- Click here for explanation of classification scheme.

This study evaluated the influence that expanding a home delivered meals service to include breakfast and lunch would have on the nutritional status and quality of life of at-risk older adults.

Clients of five Elderly Nutrition Programs that participated in the Morning Meals on Wheels pilot study were eligible to participate in the study if they:

• Had been receiving home delivered meals continuously for at least six months
• Were at least 60 years old
• Had at least two functional limitations
• Lived on limited or low income
• Were at risk for malnutrition based on their Nutrition Screening Initiative (NSI) score which refers to the score on the NSI's Determine Your Nutritional Risk Checklist. 

Participation was voluntary and did not influence receipt of services.
 

Client of the five Elderly Nutrition Programs that did not meet the inclusion criteria.

Recruitment

Agencies recruited meal clients for both study groups.

Design

This cross-sectional field study compared two groups. The breakfast group received a home delivered breakfast and lunch five days per week. The comparison group received a home delivered lunch five days per week. Participant's 24-hour recall, demographics, malnutrition risk, functional status and surveys of quality of life as health, loneliness, food enjoyment, food security and depression were obtained.

Blinding used

Not used

Intervention  

Not applicable

Statistical Analysis

• Descriptive statistics were used to assess group comparability
• Independent sample t-tests were used to examine group differences
• Bonferroni's method was used to control for familywise Type I error.

 

Timing of Measurements

One time administration of questionnaires by investigator or trained agent.

Dependent Variables

• Nutrient intake: Kilocalories, protein, carbohydrates, fat, dietary fiber, potassium, vitamin A, vitamin B₆, vitamin B₁₂, folate, vitamin C, vitamin D, vitamin E, calcium, iron, magnesium, zinc
• Quality of life scales: Global quality of life uniscale, quality of heath uniscale, loneliness uniscale, food enjoyment scale, food insecurity scale, geriatric depression scale.

Independent Variables

Breakfast and lunch inclusion in home-delivered meals service

Control Variables

• Age
• Years in program
• Number of ADL
• Number of I-ADL
• NSI score
• Gender
• Ethnicity
• Income level
• Rural
• Lives alone.

• Initial N: 381 subjects
  • 167 in breakfast group
  • 214 in comparison group
• Attrition (final N): As above
• Age: 60 to 100 years
  • Breakfast group: Mean age 79.8±8.1 years
  • Comparison group: Mean age 77.7±9.1 years
• Ethnicity:
  • Breakfast group: 
    • 6.3% African American
    • 48.7% White
    • 43% Hispanic
    • 1.9% Native American
  • Comparison group:  
    • 7.6% African American
    • 26.1% White
    • 64.1% Hispanic
    • 2.2% Native American
• Other relevant demographics:
  • Breakfast group: 28.1% male, 71.9% female
  • Comparison group: 29.4% male, 70.6% female
• Anthropometrics: The Breakfast group had significantly more white participants whereas the Comparison group had significantly more Hispanic participants (P<0.001).
• Location: Participating agencies were located in:
  • South Texas
  • South Florida
  • Western Montana
  • Southwestern Virginia
  • Eastern Maine.

Results for Nutrient Intake:

• Breakfast group participants consumed approximately 300kcal, 14g protein, 36g carbohydrate, 12g fat and 4g fiber more than the comparison group (P≤0.001)
• The breakfast group also consumed significantly greater amounts of potassium (P<0.001), folate (P=0.003), calcium (P=0.001), iron (P<0.001), magnesium (P<0.001) and zinc (P=0.002)
• The breakfast group tended toward greater consumption of vitamins A, B₆, B₁₂ and D.

Results for Quality of Life:

• Breakfast group participants had significantly greater levels of food security and significantly fewer depressive symptoms than comparison group participants (P=0.002)
• The comparison group had a greater number of depressive symptoms than the breakfast group (P=0.003)
• Both study groups rated global quality of life and loneliness at average or moderate levels with no group differences
• No group differences were found for quality of health or food enjoyment, but based on the effect size for these factors, in a larger sample size, a significant difference would be observed.

Results for the Multi-Item Scales

• Breakfast group participants were significantly less bothered than comparison group participants by dietary restrictions (P=0.002), money problems (P=0.002) or problems with cooking (P=0.002)
• There was also a tendency for more breakfast group than comparison group participants to maintain their sense of taste, but the effect of oral/dental problems on food choice was a significantly greater issue for the breakfast group than the comparison group (P<0.001)
• The comparison group worried more than the breakfast group about whether they would eat well because they needed help with grocery shopping (P<0.001) and food preparation (P=0.002). The data suggested that they also worried more about whether they could afford enough food.
• Significantly more breakfast group participants were in good spirits most of the time (P=0.001) and were happy most of the time (P=0.001)
• There was a tendency for breakfast group participants to enjoy getting up in the morning and fewer breakfast group members got bored often, felt worthless and believed that their situation was hopeless. 

 

The study participants were at risk for malnutrition by virtue of sociodemographic factors, functional limitations and poor health. Participants were similar in age and sex to typical Title-III home delivered meal clients; however, a greater percentage of study participants lived alone, in rural areas and at or below 100% of poverty guidelines. Study participants were also more functionally limited than the average home delivered meals client. The demographics of this study sample reflect the trends of older adults living longer, women outliving men and the likelihood of living in poverty or developing chronic health conditions or disabilities as age increases.

Breakfast group participants consumed greater levels of key nutrients which brought them better in line with the DRIs and better reflect recommendations to reduce the risk of chronic disease. Home delivered meals provided acceptable percentages of DRIs for key nutrients except for vitamins D and E. Vitamin D and E inadequacies are a concern for older adults especially those that are homebound. Vitamin D supplementation has been suggested. Because energy requirements decrease as a person ages, no single energy level is appropriate for all older adults so macronutrient target values for home delivered meals in this study may be misleading.

In this study, quality of life was limited to health-related quality of life factors that might be affected by the Elderly Nutrition Program. There were no group differences in mean scores on the self-rated global quality of life or quality of life uniscales. This may have been related to participant outlook. Loneliness has been related to quality of life and quality of health in older adults. Breakfast and lunch were delivered simultaneously, so the breakfast group received no more contact than the comparison group and there were no group differences in ratings of loneliness.

Breakfast group participants tended to experience more food enjoyment than the comparison group. Also, breakfast group participants had fewer food-related money and cooking problems which could be attributed to a reduced need to purchase and cook food. Greater food security among breakfast group participants may be due to an expanded meal service that reduces the need to purchase and cook food.  In this study population, the physical acquisition of food—transportation, walking, lifting and preparing was the primary issue and this relates to food security. In this study, 81% of the breakfast group and 92% of the comparison group had at least one symptom of food insecurity. Depression is an important issue for older adults. In this study, breakfast group participants reported less depression. 

Overall, meal programs should be encouraged to expand their services to include a daily breakfast and lunch meal. A breakfast program could be marketed locally as a low cost method of improving food security, food and nutrient consumption and reducing depressive symptoms among frail, homebound older adults. Improvement in nutrition services may reduce the anxiety of shopping, food preparation and food cost. It could also improve energy levels and outlook on life. These measurable outcomes can be tracked to demonstrate program effectiveness.

Government:	Agency for Healthcare Research and Quality and the Administration on Aging, USDHHS
Other:	Florence Bayuk Foundation

The authors noted the following limitations:

• A randomized sample would have been ideal; however, only a small number of Elderly Nutrition Programs were appropriate for this study, limiting the client pool
• A convenience sample was used to obtain enough participants to maintain satisfactory power, but may have created sample bias
• Type I error rate was minimized using Bonferroni's method, but is often very conservative and may have underrated important group differences
• Because of funding, the longevity of the breakfast program services is uncertain, the survey design was used to enable data collection within a relatively short period of time. A drawback of this design is that it disallows causal conclusions.
• The assessment of nutrient intake was based on 24-hour food intake reports most of which were excluded from analysis as incomplete, dubious or apparent outliers. This circumstance was not thought to change the overall outcome. Although the number of usable intake reports was limited, it was representative of the breakfast program's target population.