Several studies have attempted to

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1 Nutrition risk, nutrient intake, and selected socioeconomic characteristics of elderly food stamp recipients were compared with elderly people who were eligible for food stamps but did not participate in the program. Data were collected by survey using a convenience sample of 200 low-income elderly people living in subsidized housing. Although there were no significant differences in food group or nutrient intake between participants and nonparticipants, overall, these lowincome subjects did not meet minimum Dietary Reference Intake (DRI) standards for many nutrients and had caloric and food group serving intakes that were below recommendations. Food Stamp Program participants were at significantly higher nutrition risk than their nonparticipating peers as detected by the Nutrition Screening Initiative Checklist (P.01) and other indicators of disability. It seems that those already at highest risk were in fact participating in the Food Stamp Program because those eligible but not participating had significantly higher incomes and were at significantly lower nutritional risk. J Am Diet Assoc. 2003; 103: Elderly food stamp participants are different from eligible nonparticipants by level of nutrition risk but not nutrient intake NANCY FEY-YENSAN, PhD, RD; CATHERINE ENGLISH, PhD, RD; HOLLY E. PACHECO, MS; MONICA BELYEA, MPH, RD; DIANE SCHULER ABSTRACT Several studies have attempted to correlate Food Stamp Program participation with improved nutritional status, although little work has specifically focused on elderly participants (1-3). Although poverty rates and nutrition risk continue to increase in older populations, estimations are that only one third of eligible elderly people participate in the Food Stamp Program and that they are less likely than younger householders to participate in the program overall (4,5). For elderly people, unwillingness to participate can be based on pride, social acceptability, or perceived difficulty in getting on the program (6,7). Few studies have compared the nutritional status of elderly participants with their nonparticipating peers. N. Fey-Yensan and C. English are associate professors, and H. E. Pacheco and M. Belyea are graduate students, Department of Nutrition and Food Sciences, University of Rhode Island, Kingston; D. Schuler is a nutrition program assistant, University of Connecticut FNP, Norwich. Address correspondence to: Nancy Fey-Yensan, PhD, RD, University of Rhode Island, Department of Nutrition and Food Sciences, 106 Ranger Hall, Kingston, RI Copyright 2003 by the American Dietetic Association /03/ $35.00/0 doi: /jada Journal of THE AMERICAN DIETETIC ASSOCIATION / 103

2 For poor elderly people, disposable income may be used to pay for utilities, telephone service, or medications over food purchases. Nutrient intake studies indicate that this population typically consumes less than the recommended amounts of energy and of several key nutrients (8-11). A few studies have found that Food Stamp Program participation has a small yet positive influence on nutrient intake in elderly participants as compared with nonparticipants (12,13). The objective of this work was to compare nutrition risk, nutrient intake, and selected socioeconomic characteristics of low-income elderly people based on eligibility and/or participation in the Food Stamp Program. METHODS A comprehensive nutrition needs assessment survey was conducted to gather data on low-income, Food Stamp Program participating or eligible elderly people in Connecticut. The study recruited a convenience sample of limitedincome elderly people living in subsidized housing in designated poverty tracts to ensure contact with foodstamp eligible people. Trained nutrition researchers collected data over a 1-year period ( ). Two home-based interviews were conducted with each subject, each 60 to 90 minutes in length. The data reported here represent a portion of the data set collected and include demographics, social/economic resources, perceptions of the Food Stamp Program, and measures of health and functional status. Nutrition risk was determined using the Nutrition Screening Initiative Checklist (14), and food and nutrient intake was estimated from the National Cancer Institute food frequency questionnaire (15). Functional status was measured using activities of daily living (16). Data were analyzed using SPSS for Windows (version 10, 2000, MacGraw Hill, Chicago, Ill). Group differences were detected using 2 analysis and analysis of variance (17). RESULTS AND DISCUSSION Subjects Two hundred twenty-nine elderly people were assessed. Two hundred subjects met inclusion criteria (minimum age of 60 years and provision of all necessary data to compute Food Stamp Program eligibility). The study population was primarily female (n 171, 86%), and white (n 182, 91%). Ninety-seven percent lived alone, and the average age of participants was years. Researchers calculated Food Stamp Program eligibility using current income, asset, and deduction standards for participation. Subjects were divided into three groups: 18% were receiving food stamps (n 35), and 33%, although eligible, were not receiving Food Stamp Program benefits (eligible not receiving, n 65). Half of the subjects were not eligible (n 100) in spite of low incomes. The lowest annual incomes in each group were around $5,000, indicating that the not eligible subjects had additional assets, cars, or other monetary resources regarded as income. Table 1 presents demographic and foodstamp-related data. Subjects receiving food stamps were significantly younger and were more likely to be divorced than those in the other two groups. More than half (57%) of those who were eligible but not receiving food stamps never completed high school, making them the least educated of the three groups. Subjects who were receiving food stamps had significantly lower incomes. The mean yearly income of individuals not eligible for food stamps was nearly double that of those receiving food stamps, whereas the eligible but not receiving group was midway between the two. Food Stamp Program Participation and Perceptions The majority of elderly people who were receiving food stamps thought that they needed them (97%), whereas those not currently on the program thought that they did not. A small number of those who were eligible but not receiving food stamps (13%) indicated that they needed food stamps at the time of the interview, and 23% wanted more information on the Food Stamp Program. Eighty percent of participants reported that their food stamp benefits allowed them to buy more needed foods, even though the mean monthly food stamp benefit was $34 and over half (57%) of the participants received only $10-$24 in benefits. Fifty-two percent of the eligible but not receiving food stamps group indicated that they would apply for the Food Stamp Program if they knew they were eligible. In response to the question, Is there anything about food stamps that would keep you from using them?, 30% of the eligible but not receiving food stamps group said that they did not need the benefit, 20% believed that they were not eligible, 30% said they were too embarrassed, and 19% indicated that it was too difficult to get on the program or that the level of food stamp benefits was not worth the trouble. Health Status, Nutrition Risk, and Nutrient Intake Table 2 describes health status, nutrition risk, and nutrient intake. Although there was no significant difference in self-rated health status, the overall health of the group receiving food stamps seems to be worse than that of the other groups. Food Stamp Program participants reported more days in the previous 6 months when they were unable to perform activities of daily living (16). A greater proportion of these subjects had a body mass index of 27, and had significantly greater nutritional risk scores (nearly three quarters were in the highest risk category). There were two statements on the Nutrition Screening Initiative Checklist that were significantly different. Fifty-three percent of the receiving food stamps group answered affirmatively to the statement I don t always have enough money to buy the food I need. This is in stark contrast to 4% of those not eligible and 8% of the eligible but not receiving food stamps group. In addition, they were more likely to eat fewer than two meals per day. Overall, subjects did not meet Dietary Reference Intake standards for many nutrients and did not meet all standards set for food groups based on the US Department of Agriculture Food Guide Pyramid (18). Nutrient intakes were remarkably similar across the three groups. Calculated average daily caloric intakes were below recommended levels. Macronutrient distribution based on caloric intake came close to recommendations, with slight overconsumption of calories as fat. Across all study groups, Pyramid food group servings were not met for the bread, cereal, and pasta group or for milk, cheese, and yogurt. Dietary intake of calcium, vitamin E, folate, magnesium, and fiber (11 g/day) was below standards set for both genders across all groups. Considering the profiles of the three study groups, the Food Stamp Program seems to be reaching those elderly people who are in greatest need. Increased nutrition risk, higher body mass index, decreased functional status, and very low income are characteristics that were more pronounced in the receiving food stamps group. With the exception of 104 / January 2003 Volume 103 Number 1

3 Table 1 Demographic characteristics and food stamp use of subjects Receiving food stamps (n 35) Not eligible (n 100) Eligible not receiving (n 65) All subjects (n 200) 4 n (%) 3 Demographics Age (years)*** (20) 2 (2) 0 (0) 9 (5) (49) 31 (31) 18 (28) 66 (33) (17) 52 (53) 33 (52) 91 (46) 85 and over 5 (14) 14 (14) 13 (20) 32 (16) Education** Less than high school 11 (31) 30 (30) 36 (57) 77 (39) High school 15 (43) 35 (36) 19 (30) 69 (35) Trade school 6 (17) 25 (25) 8 (13) 39 (20) Some college 3 (9) 9 (9) 0 (0) 12 (6) Marital status*** Single 1 (3) 10 (10) 8 (13) 19 (10) Married 2 (6) 5 (5) 1 (1) 8 (4) Widowed 14 (40) 67 (68) 46 (73) 127 (64) Divorced 15 (43) 15 (15) 8 (13) 38 (19) Separated 3 (8) 2 (2) 0 (0) 5 (3) Annual income ($) Mean SD 6,903 1,271 a 12,282 4,349 a 9,099 1,721 a 9,497 3,534 Range 5,100-8,880 5,448-26,400 5,412-12,468 5,100-26,400 Food stamp use Ever received food stamps? (% yes)*** Believe you need food stamps?*** Yes No Sometimes Need more information on food stamps? Yes No Sometimes SD standard deviation. a Items with the same superscript are significantly different (P.01). ** 2 was used for analysis (P.01). *** 2 was used for analysis (P.001). body mass index, these characteristics are consistent with profiles of an older, food-insecure national sample (11). Body mass index calculations in this study were based on self-reported heights and weights, and therefore may not be fully accurate. Although food group and nutrient intakes were low, and no significant differences were detected between groups, the nutrient intake data presented here are also consistent with the literature (8,11). Baseline dietary status was not established for the receiving food stamps group before Food Stamp Program participation. It is possible that at minimum, food stamp benefits increased food purchasing power, which may have raised the nutrient intake of those at highest nutrition risk (receiving food stamps), thus equalizing nutrient intake across the groups. Importantly, this group perceived that their food stamp benefits enabled them to buy more of the foods they needed. APPLICATIONS Elderly people with the greatest nutrition needs are using a program that is designed to extend their food resources and potentially improve their nutrient intakes. They are motivated to participate and view food stamps as a valuable resource. Practitioners need to understand and capitalize on this motivation, providing increased support in the form of nutrition education to maximize nutrientdense food purchases. This, along with increased benefits, would likely result in more dramatic and detectable improvements in nutrition outcomes. A significant number of eligible nonparticipating elderly people indicated that they would consider Food Stamp Program participation. Clarification and elimination of perceived barriers and participation stigmas along with tailored outreach efforts could serve to bring these people into the Food Stamp Program. Nutrition educators should work more closely with local Food Stamp Program staff to promote food stamps, establish eligibility, and facilitate participation for as many eligible elderly people as possible. In addition, the eligible but not receiving food stamps group may have other environmental or personal characteristics at play that either keep them from Food Stamp Program participation or fill the gap related to nutrition risk. Understanding these characteristic will help to shape outreach. Finally, longitudinal research including a baseline assessment of the nutrition status of elderly people before participation in the Food Stamp Program is needed to help clarify the extent to which food stamps improve purchasing power, nutrient intake, and diet quality in this population. Journal of THE AMERICAN DIETETIC ASSOCIATION / 105

4 Table 2 Health status, nutrition risk, and nutrient intake of subjects Receiving food stamps (n 35) Not eligible (n 100) Eligible, not receiving (n 65) n (%) All subjects (n 200) 4 3 Health status Self-rated health Poor 5 (14) 9 (9) 4 (6) 18 (9) Fair 16 (46) 37 (37) 18 (28) 71 (36) Good 10 (29) 45 (46) 36 (55) 91 (46) Excellent 4 (11) 8 (8) 7 (11) 19 (9) Decreased functional status a 0-6 days 19 (55) 82 (82) 53 (81) 152 (76) 7-42 days 13 (36) 11 (11) 8 (13) 34 (17) months 3 (9) 7 (7) 4 (6) 14 (7) Body mass index b, * 22 6 (17) 27 (28) 7 (11) 40 (20) (23) 34 (35) 23 (37) 65 (33) (60) 37 (37) 33 (52) 91 (47) Mean SD c c Range Nutrition risk d NSI nutrition risk score Mean SD e,f e f Range NSI nutrition risk categories** Low risk (0-2) Moderate risk (3-5) High risk (6 or more) NSI significant questions (% yes) I eat fewer than two meals per day** I do not have enough money to buy the food I need*** Nutrient intake Energy Mean SD Range Mean SD 3 Percent of energy Fat Carbohydrate Protein Food group servings Bread/cereal/pasta Vegetable Fruit/fruit juice Milk/cheese/yogurt Meat/fish/eggs/beans Fats/oils/sweets SD standard deviation. a How often subjects reported being unable to complete activities of daily living in the past 6 months. b Body mass index categories follow the recommendations of the NHLBI Obesity Education Initiative (1998); a body mass index value of less than 22 or greater than 27 is an indicator of nutrition risk. c Values with the same letter are significantly different (P.05). d Nutrition risk was estimated based on responses to the Determine Your Nutritional Health checklist, developed by the Nutrition Screening Initiative (11). e,f Values with the same letters are significantly different (P.001). * 2 was used for analysis (P.05). ** 2 was used for analysis (P.01). *** 2 was used for analysis (P.001). References 1. Rose D, Habicht J, Devaney B. Household participation in the Food Stamp and WIC programs increases the nutrient intakes of preschool children. J Nutr. 1998;128: Emmons L. Relationship of participation in food assistance programs to the nutritional quality of diets. Am J Public Health. 1987;77: Basiotis P, Brown M, Johnson S, Morgan K. Nutrient availability, food costs and food stamps. Am J Agr Econ. 1983;65: McConnell S, Ponza M. The Reaching the Working Poor and Poor Elderly Study: What We Learned and Recommendations for Future Research. Washington, DC: US Department of Agriculture, Food and Nutrition Service; Cody S, Castner L. Characteristics of Food Stamp Households Fiscal Year Washington, DC: US Department of Agriculture, Food and Nutrition Service; US General Accounting Office. Food Stamps: Reasons for Nonparticipation. Washington, DC: US Congress House of Representatives; Blaylock J, Smallwood D. Reasons for nonparticipation in the food stamp program. West J Ag Econ. 1984;9: Weimer J. Factors Affecting Nutrient Intake of 106 / January 2003 Volume 103 Number 1

5 the Elderly. Washington, DC: US Department of Agriculture, Economic Research Service; Agricultural Economic Report No Position of the American Dietetic Association: nutrition, aging, and the continuum of care. JAm Diet Assoc. 2000;100: Russell R, Rasmussen H, Lichtenstein A. Modified food guide pyramid for people over seventy years of age. J Nutr. 1999;129: Lee J, Frongillo E. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr. 2001;131: Posner B, Ohls J, Morgan J. The impact of food stamps and other variables on nutrient intake in the elderly. J Nutr Elderly. 1987;6(3): Hama M, Chern W. Food expenditure and nutrient availability in elderly households. J Consumer Affairs. 1988;22(1): 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; National Cancer Institute. Health Habits and History Questionnaire: Diet History and Other Risk Factors, version 3.0. Bethesda, MD: National Cancer Institute; Fillenbaum G, Multidimensional Functional Assessment of Older Adults: The Duke Older Americans Resources and Services Procedures. Hillsdale, NJ: Lawrence Erlbaum; Tabachnick B, Fidell L. Using Multivariate Statistics. New York, NY: Harper & Row; Food Guide Pyramid: A Guide to Daily Food Choices. Washington, DC: US Dept of Agriculture, Human Nutrition Information Service; Home and Garden Bulletin No Journal of THE AMERICAN DIETETIC ASSOCIATION / 107