July 31, 2017
Social Science Policy Analyst
Office of Policy Support, Food and Nutrition Service
3101 Park Center Drive, Room 1014
Alexandria, VA 22302
Re: Evaluation to Improve Elderly Access
Dear Mr. Burt,
The Academy of Nutrition and Dietetics (the "Academy") and the undersigned partner organizations appreciate the opportunity to submit comments to the Food and Nutrition Service (FNS) at the United States Department of Agriculture (USDA) related to its May 30, 2017 information collection, "Evaluation to Improve Elderly Access." Representing more than 100,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States committed to a vision of a world where all people thrive through the transformative power of food and nutrition. Federal nutrition programs, such as the Supplemental Nutrition Assistance Program (SNAP), provide critical services, including healthy meals, that ameliorate one measure of food insecurity among all participants and help older adults in particular live as independently as possible. The undersigned partner organizations agree with the position of the Academy's that "all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutritional status,"2 and we strongly support FNS’s initiatives to increase seniors' enrollment, access, and utilization of SNAP.
A. Seniors and SNAP
Seniors are a large and growing demographic with significant unmet food security challenges. The population of Americans 65 and over has increased from 35.9 million in 2003 to 44.7 million in 2013 (a 24.7% increase) and is projected to more than double to 98 million in 2060.3 Within this population in 2014, 10.2 million older Americans faced the threat of hunger, representing 15.8% of U.S. adults aged 60 and older.4 Older Americans on fixed incomes include more than 6.3 million seniors living below the poverty level who are eligible to use SNAP's modest allotment to delay the need to make the difficult decision of choosing among two or more necessities, such as food or health care."5
One established purpose of SNAP is to address food insecurity in older adults, and indeed, the program has been effective in that regard over time. Nonetheless, over three million households with seniors experienced food insecurity in 2014, and the total number of such seniors is expected to increase 50% by 2025.6 The National Council on Aging notes the disturbing fact that "3 out of 5 seniors who qualify for SNAP do not apply. This means that 5.2 million seniors miss out on benefits. Older Americans who qualify for SNAP are significantly less likely to participate in the program than other demographic groups."7 Much can and must be done to encourage eligible seniors to apply for and use SNAP, although it will take significant effort to break down existing "barriers related to mobility, technology, and stigma and are discouraged by widespread myths about how the program works and who can qualify."8
We are hopeful as a result of recent efforts to improve access to groceries for homebound seniors and people with disabilities who participate in SNAP. The promise of seniors' continuing independence at home is enhanced now that the USDA can now, for the first time, allow grocery purchasing and delivery services run by government and nonprofit organizations to accept SNAP benefits as payment, allowing for home delivery to those unable to shop for food.9
B. Food Insecurity and Diminished Health Status among Seniors
High rates of seniors' food insecurity brings expensive, concomitant concerns. "[F]ood insecure seniors are 22 percent more likely to experience limitations in their Activities of Daily Living (ADLs), which are those fundamental activities, such as eating, dressing, and bathing, that individuals typically can perform independently."10 In 2014, three million households with seniors older than the age of 65 years experienced food insecurity, while 1.2 million seniors living alone were food insecure. Food-insecure seniors are at an increased risk for chronic health conditions; they are 60% more likely to experience depression, 53% more likely to report a heart attack, and 40% more likely to report an experience of congestive heart failure. These numbers will only get worse as the population ages; by 2025, the number of food-insecure seniors is projected to increase by 50%.11 Food and nutrition services are intended to promote health and quality of life while delaying adverse health conditions, such as malnutrition and injuries from falls, as well as declines in mood and cognitive function. Thus, one critical strategy to bending the curve of health care costs is to focus on improving the nutrition status and food security of Americans generally and seniors specifically through increased enrollment and utilization of low-cost, high return programs such as SNAP.
C. Food Insecurity, Malnutrition, and Hospital Readmissions
One particularly challenging result of food insecurity is malnutrition; studies even show up to 15% of community-dwelling older adults are malnourished.12 Moreover, poor access to healthy food and availability of care are likely predictive factors: malnutrition prevalence is highest in poor, rural, African-American communities and in seniors of advanced age,13 precisely those disparate populations with documented insufficient access and physical limitations restricting accessibility of services.
We recognize the significant impacts of the related high rate of hospital readmissions, some of the causes of which likely originate at time of original discharge. Approximately one out of six Medicare patients are readmitted, with estimated associated annual costs of $17 billion.14 Malnourished adults are 50% more likely to be readmitted, and malnutrition is a factor in almost two million hospital stays annually.15 Moreover, 74 million adults are expected to be eligible for Medicare by 2030, with Medicare costs rising faster than average healthcare costs.16 This convergence of factors translates to substantial additional procedures and costs now and in the future. In addition, significant disruption, pain and discomfort to the patient theoretically could be avoided by assuring seniors are food secure and adequately nourished.
Half of seniors recently discharged from the hospital are malnourished, and hospitalization within the previous six months is a risk factor for malnutrition in some seniors.17 A recent study suggests significant food insecurity in patients with high rates of inpatient hospitalization. According to the study, "[u]sing the USDA definition of food insecurity, 30% (95% CI, 17% to 47%) were food insecure and 25% (95% CI, 13% to 41%) were marginally food secure. Forty percent responded that, in the past 30 days, they worried that their food would run out; 35% that their food would not last; 17.5% that they did not eat for a full day; and 10% that they were hungry but did not eat some or all of the time. More than half reported using food pantries or other community food resources."18 We encourage FNS to ensure the evaluation facilitates assessment of any correlation or causation between hospitalizations and food insecurity.
Recognizing malnutrition's substantial role in readmissions, health care systems are beginning to implement hospital-to-home transition programs.19 These programs may begin with an individualized nutritional follow-up performed during a home visit soon after discharge, which can be shown to reduce readmissions by up to 60%.20 Screening may include evidence-based physical measures such as a handgrip assessment,21 an assessment of food security, functional and sensory capacity to acquire and prepare food,22 as well as social screening to assist patients with issues such as insurance coverage, and access to federal food and nutrition assistance programs, including home-delivered meals and other community services.23 We encourage FNS to work closely with its various partners throughout government, including the Centers for Medicare and Medicaid Services and the Administration on Aging, to identify strategies for avoiding siloes and instead comprehensively assisting seniors with enrolling, accessing, and utilizing the entirety of available benefits to provide wrap-around care that improves their health and lowers health care expenditures.
D. The Impact of Chronic Illness on Ability to Access SNAP
Chronic illness is on the rise for older adults: approximately 92% of older adults have at least one chronic disease, and 77% have at least two.24 Individuals with chronic health conditions count for approximately 86% of all health care spending.25 Combined with the fact that 75% of seniors were unable to shop for food on their own and 58% were unable to prepare their own food, means risk factors align for malnutrition.26
Inability to shop or cook because of illness and ADL limitations is an everyday reality for the clients of agencies in the Food Is Medicine Coalition, an association of nonprofit, medically tailored food and nutrition services (FNS) providers from across the country who provide medical nutrition therapy and millions of medically tailored, home-delivered meals to people living with severe and or chronic illnesses. Clients who come to FIMC agencies for help are unable to eat meals from other meal programs, because of their complicated medical situations and nutritional needs. These senior clients are often eligible for SNAP, but struggle to use the benefits.
We ask FNS to investigate the number of seniors who are unable to shop or cook for themselves due to illness. We also encourage FNS to ensure evaluation of illness-sensitive nutrition models, like the agencies in FIMC, to inform the future of how SNAP benefits might be used.
The Academy and the undersigned appreciate the opportunity to comment on FNS's proposed information collection, "Evaluation to Improve Elderly Access." Whether through collective policy advocacy, or through the efforts of individual members, the Academy and its coalition partners will continue working to demonstrate the connection between improved senior hunger and health outcomes. Please contact either Jeanne Blankenship at 312/899-1730 or by email at email@example.com or Pepin Tuma at 202/775-8277, ext. 6001 or by email at firstname.lastname@example.org with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Government & Regulatory Affairs
Academy of Nutrition and Dietetics
Apicha Community Health Center - New York, NY
Center for Health Law and Policy Innovation of Harvard Law School - Jamaica Plain, MA
Community Servings - Jamaica Plain, MA
Direct Services - Columbus, GA
FeedMore, Inc. - Richmond, VA
Food & Friends - Washington, DC
Food For Thought - Forestville, CA
God's Love We Deliver - New York, NY
Greater Chicago Food Depository - Chicago, IL
Heartland Alliance - Chicago, IL
Hood County Senior Center - Meals on Wheels, Granbury, TX
Kaiser Permanente Home Health Division Diablo Service Area - Contra Costa County, CA
Kitchen Angels - Santa Fe, NM
Mama's Kitchen - San Diego , CA
MANNA - Philadelphia, PA
Meals on Wheels America - Arlington, VA
Meals on Wheels of Central Indiana - Indianapolis, IN
Meals on Wheels of Lehigh County - Allentown, PA
Meals On Wheels of Sheboygan County - Sheboygan, WI
Morongo Basin Healthcare District - Yucca Valley, CA
Moveable Feast - Baltimore, MD
National Association of Nutrition and Aging Services Programs (NANASP) - Washington, DC
OC Food Access Coalition - Santa Ana, CA
Open Hand Atlanta - Atlanta, GA
Project Angel Foo - Burbank, CA
Project Angel Heart - Denver, CO
Project Hospitality - Staten Island, NY
Project Open Hand - San Francisco, CA
SeniorServ - Anaheim, CA
Serving Seniors - San Diego, CA
The FGE Food & Nutrition Team - New York, NY
THE Kitchen - Meals on Wheels - Wichita Falls, TX
The Poverello Center, Inc. - Wilton Manors, FL
Tulsa CARES - Tulsa, OK
West Central IL Area Agency on Aging - Quincy, IL
1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 Kamp B. Position of the American Dietetic Association, American Society for Nutrition, and Society for Nutrition Education: Food and nutrition programs for community-residing older adults. J Am Diet Assoc. 2010;110(3):463-472.
3 US Department of Health and Human Services. A profile of older Americans: 2014. Administration on Aging website. Accessed July 20, 2017.
4 The State of Senior Hunger in America 2014: An Annual Report. National Foundation to End Senior Hunger website (June 2016). Accessed July 20, 2017.
5 Spotlight on Senior Health Adverse Health Outcomes of Food Insecure Older Americans Executive Summary. Feeding America website. Accessed June 20, 2017.
6 Rinehart SW, Folliard JN and Raimondi MP. Building a connection between senior hunger and health outcomes. J Acad Nutr Diet. 2016 May;116(5):759-763.
7 Senior Hunger Fact Sheet. NCOA website. Accessed July 20, 2017.
9 USDA proposes new ways to help meet nutrition needs of low-income, homebound seniors and people with disabilities. Published 2015. Accessed January 27, 2016.
10 Spotlight on Senior Health Adverse Health Outcomes of Food Insecure Older Americans Executive Summary. Feeding America website. Accessed June 20, 2017.
11 Spotlight on Senior Health Adverse Health Outcomes of Food Insecure Older Americans Executive Summary. Feeding America website. Accessed June 20, 2017.
12 Ahmed T, Haboubi, N. Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. 2010; 5: 207–216.
13 Weiss, AJ, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD.
14 Buys DR, et al. Meals Enhancing Nutrition After Discharge: Findings from a Pilot Randomized Controlled Trial. J Acad Nutr Diet. 2017 Apr;117(4):599-608.
15 Weiss, AJ, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD.
16 Defeat Malnutrition Today. (2017). National Blueprint: Achieving Quality Malnutrition Care for Older Adults.
17 Buys, DR, et al.
18 Phipps EJ, Singletary SB, Cooblall CA, Hares HD, Braitman LE. Food Insecurity in Patients with High Hospital Utilization. Popul Health Manag. 2016;19(6):414-420.
19 Buys, DR, et al.
20 Lindegaard Pedersen J, Pedersen PU, Damsgaard EM. Nutritional Follow-Up after Discharge Prevents Readmission to Hospital - A Randomized Clinical Trial. J Nutr Health Aging. 2017;21(1):75-82.
21 Allard JP, et al. Lower handgrip strength at discharge from acute care hospitals is associated with 30-day readmission: A prospective cohort study. Clin Nutr. 2016 Dec;35(6):1535-1542
22 White JV, et al. Managing Postacute Malnutrition (Undernutrition) Risk. JPEN J Parenter Enteral Nutr. 2013 Nov;37(6):816-23.
23 Defeat Malnutrition Today. (2017). National Blueprint: Achieving Quality Malnutrition Care for Older Adults.
24 According to the National Council on Aging. Accessed July 24, 2017).
25 According to 2010 data. Chronic Disease Overview, Ctrs. for Disease Control & Prevention. Accessed Mar. 28, 2017.
26 Ibid. Phipps et al.