Background Older Adult Population Growth 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). Program Administration 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. Federally-Supported Nutrition Guidelines 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. Screening and Assessments 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. Nutrition Professionals 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. Conclusions 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. Recommendations for Executive Action 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) Agency Comments and Our Evaluation 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. Federal Data 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. Literature Search 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. Site Visits 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 GAO Contact 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.