The Older Americans Act (OAA), enacted in 1965, and since reauthorized
14 times, established the Administration on Aging (AoA). The
goals of the OAA are to provide services to older individuals with the
greatest economic and social need, especially to low-income minorities and
residents of rural areas. The AoA funds a network of State units on aging
and area agencies on aging (AAA) to coordinate a comprehensive array of
home and community-based services to people ages 60 and older that enable
them to remain in their own homes.
Together, the congregate and home-delivered meals programs constitute the
largest share of funding for any service under Title III of the Older Americans
Act. AAAs administer the nutrition program and contract with
providers to prepare and deliver the meals. Sites for the congregate meals
program include senior centers, schools, and senior housing facilities.
The purpose of this study was to validate a Diet Screening tool developed
by representatives of State and area agencies on aging that participated in
the Performance Outcomes Measures Project (POMP) under the auspices of
AoA. The starting point was the nutrition screening initiative (NSI), which
the network uses for administrative reporting to AoA. POMP grantees modified
the NSI to more accurately reflect areas over which the network had
some influence. The questions on the Diet Screener expanded the NSI by
asking clients to report the number of servings of foods they usually eat in a
day in each major food group and by omitting questions on alcohol
consumption, over-the-counter and prescription drugs, and dental problems
that interfered with eating.
The study served to evaluate a diet adequacy scoring system developed in
POMP to measure the impact of the nutrition program. The adequacy score
assigns the client to one of three categories: “Adequate” (=17), “Marginal”
(16-l1), and “Poor” (<11) diet. The score measures the participants’ food
intake against USDA’s Food Guide Pyramid, published with the Dietary
Guidelines for Americans, 2000.
To evaluate the validity of the POMP Diet Screener, which asks about
food behavior and usual intake for seven foods and food groups, the
study compared it with the Diet History Questionnaire (DHQ), a food
frequency questionnaire (FFQ) developed and validated by the National
Cancer Institute (NCI). The DHQ asks about usual intake over the past
year for more than 130 foods.
Congregate meals clients who had completed the Diet Screener were
recruited in South Bend, IN, and Montgomery County, MD, to participate in
the validation study. Approximately 1 month later an interviewer administered
the food frequency questionnaire by telephone. Data were entered
from the Diet Screener into an Access database, and the FFQ was scanned
using a specific diet calculation program. The Diet*CALC software developed
by NCI yielded nutrient and food group intake estimates from the
DHQ. Analyses included range checks of all data elements to check for
possible outliers and the calculation of adequate servings of food groups and
Diet Adequacy scores for each participant. The study then compared the
adequate serving sizes of the Diet Screener with those of the DHQ, the
criterion measure. Finally, the diet adequacy scores obtained from the two
methods were compared.
The majority of the participants were White females ages 75 and older
living alone with household incomes below $20,000, which is similar to the
demographic profile of participants nationwide.
The Diet Screener performed well compared with the DHQ in estimating
intakes from the Vegetable and Dairy groups. However, it underreported
the number of servings from the fruit category by 31 and 35
percent and grain category by 29-45 percent (males and females, respectively).
It also overreported the number of servings of meat/beans for males
and females by 30 and 40 percent.
Almost 90 percent of males and females met the “Adequate” standard
for number of meals per day using the Diet Screener (this information
was not captured on the DHQ). For all food groups except meat/beans,
however, fewer participants reported an adequate number of servings using
the Diet Screener compared with the DHQ. In addition, while 37 percent
of men and more than 23 percent of women reported adequate grain servings
on the DHQ, none reported an adequate number of servings on the
Diet Screener.
Results suggested that the Diet Screener incorrectly categorized participants
downward compared with the DHQ. The screener classified more than 38
percent of males and almost 40 percent of females as having “Poor” diets,
whereas the DHQ classified only about 20 percent of males and 23 percent
of females into the same category.
The results of this study are in general agreement with earlier findings—
the POMP Diet Screener misreports number of servings for most food
groups and misclassifies congregate meals clients as having “Poor”
diets. These results occurred even though the POMP project area agencies
refined the food questions in the NSI to capture dietary intake in more
detail (suggesting more accuracy). There are a number of possible explanations
for these findings. First, they could be related to people’s perceptions
of what they eat. A USDA study found that older respondents overestimated
their meat/bean, dairy, fruit, and vegetable intakes and underestimated their
grains when using a screener to report intake. Second, they could be associated
with problems in measuring diets among the elderly—memory,
comprehension, literacy, special diets, and dentition can all contribute to
inaccurate reporting. And third, the questionnaire design may have caused
respondents to overreport or underreport their foods. The POMP Diet
Screener has the potential to be a useful tool for the AoA Nutrition
Program to inform the diet adequacy of its clients and measure the impact
of the program on their dietary status. The results of this study provide
valuable information for refining this simple tool to measure diet adequacy
in an elderly population. Future research needs to be considered that
focuses on cognitive and focus group testing to better understand the abilities
of the elderly population to complete a self-administered instrument
about their diet.