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COMMENTS
ON THE 2000 OLDER AMERICANS ACT: NUTRITION SERVICES PART
C-NUTRITION SERVICE Topic/Issue:
Inconsistent wording: May include vs. provide in other
sections of the Act, such as in Sec.339 (2)(J); Definition: appropriate
nutrition services. Recommend: AoA guidance should encourage nutrition education services, as essential based on participant needs. To do so, AoA regulations should define nutrition education in accord with the American Dietetic Association and Society of Nutrition Education: Nutrition education is any set of learning experiences designed to facilitate the voluntary adoption of eating and other nutrition-related behaviors conducive to health and well-being (3,4). Behaviors are identified according to the needs, perceptions, motivations, and desires of the target audience, as well as from national nutrition and health goals and science based research (3,5). AoA regulations should also define appropriate nutrition services, citing examples that include nutrition screening, nutrition education, nutrition assessment, nutrition counseling, nutrition care planning, health and wellness programs, shopping assistance and transportation, and assistance with Food Stamp program enrollment, etc. SUBPART 2 - HOME DELIVERED NUTRITION SERVICES SEC. 336 The Assistant Secretary shall carry out a program for making grants to States under State plans approved under section 307 for the establishment and operation of nutrition projects for older individuals…provide at least one home delivered hot, cold, frozen, dried, canned, or supplemental foods (with a satisfactory storage life) meal per day and any additional meals which the recipient of the grant or contract under this subpart may elect to provide. (1) Topic/Issue: Confusing terminology: supplemental foods. Rationale: The term supplemental foods in the Act refers to USDA commodities that were more commonly distributed to Older Americans Act Nutrition Programs in the 1980s. There is confusion between supplemental foods and medical foods, the latter as defined in Public Law 100-290, The Orphan Drug Amendment of 1988, April 18, 1988. It defines medical food as food which is formulated to be consumed or administered enterally under supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. Medical foods are often known by a variety of names, such as nutrition supplements, "liquid meals," oral supplements. However, the most appropriate statutory term is medical food. Recommend: When the Older Americans Act is next reauthorized, the term supplemental commodity foods or merely commodity foods should be used. In the meantime, AoA guidance should clarify that supplemental foods in this section of the Act refers to USDA commodity foods. (2) Topic/Issue: Definition: satisfactory storage life. Rationale: The term satisfactory storage life is too vague. Recommend: AoA guidance to State Units on Aging (SUAs) and Area Agencies on Aging (AAAs) should define satisfactory storage life for a meal as delivered, i.e., time limits for storing the entire meal and/or its components. Such guidance should reference Cooperative Extension, USDA, and FDA Food Code guidelines concerning safe food handling and storage. SEC.
337 CRITERIA Topic/Issue: Development of standards for home delivered meals with consultation from appropriate organizations. Rationale: This section of the Act has never been implemented. Aging Network consensus (and buy-in) is needed regarding the effective administration and provision of nutrition services for older adults. Recommend: AoA should implement this section. AoA should further describe any other appropriate group. The National Policy and Resource Center on Nutrition and Aging at Florida International University, Miami, is a logical participant and could be assigned the facilitator role to help implement this section of the Act. The Center, under its Cooperative Agreement with the Administration on Aging, is developing a State Units on Aging Best Practices Toolkit to address guidance and technical assistance needs of the Aging Network not just for home delivered nutrition services, but for the full range of nutrition services and its administration. The Center has and is continuing to develop collaborative relationships with organizations specified in the Act. SUBPART
3 - GENERAL PROVISIONS Topic/Issue: Definition: comparable expertise; Delineate responsibilities of position. Rationale: This section of the Act is unclear. A number of SUAs have no lead dietitian at the state level. Hence, there is no state nutrition leadership for nutrition policy, program planning and oversight, technical assistance, program evaluation, data coordination and/or outcomes research. In some states, AAAs and local providers have more expertise concerning nutrition services than the SUA. Some SUAs tend to overlook the importance of nutrition in later years. The Institute of Medicine (IOM) states "Poor nutrition is a major problem in older Americans. Inadequate intake affects approximately 37-40% of community-dwelling individuals over 65 years of age." (6). "87% of older Americans have either diabetes, hypertension, dyslipidemia, or a combination of these chronic diseases (7). The IOM adds "These conditions all have adverse outcomes that can be ameliorated or reduced with appropriate nutrition interventions" (6). Recommend: AoA regulations should define comparable expertise and the qualifications of this individual, i.e., completed post-secondary education in human nutrition and/or food service management. AoA guidance should delineate the roles and responsibilities of this content-specific professional position at SUAs and perhaps in AAAs and at the local provider level. For example, roles and responsibilities of the SUA nutritionist extend beyond and may not even include menu planning in larger states. SEC.
339 (2) ensure that the project- Topic/Issue: Compliance with the 2000 Dietary Guidelines for Americans. Rationale: This section of the Act does not specify "the most current edition" of the Dietary Guidelines. New Guidelines supercede older ones and should be considered to do so by the Aging Network. State meal requirements vary. Some states have not updated meal requirements since the OAA Nutrition Program began almost 30 years ago. Some states allow flexibility in menu planning at local levels and unfortunately others do not. Local providers sometimes have difficulty balancing customer preferences with overly restrictive meal requirements. The food industry lacks the incentive of national uniformity to develop new products for OAA Nutrition Programs. Recommend: AoA regulations should specify that SUAs implement the most recent edition of the Dietary Guidelines for Americans within a reasonable period of time, e.g., one year after publication. SUAs should be required to provide technical assistance to insure its implementation at AAA and local levels. While the Act should continue to allow flexibility for local menu options, timely guidance is necessary to incorporate emerging science regarding the nutrition needs of older adults. SEC.
339 (2) ensure that the project- Topic/Issue: Compliance with Dietary Reference Intakes (DRIs); Misinterpretation by some states. Rationale: This section of the Act does not specify "the most current" Dietary Reference Intakes (DRIs), which have replaced the Recommended Dietary Allowances (RDAs). New values should supercede older ones. State meal requirements vary. Some states have not updated meal requirements since the OAA Nutrition Program began almost 30 years ago. Some states allow flexibility in menu planning at local levels and others do not. Local providers sometimes have difficulty balancing customer wants with overly restrictive meal requirements. Many local providers serve two (or more) meals a day based on need (e.g., breakfast and a hot lunch, or a hot lunch and cold supper). Some states are overly restrictive in their interpretation of meeting 2/3s of the RDA by requiring that each meal, on its own, provide 1/3 of the RDA. Effective menu planning and the use of computer assisted nutrient analysis can reduce food cost and allows for greater flexibility in the type and amount of foods served, e.g., less protein at breakfast with greater amounts at later meals. Recommend: AoA regulations should specify that SUAs implement the most recent edition of the Dietary Reference Intakes (rather than the RDAs), within a reasonable period of time, e.g., one year after publication. SUAs should be required to provide technical assistance to insure its implementation at AAA and local levels. While the Act should continue to allow flexibility for local menu options, timely guidance is necessary to incorporate emerging science regarding the nutrition needs of older adults. AoA guidance should encourage SUAs and AAAs to allow providers the option when serving two meals that their combined nutrient value meet or exceed 2/3s of the DRIs. Encouraging SUAs to do so could result in cost savings and a greater likelihood of developing menus that more closely reflect typical meal patterns. SEC.
339 (2) ensure that the project- Topic/Issue: Clarification regarding the use of medical foods, foods for special dietary uses, dietary supplements, and functional foods in meeting individual needs, including special diets; Clarification regarding the use of federal funding for them. Rationale: The Act does not address the use and funding of medical foods, foods for special dietary uses, dietary supplements, or functional foods. Their use is increasing. They can play a positive role in people's health and may help improve the poor nutritional status of needy older adults. Many older adults are at nutrition risk because of low calorie intakes, poor food choices, economic reasons, chronic diseases (e.g., osteoporosis), and/or special needs (e.g., dysphasia). Also, many congregate and home delivered meal participants are unable to consume a complete meal when served or delivered. Therefore, greater flexibility in what constitutes a meal and other ways to provide meals that to the maximum extent practical, are adjusted to meet any special dietary needs of program participants should be allowed when prescribed by a registered dietitian (RD) or physician in conjunction with an individualized nutrition care plan. The use of medical foods, foods for special dietary uses, and/or functional foods, and in special circumstances, even dietary supplements, may allow OAA Nutrition Programs to appropriately address individual nutrition needs in a comprehensive individualized nutrition care plan under the direction of an RD or MD. Definitions are provided below regarding nutrition-related terminology. Medical
food, as defined in Public Law 100-290, The Orphan Drug Amendment
of 1988, April 18, 1988, is food which is formulated to be consumed
or administered enterally under supervision of a physician and which
is intended for the specific dietary management of a disease or condition
for which distinctive nutritional requirements, based on recognized
scientific principles, are established by medical evaluation. Food for special dietary uses, according to Section 201 of the Federal Food, Drug, and Cosmetic Act, is the term applied to food for man, means particular (as distinguished from general) uses of food, as follows: (i) uses for supplying particular dietary needs which exist by reason of a physical, physiological, pathological or other condition, including but not limited to the conditions of diseases, convalescence, … underweight and overweight; (ii) uses for supplying particular dietary needs which exist by reason of age, …; (iii) uses for supplementing or fortifying the ordinary or usual diet with any vitamin, mineral or other dietary property. Food for special dietary uses are often useful when there are chewing and swallowing problems and to speed recovery when there is illness-related cachexia and/or to halt unintended weight loss. A dietary supplement is defined in section 201(21 USC 321) as a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following ingredients: (A) a vitamin; (B) a mineral; (C) an herb or other botanical; (D) an amino acid; (E) a dietary substance for use by man to supplement the diet by increasing the total dietary intake; or (F) a concentrate, metabolic, constituent, extract, or combination of any ingredient described in clause (A), (B), (C), (D), or (E). In the 2000 Dietary Guidelines for Americans, older adults are mentioned specifically as a group who may benefit from dietary supplements to meet specific nutrient needs. While there
is no universally accepted definition of functional foods,
two definitions provide insight into this category. The American Dietetic
Association broadly defines functional foods to include whole
foods and fortified, enriched, or enhanced foods that have a potentially
beneficial effect on health when consumed as part of a varied diet on
a regular basis (8). The Institute of Medicine defines functional
foods as those foods in which the concentrations of one or more ingredients
have been manipulated or modified to enhance their contribution to a
healthful diet (9). Recommend: AoA guidance should clarify the use and funding of medical foods, foods for special dietary uses, dietary supplements, or functional foods. For any/all nutrition-related terms, synchronous contemporary definitions should be used, including those that are federally defined in all AoA guidance. Guidance should allow their usage in a "meal" when prescribed by a registered dietitian or physician in conjunction with an individualized nutrition care plan. At a minimum, AoA guidance could encourage SUAs to develop policies regarding the incorporation of readily available, cost-neutral functional foods. The use of functional foods would enable many Programs to address common public health nutrition issues and/or recognized dietary deficiencies seen in special population segments of older adults. SEC.
339 (2) ensure that the project- Topic/Issue: Encourage SUAs to clearly address time and temperature holding limits to ensure food safety and quality for various circumstances and delivery modes. Rationale: This section of the Act makes reference to contracts but does not address meals not prepared under contract. Recommend: AoA regulations should require SUAs to clarify time and temperature holding limits to ensure food safety and quality that are realistic for various circumstances (e.g., rural) and delivery modes. SEC.
339 (2) ensure that the project- Topic/Issue: Arrangements with schools and other facilities. Rationale: Co-locating meal services in schools and other facilities are limited in the Aging Network. Best practice examples and incentives to encourage such arrangements may promote broader use of venues that promote intergenerational interaction. Recommend: AoA guidance should describe arrangements that have been successful (i.e., co-location of congregate programs in schools, contracting with school food service, co-locating child and adult day programs, etc.). SEC.
339 (2) ensure that the project- (1) Topic/Issue: Food safety is not consistently addressed by SUAs. Rationale: There is variation in the adequacy of State Health Department standards and local implementation in relation to food safety issues. Thus, not all facets of meal service and delivery are addressed, e.g., use of appropriate carriers, hot/cold delivery trucks, food trays and containers, time/temperature in transit, and temperature monitoring. While SUAs follow their own food safety laws, national guidance could help fill in the gaps not adequately addressed. Recommend: AoA guidance should provide technical assistance to SUAs and AAAs on facets of the food services system that are not adequately covered at the State or local level, i.e., time/temperature holding in relation to food quality and nutrient retention. (2) Topic/Issue: Food handling behaviors by congregate and home delivered meal participants and food safety education. Rationale: Studies indicate that significant proportions of home delivered meal participants, as well as some congregate participants, do not consume their entire meal at one time (1). Many may store them inappropriately, increasing their risk of food borne illness (10,11). Recommend: AoA guidance should provide technical assistance to address the special needs of home delivered meal participants concerning food handling and food packaging, i.e., reheating and storage instructions, appropriate packaging, for example, two half-portions of the entree. SEC.
339 (2) ensure that the project- Topic/Issue: Definition: dietitian (or individuals with comparable expertise). Rationale: This section of the Act is unclear. A number of providers are without a dietitian. Without AoA guidance, providers may overlook the importance of bona fide nutrition expertise that will help programs meet the needs of participants and ensure safe, tasty food. The use of an RD or state licensed dietitian is strongly recommended. The Institute of Medicine has acknowledged the RDs as "currently the single identifiable group with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy (6). Recommend: AoA regulations should define comparable expertise and qualifications of this individual to best protect older adults. AoA guidance should delineate position responsibilities at the SUA, AAA, and provider levels. AoA guidance should encourage the use of RDs at the AAA and local provider levels. Staffing ratios at AAA and provider levels that guarantee quality nutrition services and foodservice administration should be developed. In the past, advisory councils at AAAs or local providers were interpreted as other individuals knowledgeable with regard to the needs of older individuals. Such councils could affectively augment, but not replace, the expertise of RDs and add considerably to the Programs. SEC. 339 (2) ensure that the project- (H) ensures that each participating area agency establishes procedures that allow nutrition project administrators the option to offer a meal…and to individuals with disabilities who reside at home with and accompany older individuals eligible under this chapter. Topic/Issue: Definition: individuals with disabilities. Rationale: Confusion continues regarding who can be considered disabled, although the OAA amended in 1992 included definitions. If this includes short-term disability, the limited service dollars may not be directed toward eligible older individuals. Recommend: AoA regulations should clarify the definition of individuals with disabilities. SEC.
339 (2) ensure that the project- Topic/Issue: Definition: housing facilities occupied primarily by older individuals. Rationale: There has been confusion regarding meal service available to disabled individuals residing in housing facilities that serve congregate meals. Provision of OAA services should target frail older adults. Recommend: AoA regulations should clarify the definition of housing facilities occupied primarily by older individuals. The regulation should limit the provision of nutrition services to non-elderly disabled to congregate settings only. AoA guidance should encourage local providers to use other funding sources for nutrition services including meals for ineligible participants, e.g., Medicaid waiver for home and community based care and private insurance (12). SEC.
339 (2) ensure that the project- Topic/Issue: Confusion regarding requirement to provide nutrition screening vs. only where appropriate; Protocols needed: nutrition services for screening, education, counseling and care planning. Rationale: The phrase, where appropriate, seems to encourage a misinterpretation of the need to provide for nutrition screening. Provide for nutrition screening is requirement, not an option. Nutrition education and counseling are also required when and where appropriate. Nutrition screening, assessment and intervention tools are available and should be promoted by SUAs for use by area and local providers. Nutrition screening should be consistent with protocols established by the Nutrition Screening Initiative and others. Nutrition screening should be a critical component of service to reduce nutrition risk and improve food security in older adults. Recommend: AoA guidance to SUAs, AAAs, and local providers should specify who, when, and how individuals are screened, i.e., all new congregate or home delivered meal participants upon enrollment and, at least annually thereafter. SUAs should then specify a minimum set of screening criteria, such as that used for the Performance Outcomes Measurement Project, Nutrition Screening Initiative Determine Checklist or Nestle's Mini-nutrition Assessment. Participants at moderate to high nutrition risk should then be referred to an RD or "other" appropriate individual for nutrition care planning. AoA guidance should encourage the Aging Network to use other funding sources for nutrition screening and intervention, i.e., Medicaid waiver for home and community based care (12), Medicare coverage of medical nutrition therapy for certain conditions (6), and private insurance. SEC.
311 NUTRITION SERVICES INCENTIVE PROGRAM Topic/Issue: Lack of information provided to the state and lack of support. Rationale: States have the option to elect to receive cash-in-lieu of commodities, commodities, or a combination of the two for their grantees. The USDA Commodity processing program can provide commodities in a most useable form that, in turn, may help reduce food costs. Providers without the facilities or desire to handle many commodity products can take advantage of the option to participate in the commodity processing program. Recommend: AoA guidance to SUAs and AAAs as technical assistance could encourage participation in the commodity processing program. PART
B - SUPPORTIVE SERRVICES AND SENIOR CENTERS Topic/Issue:
Provision of nutrition screening and nutrition services to home care
clients. Rationale: Nutrition services, including screening, assessment, education, and counseling, are integral parts of home care services. Such nutrition services are required for a home health care agency to be accredited by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO). It would follow that such requirements be appropriate for all home health care providers. Recommend: AoA guidance to SUAs and AAAs should provide technical assistance and support for the provision of nutrition services, including screening, assessment, education, and counseling, to home care clients. Nutrition screening should be consistent with protocols established by the Nutrition Screening Initiative and others recognized groups. Nutrition screening is a critical component of services to reduce nutrition risk and improve food security in older adults. AoA regulations should define qualifications of individuals providing these services to best protect older adults, as in SEC. 339 (2) (J) provide for nutrition screening and, where appropriate, for nutrition education and counseling. SEC.
321(a) The Assistant Secretary shall carry out a program for
making grants to States under State plans approved under section 307
for any of the following supportive services: Topic/Issue: Provision of nutrition screening and nutrition services. Qualifications of individuals providing nutrition services. Rationale: Nutrition screening and assessment, and the provision of appropriate nutrition education and counseling is an integral part of the continuum of nutrition services that should be provided by AAAs and local providers. It is important that qualified individuals provide these services. Recommend: AoA guidance to SUAs and AAAs should provide technical assistance and support for the provision of nutrition services, including screening, assessment, education, and counseling, to older adults. AoA regulations should define qualifications of individuals providing these services to best protect older adults and follow SEC. 339 (2) (J) provide for nutrition screening and, where appropriate, for nutrition education and counseling. SEC.
321(a) The Assistant Secretary shall carry out a program for
making grants to States under State plans approved under section 307
for any of the following supportive services: Topic/Issue: Provision of nutrition screening and nutrition services. Qualifications of individuals providing health and nutrition education services. Rationale: Nutrition screening and assessment, and the provision of appropriate nutrition education and counseling is an integral part of the continuum of services that may be provided through the AAA. Participants should have the opportunity to receive health and nutrition education screening. It is important that qualified individuals provide these services. Recommend: AoA guidance to SUAs and AAAs should provide technical assistance and support for the provision of nutrition services, including screening, assessment, education, and counseling, to older adults. AoA regulations should define qualifications of individuals providing these services to best protect older adults and follow SEC. 339 (2) (J) provide for nutrition screening and, where appropriate, for nutrition education and counseling. PART
E-NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM Topic/Issue: Provision of nutrition services to caregivers. Qualifications of individuals providing nutrition services. Rationale: Nutrition services are important to ensure the health, nutritional status and well-being of caregivers themselves, as well as their care recipients. Caregivers are a group at increased nutrition risk (13). It is important that qualified individuals provide these services. Recommend: AoA guidance to SUAs and AAAs should provide technical assistance and support for the provision of nutrition services to caregivers. AoA regulations should define qualifications of individuals providing these services and follow SEC. 339 (2) (J) provide for nutrition screening and, where appropriate, for nutrition education and counseling. Assessment forms that are currently in use to determine the nutrition risk of participants can be used to screen and track caregivers. SEC. 373 (b) SUPPORT SERVICES- The services provided, in a State program under subsection (a), by an area agency on aging, or entity that such agency has contracted with, shall include- (5) supplemental services, on a limited basis, to compliment the care provided by caregivers. Topic/Issue: Definition: supplemental services should include nutrition services. Rationale: Nutrition services are important to ensure the health, nutritional status and well-being of caregivers themselves, as well as their care recipients. Caregivers are a group at increased nutrition risk (13). It is important that nutrition services, including home-delivered meals, may be provided to caregivers and recipients based on an assessed need. Recommend: AoA guidance to SUAs and AAAs should provide technical assistance and support for the provision of nutrition services to caregivers and their care recipient. REFERENCES The National Policy and Resource Center on Nutrition and Aging is supported, in part, by award number 90-AM-2390 from the Administration on Aging, Department of Health and Human Services, Washington, DC 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, reflect official Administration on Aging policy. Posted
on 12/04/01 |