FNOA: Aging Programs (2012)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The purpose of this research was to compare nutrition risk, nutrient intake and selected socioeconomic characteristics between elderly food stamp recipients and eligible, elderly people who did not participate in the food stamp program

Inclusion Criteria:

Inclusion criteria included age ≥60, low income and ability to provide necessary information to determine Food Stamp eligibility.

Exclusion Criteria:

Exclusion criteria included age <60 or inability to provide necessary information to determine Food Stamp eligibility.

Description of Study Protocol:

Recruitment

The subjects were described as a "convenience sample" of limited income elderly people living in subsidized housing in designated poverty tracts. The process of recruiting subjects was not described. 

Design

Cross-sectional Study

Two home-based interviews were conducted by trained nutrition researchers over a one-year period (1996-1997). Each interview was 60-90 minutes in length. The study subjects were divided into three groups for comparison, based on their eligibility and participation in the Food Stamp Program: 

  • Eligible for and  participating in the Food Stamp Program
  • Eligible but not participating
  • Not eligible based on financial resources.

Blinding Used  

Not applicable

Intervention

Not applicable

Statistical Analysis

Group differences were measured by X2 analysis and analysis of variance using SPSS for Windows (version 10, 2000, MacGraw Hill, Chicago, IL).

Data Collection Summary:

Timing of Measurements

Two home-based interviews were conducted over a one-year period. The interval between the two interviews was not described, nor was there an indication of whether the subjects all entered the study at the same or different times during the year period.

Dependent Variables

  • Perceptions of the Food Stamp Program
  • Measures of health and functional status
  • Nutrition risk was determined by the Nutrition Screening Initiative Checklist (American Academy of Family Physicians, The American Dietetic Association and the National Council on the Aging, Inc. The Nutrition Screening Initiative. Washington, DC: Nutrition Screening Initiative; 1992) 
  • Food and nutrient intake was estimated from the National Cancer Institute food frequency questionnaire (National Cancer Institute. Health Habits and History Questionnaire: Diet History and Other Risk Factors, version 3.0. Bethesda, MD: Nation Cancer Institute; 1995).
  • Functional status was measured using activities of daily living (Fillenbaum G, Multidimensional Functional Assessment of Older Adults: The Duke Older Americans Resources and Services Procedures. Hillsdale, NJ: Lawrence Erlbaum; 1988. 
  • Self-reported height and weight (used to calculate Body Mass Index).

Independent Variables

  • Demographic and socioeconomic resources: 
    • Age
    • Education
    • Marital status
    • Income
  • Food stamp use.

Control Variables 

Description of Actual Data Sample:
  • Initial N: 229 subjects
  • Attrition (final N): 200 subjects met all eligibility criteria, 86% female
  • Age: >60, average age 77+7.6 years
  • Ethnicity: 91% white
  • Other relevant demographics:
    • 74% high school or less education
    • 96% single (single, widowed, divorced, separated)
    • 97% live alone
  • Anthropometrics: Body Mass Index (BMI) was calculated from self-reported height and weight 
  • Location: Connecticut.
Summary of Results:

Food Stamp Use 

  • 18% (n=35) receiving Food Stamps 
  • 33% (n=65) eligible but not participating
  • 50% (n=100) not eligible despite low income.

Group Differences 

Those receiving food stamps were significantly younger and had lower income than those not receiving the assistance. They also had significantly higher nutritional risk scores, with 72% in the high risk category. 

  Receiving Food Stamps
(n=35)
Not Eligible
(n=100)
Eligible but not Participating (n=65) Statistical Significance Between Groups
n
(percent)
n
(percent)
n
(percent)
 
Age        P≤0.001
60-74 24(69) 33(33) 18(28)
75 and over 11(31) 66(67) 46(72)
Education        
Less than high school 11(31) 30(30) 36(57)  
High school or more education 24(69) 70(70) 27(43)  
Annual Income ($)        P≤0.001
Mean±Standard Deviation 6,903±1,271  12,282±4,349  9,099±1,721 
Range 5,100-8,800  5,448-26,400  5,412-12,468 
NSI Nutrition Risk Score        P≤0.001 between recipients and each of the other two groups 
Mean±Standard Deviation  7.7±3.9  4.4±2.8  4.7±3.2 
Range  1-14  0-12  1-13 

Other Findings

  • 80% of those receiving food stamps reported that the program helped them buy needed food, although the monthly benefit was low (mean monthly benefit=$34; 57% received $10-24 per month). 52% of those eligible but not receiving food stamps indicated that they would apply if they knew they were eligible while 30% said they did not need this assistance. 
  • Those receiving food stamps reported more days when they were unable to perform activities of daily living during the past six months than the other groups.  Also, a higher percentage of those receiving food stamps rated their health as poor or fair (60%) compared to the other groups (34% for those eligible but not participating and 46% for those not eligible).
  • Responses to two questions on the Nutrition Screening Initiative Checklist were significantly different. 53% of those receiving food stamps said that they did not always have enough money to buy needed food, compared to 4% of those not eligible and 8% of those eligible but not receiving food stamps (P<0.001). Those receiving food stamps were also more likely to eat less than two meals per day (P<0.01).
  • Nutrient intakes were below recommendations for calories, calcium, vitamin E, folate, magnesium and fiber for both genders across all groups. Macronutrient distribution based on calorie intake was close to recommendations with a slight overconsumption of calories from fat. Pyramid food group servings were not met for grain and dairy foods across all three study groups.

 

Author Conclusion:

The authors conclude that those elderly with the greatest nutritional needs and highest risk are using food programs and view the Food Stamp Program as a valuable resource. They are younger and have lower income. The income of those eligible but not participating is slightly higher and nearly one-fourth would consider participation in the Food Stamp program if they knew they were eligible. 30% of that group do not feel they need the program despite low income. Although all of the study subjects were low income, half were not eligible for the Food Stamp program because of other assets which counted as income in the eligibility criteria. This study sample of low-income elderly did not meet recommended calories, many Pyramid Food Group servings and the Dietary Reference Intake standards for many nutrients. This was true of all three groups. Because there is no baseline data on nutrient intake for people before they begin the Food Stamp program, it is difficult to ascertain the extent to which nutrient intake and diet quality are improved by participation in the program.

Funding Source:
Other: not specified
Reviewer Comments:

Recruitment methods not described, question representativeness of sample. Unclear if groups were similar enough to be compared.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? No
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? No
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? No
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) ???
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? ???
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes