February 2022 Issue
As the Pandemic Turns
By KC Wright, MS, RDN
Today’s Dietitian
Vol. 24, No. 2, P. 40
Access to Food Is a Basic Social Determinant of Health
Access to safe, nutrient-dense food is essential for achieving and maintaining good health. This is a basic social determinant of health, necessary to create social and physical environments that promote good health for all, reduce the risk of illness, and improve management of chronic diseases and conditions. In March 2020, when the COVID-19 pandemic disrupted food systems and triggered an economic crisis, food insecurity—particularly in older adults—intensified as a public health issue.
Among adults aged 60 and older, food insufficiency—a measure of severe food insecurity—increased by 75% during the early stages of the pandemic.1 Food insecurity defined by the USDA is a lack of consistent access to enough food for an active, healthy life. And it’s a key risk factor for malnutrition. Although food insecurity had been on the decline prepandemic, more than 7% of older adults were already food insecure, experiencing periods of being uncertain about food availability or unable to acquire enough food to meet their needs due to lack of funds or other resources.2 In fact, in 2015, there were more food insecure older adults in the United States than there were during the Great Recession (2007–2009).3 In 2018, more than 2.9 million food insecure households included an adult aged 65 or older.
Hunger, a consequence of food insecurity, refers to the personal, physical sensation or discomfort of going without eating. In 2019, 5.2 million people aged 60 and older faced hunger.3 One of every 14 older adults have been food insecure, especially those who are Black or Latinx, live in rural areas, have disabilities, and rent their housing. A recent poll focusing specifically on food insecurity among older adults found that 1 in 7 adults between the ages of 50 and 80 had difficulty procuring adequate food due to cost or other issues.4 Food insecurity was highest among those with household incomes of less than $30,000.
Yet other recent research demonstrates that there are multiple and significant nonfinancial constraints among older adults that drive food insecurity.5 With the onset of COVID-19 and the subsequent national stay-at-home mandates, many community resources—food stores, restaurants, and senior centers where food insecure older adults might get at least one daily meal—shut down. Recall the nightly news video clips showing miles-long car lines for free grocery distribution to those in need of food and supplies that became too costly or scarce with the pandemic. While some community organizations mobilized to deliver meals to the homes of older adults, lack of transportation or the inability to stand in long lines make it a challenge to access free or low-cost food offerings. Even when grocery stores allocated shopping hours exclusively for older adults, many remained fearful of being in public and lacked the skills or technology to place online orders. Congregate meal sites became take-out or drive-through meal pick-ups. To make matters worse, as older adults age, many experience a decline in appetite with a decrease in metabolism and a decrease in thirst receptor sensitivity, and may live and/or eat alone—all factors that can increase their risk of malnutrition.
Nutritional and Other Health Implications
Data from the 1999–2016 National Health and Nutrition Examination Survey (NHANES) showed that food insecure older adults are more vulnerable with respect to nutrition outcomes and health measures when compared with their food secure peers.6 Specifically, they consume lower quantities of key nutrients, particularly iron, calcium, and protein, by 8% to 24%. In addition, they had intake levels of antioxidant vitamins A (14.9%) and C (12.9%) that were lower than those of food secure older adults. All of these nutrients are essential and contribute to both normal metabolism and immune function. When older adults are food insecure, they are 74% more likely to have diabetes, more than twice as likely to have poor general health, three times more likely to suffer from depression, 20% more likely to be limited in at least one activity of daily living, almost 20% more likely to have hypertension, 71% more likely to have congestive heart failure, 64% more likely to have had a myocardial infarction, and 71% more likely to have asthma.6 The NHANES data are consistent irrespective of distinct demographic categories.
COVID-19 has threatened the overall well-being and mental health of many people. In older adults, research has shown that food insecurity, and more specifically, low intake of both protein and fiber, were found to be significant factors associated with psychological distress.7 This demonstrates the importance of considering food insecurity as an independent predictor of negative health and nutrition outcomes, especially among lower-income older adults. In a recent nationally representative survey, 1 in 3 older adults reported financial hardship as a result of COVID-19, while those with cognitive impairments were also associated with higher levels of economic constraints.8 As food insecurity is associated with several chronic illnesses, it puts people at a higher risk of the more severe complications of COVID-19.9
Food and Nutrition Support for Older Adults During COVID-19
As did medical providers, nutrition programs had to pivot quickly in the wake of the pandemic to protect participants from the virus and continue to provide services to those in need. Federal and state governments, along with local agencies, initiated benefits and programs to help fill the void of food resources and access. The Older Americans Act (OAA), part of the Administration on Aging within the Administration for Community Living, provides grants to help support nutrition services for any person at least 60 years of age to participate in either congregate or home-delivered nutrition programs.10 The Families First Coronavirus Response Act allocates $160 million of additional funding for OAA home-delivered meals and $80 million for congregate meals.11 The CARES Act appropriates $480 million for OAA nutrition services as well as a waiver for state matching requirements for OAA programs and flexibility for individuals staying home to qualify for home-delivered meals.12 Many older adults rely on these programs to remain living independently in their communities. The pandemic has greatly affected both the existence and effectiveness of community-based nutrition services for older adults as the number of people seeking services has swelled, while the demand on the food supply has become strained.
Across the nation, programs are responding to the growing need for nutrition services, particularly food insecurity for older adults, in new and innovative ways. For example, the Vermont agency of Human Services sought to improve how individuals 60 years of age and older access the 3SquaresVT, the federal Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps. It became evident that large numbers of individuals did not reapply for benefits, and the number of first-time applicants declined. The enrollment application was simplified from 16 pages to five, with a recertification period extending to three years (vs annually). An outreach campaign resulted in an increase of almost 500 new applicants since October 2020.
In Piedmont, North Carolina, the regional agency on aging launched a grocery and medication delivery program to help at-risk older adults stay safely in their homes during the pandemic. Gift cards are used for participants to receive a basic selection of groceries while program staff or a volunteer delivers their medications. Meanwhile, the Michigan Department of Health and Human Services initiated a virtual food drive in partnership with the Aging and Adult Services Agency and the state’s Food Bank Council. The program is an innovative model to help alleviate household food insecurity for older adults and to reduce the spread of COVID-19. In Tarrant County, Texas, Meals on Wheels partnered with other area social service agencies to provide food to older adults during the pandemic that included a 10-lb box of older adult–friendly canned goods (ie, flip top) and fresh produce to all participants, who also received toiletries and telephone reassurance calls. In Oklahoma, Tulsa Transit’s lift service operators transitioned multiple paratransit vehicles to operate a delivery service for Meals on Wheels. The first transit team delivered almost 43,000 meals while the call center made more than 2,900 wellness check calls to those in the program.
COVID-19 and Nutritional Needs of Older Adults
It’s important for dietitians to understand the impact of COVID-19 on food insecurity. For 2021, projected overall food insecurity rates range from 8.1% in North Dakota to 18.7% in Minnesota,3 reflecting a significant increase in all states from 2019. The OAA mandates that older adult nutrition programs must comply with the latest Dietary Guidelines for Americans to supply a minimum of one-third of the referenced intakes per meal, while promoting three meals per day.13 Meanwhile, the Red Cross recommends that older adults maintain a two-week surplus inventory of food at home in case of an emergency.
Nutrition professionals can offer patients sample meal patterns and grocery lists, as well as references for both resource access and supply deliveries for those who can prepare their own meals. Nutritious foods for older adults should be low in sodium, saturated fats, and added sugars, while being high in fiber sourced from whole grains, vegetables, and fruits. To help boost the immune system, foods that provide necessary protein; B vitamins; vitamins C, D, and E; and zinc need to be part of a daily diet. Menus and meals should also comprise adequate calories to maintain a healthy body weight. In general, a meal for an older adult should deliver approximately 600 calories. The definition of malnutrition includes not just a lack of calories or essential nutrients but also poor nutrition when people eat too many foods that are of low nutrient density; high in sodium, saturated fat, total fat, and added sugars; and highly processed. This eating pattern would be indicative of a diet high in junk or fast food.
The Food Research & Action Center, a leading national nonprofit organization working to eradicate poverty-related hunger and malnutrition in the United States, advocates for safe food access. Its website offers a free online course to help health care providers address hunger among older adults, including how to screen for food insecurity and how to connect those in need with key nutrition resources such as SNAP. The course was developed with AARP and is approved for 1 AMA PRA Category 1 Credit of Continuing Medical Education. There are other patient-centered resources available for older adults who are technology savvy. FoodFinder is a downloadable app for a nonprofit food pantry locator that services more than 10,000 towns and cities nationwide. The National Council on Aging has a free online service, BenefitsCheckUp.org, where answering a few simple questions provides a personalized report listing local community resources about food and nutrition programs.
As it is, older adults are at an especially high risk of COVID-19 infection, hospitalization, and mortality due to their weakened immunity and other health vulnerabilities.5 For an older patient diagnosed with COVID-19, an early assessment of nutritional risk is in many cases modifiable, so it’s imperative to help provide a better immune system response and, thus, a more favorable prognosis or outcome. Although there’s no gold standard for identifying nutritional risk or malnutrition, the medical team and a clinical RD can work together to apply screening tools. The Mini Nutritional Assessment (and its short form, MNA-SF), the Geriatric Nutrition Risk Index, the Malnutrition Universal Screening Tool, and the Nutritional Risk Index were all developed specifically to identify nutritional risk or malnutrition in older adults.14 Most of these screening tools have high sensitivity, are convenient, and are inexpensive, with a good predictability for clinical outcomes. Certainly, if the patient is in the ICU, identifying nutritional risk is very difficult due to the critical nature of the illness. Follow-up nutritional care is also an essential element in rehabilitating older adults who survive COVID-19.
The COVID-19 pandemic is far from over, as are its health implications, and it will likely take a long time for food insecurity levels to recover. Addressing food insecurity among seniors requires a multidisciplinary approach including health care providers, health equity advocates, RDs, and governments. Older adults who are food insecure face a critical challenge precipitated by limited financial resources, declining health, and mobility. Providing quality nutrition services after federal emergency funding ends will require thoughtful and robust engagement. While there are millions of older adults who may not know where their next meal is coming from, millions more will join them just a few decades ahead. Aside from the support of existing senior hunger programs, there’s an urgent need to promote research, policies, and procedures to protect vulnerable older adults from food insecurity during and after the pandemic.
— KC Wright, MS, RDN, is a research dietitian advocating for sustainable foods and planetary health at wildberrycommunications.com.
References
1. Ziliak JP. Food hardship during the Covid-19 pandemic and great recession. Appl Econ Perspect Pol. 2021;43:132e52.
2. Food security in the U.S. Economic Research Service, United States Department of Agriculture website. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx. Updated September 8, 2021. Accessed October 24, 2021.
3. Senior food insecurity studies: the state of senior hunger in America. Feeding America website. https://www.feedingamerica.org/research/senior-hunger-research/senior. Published August 2021. Accessed October 24, 2021.
4. National Poll on healthy eating. How food insecurity affects older adults. University of Michigan website. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/155333/NPHA_Food-Insecurity-Report-FINAL-05102020-doi.pdf?sequence=4&isAllowed=y. Published May 2020. Accessed October 28, 2021.
5. Choi SL, Men F. Food insecurity associated with higher COVID-19 infection in households with older adults. Public Health. 2021;200:7-14.
6. Ziliak J, Gundersen C. The Health Consequences of Senior Hunger in the United States: Evidence from the 1999-2016 NHANES. Report for Feeding America. https://www.feedingamerica.org/research/senior-hunger-research. Published August 2021. Accessed October 23, 2021.
7. Malek Rivan NF, Yahya HM, Shahar S, et al. The impact of poor nutrient intakes and food insecurity on the psychological distress among community-dwelling middle-aged and older adults during the COVID-19 pandemic. Nutrients. 2021;13(2):353.
8. Ankuda CK, Fogel J, Kelley AS, Byhoff E. Patterns of material hardship and food insecurity among older adults during the COVID-19 pandemic. J Gen Intern Med. 2021;23:1-3.
9. Balch B. 54 million people in America face food insecurity during the pandemic. It could all have dire consequences for their health. Association of American Medical Colleges website. https://www.aamc.org/news-insights/54-million-people-america-face-food-insecurity-during-pandemic-it-could-have-dire-consequences-their. Published October 15, 2020. Accessed October 23, 2021.
10. Celebrating the Senior Nutrition Program. Administration for Community Living website. https://acl.gov/programs/health-wellness/nutrition-services. Updated August 6, 2021. Accessed October 23, 2021.
11. Families First Coronavirus Response Act public law 116–127—Mar. 18, 2020. https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf. Accessed October 23, 2021.
12. Text - H.R.748 - 116th Congress (2019-2020): CARES Act. (2020, March 27). https://www.congress.gov/bill/116th-congress/house-bill/748/text
13. Nutrition & connection. Nutrition and Aging Resource Center website. https://acl.gov/senior-nutrition/nutrition-and-connection. Updated October 2021. Accessed October 23, 2021.
14. Silva DFO, Lima SCVC, Sena-Evangelista KCM, Marchioni DM, Cobucci RN, Andrade FBd. Nutritional risk screening tools for older adults with COVID-19: a systematic review. Nutrients. 2020;12(10):2956.