 percent) died during the Native Foreign Born Native Foreign Born Age Male Female Male Female Male Female FIgURE 2-3 Age structure for the U.S. native- and foreign-born populations. SOURCE: U.S. Current Population Survey, Annual Social and Economic Supple- ment, 2002. Figure 2-3

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS FIgURE 2-4 Life expectancy at ages 65 and 85 years, by sex, from the years 1900–2004. NOTE: These data refer to the resident population. SOURCE: National Vital Statistics System, 2008. first one or two years of life. By 2004, this early drop-off all but disap- peared. Meanwhile, survival at later ages has increased. For example, only 50 percent of white females survived to the age of 60 years in 1901, and only about 5 percent of white females who reached the age of 50 survived to the age of 90. In 2004, about 90 percent of white females survived to the age of 60, and more than 25 percent of white females who survived to the age of 50 survived to the age of 90. Kinsella explained how the shift of the entire survivorship curve in Figure 2-5 has led to an interesting debate in gerontology with regard to what the future shape of the curve will look like. There is no sign that the trend is going to stop, but how far will it go? Will people be living to the age of 120 or 150? What are the limits to life expectancy? Trends in Health in the Older Population Kinsella raised the question: While it is clear the people are living longer, are they living any better? Are these added years healthy years, or does it mean that society will be experiencing more disease and disability? Until very recently, very few countries had data that could be used to de-

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE 2004 1901 ---------------------------------------------------------------- ----- | | | | | | | | | | | | 10 20 30 40 50 60 70 80 90 100 Age FIgURE 2-5 Survivorship curve among U.S. white females, for the years 1901 and 2004. SOURCES: U.S. Census Bureau,gure 2-5 revised Center for Health Statistics Fi 1936; National (NCHS), 2007. finitively answer these questions. Data from the U.S. National Longer-Term Care Surveys (NLTCS)1 have only recently begun to provide some insight into disease and disability patterns and changes with aging. The good news, Kinsella said, is that non-disabled component of the Medicare-enrolled 65-and- over population has been rising over time. In 1982, 74 percent of Medicare- enrolled 65-and-older individuals were “non-disabled.” That number rose to 81 percent in 2004–2005. This trend is reflected in the fact that the percentage of Medicare-enrolled 65-and-older individuals who reside in institutional set- tings (i.e., nursing homes) has decreased over time, to less than 5 percent in 2004–2005. While largely non-disabled, substantial proportions of the older popula- tion nonetheless reported chronic conditions in the National Health Inter- view Survey. About half of all men (52 percent) and women (54 percent) over the age of 65 report hypertension (this does not include individuals with undiagnosed hypertension); and about half (43 percent of men, 54 percent 1 NLTCS are nationally representative surveys of Medicare beneficiaries aged 65 and over with chronic functional disabilities. The first NLTCS survey was administered in 1982, with follow-up surveys conducted in 1984, 1989, 1994, 1999, and 2004. For more information, see http://www.nltcs.aas.duke.edu/ and http://aspe.hhs.gov/daltcp/reports/nltcssu2.htm.

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS FIgURE 2-6 Percent of people age 65 and over who reported having selected chronic conditions, by sex, 2005–2006. NOTE: Data are based on a 2-year average from 2005–2006 and refer to the civil- ian, non-institutionalized population. SOURCE: NCHS, 2008. of women) report arthritis (Figureimage Figure 2-6, fixed 2-6). Overweight (defined as a body mass index [BMI] of 25 or greater) and obesity (BMI of 30 or greater) are also prevalent among the older population, with nearly 80 percent of men and 70 percent of women between the ages of 65 and 74 considered overweight according to the 2005–2006 National Health and Nutrition Examination Survey (NHANES).2 Even in the 75-and-older populations, the levels of overweight are nearly as high. Importantly, the percentage of older adults who are overweight or obese has been increasing. Kinsella said obesity is not just a problem with “young kids eating a lot of junk food.” Many older adults also report problems with hearing, seeing, and oral health (Figure 2-7). Kinsella noted the high percentage of people over the age of 65 who have no natural teeth (about a quarter of the population), which he said is important to keep in mind when considering food con- sumption in the older population. Finally, a substantial proportion of the older population experiences at least some level of memory impairment, which may be important to keep in mind when considering how older adults decipher food messages and plan nutritional intake. 2 Available online: http://www.cdc.gov/nchs/nhanes.htm (accessed August 23, 2010).

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4 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE FIgURE 2-7 Percentage of people age 65 and older who reported having any trouble hearing, any trouble seeing, or no natural teeth, by sex, 2006. NOTE: Respondents were asked “Which statement best describes your hearing without a hearing aid: good, a little trouble, a lot of trouble, deaf?” For the pur- poses of this indicator the category “Any trouble hearing” includes “a little trouble, a lot of trouble, and deaf.” Regarding their vision, respondents were asked “Do you have any trouble seeing, even when wearing glasses or contact lenses?” The category “Any trouble seeing” also includes those who in a subsequent question report themselves as blind. Lastly, respondents were asked, in one question, “Have you lost Figure 2-7, fixand lower natural (permanent) teeth?” Data refer to the all of your upper ed civilian non-institutionalized population. SOURCE: NCHS, 2008. Socioeconomic Trends in the Older Population Kinsella pointed out several socioeconomic indicators that may have some relevance to the workshop discussion: • Educational attainment. In 1965, only about one quarter of indi- viduals over the age of 65 had completed high school. Today, more than three-quarters of the older population has completed high school, with a much slower but noticeable increase in the percentage of older people who have attained bachelor’s degrees as well. • Marital status. While the current 65-and-older population has a rela- tively low percentage of people who are divorced or separated (around 9 percent), those figures are much higher for the 45–54 and 55–64 age

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS groups (around 18–19 percent). This means that, in the future, a much higher proportion of the older population will be divorced or separated, which will have implications for caregiving and social support. • living alone. A high percentage of older adults, particularly women (nearly 40 percent), live alone, which may have implications for food delivery, etc. • Poverty. In the early 1960s, the older population had a higher proportion of people living in poverty than any other age group. Today, the older population has a lower proportion of people living in poverty than any other age group. Kinsella noted that Medicare, which was introduced in the early 1960s, seems to have had a rather important effect on alleviating poverty among older adults. He remarked that most of the poverty that does exist in the 65-and- older population is concentrated in the South and parts of the upper Midwest. • Food expenditure. According to a 2005 survey by the Federal Forum on Aging Related Statistics,3 people in all older age groups (55–64, 65–74, and 75-and-over) spend 13 percent of their total household annual expenditures on food. • dietary quality. According to a 2001–2002 survey by the same fo- rum, Healthy Eating Index4 scores are roughly the same for all older age groups (a score of 64 for 55-64 year olds and scores of 68 for the 65–74 and 75-and-over groups). Lessons from Other Countries In conclusion, Kinsella remarked on the value of looking at what other countries are doing to accommodate older populations. With the exception of Japan, which ranks as the world’s oldest country (i.e., 21.6 percent of Japan’s population is 65 years or older, which is higher than any other country), all of the other 25 oldest countries are in Europe (Figure 2-8). The United States is not even on the list. He pointed to the United Kingdom’s traffic light labeling system for ranking ingredients in food products, which had been described in the introductory presentation by Steve Sundlof (see Chapter 1), as something that another country has successfully implemented in an effort to accommodate its growing older population and which may be something for the United States to consider. Kinsella suggested that there are probably other interesting and relevant 3 Available online: www.agingstats.gov (accessed August 27, 2010). 4 The Healthy Eating Index is a measure of diet quality that assesses conformity to U.S. fed- eral dietary guidance. The components of the index and scoring standards are available online at: http://www.cnpp.usda.gov/Publications/HEI/healthyeatingindex2005factsheet.pdf.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE FIgURE 2-8 The world’s 25 countries with the highest percentage of the popula- tionPercent of or older. age 65 years Population 65 Years or Older SOURCE: U.S. Census Bureau, International Database, 2008. initiatives under way in the countries in Figure 2-8 that we may benefit from knowing about. Figure 2-8, PREPARATION AND CONSUMPTION HABITS FOOD fixed OF COMMUNITY-DWELLINg POPULATIONS Presenter: nancy Wellman Wellman began her presentation by commenting on the fact that most Americans over the age of 65 live in the community, not in nursing homes or other institutions. Only 4.5 percent (about 1.5 million) of older adults live in nursing homes and 2 percent (1 million) in assisted living facili- ties. The majority of older adults (93.5 percent, or 33.4 million) live in the community. In fact, she remarked that it is U.S. federal policy to keep

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS people out of nursing homes and to move people who currently live in nursing homes out of nursing homes, partly for budgetary reasons.5 For the remainder of her presentation, she focused on food shopping, prepara- tion, and consumption habits of older adults; food insecurity among older adults; and home and community-based food and nutrition programs that service older adults. Food Shopping Behavior First, Wellman shared data on various food shopping behaviors among all consumers (not differentiated by age) and among consumers age 55 years and older: • How much time shoppers (not differentiated by age) spend in differ- ent types of stores (grocery stores, dollar stores, etc.). The time spent in stores varies, depending on the type of store and other variables such as frequency of shopping. For example, 36 percent of grocery store shopping trips last 15–30 minutes, but only 5 percent of con- venience store shopping trips last that long. • How much time shoppers (not differentiated by age) spend in front of shelves looking at different foods. Again, this varies, depending on food category and other variables such as whether the consumer has seen an advertisement for a product or is try- ing a new product. The average is around seven seconds, which Wellman described as “quick” and impinging on front-of-package and shelf labeling. • How shoppers  years and older use information on food packag- ing labels to make decisions. Based on surveys conducted by the International Food Information Council Foundation (IFIC),6 older adults generally tend to look at the Nutrition Facts panel, the ex- piration date, and the ingredient list and are not as concerned with other features such as brand name, country of origin, and whether a product is organic. Figure 2-9 illustrates these concerns. • What type of information shoppers  years and older are looking for when they look at the ingredients portion of a food package. The same IFIC surveys indicate that the top three concerns for older adults are type of fat or oil, type of sweetener, whether ingredients are natural, and the order of ingredients. 5 deficit Reduction Act of 00, §6071, 6086, 6087. 6 Available online: http://www.foodinsight.org/ (accessed August 5, 2010).

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE FIgURE 2-9 Food and beverage package information used by shoppers when de- ciding to purchase or eat a food or beverage. NOTE: Survey respondents were asked “What information do you look for on the food or beverage package when deciding to purchase or eat a food or beverage? Check all that apply.” SOURCE: IFIC, 2009. Figure 2-9, fixed • Whether shoppers  years and older have made a change based on hearing something about food, food safety, or nutrition in the news. The IFIC surveys also revealed that about 60 percent of shoppers 55 years and older had heard or read something that prompted them to change their mind about a food purchase. Food Preparation and Consumption Behavior Wellman remarked that most of the data she would be sharing on food preparation and consumption behavior were proprietary data made avail- able by the NPD Group, a Chicago-based market research company, and she thanked Suzie Crocket from General Mills for allowing her to access the data. Using a variety of sources, the NPD Group collects data on pantry preparation, individual consumption behavior, motivations and attitudes that drive people to eat the way they do, etc. Wellman focused on two categories of data: (1) “boomers without children”: one- or two-member households without children (adults 44–62 years old) and (2) “matures”: one- or two- member households without children (adults 63 years and older).

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS Preparation Behavior Both boomers without children and matures spend less time overall pre- paring and cooking foods than families with children, with much less time spent preparing and cooking in the morning compared to later in the day. For example, both groups spend about 2 minutes preparing and another 2 minutes cooking their morning meals and about 12 minutes preparing and 25 minutes cooking their evening meals. For both groups, the number of dishes per meals is fairly small and increases as the day goes on. For example, not including beverages, both groups prepare and cook about 1.5 dishes for breakfast, 2 dishes for lunch, and 2.5 dishes for dinner. Matures tend to eat more of their meals at home than boomers without children do, with breakfast being the meal most often eaten at home. For matures, breakfast is also generally considered the most satisfying in terms of nutritional quality. As people age, dinners tend to be aimed at meeting convenience needs, with less planning, less use of ovens, grills, or stovetops, greater use of appliances such as microwaves and toasters, (matures have the highest lunchtime appliance use, probably because more are retired and eat lunch at home) and less clean up. Because the goal is convenience, din- ners tend to be not as satisfying from a nutritional quality standpoint. Wellman briefly discussed IFIC survey data showing that while re- spondents ages 55 and older were a little more likely to regularly perform actions to ensure food safety when cooking, preparing, and consuming food products, there is room for improvement among respondents of all age groups in regularly performing these actions. In terms of microwavable meals, older adults are slightly more likely than other age groups to follow all cooking instructions, check the label for conditions of use, and let the food stand for an appropriate time after microwaving. Nonetheless, only 40–80 percent of respondents in all age groups reported regularly following any of those actions. As shown in Figure 2-10, all respondents, particularly those in the 18–44 year-old age group, reported a number of obstacles to safe food handling, all associated with a lack of something—information, time, proper equipment, or interest. Consumption Habits For both boomers without children and matures, most consumption choices are driven not by health but by convenience, taste, and indulgence. That said, according to NPD Group data, health is the most important driver in the morning, and it drives more food choices in general among matures (34 percent) than among boomers without children (27 percent). This may be because different moods affect food choices, and matures tend to be more relaxed, calm, and content than boomers without children.

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0 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE FIgURE 2-10 Obstacles survey respondents reportedly face when handling food safely. NOTE: Survey respondents were asked, “What obstacles, if any, do you face when handling food safely? Check all that apply.” SOURCE: IFIC, 2009. Figure 2-10, fixed In terms of what people actually eat for breakfast at home, for both matures and boomers without children, juices and healthy ready-to-eat cereals rank fairly high (only coffee ranks higher than either). Other top choices include fruit, bread (toast, bagels, etc.), hot cereals, eggs and om- elets, milk, hot tea, pancakes/waffles/French toast, bacon, carbonated soft drinks, and fruit drinks. Matures consume more fruit juice and hot cereal than boomers do. For lunch at home, top foods and beverages include sandwiches, fruit, vegetables, carbonated soft drinks, milk, soup, tea, salads, salty snacks, coffee, and crackers. Matures tend to eat more vegetables, milk, soup, and coffee than boomers do. For dinner at home, top food and beverage choices include vegetables, salads, potatoes, fruit, carbonated soft drinks, tea, sandwiches, poultry, milk, bread, beef, soup, coffee, and alcoholic beverages. Matures tend to eat more fruit at dinner than boomers do. Wellman noted that these choices do not look so bad, given that health drives only 1 in 10 dinner choices. Most dinner choices are driven by convenience (38 percent for boomers without children, 41 percent for matures) and personal preference and taste (34 percent for boomers, 31 percent for matures).

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS Everyone snacks, with indulgence driving about half of all snack choices. So even though many people do fairly well in terms of eating nutritiously at breakfast and lunch, they tend to snack on what they really like without much consideration for health. Only 8 percent of boomers and 9 percent of matures cited health as a driver of snack choices. Top snack foods include candy, fruits, nuts and seeds, ice cream, cookies, potato chips, crackers, pretzels, microwave popcorn, yogurt, tortilla chips, and ice cream bars. Matures tend to favor cookies, crackers, pretzels, and yogurt more than boomers do. Overall and based on the Healthy Eating Index, matures tend to eat more healthfully than boomers without children do, although overall they could be eating even more healthfully. Thirty-eight percent of matures have “most healthful” eating habits, compared to 25 percent of boomers; 41 percent of matures have “moderately healthful” eating habits, compared to 44 percent of boomers; and 21 percent of mature have “least healthful” habits, compared to 31 percent of boomers (Figure 2-11). Matures are more concerned with negative food attributes, such as salt, fat, and cholesterol, than boomers without children. For example, accord- FIgURE 2-11 Percent of matures and boomers without children falling into three Healthy Eating Index categories. NOTE: “Boomers without children” are defined as one- or two-member households without children (adults 44–62 years old). “Matures” are defined as one- or two- member households without children (adults 63 years and older). SOURCE: NPD Group/Food and Beverage Services.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE ing to NPD Group data, 70 percent of matures are concerned with total fat content, compared to 64 percent of boomers; 63 percent of matures are concerned with salt, compared to 61 percent of boomers; and 64 percent of matures are concerned with cholesterol, compared to 60 percent of boomers. Dieting, however, tends to decrease with age, with 25 percent of boomers and 21 percent of matures reporting that they were on a diet in one NPD Group survey. Food Insecurity and Hunger Based on USDA data (2009), Wellman described how food spending has decreased over the past several years—12 percent relative to the rising cost of the USDA Thrifty Food Plan7 and 6 percent relative to the rising consumer price index (CPI) for food and beverages. The largest decline has been in the second lowest income quintile, where average CPI-inflation- adjusted spending for food decreased 16 percent. Median food spending among older adults living alone dropped 5.4 percent between 2000 and 2007. This decrease, coupled with the fact that one in six older adults al- ready eats fewer than 1,000 calories a day, raises serious questions about food insecurity. Among older adults living alone, very low food security (i.e., hunger) increased 1 percent from 1.9 percent to 2.8 percent between 2000 and 2007. Two research reports by Ziliak and colleagues (2008, 2009)8 show that 11.4 percent of all seniors experienced some form of food insecurity between 2000–2005 because they did not have enough money. Of these, about 2.5 million were at risk of hunger, and 750,000 actually suffered from hunger due to financial constraints. These reports find that the risk of hunger is greatest among those with limited incomes (almost half of all older adults at risk of hunger are low income or below poverty), those under the age of 70, African-Americans and Hispanics, never-married in- dividuals, renters, and people who live in the South. Together, the data indicate that food insecurity is a major problem, with Ziliak and colleagues predicting that by 2025, millions of older Americans will be facing hunger. By 2025, an estimated 9.5 million older Americans will be marginally food insecure, 3.9 million will be food insecure, and 1 million will be very low food secure. 7 The Thrifty Food Plan is a USDA-developed national standard for a nutritious diet at minimal cost. It is based on average national food prices adjusted for inflation and is used as the basis for food stamp allotments. 8 Available online: http://www.mowaa.org/Page.aspx?pid=654 (accessed August 27, 2010).

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS USDA Federal Nutrition Assistance Programs Given this trend in food insecurity, Wellman argued that efforts to reduce hunger will need to be continued and strengthened. One way to do this is through federal nutrition assistance programs, many of which are USDA programs. Wellman briefly described these programs and suggested ways they could be improved: • Supplemental nutrition Assistance Program (SnAP): The good news, Wellman argued, is that President Obama has increased fund- ing for SNAP to a total budget of $48 billion for fiscal year 2010. The bad news is that only 30 percent of older adults who are eli- gible participate, compared to 65 percent participation by the total eligible population. Of all food stamp participants, only 9 percent are older adults. Based on criteria set by the USDA Thrifty Food Plan, the monthly benefit for single older adults is lower ($74) than it is for younger adults (up to $100), so age is somewhat penalizing. Wellman suggested that the nutritionists and economists responsible for developing the USDA Thrifty Food Plan need to consider that homebound or bed-bound older adults may need more pre-prepared foods or convenience foods in order to eat more healthfully. • SnAP Education Program: States have the option to provide nutri- tion guidance to accompany the SNAP Program, but the focus is on women and children, not older adults. Because older adults are generally seen as interested in improving their food and nutritional intake, Wellman suggested that they would probably listen to the advice. This is particularly true given that they are receiving less money than younger adults and therefore need more help using that money wisely. • Commodity Supplemental Food Program: Perhaps surprisingly, 93 percent of participants in this program are older adults (i.e., 444,000 older adults participate, compared to 31,000 other people). How- ever, the quantities of food packages provided in the commodity boxes are often impractical for one- or two-person households. Although USDA has been making some changes to the quality and quantity of food offered through this program, additional improve- ments could be made. • the Emergency Food Assistance Program: Because this is an emer- gency program, it cannot be considered a hallmark of federal efforts to reduce food insecurity; and although it is intended to supplement low-income, in-need individuals, including older adults, states set the criteria. Moreover, the commodity foods are not sent directly to

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4 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE individuals but rather are sent to local distributing agencies, such as food banks and soup kitchens, which do not always prioritize older adults. Wellman noted that sensitivity to older adult needs among local distributing agents must be improved. • Senior Farmers’ Market nutrition Program: Forty-three states and seven tribes have this program in place. However, it is available only during the local growing season; and the budget is very small. The average benefit per person is only $23 per year, or approximately $2 per month. (During the discussion session following this pre- sentation, a member of the audience commented that the program provides $20.6 million annually through 2012 and that states that receive grants are required to provide nutrition education.) • Child and Adult Care Food Program (CACFP): Intended primarily for children, disabled adults, and older adults in non-residential day centers, this program is state-regulated with no data available on older adult participation. Wellman described a new Institute of Medicine (IOM) Food and Nutrition Board consensus study under way, which will review and assess the nutritional needs of the target populations and make meal requirement recommendations for the CACFP. U.S. Department of Health and Human Services Federal Nutrition Assistance The largest federal nutrition assistance program for older adults is the Older Americans Act (OAA) Nutrition Program, operated by the U.S. Department of Health and Human Services Administration on Aging. The purpose of the program, which is popularly known as “Meals on Wheels” and “Senior Dining,” is to reduce hunger and food insecurity, promote socialization of older individuals, and promote the health and well-being of older individuals. Unlike the USDA programs, it has no income require- ments and forbids means testing. Although the program targets individuals in greatest economic and social need, low-income minorities, and people living in rural areas, the only real criterion is that a participant be more than 60 years of age. Because states drive the program, with minimal fed- eral regulations and minimal uniformity, there is considerable variation in how the program operates across the country. One of the problems with the program is its limited nutrition capacity and technical assistance. There is only one national nutritionist, only one regional nutritionist (in New England), no nutritionists in 55 percent of the state-level units on aging, and no national nutrition resource center. The program reaches about 2.6 million older adults, serving about 241 million meals annually. Most of these are home-delivered, but about a third

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS are congregate meals served to senior centers, etc. Overall, the number of home-delivered meals is increasing—about 61 percent of OAA meals served in 2008 were delivered to the home, reaching 909,913 older adults. That amounts to 161 meals per participant. Wellman said, “If we are going to keep people out of nursing homes, we probably could do a better job of providing more than 161 meals to people who are homebound.” Total annual expenditure averaged $828 per participant—a figure, Wellman ob- served, that is equal to the cost of one day in the hospital. Also in 2008, 39 percent of total meals served were served as congregate meals, reaching 1,656,634 older adults (58 meals per participant), with the total annual expenditure averaging $384 per participant. Forty-eight percent of older adults who receive homebound meal de- liveries live alone, and 63 percent are female. Thirty-five percent of older adults who go to senior centers to eat meals live alone, and 63 percent are female. Even though people need be only 60 years of age to participate, the average age of OAA meal participants is about 74 to 75. About a third of the home-delivered participants are considered nursing home-eligible because of the number of disabilities they have. When asked, 93 percent of participants said that having one meal delivered five days a week allows them to stay home. For about 60 percent of older adults receiving meals either at home or in senior centers, that single meal comprises over half of their food intake for the day. Wellman compared the OAA Nutrition Program with the Supplemen- tal Nutrition Program for Women, Infants, and Children (WIC), both of which started at about the same time. The OAA Nutrition Program had a budget of $125 million its first year (1974), and WIC had a budget of $20.6 million (1975). In 2008, the OAA program’s budget was $784 mil- lion, compared to WIC’s $6.2 billion. Appropriations for the older adult program have grown only six-fold, whereas funds for WIC have grown 332-fold. One of the reasons for this discrepancy, Wellman argued, may be that outcomes for WIC have been documented from the very begin- ning, with a focus on nutrition. The OAA program is not as focused on outcomes. A New Position Statement on Food and Nutrition Programs for Community-Dwelling Older Adults Far too often, Wellman said, community food and nutrition programs for older adults are disregarded, taken for granted, or underfunded. Because of this, the American Dietetic Association (ADA), the American Society for Nutrition (ASN), and the Society for Nutrition Education (SNE) developed a position statement on food and nutrition programs for community-dwell- ing older adults (Kamp et al., 2010):

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE • Given the federal cost containment policy to rebalance long-term care away from nursing homes to home and community based services, it is the position of ADA, ASN, and SNE that all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutrition status. • Appropriate food and nutrition programs include adequately funded nutrition assistance and meal programs, nutrition education, screen- ing, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to assure healthier aging. • The growing number of older adults, the health care focus on pre- vention, and the global economic situation accentuate the fundamen- tal need for these programs. In closing, Wellman said that the position statement essentially states that the trend in the United States is toward community living and keeping older adults out of institutional settings. Given this situation, the position statement encourages the intensification of efforts to feed older adults at home. QUESTIONS AND DISCUSSION Kinsella and Wellman’s talks prompted questions about data on pov- erty and aging, the relationship between obesity and longevity, and the trend among aging populations toward increased community living (and assisted living) and away from nursing home living. Poverty and Aging The first question pertained to Kinsella’s data showing a decline over time in poverty among older adults, whereas Wellman’s data showed an increase in hunger among older adults as a result of increased poverty. The questioner asked how these seemingly contradictory trends should be inter- preted. Kinsella explained that while the percentage of older adults in poverty has decreased, the absolute number of older adults in poverty has increased and is still significantly high. Wellman agreed and explained that the data she presented were from a report prepared for Congress and that the figures were represented in actual numbers (i.e., millions of people), not percentages. The Relationship Between Obesity and Longevity There was another question about Kinsella’s data showing an increase over time in longevity, even though some experts have predicted a decline in longevity because of obesity. Kinsella replied, “That’s the 64 million dollar question right now.” He stated that the relationship between obesity and

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 SIZE And dEMogRAPHICS oF AgIng PoPUlAtIonS mortality is not well established and that while intuitively it makes sense, so far there is remarkably little scientific evidence showing that in fact obe- sity is related to mortality. Another audience member remarked that while obesity may not be directly associated with mortality, there are quite robust data showing an association between obesity and functional decline with aging, including mobility impairments, and an increased risk of becoming homebound. He stated that in terms of quality of life and the ability to live independently, obesity is an important issue with respect to aging. The same audience member remarked that many obese older adults “may not be for want of food energy” but “eat such poor quality diets they are malnour- ished.” He noted a very high prevalence of dietary and serum micronutrient deficiencies in obese community-dwelling elderly people. Chapter 3 includes a more detailed discussion of inadequate nutrient intakes among older adults. The Trend Toward Community Living (and Assisted Living) Another audience member asked about the trend toward not living in nursing homes: Where are people living, and does the OAA Nutrition Program deliver meals to assisted living facilities? Wellman explained that the program does not generally service assisted living facilities. However, she noted that meals could be provided at adult day centers, not necessar- ily by the OAA program but by the Child and Adult Care Food Program. She predicts that there will be a growing demand for adult day centers as efforts continue to be directed toward keeping older adults out of nursing homes and in the community. Kinsella reiterated that the proportion of the older population residing in nursing homes or institutional residences has declined over the last 20 years or so, with a corresponding rise in the proportion of people living in assisted living facilities. However, there are many forms and gradations of assisted living, making it difficult to lump them all together and identify trends. With respect to the trend toward living alone, he noted that 40 percent of older women live alone. While some people interpret this as an “epidemic of isolation” and something to be concerned about, living alone may be more a function of being able to afford living alone rather than a reflection of social isolation. Older women today are much more likely to have some sort of social security or pension income than they did decades ago, and surveys have shown that if given a choice most people would like to spend as much of their life as possible at home. For Kinsella, the trend toward living alone and with the help of programs like the OAA Nutrition Program is a positive, not negative, sign. Finally, an audience member remarked that the IOM Food and Nutri- tion Board has developed a proposal and is searching for sponsors for a future workshop on food and nutrition services for older adults.

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