Nutrition Assistance Programs: Agencies Could Do More to Help Address the Nutritional Needs of Older Adults

The U.S. population is aging and, by 2030, the U.S. Census Bureau projects that one in five Americans will be 65 or older. Recognizing that adequate nutrition is critical to health, physical ability, and quality of life, the federal government funds various programs to provide nutrition assistance to older adults through meals, food packages, or assistance to purchase food. This report examines (1) the relationship of older adults' nutrition to health outcomes and the extent to which federal nutrition guidelines address older adults' nutritional needs, (2) nutrition requirements in federal nutrition assistance programs serving older adults and how these requirements are overseen, and (3) challenges program providers face in meeting older adults' nutritional needs. GAO reviewed relevant federal laws, regulations, and guidance and conducted a comprehensive literature search; visited a nongeneralizable group of four states—Arizona, Louisiana, Michigan, and Vermont—and 25 meal and food distribution sites, selected for a high percentage of adults 60 or older, and variations in urban and rural locations, and poverty level; and interviewed officials from HHS, USDA, states, national organizations, and local providers.

Research shows that nutrition can affect the health outcomes of older adults. Federal nutrition guidelines provide broad guidance for healthy populations, but do not focus on the varying nutritional needs of older adults. Department of Health and Human Services (HHS) data show that the majority of older adults have chronic conditions, such as diabetes or heart disease. Research shows that such individuals may have different nutritional needs. As older adults age, they may also face barriers, such as a reduced appetite, impairing their ability to meet their nutritional needs. HHS plans to focus on older adults in a future update to the guidelines, but has not documented a plan for doing so. Documenting such a plan could help ensure guidelines better address the needs of the population.

Of the six federal nutrition assistance programs serving older adults, four have requirements for food that states and localities provide directly to participants, and federal agencies oversee states' monitoring of these requirements. In HHS's and U.S. Department of Agriculture's (USDA) meal programs, states must ensure meals meet requirements. Yet, HHS does not gather information from states, such as approved menus, to confirm this, and localities in two of the four selected states said state monitoring of menus was not occurring. Further, USDA regional officials told GAO they lack information on how meal programs operate at adult day care centers as they primarily focus on other sites for their on-site reviews. Additional monitoring could help HHS and USDA ensure meal programs meet nutritional requirements and help providers meet older adults' varying needs.

In the states GAO selected, meal and food providers of the four nutrition programs with nutrition requirements reported various challenges, such as an increased demand for services. Providers in three of the four states reported having waiting lists for services. Providers of HHS and USDA meal programs in all four states also reported challenges tailoring meals to meet certain dietary needs, such as for diabetic or pureed meals. HHS and USDA have provided some information to help address these needs. However, providers and state officials across the four states reported that more information would be useful and could help them better address the varying nutritional needs of older adults.

GAO is making five recommendations, including that HHS develop a plan to include nutrition guidelines for older adults in a future update, and that HHS and USDA improve oversight of meal programs and provide additional information to meal providers to help them meet older adults' nutritional needs. HHS and USDA generally concurred with our recommendations.

The U.S. population is aging and, with life expectancy increasing, the  older adult population is expected to continue growing. By 2030, the U.S.  Census Bureau projects that one in five Americans will be 65 or older.  According to the U.S. Department of Health and Human Services’ (HHS)  Administration on Aging, adequate nutrition is critical to good health,  physical ability, and quality of life, and it is an important component of  home and community-based services for older adults. Various federal  programs provide nutrition assistance to older adults in the form of meals,  food packages, and assistance to purchase food. These include  programs overseen by the U.S. Department of Agriculture (USDA), as  well as programs overseen by HHS that are authorized under the Older  Americans Act of 1965, as amended (Older Americans Act). State  agencies and local nutrition program providers, including state  government entities and private nonprofit organizations, are generally  responsible for administering these programs and providing nutrition  assistance to older adults.

In the last decade, attention has been given to federal nutrition assistance  programs serving children, with a focus on improving the nutritional  benefits of foods provided, but the extent to which this focus has been  incorporated into programs serving older adults is unclear. This report  examines (1) the relationship of older adults’ nutrition to health outcomes  and the extent to which federal nutrition guidelines address older adults’  nutritional needs; (2) the extent to which federal nutrition assistance  programs serving older adults have nutrition-related requirements and  how these requirements are overseen; and (3) challenges program  providers face in meeting the nutritional needs of older adults.

We relied on several methodologies to inform our objectives. At the  federal level, we reviewed relevant federal laws, regulations, guidance,  and program oversight documents, and interviewed relevant officials from  HHS’s Administration for Community Living and USDA’s Food and  Nutrition Service. Specifically, we interviewed officials from the  departments’ national offices and all of their regional offices. To  understand challenges state agencies and local providers faced  implementing federal nutrition assistance programs with nutrition-related  requirements, as well as how these programs are overseen by states, we  visited a nongeneralizable group of four selected states—Arizona,  Louisiana, Michigan, and Vermont—between December 2018 and March  2019. We selected states and local sites within those states with a high  percentage of adults 60 or older, and to ensure variation across the sites  in geographic location, urban and rural location, percentage of older  adults in poverty, and program provider and site type. In the four states,  we interviewed relevant state agency officials, and representatives from  20 local provider organizations and visited 25 meal and food distribution  sites in the selected local areas. Because we relied on a  nongeneralizable sample of sites and states, the views of the entities we  interviewed do not represent the views of all providers of federal nutrition  assistance programs providing meals and food packages to older adults  or participants in those programs. To obtain additional information on  program implementation challenges, we interviewed representatives from  a range of national-level organizations involved in research, service  provision, or advocacy related to nutrition assistance for older adults.

In addition, to address our first objective on older adults’ nutritional needs  and our second objective on nutrition assistance programs with nutrition- related requirements, we reviewed relevant research. Such research  included relevant peer reviewed studies on the relationship between  nutritional needs and health outcomes of older adults, the two federally  supported guidance documents that detail the nutrition requirements for  Americans—the 2015-2020 Dietary Guidelines for Americans and the  Dietary Reference Intakes—and the evaluations of scientific evidence  undertaken to support these guidance documents. In addition, we  reviewed relevant studies evaluating the impact of HHS’s nutrition  assistance programs on older adults’ nutrition.

We assessed efforts by HHS and USDA to ensure federal guidelines  reflect older adults’ nutritional needs, to oversee the nutrition-related  requirements of nutrition assistance programs serving older adults, and to  assist providers of these programs, against Standards for Internal Control  in the Federal Government and other relevant criteria. For more  information on our scope and methodology, see appendix I.

We conducted this work from June 2018 through November 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

The U.S. older adult population is growing and is projected to steadily  increase in the coming decades. By 2060, the U.S. Census Bureau  projects that adults 65 or older will make up nearly one-quarter of the total  U.S. population. In addition to the overall growth in this population, the  number of adults 85 or older is expected to nearly triple, from 6.4 million  in 2016 to 19 million in 2060 (see fig. 1).

Federal Nutrition Assistance Programs Serving Older Adults

Several federal nutrition assistance programs serve older adults, which  are overseen by HHS’s Administration for Community Living (ACL) and  USDA’s Food and Nutrition Service (FNS). The characteristics of older  adults served by these programs vary, as do the types of assistance  provided, the numbers of participants, and the amounts of federal  expenditures (see table 1).

The nutrition assistance programs serving older adults are overseen by  ACL and FNS’s national and regional offices and are generally  administered by state and local entities. The ACL and FNS national  offices allocate funding and develop program regulations and guidance,  and their respective regional offices provide support, such as technical  assistance and training, to state agencies. State agencies implement the  programs directly or through local entities. In the four programs that  provide meals and monthly food packages to participants, state agencies  work with regional and local agencies, such as government entities or  private nonprofit organizations, to provide nutrition assistance to  participants (see fig. 2). Specifically, in FNS’s two programs, state  agencies work directly with local providers, while in ACL’s two programs,  states work with regional level area agencies on aging, which generally  contract with local providers. Area agencies on aging are public or  private nonprofit entities that are responsible for planning and delivering  services to older adults within their geographic service area.

The Dietary Guidelines for Americans and the Dietary Reference Intakes  (DRIs) are the two federally supported scientific bodies of work that  provide broad information and guidance on the nutritional needs of  healthy populations to help individuals maintain health and prevent  nutrition-related chronic diseases. The dietary guidelines are developed  by HHS and USDA and summarized in a federal policy document that  focuses on providing practical nutritional and dietary information and  guidance for Americans ages 2 and older. Overall, the 2015-2020  Dietary Guidelines recommend the consumption of a variety of  vegetables, fruits, grains (at least half of which are whole grains), and  protein, as well as fat-free or low-fat dairy and oils—sources of essential  fatty acids and vitamin E. They also recommend foods and beverages  that limit saturated and trans fats, as well as added sugars and sodium.  Developed by the National Academies of Sciences, Engineering, and  Medicine, the DRIs are a set of values used to plan and assess diets and  nutrient intakes in both the United States and Canada, and the DRIs also  provide scientific support for the development of the dietary guidelines.  Specifically, the DRIs provide nutrient intake recommendations at levels  considered safe for consumption of a wide range of nutrients, including  vitamins, such as vitamins A and C; minerals, such as sodium and iron;  and macronutrients, such as fiber and fat.

Evidence Shows Nutrition Is Associated with Older Adults’ Health Outcomes, but Federal Nutrition Guidelines Do Not Address Their Varying Needs

The Majority of Older Adults Have Chronic Conditions and Evidence Shows Older Adults’ Nutrition Is Associated with Their Health Outcomes

The majority of older adults in the U.S. have chronic conditions, and  evidence shows that nutrition is associated with the development of such  conditions. Older adults are the fastest growing segment of the  population, and they also have the greatest prevalence of chronic  conditions. For example, according to the most recent data available from  the Centers for Disease Control and Prevention (CDC), 62 percent of  older adults 65 and older had more than one chronic condition in 2016,  such as diabetes or heart disease, compared to 18 percent of adults ages  18 to 64. Although the risk of developing chronic conditions increases  with age, research has shown that poor nutrition is a contributor to  negative health outcomes, including many chronic conditions. For  example, research shows that over- and under-consumption of certain  nutrients, in addition to physical inactivity, is associated with the  development of chronic conditions, including certain cancers, obesity,  heart disease, and diabetes. The CDC reported that, in 2016, nutrition- related chronic conditions, including heart disease and stroke, were  among the leading causes of death for older adults 65 and older in the  United States, with heart disease accounting for 25 percent of deaths  among this population.

At the same time, research shows that nutrients and diet can prevent,  delay, or assist in managing many chronic conditions, and individuals with  certain chronic conditions may have different nutritional needs compared  to healthy individuals. For example, according to research reviewed  during development of the dietary guidelines and DRIs: diets low in sodium that also replace some carbohydrates with protein  or unsaturated fats lower blood pressure and cholesterol levels, both  reducing the risk of developing heart disease and helping to manage  it;  consumption of certain types of dietary fats, such as omega-3 fatty  acids found in fish and flaxseed, for example, may help prevent or  manage heart disease;  increased consumption of fiber reduces total blood cholesterol, and  high cholesterol is both a chronic condition as well as an increased  risk for developing other chronic conditions, such as heart disease  and stroke; and decreased consumption of foods high in added sugars, saturated fats,  and sodium helps reduce the risk of diabetes, stroke, or heart attack.

Barriers to Older Adults’ Meeting Nutritional Needs May Negatively Affect Their Health Outcomes

Research has shown that certain age-related changes may impair older  adults’ ability to meet their nutritional needs, potentially resulting in  negative health outcomes. According to a study conducted by the  Academy of Nutrition and Dietetics, physiological changes that occur with  age, such as decreased metabolism and reductions in muscle mass and  nutrient absorption, may make it difficult for older adults to meet their  nutritional needs. Research reviewed to develop the dietary guidelines  also indicates that older adults experience a decline in calorie or energy  needs as they age, due in part to decreased physical activity. As a result  of reduced energy needs, older adults exhibit less hunger and also  experience changes in taste sensation and sense of smell, all of which  may lead to decreased food consumption, according to the Academy of  Nutrition and Dietetics study. Inadequate consumption of certain  nutrients, such as potassium, may lead to increased risk of negative  health outcomes, including the development of chronic conditions, as  noted earlier.

Age-related physical or mental impairments also may impact older adults’  ability to meet their nutritional needs, potentially resulting in negative  health outcomes. The Older Americans Act defines disability to include a  physical or mental impairment, or combination of the two, that results in  substantial functional limitations to certain major life activities, including  self-care and mobility, among other things. An HHS official we spoke  with noted that some older adults’ inability to perform daily activities— which can include eating, walking, or leaving the home to obtain groceries  or meals, because of a physical or mental impairment—can contribute to  inadequate nutrition. According to the CDC, age-related declines in  cognitive functioning, such as the ability to reason and remember, may  affect some older adults’ ability to leave their homes and shop for food,  hindering their ability to meet their nutritional needs.

Further, HHS reported that older adults with age-related physical  impairments, such as impaired mobility and vision, may have difficulty  opening, reading, and using food packaging, limiting their ability to  prepare food. According to an Academy of Nutrition and Dietetics study,  older adults with a physical impairment, such as an inability to chew or  swallow food, may have reduced ability to consume nutrients, which, as  previously noted, may increase their risk of negative health outcomes.

Older adults may also require the use of medication, which may impact  their ability to absorb or consume nutrients and meet their nutritional  needs. For example, according to the National Institute on Aging,  common side effects of certain medications can include reduced appetite  and dry mouth, which may make it difficult to chew and swallow. In  addition, some medications require older adults to limit their consumption  of certain foods, such as citrus fruit, as consumption of these foods may  change the effectiveness of the medications or cause other negative  health outcomes. However, such restrictions may impact older adults’  ability to obtain the nutrients commonly found in those foods.

Further, some older adults experience food insecurity, and therefore have  limited access to adequate food and nutrients, which research has shown  may lead to negative health outcomes. According to research reviewed  to develop the dietary guidelines, food insecurity is a leading nutrition- related public health issue that compromises nutrient intake, potentially  resulting in an increased risk of developing a chronic condition, as well as  difficulty managing chronic conditions. USDA reported that 8 percent of  U.S. households with an older adult and 9 percent of U.S. households in  which an older adult lived alone experienced food insecurity in 2017—the  most recent year for which data are available. According to HHS, food  insecure older adults are more likely to experience negative health  outcomes than their food secure counterparts. For example, research  has shown that older adults who are food insecure consume lower  amounts of essential nutrients and are more likely to experience negative  health outcomes, like diabetes or physical or mental impairments.

Federal Nutrition Guidelines Do Not Address the Varying Nutritional Needs of Older Adults

The federal nutrition guidelines—the dietary guidelines and Dietary  Reference Intakes (DRIs)—provide broad nutrition guidance for healthy  populations. However, the guidelines do not address the nutritional needs  of older adults, including the majority of older adults in the United States  who have multiple chronic conditions. Specifically, the guidelines focus  on the foods and nutrients healthy individuals need to maintain health and  prevent nutrition-related chronic conditions, which limit their applicability  to older adults who already have chronic conditions. According to the  scientific report for the 2015-2020 Dietary Guidelines, the guidelines are  expected to evolve to address public health concerns and the nutritional  needs of specific populations. Further, a report from a DRI working  group indicates that the growth of the older adult population and the  prevalence of chronic conditions in this group highlight the importance of  understanding how nutrition can help to address chronic conditions.  Although DRI researchers recently took steps to examine research on the  relationship between nutrition and chronic conditions, they noted in a  March 2019 report that current research on this issue is somewhat  limited.

At the same time, the federal nutrition guidelines do not address the  varying nutritional needs of older adults of different ages and instead  focus on guidelines for broad age groups. Specifically, the dietary  guidelines provide information by gender on the nutrient needs of all adults 51 or older, and the DRIs provide this information by gender for  older adults 51 through 70 and 71 or older. However, research has shown  that these broad age categories do not account for how needs change  with age among older adults, particularly for those 71 or older. For  instance, according to the Academy of Nutrition and Dietetics study, the  nutrient needs of older adults can be wide-ranging given the various  changes that may occur with aging, such as those associated with  reduced energy needs. Further, according to a summary report on the  DRIs, physiological functioning, such as nutrient absorption, varies greatly  after age 70. HHS officials similarly noted that nutritional needs change  with each stage in life, and the needs of older adults who are in their 60s  and those who are in their 90s or older may be substantially different.

Additionally, researchers note that information on the varying nutritional  needs of the different age groups of older adults is limited. For instance,  the advisory committee that developed the 2015-2020 Dietary Guidelines  noted that more data are needed on older adults’ diets, particularly for  those 71 or older, and the degree to which age-related changes affect  older adults’ ability to establish and maintain proper nutrition. Similarly,  researchers at the Jean Mayer USDA Human Nutrition Research Center  on Aging—one of the largest research centers studying nutrition and  aging in the United States—told us that research on different age groups  has been hindered in part by limitations in national nutrition and health  data on older adults, and adults 85 or older, in particular, despite the  projected growth of this age group.

HHS officials said they intend to include a focus on nutritional guidance  for older adults in the 2025-2030 Dietary Guidelines update, but they  have not yet documented their plans to do so. Broadly, HHS and USDA  officials told us they intend to address the nutritional needs of individuals  across the entire lifespan in future updates to the dietary guidelines.  USDA is leading the 2020-2025 Dietary Guidelines update, which will  include guidance for those individuals in the earliest stages of life. HHS  officials said that when they lead the 2025-2030 Dietary Guidelines  update, they intend to include a focus on nutritional guidance for older  adults. However, HHS has not yet documented this intention, such as  through a formal plan. As noted, older adults’ nutritional needs can vary  with age and many face certain challenges that additional nutrition  guidance could help address, such as the management of chronic  conditions or age-related changes, yet guidance currently falls short in  part because of limited research evaluating older adults’ nutritional needs.  In its Strategic Plan for fiscal years 2018-2022, HHS notes that one of the  department’s objectives is to prevent, treat, and control communicable  diseases and chronic conditions. As previously noted, the dietary  guidelines are also expected to evolve to address public health concerns  and the nutritional needs of specific populations. A plan for incorporating  a focus on older adults in a future dietary guidelines update, such as one  that addresses their various needs based on available research on this  population and identifies existing information gaps, could help ensure  federal nutrition guidelines better address the nutritional needs of this  population.

Several Nutrition Assistance Programs Serving Older Adults Include Nutrition- Related Requirements, and Federal Oversight of Requirements in Some Programs Is Limited Four of the Six Federal Nutrition Assistance Programs Serving Older Adults Include Nutrition Requirements

The four federal nutrition assistance programs that we reviewed and that  provide meals and food directly to older adults have federal nutrition  requirements, while two other programs we reviewed that provide older  adults with benefits to purchase food do not. Specifically, HHS’s  congregate and home-delivered meal programs and USDA’s Child and  Adult Care Food Program (CACFP) have nutrition requirements for older  adults’ meals, and the Commodity Supplemental Food Program (CSFP)  has nutrition requirements for the monthly food package provided to older  adults. Two other federal programs—USDA’s Supplemental Nutrition  Assistance Program (SNAP) and Senior Farmers’ Market Nutrition  Program—provide older adults with benefits to purchase food, and neither  program has specific nutritional requirements that must be met when  purchasing food.

The four programs with nutrition requirements used the federal nutrition  guidelines—the Dietary Guidelines for Americans—as the basis for their  nutrition requirements. These guidelines are also the basis for nutrition  requirements in other federal nutrition assistance programs, such as  those that serve children. As discussed earlier, the current guidelines  provide broad guidance on nutrition for healthy populations and therefore  serve a role in health promotion for all individuals.

Several Programs Also Require the Provision of Services to Help Older Adults Meet Nutritional Needs Nutrition Education

Several of the nutrition assistance programs that have nutrition  requirements for meals or food served to older adults also require other  services to help ensure older adults’ nutritional needs are met. These  services include nutrition education, screenings and assessments, and  the use of nutrition professionals.

Three of the four selected nutrition assistance programs serving older  adults that have nutrition requirements also require nutrition education to  support efforts to meet older adults’ nutritional needs. These programs  are HHS’s congregate and home-delivered meal programs and USDA’s  CSFP, which provides monthly food packages. See figure 5 for  examples of nutrition education materials from selected states.

To help promote health and delay adverse health conditions among older  adults, area agencies on aging, either directly or through their local  providers, are required to provide nutrition education to congregate and  home-delivered meal participants. According to HHS regional officials  we spoke with, there are no requirements for the frequency or type of  nutrition education that must be provided, though as officials in one region  noted, programs are encouraged to provide education that is science- based. According to the nationwide evaluation of the congregate and  home-delivered meal programs, almost half of state agencies surveyed in  2014 required area agencies on aging, either directly or through their  local providers, to provide nutrition education at least quarterly, and about  one-quarter of state agencies require it to be provided semi-annually or  annually. Officials from two of the four state agencies told us local  providers educate participants in a variety of ways, including by directly  sharing nutrition-related information about specific menu items or meals  offered to participants or by partnering with other entities, such as  universities, to help educate older adults on nutritional well-being.

State agencies overseeing CSFP food packages must also establish a  nutrition education plan and ensure that local providers provide nutrition  education to program participants. For example, providers must include  information about the nutritional value and use of the foods provided in  the food package and should account for specific ethnic and cultural  characteristics of program participants. USDA regional officials and  state agency officials overseeing CSFP in three of the four states told us  that providers generally use USDA’s household foods fact sheets—which  includes food product descriptions, general food storage information,  recipes, and nutritional information—to provide nutrition education to  CSFP participants. State officials in our selected states also noted other  methods CSFP providers used to support nutrition education. For  example, officials in one of the states told us one of their distribution sites  provides nutrition education materials in 17 languages to accommodate  the different cultural backgrounds of the population it serves. Officials in  another state we visited told us some of their provider sites partner with  universities, inviting staff from the university’s nutrition program to the  provider site to share and discuss nutrition information with participants.

Both of HHS’s congregate and home-delivered meal programs require  states to ensure area agencies on aging or local providers conduct  nutrition screenings and assessments of participants to help identify  health risks.

According to HHS data for fiscal year 2016, the most recent year for  which data are available, just over one-fifth (347,002) of the 1.6 million  congregate meal participants served and more than one-half (496,729) of  the 868,382 home-delivered meal participants served were deemed at  high nutrition risk. HHS officials stated that there is no federal policy or  requirement on how assessments are conducted or their frequency, and  states have the flexibility to determine their own process for assessing the  nutritional needs of participants. However, HHS provides a tool that states  may use for these assessments. See sidebar for the Federal Nutrition  Screening tool used to determine a person’s nutrition risk. According to  the nationwide evaluation of the congregate and home-delivered meal  programs, over half of area agencies on aging and local providers of  congregate and home-delivered meal programs had a formal process for  assessing nutritional needs. Further, HHS regional officials we spoke  with suggested that these assessments generally occur annually. Across  the four selected states we visited, the majority of area agencies on aging  conducted nutrition screenings and assessments, with the frequency  varying from every 6 months to every few years.  The Older Americans  Act requires states to prioritize certain groups with high social and  economic needs, such as those who are low-income, minorities, or  isolated, and two area agencies on aging told us they use nutrition risk  screenings and assessments to address malnutrition and identify those  individuals who fall in these categories.

HHS’s congregate and home-delivered meal programs require the use of  nutrition professionals, such as registered dieticians, to help local  providers meet the nutritional needs of older adults—primarily through menu reviews to verify that each menu is following federal nutrition  requirements, according to HHS officials. According to the nationwide  evaluation of the congregate and home-delivered meal programs, at least  one-half of the state agencies, area agencies on aging, and local  providers used the services of a nutrition professional to help meet the  nutritional needs of older adults. In the four selected states, three state  agencies had a nutrition professional on staff or contracted with a nutrition  professional who worked with area agencies on aging to review menus,  and in the other state, a nutrition professional was on staff or contracted  for by area agencies on aging or local provider sites. In addition to menu  reviews, nutrition professionals in the four selected states were also  involved in activities such as training meal providers or providing nutrition  education and counseling to participants.

Federal Oversight of Meal Programs Provides Limited Information on the Extent to Which Programs Are Adhering to Nutritional Requirements and Addressing Challenges

As part of HHS’s oversight of the congregate and home-delivered meal  programs, regional officials meet with state staff and review state plans  and other program information, but these efforts do not require states to  provide documentation that meals served to participants comply with the  programs’ nutrition requirements. State agencies are responsible for  monitoring area agencies on aging’ implementation of these programs  and ensuring that meals are consistent with the programs’ nutritional  requirements. HHS regional offices, in turn, conduct oversight of the  nutrition programs through its reviews of states. HHS’s guidance directs  regional staff to collect information from states on the use of nutrition  professionals in these programs. However, HHS’s guidance does not  direct regional staff to systematically review or collect any other  information from states, such as approved menus, to confirm that meals  served to participants are consistent with the programs’ nutrition  requirements.

A recent national evaluation of meals provided through the congregate  and home-delivered meal programs, however, indicates that state  oversight of meals’ consistency with program nutrition requirements may  have limitations. According to the 2017 evaluation, while program meals  generally contributed positively to participants’ diets, the meals were  higher in sodium and saturated fat than the recommended limits. For  example, the diets of the majority of congregate and home-delivered meal  participants included adequate amounts of a range of vitamins and  minerals, with the exception of magnesium and calcium. However, a  majority of participants had intakes of sodium and saturated fat from  these meals that exceeded the dietary guidelines’ recommended limits.  Specifically, 94 percent of congregate meal participants and 69 percent of  home-delivered meal participants had sodium intakes from program  meals that exceeded the dietary guidelines’ recommended limit.  Likewise, 89 percent of congregate meal participants and 72 percent of  home-delivered meal participants had saturated fat intakes from program  meals that exceeded the recommended limit, despite the role state  agencies play in monitoring programs to ensure meals meet federal  nutrition requirements. According to the evaluation, overconsumption of  sodium and saturated fat may pose a public health concern.

Information obtained from the selected states we visited also suggests  that state oversight of congregate and home-delivered meals’ consistency  with program nutritional requirements may have limitations. Specifically,  some selected states did not utilize a nutrition professional at the state  level to help ensure meals served through the programs met federal  nutrition requirements. For example, in one state, the state-level nutrition  professional position was vacant and, officials from an area agency on  aging we spoke with confirmed that state-level monitoring of menus for  compliance with nutrition requirements had not occurred due to the  vacancy. Area agency on aging officials added that the vacancy has also  meant that state staff are not available to train or provide guidance to  area agencies on the programs’ nutrition requirements. In the other state,  officials from an area agency on aging told us the state agency has not  focused on oversight of providers’ menus. HHS is responsible for  overseeing its federal nutrition assistance programs to ensure compliance  with the programs’ nutrition requirements. More complete information on  state efforts to assess meal consistency with federal nutrition  requirements could help HHS assure that meals served to program  participants are meeting those requirements.

In USDA’s CACFP, which provides meals to older adults at adult day care  centers, USDA regional offices review states’ monitoring of local  providers for consistency with federal meal pattern requirements. States  are required to review each entity involved in the CACFP at least once  every 3 years. During these reviews, state staff must assess provider  compliance with federal requirements, which includes a review of a  sample of the provider’s menus to ensure they comply with federal meal  pattern requirements. Through federal management evaluations, USDA  regional staff review states’ monitoring of the program, including their  reviews of menus to ensure compliance with meal pattern requirements,  and conduct onsite reviews at both the state agency and local provider  level. Regional staff told us they review all states at least once every 3  years.

However, USDA regional officials told us they lack information on how the  program is working at adult day care centers, in part because its onsite  reviews of adult day care providers are generally limited, unlike on the  child care side of the program. According to USDA officials, the majority  of state agencies oversee both child care and adult day care CACFP  providers, and USDA’s criteria for selecting providers for onsite reviews  focus on those providers receiving the highest reimbursement amounts.  According to regional officials, because CACFP serves a significantly  greater number of meals to children than to adults, providers receiving the  highest reimbursement amounts are those serving meals in child care  sites in the majority of states. Thus, federal onsite reviews of providers  serving meals to older adults in adult day care centers generally have  been limited.

USDA’s regional officials told us that because they have not done onsite  reviews at most adult day care centers recently, they lack information on  how the program is working in those centers. USDA officials in four of the  seven regional offices told us they receive few questions or requests for  technical assistance from state agencies or providers operating the  program in adult day care centers. However, our discussions with  providers in the four selected states suggest that they face challenges  operating the program in these centers and addressing the varying needs  of participants they serve, such as those with physical and mental  impairments, and may benefit from additional information or assistance.  USDA is statutorily required to review state agency and provider  compliance with regulations governing program administration and  operation of certain nutrition assistance programs, including CACFP.  Further, USDA guidance notes that its management evaluations are  critical for monitoring state agency program compliance and improving  program operations by providing a basis for assessing the administration  of the CACFP and developing solutions to challenges in program  operations. Without taking action to ensure on-site reviews of adult day  care centers participating in CACFP are conducted more consistently,  USDA may be missing an opportunity to identify and help address  challenges adult day care centers face in operating the program, such as  challenges meeting varied needs of participants. Such efforts could help  them better assess the extent to which centers are meeting the nutritional  needs of the older adults they serve and to better target technical  assistance.

For USDA’s CSFP, which provides monthly food packages to older  adults, USDA regional office oversight includes reviews of state agencies’  monitoring of local providers and visits to local providers, covering all  states at least once every 3-5 years. Regional staff indicated that they  review monthly participation data, food inventory reports, and state plans  as part of their oversight of the program. As part of their visits with local  providers, regional officials told us they open and review food packages  at local sites to ensure packages include the required food components  and assess the types of nutrition education provided to participants, such  as recipes or cooking classes.

Providers Face Challenges, Such as Increased Demand for Nutrition Programs and Meal Accommodations, and Some Lack Information to Address Them Providers Reported Challenges Meeting Increased Demand for Nutrition Programs, with Some Leveraging Additional Resources to Meet Needs

The growth in the older adult population has led to an increased demand  for nutrition programs to serve them, and some providers told us they  faced challenges meeting the nutritional needs of this population. From  2009 through 2018, the population of adults 60 or older grew by 31  percent. Federal funding for certain nutrition assistance programs  serving older adults has not increased at the same rate as the  population. Specifically, during that same time period, federal funding  for HHS’s congregate and home delivered meal programs grew by 13  percent. HHS officials told us that with the increased demand for these  programs and relatively flat federal funding, some providers have been  unable to maintain the same level and quality of service that they have  historically provided.

According to state officials and providers in three of the four selected  states we visited, the increased demand for older adult nutrition programs  has resulted in waiting lists, in particular for the home-delivered meal  program. For example, state officials in one selected state we visited  told us they have large waiting lists in their state for the home-delivered  meal programs due to a higher demand for services. They indicated that,  in the absence of other changes, they will only be able to serve new  people through attrition of current program participants. One provider in  the same state said they have a waiting list of more than 12,000 older  adults for their home-delivered meal program. Another provider told us  they are currently serving about 10 percent of the older adult population in  their area, although the need for these services is greater, and they have  continually had a waiting list for their home-delivered meal program.

Some providers have leveraged additional funding sources to decrease  waiting lists and expand the reach of their congregate and home- delivered meal programs. Specifically, in two of the four states we visited,  some providers said they have received additional funding to support  nutrition and other services for older adults through a local property tax— called a millage tax. In one of these states, a local provider told us that  the local millage tax provided $9.8 million for older adult services in 2018.  Officials noted that these funds allowed providers to add new meal routes  and decrease waiting lists for home-delivered meals, as well expand the  capacity of senior centers to serve more older adults through nutrition and  other programs.

In three of the four selected states, some providers reported partnering  with various entities, including grocery stores, local farmers, and others to  obtain food at low or no cost or serve more older adults, which helped  them to meet the increased demand for the congregate and home- delivered meal programs. For example, in one state, the area agency on  aging that directly provides meals joined a larger consortium of  organizations to purchase food at a lower cost from a food vendor. In  another state we visited, a provider we spoke with reported that the  majority of its food for older adults’ meals came from food donations provided by local grocery stores and food banks and through a program  in which local farmers dedicate some of their produce for donation. This  provider indicated that food donations saved them $140,000 in food costs  in 2018 (see fig.6).

Providers Face Challenges Meeting Needs for Certain Meal Accommodations and Some Lack Information to Help Address These Needs.

Providers we spoke with in the four selected states reported challenges  meeting older adults’ needs for certain meal accommodations, and both  providers and state officials that administer the congregate and home- delivered meal programs as well as the CACFP meal program across the  four states reported a need for additional information from the federal  agencies overseeing these programs. As previously noted, the majority of  older adults in the United States now have more than one chronic  condition and older adults may have physical or mental impairments—all  factors that may necessitate certain accommodations to ensure meals  meet their nutritional needs. Although some providers we spoke with have  taken steps to mitigate challenges meeting these needs, some reported  that they continue to face challenges, such as the lack of skilled chefs  and other resources, to make such accommodations.

Congregate and Home- Delivered Meal Programs

Providers of HHS’s congregate and home-delivered meal programs in  three of the four states said they faced challenges making meal  accommodations to meet the dietary needs of older adult participants with  chronic health conditions. As previously noted, 62 percent of older adults  65 and older had more than one chronic health condition in 2016—the  most recent year for which data are available. Eight of the 14 congregate  and home-delivered meal providers across the selected states we visited  said they do not tailor meals to meet participants’ special dietary needs— for example, due in part to limited resources and capacity. For example,  four providers told us it is cost prohibitive to tailor meals. At one site we  visited that does tailor meals, local officials told us that their vendor  charges more for tailored meals because of the additional work involved  to customize meals to meet the needs of participants with specific health  conditions. Another provider said that some chefs lack the skills needed  to prepare such meals. For example, the provider said that although  some older adults need mechanically soft or pureed meals because of  oral health issues, staff may lack the skills to produce those meals.  Federal restrictions on reimbursing liquid meals may make providing such  meals cost-prohibitive, according to officials in selected states. For  example, state and local officials and a provider in two selected states  said that program participants who are unable to chew, swallow, or digest  solid foods due to various health conditions, may need such meals, yet  these meals do not qualify for federal meal reimbursement. According to  HHS officials, while a liquid meal does not qualify for meal replacement,  states may use federal funds dedicated to providing nutrition education,  counseling, and other aging services to purchase these meals.

Some of these program providers in the selected states used additional  funding sources to help them make meal accommodations for program  participants with special dietary needs, and HHS also funds awards that  can be used for this purpose. For example, an area agency in one  selected state we visited received a grant from a local foundation to  provide some of their home-delivered meal participants with special  dietary meals, including for those with renal conditions and diabetes for  up to 3 months. Similarly, another provider used a grant to provide liquid  meals to home-delivered meal participants who needed them. Since  2017, HHS has also awarded grants to support innovative projects that  enhance the quality, effectiveness, and outcomes of the congregate and  home-delivered meal programs, and some of the projects have focused  on providing meal accommodations for certain program participants. For  example, a grantee in one state used these grant funds to develop and  deliver modified meals appropriate for home-delivered meal participants  with reduced dental function. Another state grantee created new  medically-tailored meals for program participants transitioning from  hospital to home.

According to HHS officials, the department has seen positive preliminary  results from the innovation grants, but does not currently have a  centralized location that compiles information for congregate and home- delivered meals providers on promising approaches for making meal  accommodations for participants with special dietary needs. HHS officials  said they have shared some information on the projects through webinars  and conferences and provided links to webinar materials on the National  Resource Center on Nutrition and Aging website—funded by HHS.  Further, HHS officials noted that they posted additional relevant materials,  such as a toolkit focused on lowering sodium in meals, on the Center’s  website. However, these materials are not compiled in one location on the  Center’s website, which may hinder meal providers’ ability to locate all of  the relevant information HHS has compiled. State officials and providers  across the four selected states said that federal guidance on  accommodating the special dietary needs of older adult program  participants is limited and additional support would be helpful. HHS is  responsible for collecting and disseminating information on older adults.  Providing information on promising practices and available opportunities  may help support providers’ efforts to accommodate the special dietary  needs of some older adults participating in these programs.

Child and Adult Care Food Program (CACFP)

State and local entities administering USDA’s CACFP in adult day care  centers in the four selected states reported that they face challenges  providing meal accommodations to meet the nutritional needs of program  participants. Officials in three selected states said they believe the  federally-required meal patterns do not fully address older adults’  nutritional needs, including those with special dietary needs. For  example, milk is a federally-required component of breakfasts and  lunches served through the program, though officials from three selected  states said that milk can be problematic for older adults because many  are lactose-intolerant or do not like drinking milk. Further, officials in one  state said that the meal pattern includes a significant amount of  carbohydrates, which is inconsistent with the needs of older adults who  have diabetes. Although CACFP requires adult day care centers to serve  meals consistent with federal meal pattern requirements or a participant’s  plan of care, which may include medically-prescribed meal  accommodations, state officials reported some older adults face barriers  to obtaining medical documentation of meal accommodation needs.  Specifically, officials from two selected states said that some participants  may not have access to medical providers, and officials from one of those  states explained that a visit to a medical provider is sometimes cost- prohibitive for those with limited incomes.

Officials in two of the four selected states said adult day care meal  providers have used available federal options that allow older adults to  tailor their own meals to meet their nutritional needs, though officials also  noted that these options have limitations. For example:

State officials in one selected state said they encourage adult day  care centers to implement the federal “offer versus serve” option. This  option allows adult participants, including older adults, to decline, for  example, up to two of the five meal components required with a  lunch—milk, fruits or vegetables, grains, and meat or meat alternate.  According to USDA guidance, this option may reduce waste and give  adults more choices. However, officials in this state noted that  making choices is sometimes difficult and time-consuming for  program participants with cognitive impairments, such as Alzheimer’s  disease or dementia.

State officials in another state said that the federal family-style meal  service option, which allows older adults to serve themselves from  communal platters of food with assistance from supervising adults, if  needed, also provides older adults with the ability to tailor meals to  meet their needs. However, state officials in this state noted this meal  service approach also creates challenges with feeding certain older  adults appropriately. For example, this approach makes it harder to  meet the needs of those with particular dietary or functional  requirements, such as those who have specific nutritional needs due  to chronic conditions or those with swallowing or chewing issues.

State officials and adult day care providers across all four selected states  said that federal guidance for providing meals to older adults in adult day  care centers is limited, and providers in two of the states said they lack  information on ways to address some of the challenges associated with  providing meals that meet the nutritional needs of older adults in these  centers. For example, providers noted that information on promising  practices for serving the differing needs of older adults in these centers,  including those with special dietary needs and those with functional  limitations, would assist their efforts to meet participants’ nutritional  needs. State officials or providers in all four selected states said that  FNS’s efforts to provide guidance and trainings are more focused on the  child care component of the CACFP than the adult day care component.  USDA officials confirmed their efforts to provide guidance to meal  providers have been primarily focused on the child care side of the  program in light of the larger number of participants served.

Although USDA provides some guidance and information to address the  adult component of the CACFP, some CACFP entities serving older  adults may not be aware of these resources, and information on  promising practices or other resources to help providers meet the varying  needs of older adults is more limited. USDA officials said CACFP  guidance and trainings address the implementation of adult meal pattern  requirements and existing flexibilities with these requirements, such as  allowable substitutions for milk. USDA also produced a handbook  specifically for adult day care centers in 2014 to help assist providers in  these centers. However, USDA officials said that awareness of existing  guidance and trainings available may be lacking, in part, because  turnover for CACFP providers is high and new providers may not be  aware of existing resources. Some providers also said that more  information on how to address the special dietary needs and functional  limitations of some participants would be helpful, as USDA’s existing  guidance and trainings focus on standard adult meal pattern  requirements. For example, while the 2014 handbook includes  information on meal patterns and different serving methods to provide  meals, it does not include information specific to meeting the differing  needs of older adults in these centers. In October 2019, USDA officials  told us that they are in the process of updating this handbook to reflect new policies, guidance, and promising practices for addressing the needs  of older adults. USDA officials also stated that they are in the process of  reviewing a promising practice to address meal accommodations for older  adults with varying needs. USDA is responsible for providing training and  technical assistance to states in order to assist state agencies with  program management and facilitate effective operation of the program.  Without awareness of existing resources and additional guidance and  information to help adult day care providers address the challenges they  face meeting the nutritional needs of the older adults they serve,  providers may continue to be limited in their ability to do so.

Commodity Supplemental Food Program (CSFP)

USDA, state, and local officials administering the CSFP said that the  federal requirements for foods provided in each monthly food package  limit the extent to which providers can tailor or alter the foods provided to  accommodate individual participants’ nutritional needs; though some  approaches and recent changes help address this challenge. For  example, two food package providers we spoke with said they use other  methods of food delivery along with the food package such as a pantry or  grocery store-style model, which allows participants to come to a site and  choose from a variety of foods that meet the requirements (see fig. 7).  USDA also recently issued updated federal requirements for the type and  quantity of foods provided in the food package, which department officials  said provide more variety to be more useful to older adults. As previously  noted, some regional USDA officials told us that early feedback from  states on the changes has been positive, though states have until  November 2019 to implement the new requirements. For example, USDA  officials in one regional office said states provided positive feedback on  the introduction of new food items, such as lentils.

Providers Also Reported Other Challenges That Hinder Efforts to Meet Older Adults’ Nutritional Needs, Though Some Have Taken Actions to Help Address Them

Providers reported ongoing program administration challenges, such as  staffing constraints, which to some extent challenge their efforts to meet  the nutritional needs of older adults. For example, state and local officials  and providers of the congregate and home-delivered meal programs  across three of the four selected states said they face challenges finding  and retaining a sufficient number of staff for program operations, which  could include preparing and serving meals, and delivering meals. Four of  the 14 providers of these programs reported that they struggle to offer  competitive wages and benefits, which hinders their ability to hire and  retain staff.

To help overcome staffing constraints, some providers partnered with  various entities. For example, in all four selected states, providers of the  congregate and home-delivered meal programs established partnerships  with entities such as colleges and local businesses to solicit volunteers to  help with program operations. In one state, a provider partnered with a  local college’s nursing program and students volunteered to assist with  assessments for home-delivered meal participants. In another state, staff  from a local police department volunteer and deliver meals to home- delivered meal participants in one area. One meal provider said that the  efforts of volunteers, who donate their time and cover expenses for gas  and vehicle insurance to help provide home-delivered meals to  participants, are worth $100,000 in annual support to their program. This  provider noted that they would be unable to operate the program without  volunteers. See figure 8 for pictures of volunteers helping to prepare food  in selected states.

Providers of the CSFP food packages and congregate and home- delivered meal programs in three selected states we visited also reported  challenges obtaining transportation to bring older adults to meal and food  distribution sites and deliver meals and food packages to older adults,  though some have found ways to mitigate these challenges. For example,  providers in three selected states said a lack of transportation options  prevents some older adults from visiting congregate meal sites as well as  food package distribution sites, as public transportation is not always  available and many older adult participants do not drive. According to  local officials in one state, transportation is also a challenge for the home- delivered meal program, particularly in rural areas, because the distance  between participants’ homes affects the cost of delivering meals.  Similarly, officials at one local agency on aging said providers in its area  would like to serve more people, but are unable to add additional routes  because of transportation costs.

To help mitigate transportation challenges and manage associated costs,  some providers in the selected states have adjusted meal services and  found alternative ways to transport clients to meal service sites. For  example, to help control transportation costs, three providers in two  selected states changed from delivering one hot meal daily to delivering  multiple frozen meals once a week to home-delivered meal participants.  In addition, one provider partnered with a local meal delivery service that  used FedEx to deliver 10 home-delivered meals every 2 weeks to  program participants. To help alleviate transportation challenges that  older adults face getting to meal sites, three providers in two states  partnered with private companies to provide participants with rides to and  from meal sites for a minimal fee. Another provider used grant funds they  received from their state to purchase vans they then used to provide older  adults with transportation to and from the meal sites.

Some providers also reported challenges accommodating the varied  dietary preferences of different groups of older adults, as preferences  sometimes vary by age and cultural or ethnic background, and being  responsive to these preferences can increase the likelihood that meals  will help older adults meet their nutritional needs. For example, HHS  officials, as well as local providers in three out of the four selected states  said the dietary preferences of adults in their 60s sometimes vary greatly  from the preferences of adults in their 90s. Local officials in two states  said that providers of congregate and home-delivered meal programs in  their states noted that “older old” adults may prefer meals that include  meat and potatoes, while “younger old” adults may prefer lighter meals,  such as those consisting of soups and salads. In addition, providers in  three selected states we visited told us they serve many older adults from  diverse cultural or ethnic backgrounds, or with dietary preferences, such  as a vegetarian diet, or who do not eat certain foods because of their  religious beliefs.

To meet the varied dietary preferences of the older adults they serve, and  increase the likelihood that meals will help participants meet their  nutritional needs, some providers reported taking various approaches.  For example, one congregate meal site we visited offered a lunch entree  choice of either meat and potatoes or a sandwich wrap with vegetables.  Another congregate meal site offered a hot lunch, plus a soup and salad  bar, in a restaurant-like setting. Providers also tried to incorporate certain  foods on their menus that reflect the cultural or ethnic preferences of  participants. For example, the adult day care provider and the congregate  and home-delivered meal providers we visited in one selected state in the  South all noted that their menus aim to include certain foods associated  with their regional culture, such as red beans and rice.

By 2060, older adults are expected to make up nearly one-quarter of the  total U.S. population. HHS and USDA play important roles in promoting  the health of this growing population both through administration and  oversight of federal nutrition assistance programs that serve older adults  and efforts to update federal nutrition guidelines, which serves as the  basis for nutrition requirements in these programs. While federal nutrition  guidelines provides broad guidance on nutrition for healthy populations,  they do not address the varying nutritional needs of older adults, such as  those who have common chronic conditions or face age-related changes.  The 2025-2030 Dietary Guidelines update is expected to include a focus  on nutritional guidance for older adults, but no formal plan to include this  focus has been developed. A plan to incorporate the varied needs of  older adults into the dietary guidelines could assist older adults with  making their own dietary decisions and help providers of nutrition  assistance programs better meet older adults’ nutritional needs.

Further, HHS and USDA administration and oversight of the nutrition  assistance programs is not fully addressing some of the challenges states  and local providers indicated hinder their efforts to meet older adults’  nutritional needs. For example, providers we spoke with faced challenges  meeting older adults’ needs for certain meal accommodations, and  information from HHS and USDA regarding promising approaches to  meeting those needs is limited or not sufficiently disseminated. Further,  both HHS and USDA’s efforts to oversee older adult meal programs have  limitations that affect information available at the federal level needed to  ensure programs are meeting older adults’ nutritional needs.

We are making the following five recommendations.

The Administrator of ACL should work with other relevant HHS officials to  document the department’s plan to focus on the specific nutritional needs  of older adults in the 2025-2030 update of the Dietary Guidelines for  Americans, which would include, in part, plans to identify existing  information gaps on older adults’ specific nutritional needs.  (Recommendation 1)

The Administrator of ACL should direct regional offices to take steps to  ensure states are monitoring providers to ensure meal consistency with  federal nutrition requirements for meals served in the congregate and  home-delivered meal programs. (Recommendation 2)

The Administrator of FNS should take steps to improve its oversight of  CACFP meals provided in adult day care centers. For example, FNS  could amend its approach for determining federal onsite reviews of  CACFP meal providers to more consistently include adult day care  centers. (Recommendation 3)

The Administrator of ACL should centralize information on promising  approaches for making meal accommodations to meet the nutritional  needs of older adult participants in the congregate and home-delivered  meal programs, for example in one location on its National Resource  Center on Nutrition and Aging website, to assist providers’ efforts.  (Recommendation 4)

The Administrator of FNS should take steps to better disseminate existing  information that could help state and local entities involved in providing  CACFP meals meet the varying nutritional needs of older adult  participants, as well as continue to identify additional promising practices  or other information on meal accommodations to share with CACFP  entities. (Recommendation 5)

We provided a draft of this report to HHS and USDA for review and  comment. In its written comments, HHS agreed with our three  recommendations to ACL (Recommendations 1, 2, and 4). In response to  our first recommendation, HHS stated that ACL plans to work with the  Office of Disease Prevention and Health Promotion and other relevant  HHS officials and agencies to document HHS’s plans to emphasize the  specific and varying nutritional needs of older adults in the 2025-2030  update. HHS also stated that ACL plans to acquire the services of a  registered dietician with specialized expertise in older adults’ nutritional  needs. In response to our second recommendation, HHS stated that  ACL’s program and evaluation offices will collaborate on the development  of plans to ensure state compliance with federal requirements. In  response to our recommendation that ACL centralize information on  promising practices, HHS stated that ACL will award a contract in fiscal  year 2020 for a new National Resource Center on Nutrition and Aging to,  among other things, centralize information on promising approaches so  nutrition services providers can access it easily. HHS’s comments are  reproduced in appendix II.

In oral comments, USDA officials, including the Directors of the FNS Child  Nutrition Program Monitoring and Operational Support Division and the  Child Nutrition Program Nutrition Education, Training, and Technical  Assistance Division generally agreed with our two recommendations to  FNS (Recommendations 3 and 5). In response to our recommendation to  improve CACFP oversight, FNS officials agreed with the intent of  improving oversight of CACFP meals provided in adult care centers.  These officials also noted that activities and changes in this area must be  consistent with statutory and regulatory requirements, balanced with  current priorities given the size of the program, and mindful of resources  available to perform additional oversight. While we recognize that the  CACFP serves fewer adults than children and that FNS oversight  resources are limited, we believe that FNS is in a position to identify the  best way to improve its oversight of CACFP meals provided in adult day  care centers while taking into consideration the availability of its  resources. In response to our recommendation to share additional  information with state and local CACFP entities, FNS officials stated that  there is existing guidance and information on the adult component of the  CACFP, which it communicates through multiple channels. These officials  said that some states and localities may be unaware of these resources,  in part, because of high turnover among staff who administer these  programs. FNS officials acknowledged that they could do more to  increase awareness of existing resources, as well as continue to identify  and share new practices to help entities providing CACFP meals in adult  day care centers address challenges associated with providing meals that  meet nutritional needs of older adults. USDA also provided technical  comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretaries of HHS  and USDA and interested congressional committees. The report will also  be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix III.

Appendix I: Objectives, Scope, and Methodology

Our report examines (1) the relationship of older adults’ nutrition to health  outcomes and the extent to which federal nutrition guidelines address  older adults’ nutritional needs; (2) the extent to which federal nutrition  assistance programs serving older adults have nutrition-related  requirements and how these requirements are overseen; and (3)  challenges program providers face in meeting the nutritional needs of  older adults. In addition to the methods discussed below, to address all  three research objectives we reviewed relevant federal laws, regulations  and guidance.

To provide context for all three research objectives, we examined federal  projections of growth in the older adult population covering the time  period of 2016 through 2060. We relied on the U.S. Census Bureau’s  projections of the U.S. population by various demographic traits including  age, sex, race, Hispanic origin, and nativity. We assessed the reliability  of these data by reviewing technical documentation describing the  methodology, assumptions, and inputs used to produce the 2017 National  Population Projections, upon which the 2020-2060 estimates are based.  We determined these data to be sufficiently reliable for the purposes of  our report.

To provide context on the federal nutrition assistance programs serving  older adults, we examined federal data on expenditures and participation  in these programs for the most recent fiscal year available. For the  congregate and home-delivered meal programs, we relied on State  Program Report data from fiscal year 2017, the most recent data  available at the time of our review, from the U.S. Department of Health  and Human Services’ (HHS) AGing Integrated Database. These data are  submitted on an annual basis by states to HHS’s Administration for  Community Living (ACL). For program expenditure and participation data  for the Child and Adult Care Food Program, Commodity Supplemental  Food Program, Senior Farmers’ Market Nutrition Program, and  Supplemental Nutrition Assistance Program (SNAP), we relied on fiscal  year 2018 data from the U.S. Department of Agriculture’s (USDA)  National Data Bank and submitted through USDA’s Food and Nutrition  Service (FNS) grantee reports. We also relied on fiscal year 2017 data  from USDA’s Characteristics of SNAP Households report on the number  of older adult participants in SNAP, the most recent year for which these  data were available. To assess the reliability of these data, we  interviewed FNS officials and reviewed relevant technical documentation.  We determined that these data were sufficiently reliable for the purposes  of our report.

To address our first objective on what is known about the relationship  between older adults’ nutrition and health outcomes, we conducted a  literature search to identify relevant peer-reviewed studies on the  relationship between nutritional needs and health outcomes of older  adults covering the time period of 2013 through 2018. We searched  research databases, such as ProQuest, Scopus, and Ebsco (AgeLine,  EconLit, and CINAHL), using search terms such as nutrition and aging  and dietary guidelines for seniors. We reviewed the results of the search  to identify publications that (1) included a literature review and synthesis  of studies on the connection between nutrition and health outcomes for  older adults, including the factors that may affect older adults’ nutritional  needs, such as age-related changes and (2) emphasized the general  diet-health relationship among broad populations of older adults. Because  these broader studies were most relevant to our objective, we excluded  studies that (1) focused on the relationship between a specific food or  nutrient and a single health outcome (e.g., salt and cardiovascular  disease) or (2) studied a narrow group of older adults (e.g., residents of a  single U.S. state or region). We conducted detailed reviews of these  studies to assess the soundness of the reported methods and the  credibility and reliability of the conclusions drawn by the authors, and  deemed them to be sufficiently credible, reliable, and methodologically  sound for the purposes of our report.

To help inform all of our research objectives and gather information about  nutrition assistance programs that provide meals and food packages to  older adults at the local level, we conducted visits to 25 local meal and  food distribution sites in four states: Arizona (5 sites), Louisiana (10 sites),  Michigan (6 sites), and Vermont (4 sites) between December 2018 and  March 2019. We interviewed officials from a variety of entities involved in  administering these programs in each of the states, including 20 state and  area agencies on aging and 20 local providers; observed meal services  and food distribution; and held conversations with older adult program  participants.

We selected states and local sites within those states based on a high  percentage of adults 60 or older, and to ensure variation across the sites  in geographic location, urban and rural location, percentage of older  adults in poverty, and program provider and site type. We visited a wide  variety of site locations including, but not limited to, senior centers,  community centers, adult day care centers, and senior housing. Because  we relied on a nongeneralizable sample of sites and states, the views of  the entities we interviewed do not represent the views of all providers of  federal nutrition assistance programs providing meals and food packages  to older adults or participants in those programs.

Prior to each selected state visit, we gathered information from state and  area agencies on aging responsible for administering these programs  using semi-structured interview questions. We collected information on  state and area agency on aging roles in administering nutrition assistance  programs for older adults, federal nutrition requirements in these  programs, oversight and monitoring of programs, partnerships to help  meet the nutritional needs of older adults, outreach efforts, assistance  from federal agencies, and challenges in administering the programs and  meeting the nutritional needs of the older adult populations served.

At each site, we gathered information from local providers and  participants using semi-structured interview questions. We collected  information on program provider operations; characteristics of the  population served; efforts to meet the nutritional needs of the population  served, other nutrition-related services; challenges with meeting the  nutritional needs of the population and efforts to address them; outreach  efforts; and assistance received from regional, state, and federal  agencies. We also collected perspectives on food received and program  impacts on health outcomes from those participating at sites. In addition,  at each site we observed food and meal delivery and the approximate  number of participants and staff operating the site.

Interviews and Reviews of Relevant Documents

To inform all three research objectives, we interviewed officials from  HHS’s Administration for Community Living and USDA’s Food and  Nutrition Service in their national office and all of their regional offices. We  also interviewed a broad range of national groups, including advocacy,  research, and service provider organizations involved in nutrition  assistance programs serving older adults. These included AARP, Feeding  America, Food Research and Action Center, Jean Mayer USDA Human  Nutrition Research Center on Aging, Mathematica Policy Research,  Meals on Wheels America, National Academies, National Association of  Area Agencies on Aging, National Association of Nutrition and Aging  Services Programs, National Association of States United for Aging and  Disabilities, National Commodity Supplemental Food Program  Association, and National Council on Aging.

To inform our first objective on the extent to which federal nutrition  guidelines address older adults’ nutritional needs, we reviewed the  federal guidance reports that detail the nutrition requirements for  Americans, including those reports supporting the 2015-2020 Dietary  Guidelines for Americans and the body of work on the Dietary Reference  Intakes.

To obtain information specific to our second objective on how nutrition  assistance programs serving older adults are overseen, we reviewed  relevant federal program documents on monitoring and oversight of these  programs. In addition, we reviewed relevant studies conducted on behalf  of HHS that evaluated the impact of its nutrition assistance programs on  older adults’ nutrition. These studies evaluated program participants’ diet  quality and nutrient intake, as well as program administration, among  other things. We assessed the reliability of results in these evaluations  by interviewing officials responsible for conducting these evaluations.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Staff Acknowledgments

In addition to the contact above, Rachel Frisk and Theresa Lo (Assistant  Directors), Claudine Pauselli (Analyst-in-Charge), Jessica Ard, and  Vernette G. Shaw made key contributions to this report. Also contributing  to this report were Priyanka Sethi Bansal, Tim Bushfield, Daniel  Concepcion, Kathleen van Gelder, Sarah Gilliland, Isabella Guyott,  Serena Lo, Stacy Ouellette, Amber Sinclair, Joy Solmonson, Almeta  Spencer, Curtia Taylor, Adam Wendel, and Sirin Yaemsiri.

Federal nutrition guidelines are the basis for nutrition assistance programs that serve older adults. However, the guidelines focus on a healthy population and not on the needs of many older adults, such as those with common health conditions and those over age 70. Most older adults have more than one chronic condition, such as diabetes or heart disease.

As the population ages, demand for federal nutrition assistance programs will increase. We recommended that the Department of Health and Human Services develop a plan to focus on older adults’ needs in a future update to the guidelines.