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Health Disparities

HD: Food Security (2011)

Hall B, Brown JL. Food security among older adults in the United States. Top Clin Nutr. 2005; 20: 329–338.
Study Design:
Narrative Review
R - Click here for explanation of classification scheme.
Quality Rating:
Negative NEGATIVE: See Quality Criteria Checklist below.
Research Purpose:

To examine food security in older adults in the United States. Authors reviewed the extent of food insecurity, the consequences of hunger, the risk factors for food insecurity, functional physical and mental impairments that can exacerbate  existing conditions and strategies to enhance food insecurity.

Inclusion Criteria:

Since this was not an experimental study, there were no inclusion criteria.

Exclusion Criteria:

Not applicable.

Description of Study Protocol:


Narrative review.

Data Collection Summary:

Timing of Measurements

Not applicable; there were no measurements as this was a narrative review.

Description of Actual Data Sample:
  • Initial N: Not applicable; there was not a specific number of subjects assessed
  • Age: Elderly population (adults aged 60 and older)
  • Ethnicity: Not applicable; several different ethnic backgrounds were reviewed in this narrative review.
Summary of Results:

Key Findings

The following information was reviewed in this analysis of previous work:

  • Extent of food insecurity and hunger among the elderly:
    • Estimates of food insecurity and hunger rate vary in elderly population from 6.0% to 16.0% due to different survey methods and populations studied
    • Data collected by the US Census Bureau for the USDA using a validated 18-item US food security survey module revealed that 6.0% of elderly households experienced  food insecurity because of lack of resources and 1.7% reported hunger, the most severe form of food insecurity
    • Most elderly households reported that hardships were due to lack of income and other resources
    • Other measures of food hardship, such as emergency food demand: In 2001 a study revealed that 11% of clients visiting a food pantry, food kitchen or other emergency food program served by America's Second Harvest, the nations largest organization of emergency food providers
  • Consequences of food insecurity and hunger:
    • Elderly populations are more likely to have chronic health conditions, deficiency diseases, conditions that impair digestion or nutrient absorption as well as increased vulnerability to infection
    • Food insecurity also contributes to malnutrition, which can worsen conditions, increase disability, decrease resistance to infection and extend hospital stays
    • Food insecurity can also lead to deteriorating mental and physical health
    • It was also found that poor nutrition in the elderly can increase care giving demands and increase national healthcare expenditures associated with premature or extended hospital or nursing home stays
  • Risk factors for food insecurity:
    • Low-income elderly:
      • Poverty is a strong determining factor in food insecurity and hunger
      • The prevalence rate increased to 16% in elderly living below 130% of federal poverty level
      • Poverty can directly affect dietary intake and nutritional health in the elderly populations
      • Older adults in the lowest income group were found to be less likely to consume three meals per day including breakfast
      • Meal energy intake, vitamin C, iron, zinc and mean usual calcium intake were also lower
      • Health Eating Index scores in lower income elderly were lower than two higher-income groups
      • Older adults with low income were also more likely to have low serum albumin and low red blood cell folate (indicators of sustained under-nutrition)
      • Older adults were also more likely to have reduced bone density or osteoporosis
    • Social isolation:
      • The loss of spouse, friend or close family members can also impact food insecurity
      • Social isolation can decrease social reasons for and pleasures associated with eating
      • Elderly individuals who live alone have higher food insecurity, food insufficiency and huger rates than households with an elderly couple or other non-elderly members
      • A reduction in  dietary variety caused by living alone was also associated with reduced energy intake and higher levels of nutritional risk
    • Minority status:
      • Minorities will comprise 26.4% of the elderly population in 2030 and up to 17.6% in 2003
      • Hispanic and black elderly persons are more likely to live in food-insecure households compared to non-Hispanic white elderly adults
      • Food insecurity prevalence was 18.9% for blacks, 15.4% for Hispanics and 3.7% for non-Hispanic white elderly households
  • Functional physical and mental impairments:
    • Oral health:
      • Poor nutrition can affect oral health and the progression and development of oral diseases in the elderly
      • Conversely, oral diseases such as tooth decay, periodontal disease, tooth loss, oral cancer and the loss of taste sensation can impact food choice, nutrition intake and ultimately the quality of life
    • Physical impairments:
      • The inability to acquire, prepare and eat food is independently associated with food insecurity in the elderly population
      • The combination of both physical impairments and poverty has the potential to exacerbate existing food insecurity and hunger
    • Reduce ability to regulate energy intake: Some elderly have an impaired ability to regulate food intake and lack the ability to maintain constant energy balance, which can lead to weight loss and possibly malnutrition
  • Strategies to enhance food security:
    •  Federal nutrition programs for the elderly:
      • Research suggests that participants in the Older Americans Act Nutrition Program (OAANP) are better nourished (defined by higher mean daily nutrient intakes) and have higher levels of socialization than nonparticipants
      • The Food Stamp Program (FSP) assisted 1.8 million elderly (8.5% of all participants), although this is lower than average participation rates and the elderly also received the lowest average monthly food stamp benefit. In 2003, it was estimated that 20% of all FSP households had elderly members, but only received 7% of all total benefits dollars.
      • The OAANP provides congregate and home-delivered meals to the elderly. It is federal law that this is available to adults 60 and older. It is estimated that 7% of the older population and 20% of low-income elders receive this assistance.
      • Other programs that assist in feeding the elderly population are  the CACFP, which provides adults 60 and older two meals and one snack each day; the CSFP, which provides food and administrative funds for the distribution of food packages to supplement diets of low-income adults aged 60 and older (in addition to new mothers and children); and the SFMNP, which provides fresh, locally grown produce
      • Emergency Food Programs, such as Second Harvest, assist elderly suffering from severe financial difficulties with the more extreme forms of food insecurity and hunger in the form of donations from emergency food pantries.

Other Findings

Research also found that when elderly adults eat with others familiar to them, dietary intake is positively enhanced. Simple health assessments often enable a participant's nutrition status and overall health to improve.

Author Conclusion:
  • It is evident that food insecurity and hunger can have severe and damaging effects on the health status of elderly adults. This can contribute to malnutrition and worsen disease, increase disability, decrease resistance to infection, deteriorate physical and mental health and extend hospital stays. Elderly adults with low income, those who are a minority or those that have physical or mental impairments have even a greater risk of food insecurity.
  • It is recognized by the authors that there are short- and long-term solutions for insecurity and that dietitians and health professionals should familiarize themselves with these options to assist elderly populations at risk.
Funding Source:
University/Hospital: Center of Hunger and Poverty, Heller School for Social Policy and Management, Brandets University, Waltham Mass
Reviewer Comments:
Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
Validity Questions
  1. Was the question for the review clearly focused and appropriate? No
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? No
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? No
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? No
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? ???
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? No
  10. Was bias due to the review's funding or sponsorship unlikely? Yes