The Longitudinal Impact of Food Assistance Program Participation on Food Insecurity and Nutritional Risk in Low-Income Community-Dwelling Older Adults in Georgia

Year: 2009

Research Center: Department of Nutrition at the University of California, Davis

Investigator: Lee, Jung Sun, Mary Ann Johnson, Stephanie Sinnett, Rebecca Bengle, and Arvine Brown

Institution: University of Georgia

Project Contact:
Jung Sun Lee
Department of Foods and Nutrition
University of Georgia
Room 129, Barrow Hall
Athens, GA 30602
Phone: 706-542-6783


With the aging population and the current economic recession, the use of convincing research designs and methods to provide evidence that food assistance programs benefit nutritionally vulnerable older adults is more critical than ever. The ideal way to assess the impact of food assistance programs would be to compare outcome measures between participants and nonparticipants with comparable level of needs for food assistance programs. This approach is difficult in practice because the nutritional needs of older participants in food assistance programs are not well characterized and difficult to determine. Furthermore, this problem is complicated by complex social and psychological dynamics of help-seeking behaviors of older adults in need of food assistance programs. A longitudinal study design to sort out need status and program impact and their changes within each older individual across an appropriate time frame is necessary to assess unbiased impacts of food assistance programs in older adults.

The Older Americans Act Nutrition Program (OAANP) has been a primary source of food assistance targeted to older adults with greatest economic and social needs while providing congregate meals (CM) and home delivered meals (HDM). Already unable to meet the program demand, this program is in urgent need of robust research designs, methods, and evidence-based outcome measures to document its benefits. Food insecurity and nutrition risk measured by the Nutrition Screening Initiative DETERMINE Checklist (NSI checklist) have been most widely recommended as outcome measures. However, the feasibility and ability of these measures to detect OAANP’s impact on a large scale is unknown.

This study examined the impact of OAANP participation on food insecurity and nutritional risk, as well as the ability of the NSI checklist to detect this impact among older Georgians, using the unique data collected from the Georgia Advanced Performance Outcome Measures Project 6 (GA Advanced POMP6). GA Advanced POMP6 was designed to accurately measure the impact of OAANP on nutritional health status while adopting several innovative approaches, including the adoption of a longitudinal study design, the waitlisted people as the best available comparable comparison group, and a modified six-item version of U.S. Household Food Security Survey Module (HFSSM) as a sensitive outcome measure of meal services.

This study analyzed two waves of self-administered mail survey data from GA Advanced POMP6 conducted 4 months apart of all persons who began OAANP participation (CM new participant, HDM new participants), as well as those added to program waitlists (CM new waitlisted, HDM new waitlisted) in Georgia between July and early November 2008 (n = 4,952). A self-administered survey measured food insecurity, NSI checklist, and various nutritional health status indicators that were developed and adapted from previously validated survey tools. Additional study participant data were retrieved from the Georgia Aging Information Management System. Descriptive and appropriate longitudinal data analysis methods, including generalized estimating equations and mixed-effects models, were used.

The study population identification process suggested a critical unmet need for OAANP in Georgia. Over the 19-week period when the economic crisis had deepened across the Nation in 2008, about 57.4 percent of those requesting OAANP services, especially a majority of HDM applicants, had to be on the waiting lists. Based on the baseline survey data, those requesting HDM services and waitlisted people were more likely to show poorer sociodemographic and nutritional health status than their counterparts.

The findings of this study suggest that food security can be reasonably measured by a mail survey and a short form of HFSSM in older adults requesting OAANP. Most of the respondents (91 percent) completed all six food security questions. Infit and outfit statistics for each of the six questions and overall Rasch model fit were within an acceptable range. Overall psychometric properties observed in the food security data were comparable to the national food security statistics provided by USDA. Some NSI checklist questions (eating few fruit or vegetable and dairy products), however, showed limited ability to reliably identify older adults at nutritional risk and to detect short-term change in nutrition risk status among OAANP participants. Improving nutrition risk-assessment tools could help to better evaluate nutrition risk and its change over time among vulnerable older adults receiving OAANP services.

OAANP improved participants’ food security over the 4-month period. At baseline, a majority of the sample was food insecure (53.8 percent) and at high nutrition risk (74.9 percent). Waitlisted people reported higher levels of persistent food insecurity (45.9 percent) or becoming food insecure (10.0 percent) than the participants (29.3 percent and 7.1 percent, respectively) over the 4-month period. While considering potential confounding factors, the estimated odds of achieving food security were 1.65 times (95 percent confidence interval: 1.10-2.48) higher in participants than in waitlisted people in the 4-month period.

Georgia’s OAANP is serving a high-risk group of older adults and helped participants achieve food security in 4 months compared with those on the waiting list. However, the critical unmet need is in GA OAANP. Given that achieving optimal nutrition is critical for older Americans to retain their independence and delay disease and disability, improving the capacity and targeting of OAANP is essential.

Direct inquiries about this study to the Project Contact listed above.