The National Evaluation of the Older Americans Nutrition Program 1993-95 (8) found that the average OANP meal provided more than 50% of the 1989 Recommended Dietary Allowances (RDAs) for many nutrients based on adult male values. The National Evaluation concluded that both congregate and home-delivered meals contributed significantly to participants' daily nutrient intake, and therefore, their nutritional status. When comparing the nutrient content of OANP meals at the time of the National Evaluation to newer Dietary Reference Intakes (DRIs) (including RDA and other values described below), the meals would have been deficient in vitamins D, E, folate, and magnesium. Other nutrients met or exceeded the newer DRI/RDA values. See Table 2 Nutrient Availability of an Older Americans Nutrition Program Meal Relative to the Dietary Reference Intakes and Recommended Dietary Allowances compiled by the National Policy and Resource Center on Nutrition and Aging (Center).
The use of the newer DRI/RDA values to plan and evaluate OANP meals was addressed by an Issue Panel convened by the Center in February 2002 (reviewed later in this chapter). Recommendations from this and future Issue Panels will continue to shape OANP practice and guidelines.
B. NUTRITION RECOMMENDATIONS
Congress reauthorized the Older Americans Act (OAA) in 2000 for 5 years. OAA Section 339 requires that nutrition projects meet the Dietary Guidelines for Americans (9), published by the Secretaries of Health and Human Services and Agriculture and the RDAs (which are now included in the DRIs) established by the Food and Nutrition Board, Institute of Medicine of the National Academy of Sciences. The National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445) requires that the Secretaries of Health and Human Services and Agriculture contract with a scientific body, such as the National Academy of Sciences, to publish reports on nutrient requirements and status of the United States on a 2 to 5 year basis and to develop Dietary Guidelines every 5 years. The Act requires that all federal food, nutrition, and health programs promote these requirements. Thus, the most recent versions of the DRIs and Dietary Guidelines serve as the cornerstone for federal nutrition policy.
The new DRIs (10-15) provide values for men and women aged 51-70 and over 70 years. The DRI values include an RDA or an Adequate Intake for nutrients with no established RDA, and a Tolerable Upper Intake Level. Refer to Table 1 Dietary Reference Intakes for Older Adults compiled by the Center for current nutrient values established by the Food and Nutrition Board.
The newer DRIs include RDAs for older adults that are higher than the 1989 RDAs for vitamins B-12, C, D, E, K, folate, calcium, and magnesium. The DRIs provide equations to calculate an individual's energy requirements based on activity level (the EER). To meet the body's daily nutritional needs while minimizing risk for chronic disease, an AMDR was established for carbohydrate to be 45-65% of total calories, for fat, 20-35% of total calories, and for protein, 10-35% of total calories. The DRIs also suggests that no more than 25% of total calories come from added sugars (those incorporated into foods and beverages during production and processing). The DRIs now emphasize the importance of physical activity and recommends that adults strive for an "active" lifestyle that is equivalent to 60 minutes of moderately intense physical activity throughout each day (15).
The 2000 Dietary Guidelines for Americans (5th ed.) are the most current guidelines to be followed when planning and serving OANP meals. These guidelines are incorporated in the selection of foods and serving sizes for meals as well as the basis for nutrition guidance for individuals and groups. The 3 main themes are:
The Center convened an Issue Panel: Dietary Reference Intakes and Dietary Guidelines in OANPs in February 2002. Panelists included nutrition and aging-related researchers, individuals involved in policy development, persons working at the federal, state, and local program level, and representatives from food industries. The Issue Panel Report includes a summary, backgrounder and working documents, and a directory of Issue Panelists (16).
The Issue Panel focused on the rationale for and the use of the most recent DRIs and Dietary Guidelines in the provision of OAA nutrition services, including nutrition education, nutrition counseling, and congregate and home-delivered meals. The Issue Panel Report was provided to the US Administration on Aging for consideration. These recommendations will assist in the development of guidance and technical assistance related to implementation of the DRIs and Dietary Guidelines in the OANP. State Units on Aging (SUAs), Area Agencies on Aging (AAAs), local service providers, and Title VI grantees can use these recommendations in the development of guidance and assistance for implementation. Recommendations from the report are included in applicable sections of the Older Americans Nutrition Program Toolkit.
The OAA states that a project shall provide a meal that complies with the Dietary Guidelines and a stated percentage of the RDAs which varies with the number of meals served to a participant. Because it is the responsibility of the SUA to implement the OAA, SUAs have incorporated these standards into their policies and procedures.
The table below presents the most current DRIs to use when planning and evaluating meals. Values are provided for serving 1, 2, or a combination of 3 meals for 1 day's consumption for the average older adult population served by the OANP. The nutrients selected include those recommended for emphasis by the Issue Panel and those found in a number of studies to be deficient or of concern in the diets of older adults. (See "Enhancing the Nutritional Quality of the Meal" section of this chapter).
* RDAs are
in bold type and Adequate Intakes (AIs) are in ordinary type followed
by an asterisk (*).
Issue Panelists generally agreed that there might be circumstances when it is not always necessary for a single meal to meet the 1/3 requirement for every nutrient for which an RDA or Adequate Intake has been established. The idea of averaging nutrients over a longer period of time, such as a few days, or week was discussed. However, averaging was rejected overall by Panelists for periods longer than 1 day for the following reasons:
The Center plans to hold another Issue Panel (2003) regarding implementation of the DRIs. It is expected that the Panel will develop more specificity for energy (calories), the percentage of carbohydrate, protein, and fat to total calories, and key nutrients that should be included in computer-assisted menu analyses. The Issue Panel recommendations will be included in future modifications of the above table and other sections of this chapter.
C. MENU PLANNING
In order to ensure nutrient quality for the health of older Americans and to comply with the requirements of the OAA, SUAs establish written standards and guidelines detailing the specific requirements for menu planning and approval. Planning menus that includes input from participants is a best practice. Information may be obtained through focus groups, advisory councils, suggestion boxes, or surveys. Suggestions may also come from food production staff, site managers, home-delivered meal drivers, and food purveyors. SUAs, AAAs, and local providers should rely on professionals, preferably registered dietitians or nutritionists, to assist in the development, implementation, and approval of menus for OANPs. (Chapter 2 provides a description of a registered dietitian). Ideally, the menu will reflect local food preferences, provide variety in shape, color, temperature, texture, and flavor, consider food availability (foods in season), and costs. Well planned menus improve meal quality and increase client satisfaction (17).
The Issue Panel recommended that OANPs plan and evaluate meals for meeting nutritional requirements using computer-assisted nutrient analysis and that Registered Dietitians (or individuals with comparable expertise) be available at the state, area, and local provider levels to assure nutrient adequacy of meals (17).
A variety of nutrient analysis and meal production software products are available. Some simply provide analysis of foods, recipes, and menus. Others offer food production, inventory, and costing capabilities. The National Policy and Resource Center on Nutrition and Aging is currently gathering information from SUAs concerning their preferences and use of nutrient analysis software products. This information will be presented in a future Ask the Experts. The following is a list of more commonly used software:
A meal pattern is best used as a menu-planning tool rather than as a standard for nutritional adequacy or as a compliance tool. Use of computerized nutrient analysis rather than a meal pattern helps ensure nutritional adequacy of meals and increases menu planning flexibility. However, a meal pattern does have positive uses such as a first step in menu planning, ensuring food plate coverage, and as a component of a catering contract. Many SUAs require documentation that menus meet nutrient requirements using computer-assisted nutrient analysis. Some SUAs specify that meals must follow a meal pattern with no deviation.
Additional guidance is often provided for accompaniments such as desserts, condiments including margarine, salad dressings, and relishes, and beverages other than milk. Specific guidance is frequently included to ensure that foods high in key nutrients are provided. Recommendations for inclusion of foods high in vitamins A and C and fiber are common. In addition, information is typically provided in SUA guidelines to ensure that menus incorporate foods that are lower in sodium, fat, saturated fat, and cholesterol.
Most SUAs (77%) (SUA Policies and Procedures: 1998 Collection of Information) had guidelines that used meal patterns for the planning and/or for determining compliance to menu requirements. These meal patterns generally specify the serving sizes of foods in 5 groups: Bread and bread alternates; Vegetables; Fruits; Milk and milk alternates; Meat or meat alternates.
1972 meal pattern (shown below) is used by many OANPs today, this pattern
does not ensure that the new DRI requirements were met for calories, carbohydrates,
magnesium, folate, vitamin E, and fiber as noted in the Issue
Panel Report: Table 4.1 Nutrient Composition of the 1972 Meal Pattern
[page 53 of 62] (16). The 1972 meal pattern first appeared in the
Guide to Effective Project Operations, The Nutrition Program for the
Elderly (the Oregon Guide, 1973). It was assumed that if a variety
of foods were provided daily in the amounts indicated and proper food
preparation and handling was practiced, the meal would provide at least
1/3 of the 1968 RDAs. The pattern became the quick checklist for determining
the nutritional adequacy of a meal. Some SUAs added requirements that
meals provide foods high in specific nutrients, such as vitamins A and
C, as well as some others.
1972 Meal Pattern (outdated)
The meal pattern below is based on the newer DRIs for energy as calculated for the table above, "Dietary Reference Intakes for Meal Planning and Evaluation." It provides approximately 685 calories per meal. The number of servings for each food group are based on USDA's Food Guide: Background and Development, Table 5 Nutrient profiles for food groups and subgroup composites (18). These profiles represent the quantities of nutrients and other components that one would expect to obtain on average from a serving of food in each group (18). Information from Table 5 Nutrient profiles... and from USDA's Agricultural Research Service, Home and Garden Bulletin No.72 (Revised October 2002) was used to determine the appropriate number of food group servings to best meet the new DRIs and is presented as a table, "Nutrient Composition of a Suggested Meal Pattern for Older Americans Nutrition Program Meals."
The updated meal pattern includes 1 additional serving of bread or bread alternate and another serving of vegetable or fruit. Serving sizes are based on the Food Guide Pyramid. The number of servings reflects an appropriate distribution of foods for the day, particularly for lunch or supper. Servings from a food group may be combined as one larger serving. For example, 2 servings from the bread or bread alternate food group may include 2 slices of bread for a sandwich or 1 cup of pasta or rice or it may include 1/2 cup pasta and 1 slice of bread. Likewise, 2 servings of vegetable may be 1/2 cup mashed potato and 1/2 cup green beans or 1 cup of either vegetable. The pattern provides the option for substituting 1 fruit serving for a vegetable serving and vice versa.
This updated meal pattern, although based on the food servings recommended in the Food Guide Pyramid, does not assure that meals meet 1/3 the RDAs/Adequate Intake and the 2000 Dietary Guidelines. Meals are likely to require specific types of fruits and vegetables, whole grains, and high fiber foods. Based on the information used from USDA's Table 5 Nutrient profiles, the updated meal pattern may be deficient in vitamin E, requiring extra care in the selection of foods that are good sources of this nutrient (see "Sources of Key Nutrients" section of this chapter). Because of the increased nutrient requirements, it may be difficult for some participants to eat the amount of food for 1 meal at 1 sitting. The use of nutrient dense foods as well as fortified and enriched products should be a priority. In addition, calories from carbohydrates, fats, and/or proteins will require adjustment for underweight or overweight individuals. As appropriate for the weight status of participants, the provision of food supplements and modifications in serving sizes of particular food groups may be needed.
(1) The number
of servings per meal provides for 1/3 of the DRIs as calculated in Table
"Nutrient Composition of a Suggested Meal Pattern for Older Americans
Nutrition Program Meals. This table is based on USDA's Food Guide Background
and Development, Table 5, Nutrient Profiles for Food Group and Subgroup
Composites. This meal pattern also relates to Table "Dietary Reference
Intakes for Meal Planning and Evaluation" in this chapter.
group information below generally follows the 2000 Dietary Guidelines
and Food Guide Pyramid. Although some foods are classified in more
than 1 food group, a serving of a food can only be counted in 1 food group
within the same meal. For example, dried beans may be counted as either
a meat alternate serving or as a vegetable serving but not both in the
same meal. Likewise, cottage cheese may be counted as either meat alternate
serving or milk alternate serving but not both.
The Issue Panel recommended that OANPs emphasize foods that are high in fiber, calcium, and protein, and continue to target vitamins A and C, with vitamin A provided from vegetable-derived (carotenoid) sources. Targeting specific nutrients mentioned in this recommendation should not be misinterpreted as permission to ignore other nutrients (16). A number of studies found specific nutrients to be deficient in diets of older adults (8,19,20). While the National Evaluation revealed that OANP meals supplied over 33% of the 1989 RDAs for key nutrients. When compared to the newer DRIs, meals were inadequate in vitamins D and E, folate, calcium, and magnesium (8). The Continuing Survey of Food Intakes by Individuals 1994-1996 found older adults' dietary intake to be low in calories, total fat, fiber, carbohydrate, vitamin E, folate, calcium, and magnesium (19). The Third National Health and Nutrition Examination Survey (NHANES III) found older adults' dietary intake to be low in calories, total fat, fiber, calcium, magnesium, zinc, copper, folate, and vitamins B6, C and E (20). Therefore, the following require special attention: vitamins A, B-6, C, D, E, and folate; calcium, copper, magnesium, zinc; and calories, carbohydrates, total fat, protein, and fiber. More definitive guidance concerning targeting key nutrients will be developed as part of the next Issue Panel on the implementation of the DRIs.
Foods considered good sources of specific nutrients are shown in the following table prepared by the Center. Information provides "good" and "high" food sources of specific nutrients. A "high source" is defined as providing 20% or more of the Daily Value for a given nutrient per serving. A "good source" is federally defined as providing 10-19% of the Daily Value for a given nutrient per serving. See summary of the use and meaning of Daily Values that follows the table. Foods selected for the table meet the above parameters using typical serving sizes.
The USDA's National Nutrient Database for Standard Reference, Release 15 Nutrient List was used to develop the table (21). The database contains reports of selected food items and nutrients sorted by food description or in descending order by nutrient content in terms of common household measures. The food items and weights are adapted from Home and Garden Bulletin No. 72, Nutritive Value of Foods.
a High Source:
20% or more of Daily Value (DV) for given nutrient per serving.
A number of SUAs and service providers have developed lists of foods considered good sources of specific nutrients but do not necessarily follow the federal food labeling definitions of good and high sources above. Such lists are commonly available for food sources of calcium, vitamins A and C, and fiber. An example from Colorado SUA is available. A number of websites provide lists of foods that are good sources of selected nutrients. Resources include Room 42 Health Tools, Nutrition Tools, Fitness Tools Resource Center and Healthcheck Systems.
Federal law requires that nutrition label information enable the public to readily comprehend the information and to understand its relative significance in the context of a total daily diet. Daily Values is the dietary reference labeling standard developed by the Food and Drug Administration (FDA) to help consumers plan a healthy overall diet. For various nutrients, it allows consumers to determine the percentage of the Daily Value provided by a serving of a food. It also provides a basis for defining descriptor terms, such as "high fiber" and "low fat" (22).
Daily Values include 2 sets of reference values for nutrients: Daily Reference Values (DRVs) and Reference Daily Intakes (RDIs). DRVs are for nutrients for which no set of standards previously existed, such as fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium. DRVs for the energy-producing nutrients (fat, carbohydrate, protein, and fiber) are based on the number of calories consumed per day. For labeling purposes, 2,000 calories was established as the reference for calculating percent Daily Values in 1990.
Because of the links between certain nutrients and certain diseases, DRVs for some nutrients represent the uppermost limit that is considered desirable. Eating too much fat or cholesterol, for example, has been linked to an increased risk of heart disease. Too much sodium can heighten the risk of high blood pressure in some people.
DRV Label Values for Fats and Sodium
replaced the term "US RDAs" (Recommended Daily Allowances).
The US RDAs are a set of values, based on the 1968 RDAs, that are used
as the food labeling standard by the FDA. These nutrient values are approximately
equivalent to the highest number recommended in the 1968 RDAs for each
of the included nutrients. US RDAs should not be confused with RDAs. The
latter are short for Recommended Dietary Allowances, which are
set by the National Academy of Sciences, and revised periodically. Food
label definitions and nutrient values used generally lag behind the latest
scientific knowledge. Plans are underway to revise the Nutrition Facts
portion of the food label to comply with the newer DRI values.
D. SPECIAL DIETARY NEEDS
Today, menu planning is more challenging due to changes in the nutrient requirements as well as the need to accommodate the growing diversity of older adults. Increasing the number and variety of meal choices can help meet both the personal preferences of program participants and nutritional or special health needs. Meals should be adjusted to meet special dietary needs of program participants to the maximum extent possible (OAA, Section 339). The definition of "maximum extent practical" takes into consideration factors such as characteristics of the older adults served in the community, number of people with a specific need, capacity and capability of the provider, availability of different caterers/vendors, requirements of different funding sources, provider expertise, etc.
The term "special dietary needs" has been variously interpreted to mean: providing meals to meet cultural or ethnic preferences, ie, culturally appropriate; tailoring menus to conform to religious requirements (eg, Kosher, Hallal); and the provision of therapeutic or meals that are modified for health conditions (eg, 2 gm sodium, diabetic, renal, texture-modified). Other interpretations include meals that provide client "choice" or selection of different meal components (eg, 2 different entrees or 3 different vegetables, choice of milk).
better serve defined populations and individuals who require menu customization
or therapeutic diets, the Issue Panel recommended that OANPs utilize Registered
Dietitians in conducting needs assessments of the program population and
in developing appropriate interventions (16). The American Dietetic Association
addressed the use of dietetics professionals in the assessment, planning
and provision of liberalized diets for older individuals. When appropriate,
such diets can enhance both quality of life and nutritional status, thus
increasing the participants satisfaction with the meals provided and reducing
noncompliance to their special dietary needs as well as any risks of malnutrition
and weight loss (23).
Modified meals meet the regular menu pattern, but contain modifications to one or more menu items. The types and amounts of all items must conform to the regular menu pattern. A health professional's authorization is not needed for a participant to receive a modified meal. However, a nutrition program may wish to prioritize the requests for modified meals. The following are examples of modified meals that a nutrition program may provide:
A therapeutic meal changes the meal pattern significantly by either limiting or eliminating one or more menu items, or by limiting the types of foods allowed and resulting in a meal that does not meet the nutrition guidelines of the Program.
Nutrition programs may obtain complex therapeutic meals from a local hospital or other facility under the supervision of a registered dietitian.
Therapeutic diets, such as two grams sodium, 40 grams protein, 1200 Calories, and/or 40 grams fat, may be provided, if feasible, under the supervision of a registered dietitian. A written physician's order may be required to provide such diets. Overly restrictive diet prescriptions with less than these amounts or with multiple restrictions should be discouraged.
The use of medical foods, foods for special dietary uses, and functional foods is increasing. These products 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 (eg, osteoporosis), and/or special needs (eg, 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 special dietary needs of program participants may 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 may allow OANPs to appropriately address individual nutrition needs in a comprehensive individualized nutrition care plan under the direction of an RD or MD. (Definitions are provided at the end of this chapter). By utilizing functional foods, the OANP may be able to more directly address public nutrition issues commonly seen in later years, such as osteoporosis. Functional foods should not be used as a replacement for important conventional foods, for example, replacing dairy products with calcium-fortified orange juice. Because of interrelationships among DRIs, Dietary Guidelines for Americans, and the Food Guide Pyramid, meals should include appropriate numbers of servings from each food group. To appropriately address the use of medical foods, foods for special dietary uses, and/or functional foods, SUAs and/or AAAs need to establish policies and procedures for their use. Such policies may reflect different program and funding requirements such as the Medicaid Waiver program.
Products not to be funded under the OAA include those used for weight loss and have reduced calories and/or fat; single or multiple vitamin or mineral supplements in tablets, capsules, liquids or any form, whether prescribed or over-the-counter; herbal remedies, teas, medicinal oils, laxatives, fiber supplement, etc; and products that require preparation such as powdered mixes or concentrated liquids.
Modifying food texture and consistency may help older adults with chewing and swallowing problems. Chopping, grinding, pureeing or blending foods are common ways to modify food textures. Texture modified food has the same nutritive value of solid foods and it can be just as tasty and appealing. Serving sizes should account for any dilution to the food item during the preparation process. Texture modified foods can be purchased in a variety of forms or may be prepared at home. Thickened liquids are often required for individuals with dysphasia. The provision of such foods should be planned and prepared under the advice of a Registered Dietitian or other appropriate professional, such as an Occupational Therapist or Speech Pathologist.
Meeting the food preferences of program participants can be challenging. Nonetheless, making adaptations to menus is essential. Today's menus often contains common ethnic foods like spaghetti and lasagna, chow mein and stir-fry beef and broccoli, corned beef and cabbage, and fried chicken and sweet potatoes. However, there may be many entrees and side dishes representative of other cultures that are often overlooked. The good feeling that participants have when served favorite ethnic foods partly comes from the recognition that their cultural preferences are important and respected. Providing culturally appropriate, nutritious, high quality, and tasty meals can be effective as outreach to bring in the target population, improve customer satisfaction, promote health and reduce health disparities.
An Ask the Experts: Providing Food Services to Meet the Needs of Your Culturally Diverse Participants offers guidance and suggestions such as:
E. MENU REVIEW AND APPROVAL
menus at State, AAA, or local levels involves verifying that they conform
to nutrition standards and menu policies. Computer analysis ensures that
menus conform to the Dietary Guidelines and provide at least minimal
levels of RDAs for older adults. Reviews may also include recommending
changes when menus contain errors, discouraging the use of extra items
to avoid added food costs, and commenting on the variety of foods, color
appeal, texture, consistency, and use of seasonal foods. States may or
may not require submission of menus for review at that level, but no matter
what level, a registered and/or licensed dietitian (or individual of comparable
expertise) is usually required to complete the review and approval of
menus - or certify the menus (17).
A complete nutritional analysis of the menu shall contain a minimum of: macronutrients:
The nutritional analysis form or equivalent computer analysis sheet should be used for the submission of the nutritional analysis. Nutrition projects are encouraged to utilize the nutritional information of the actual food products. However, if sources of food products vary, an average nutritional analysis may be used (ie, USDA Handbook No. 8).
If a 2nd (and 3rd) meal is provided to any clients for consumption on the same day as the meals mentions above, nutrient analysis shall be performed on the same Nutritional Analysis Form. For example, if an evening, multiple meal or breakfast menu is provided to clients in addition to a noon, regular meal, the 2nd (and 3rd) meal(s) should be submitted along with the "main" meals even if these meals are considered limited selection.
The specific meals that are analyzed may be chosen by the Nutrition Project. Different meals should be selected each quarter (ie, analyzed meals may not be identical to those chosen previously). The SUA may request that a nutritional analysis be performed on any meal which appears not to meet State requirements or for "spot-checking" purposes.
Nutritional analysis and/or full product descriptions for individual items used within Title III meals must be provided or made available by caterers. For consortium or joint menus, only one menu/nutritional analysis is required per menu cycle. It is the decision of the Nutrition Projects which agency(s) shall submit this information to Elder Affairs. If more than one Nutrition Project provides the same frozen/limited selection meal, only one nutritional analysis needs to be submitted. It is the decision of the Nutrition Projects which agency(s) shall submit this information to the SUA.
Menu substitutions should be comparable in nutrient content to the original menu item. SUAs often provide guidance as to the type of substitutions allowed, number of substitutions allowed during a given period of time, and the process to approve such menu changes by nutrition projects and caterers. Some states require that the nutrition program and/or a dietitian approve substitutions before they are served. Other states may also require that menu changes not only be documented and on file with the program but be submitted to the SUA within a certain time after the meal was served. Alabama requires that all menu deliveries to a dining center include an official notice of a menu change. Otherwise, the item must not be served for food safety reasons.
Some States or AAAs have written lists of acceptable food substitutions for each food group on a meal pattern. These list are similar to those in this Chapter: "Suggested Food Group Components and Serving Size," "Some High and Good Sources of Selected Nutrients," and those developed by SUAs and service providers. For example, substitute a high vitamin C source for a fruit; use a high vitamin A source for a vegetable substitute; and replace a meat with cottage cheese or peanut butter. Using a substitution list limits the need for staff to contact the dietitian each and every time there is a need to make a menu change.
F. MEAL SERVICE OPTIONS
It is common to provide a combination of 2 or 3 meals including breakfast, lunch and/or dinner, to participants receiving home-delivered meals. Multiple meal packages are typically delivered with the noon meal. Breakfast, a popular meal with older adults, contributes to their health and well being by increasing intakes of critical nutrient-dense foods associated with positive health outcomes: cereals and grains, complex carbohydrates, fruits, fiber, milk, and dairy products (24). Congregate nutrition programs may also serve breakfast and/or dinner in addition to or instead of lunch.
A number of nutrition programs offer weekend meals to frail, homebound participants receiving home-delivered meals on weekdays. Weekend meals contribute to a nutritionally adequate diet for these individuals and provide respite for caregivers, family, and friends.
Frozen meals are often provided in areas where daily delivery is limited, for weekend meal services, or to enable home delivered meal programs to offer more menu choices. Frozen meals may also be used at congregate sites in rural areas where participation is low and other food service options are not feasible. Such meals are heated and served at the site.
Menu choice using a selective menu can increase participant satisfaction by offering choices for 1 or more food items. For example, nutrition programs may offer 1 entrée but several vegetable or dessert choices. There may be ethnic and religious-based alternatives to choose from or a choice of hot, cold, or ready-to-heat entrees. Home-delivered meal participants may be offered choices of hot meals or frozen meals delivered in advance. Menu choices may also be provided by offering participants a choice of 2 distinct and complete menus. The menus may vary in their ethnic offering (ie, choice of an American or Asian menu), be based on religious custom (eg, Kosher or Hallal), or vegetarian observance.
Emergency meals generally consist of shelf-stable items. Meal packages are provided to participants determined to need at times when the program is unable to deliver meals due to weather or other problems.
Medical food, as defined in Public Law 100-290, The Orphan Drug Amendment of 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.
Medical foods are known by a variety of names, such as nutrition supplements, "liquid meals," and oral supplements. However, the most appropriate statutory term is medical food. It is interesting to note that the very same product, depending on where it is used (and how it is labeled), may at times qualify as a medical food (eg, in an institutional setting) and at other times, if purchased at retail, does not qualify as a medical food. "Non-medical" foods sold at retail always have the mandatory "Nutrition Facts" label.
Food for special dietary uses, according to Section 201 of the Federal Food, Drug, and Cosmetic Act, as the term is applied to food for humans, 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 of the Federal Food, Drug, and Cosmetic Act 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. Older adults and people with little exposure to sunlight may need a vitamin D supplement. People who seldom eat dairy products or other rich sources of calcium need a calcium supplement, and people who eat no animal foods need to take a vitamin B12 supplement. The Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences recommends that adults over age 50 get their vitamin B12 from a supplement or from fortified foods.
Functional foods have no universally accepted definition. However, 2 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 (25). 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 (26).
of Medical Food and Food for Special Dietary Uses In Elderly Nutrition
Programs: Backgrounder. Prepared
for the AoA by the Center, May 1996.
PowerPoint Presentations from the AoA Nutritionists / Administrators Conference (June 2002):
American Dietetic Association: Related Position Statements
Brewer MS, Kendall P. Biotechnology and the future of food -- Position of ADA. J Am Diet Assoc. 1995;95:1429-1432. (reaffirmed and update to be published, 2000).
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4. Ryan C. Role of the dietitian in home care of the elderly. Home Healthcare Consultant. 1998:5;8-15.
LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are
associated inversely with quality of life for participants in meal programs
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Smith R, Mullins L, Mushel M, Roorda J, Colquitt R. An examination of
demographic, socio-cultural, and health differences between congregate
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8. Mathematica Policy Research, Inc. Serving Elders at Risk, the Older Americans Act Nutrition Programs: National Evaluation of the Elderly Nutrition Program 1993-1995, Volume I: Title III Evaluation Findings. Washington, DC: US Department of Health and Human Services; 1996.
11. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998.
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