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Special Issue Elderly Nutrition Research Articles 3 Improving Calcium Intake Among Elderly African Americans: Barriers and Effective Strategies TerraL. Smith, Susan J. Stephens, Mary Ann Smith, Linda Clemens, and Dianne K. Polly 15 The Influence of the Healthy Eating for Life Program on Eating Behaviors of Non metropolitan Congregate Meal Participants Cynthia A. Long, Alma Montano Saddam, Nikki L. Conklin, and Scott D. Scheer Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders Edward A. Frongil/o, Pascale Valois, and Wendy S. Wolfe 33 Measuring the Food Security of Elderly Persons Mark Nord A Statewide Educational Intervention to Improve Older Americans' Nutrition and Physical Activity M.A. McCamey, N.A. Hawthorne, S. Reddy, M. Lombardo, M.E. Cress, and M.A. Johnson 58 Estimation of Portion Sizes by Elderly Respondents Sandria Godwin and Edgar Chambers IV Healthy Eating Index Scores and the Elderly Michael S. Finke and Sandra J. Huston 7 4 Factors Affecting Nutritional Adequacy Among Single Elderly Women Deanna L. Sharpe, Sandra J. Huston, and Michael S. Finke 83 Reduction in Modifiable Osteoporosis-Related Risk Factors Among Adults in the Older Americans Nutrition Program J.M.K. Cheong, M.A. Johnson, R.D. Lewis, J. G. Fischer, and J. T. Johnson 'I\· Ann M. Veneman, Secretary U.S. Department of Agriculture Eric M. Bost, Under Secretary , Food, Nutrition, and Consumer Services " \\1'- '\ , ... ~ Eric J. Hentges, Executive Director Center for Nutrition Policy and Promotion 0'·•' Steven N. Christensen, Deputy Director Center for Nutrition Policy and Promotion P. Peter Basiotis, Director Nutrition Policy and Analysis Staff Center for Nutrition Policy and Promotion Mission Statement To improve the health of Americans by developing and promoting dietary guidance that links scientific research to the nutrition needs of consumers. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to al l programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250- 9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. Editor Uulia M. Dinkins Associate Editor David M. Herring Features Editor Mark Lino Managing Editor Jane W. Fleming Peer Review Coordinator Hazel Hiza Family Economics and Nutrition Review is written and published semiannually by the Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, DC. The Secretary of Agriculture has determined that publication of this periodical is necessary in the transaction of the public business required by law of the Department. ifhis publication is not copyrighted. Thus, contents may be reprinted without permission, but credit to Family Economics and Nutrition Review would be appreciated. Use of commercial or trade names does not imply approval or constitute endorsement by USDA. Family Economics and Nutrition Review is indexed in the following databases: AGRICOLA, Ageline, Economic Literature Index, ERIC, Family Studies, PAIS, and Sociological Abstracts. Family Economics and Nutrition Review is for sale by the Superintendent of Documents. Subscription price is $13 per year ($18.20 for foreign addresses}. Send subscription order and change of address to Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. (See subscription form on p. 103.} Original manuscripts are accepted for publication. (See "guidelines for submissions" on back inside cover.} Suggestions or comments concerning this publication should be addressed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion, USDA, 3101 Park Center Drive, Room 1034, Alexandria, VA 22302-1594. The Family Economics and Nutrition Review is now available at www.cnpp.usda.gov (See p. 104} CENTER FOR NUTRITION POLICY AND PROMOTION Research Articles 3 Terra L. Smith, Susan J. Stephens, Mary Ann Smith, Linda Clemens, and Dianne K. Polly 15 The Influence of the Healthy Eating for Life Program on Eating Behaviors of Nonmetropolitan Congregate Meal Participants Cynthia A. Long, Alma Montano Saddam, Nikki L. Conklin, and Scott D. Scheer 25 Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders Edward A. Frongillo, Pascale Valois, and Wendy S. Wolfe 33 Measuring the Food Security of Elderly Persons Mark Nord 47 A Statewide Educational Intervention to Improve Older Americans' Nutrition and Physical Activity M.A. McCamey, N.A. Hawthorne, S. Reddy, M. Lombardo, M.E. Cress, and M.A. Johnson 58 Estimation of Portion Sizes by Elderly Respondents Sandria Godwin and Edgar Chambers IV 67 Healthy Eating Index Scores and the Elderly MichaelS. Finke and Sandra J. Huston 7 4 Factors Affecting Nutritional Adequacy Among Single Elderly Women Deanna L. Sharpe, Sandra J. Huston, and MichaelS. Finke 83 Reduction in Modifiable Osteoporosis-Related Risk Factors Among Adults in the Older Americans Nutrition Program J.M.K. Cheong, M.A. Johnson, R.D. Lewis, J.G. Fischer, andJ. T. Johnson Regular Items 92 Federal Studies 100 Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, September 2003 101 Consumer Prices 102 U.S. Poverty Thresholds and Related Statistics Volume 15, Number 1 2003 Foreword W ith this issue, we here at the Center for Nutrition Policy and Promotion celebrate the 60'h anniversary of Family Economics and Nutrition Review. From its beginning as a monthly newsletter, to its transformation as a research journal, Family Economics and Nutrition Review has provided valuable information to the American public. Whether named Wartime Family Living (1943), Rural Family Living (1945), Family Economics Review (1957), or Family Economics and Nutrition Review (1995), this USDA publication has always provided information-based on current scientific knowledge-for Americans to make decisions about food, clothing, and shelter, as well as provided information about other aspects of daily living (e.g., energy prices, welfare reform, and population trends for quality of life). . Started during World War II, Wartime Family Living, a newsletter, kept Americans abreast of war-related food concerns: distribution, production and manufacturing quotas, and rationing. USDA Cooperative Extension agents, the audience that translated the information in Wartime Family Living into forms useful to the American public, found this helpful advice in the December 27, 1943, issue: "Wartime diets for good nutrition, presented in April's Wartime Family Living, has now been printed and is called Family food plans for good nutrition. These plans, a low-cost and a moderate-cost one, have been revised slightly since their earlier release. Both will be helpful in planning diets that will measure up to the yardstick of good nutrition." We have produced several special issues: the Special Economic Problems of Low-Income Families (1965), the Economic Role of Women in Family Life (1973), Promoting Family Economic and Nutrition Security (1998), and the Food Guide Pyramid for Young Children (1999). The USDA's 60th anniversary edition of Family Economics and Nutrition Review, a special issue, focuses on our elderly population: By focusing on this growing population, we are not only addressing some important implications of aging in relation to nutrition and well-being, we are also continuing our tradition of linking "scientific research to the nutrition needs of consumers" and thus improving the well-being of American families and consumers. On the 25th anniversary, Family Economics Review was recognized as having helped the USDA reach its goal of providing Americans with a flow of information on problems affecting their welfare: "Today, Family Economics Review brings together and interprets economic data affecting consumers from USDA and many Government sources, for use by [Cooperative] Extension workers, college and high school teachers, social welfare workers, and other leaders working with farm and city people." On this 60th anniversary, Family Economics and Nutrition Review reflects the USDA's goal to improve the Nation's nutrition and health through nutrition education and promotion. It is our wish here at the Center for Nutrition Policy and Promotion that Family Economics and Nutrition Review will continue to serve the needs of the American public. Julia M. Dinkins Editor TerraL. Smith, PhD, RD The University of Memphis Susan J. Stephens, MS, RD Central North Alabama Health Services, Inc. Huntsville, AL Mary Ann Smith, PhD, RD The University of Memphis Linda Clemens, EdD, RD The University of Memphis Dianne K. Polly, MS, JD Metropolitan Inter-Faith Association 2003 Vol. 15 No. 1 Research Articles Improving Calcium Intake Among Elderly African Americans: Barriers and Effective Strategies The objectives of this pilot study were to identify barriers to and informed strategies for improving calcium intake among elderly African Americans. To accomplish these objectives, researchers recruited 56 seniors (age 60 or older) from a congregate meal site in a large urban senior center in the mid-South region of the United States. In focus group discussions, participants answered questions related to food preferences, calcium intake, motivations, and barriers to calcium intake, as well as recommended educational strategies. Researchers used both quantitative and qualitative methods to evaluate the data. The study revealed eight barriers to dietary calcium intake: concern for health and disease states, lack of nutrition knowledge, behaviors related to dairy products, limited food preferences, financial concerns, lack of food variety, food sanitation concerns, and limited food availability. Participants suggested several educational strategies, including group discussions, taste-testing sessions, and peer education at various locations. Other suggestions were direct mail, television, and newspapers with large print text and colorful depictions of diet-appropriate ethnic foods. Focus group interactions are excellent means of eliciting nutritionrelated opinions from African-American elders. T he resu lts of the Third National Health and Nutrition Examination Survey (NHANES III) (Alaimo et al., 1994) agree with the conclusions of other studies that the calcium intake of many African Americans is below recommended levels (National Research Council, 1989) and especially below the new calcium goals (Dietary Reference Intakes) for the American population (National Academy Press, 1997; Yates, Schliker, & Suitor, 1998). The limited intake of calcium by African Americans places this subgroup of the American population at risk for chronic diseases that may be alleviated by achieving adequate calcium. Although many African Americans consume milk, the consumption of dairy products-a major source of calcium in the United States-by African-American men and women is significantly lower than that of White men and women (Shirnakawa et al., 1994; Koh & Chi, 1981). Osteoporosis associated with calcium-intake deficiencies and possibly hypertension contributes to the high cost of medical care in the United States (Riggs, Peck, & Bell, 1991 ; Joint National Committee, 1993). Prevalence of deficiencies in lactase, an enzyme required to metabolize the primary milk sugar lactose, is blamed for the low intake of dairy products among African Americans (Pollitzer & Anderson, 1989). Although the consumption of milk and dairy products is inadequate in terms of calcium intake, nutrient supplementation is not a solution for many African Americans. Results from the 1992 National Health Interview Survey Epidemiology 3 Supplement (Slesinski, Subar, & Kahle, 1996) indicate that of the 1,353 Blacks surveyed, three-fourths (77 .2 percent) seldom or never used any vitan1in and mineral supplement, less than 5 percent (4.4 percent) used supplements occasionally, and 18.4 percent used them daily. Commonly called the "silent disease" because pain or symptoms are not experienced until a fracture occurs, osteoporosis is a metabolic bone disease characterized by low bone mass, which makes bones fragile and susceptible to fracture. While AfricanAmerican women tend to have higher bone mineral density than White women have, they are still at significant risk of developing osteoporosis. Furthermore, as African-American women age, their risk of developing osteoporosis more closely resembles the risk among White women. So, as the number of older women in the United States increases, an increasing number of African-American women with osteoporosis can be expected (National Institutes of Health, 1998). Background The literature is replete with studies indicating that calcium intakes of African Americans are below the recommended dietary guidelines (e.g., Alaimo et al., 1994 ), as well as the new calcium intake standards set by the Institute of Medicine (National Academy Press, 1997). In addition to verifying the poor status of calcium intake among African-American adults, much of the literature focuses on the dichotomy of lactose intolerance and bone densities of African Americans. Lactose intolerance is thought to be the primary barrier to consumption of milk and dairy products among African Americans (Buchowski, Semenya, & Johnson, 2002). The empirical work on lactose intolerance among African 4 Americans, however, does not establish that African Americans choose not to consume milk because of gastrointestinal distress. Researchers have found that lactose intolerance among some African Americans may be overestimated because of lactose digesters ' belief that consumption of milk leads to this distress (Johnson, Semenya, Buchowski, Enwonwu, & Scrimshaw, 1993). Even with lactose intolerance, small quantities of milk can be consumed with little or no discomfort, and specialty milk products and lactase tablets are available to ameliorate the symptoms related to lactose consumption. In addition, promising dietary management strategies are available, such as consuming lactose-containing dairy foods more frequently and in smaller amounts as well as with meals, eating live culture yogurt, using lactose-digestive aids, and the consumption of calciumfortified foods (Jackson & Savaiano, 2001). The other side of the dichotomy is bone mineral density and osteoporosis. A major reason for the sense of security regarding calci urn-intake research may be the higher bone mineral density of African-American women (e.g., Luckey et al. , 1989) coupled with their lower rates of osteoporosis. The implications are that high bone mineral density will protect African Americans from osteoporosis and symptoms of calcium deficiency. Silverman and Madison (1988) found that the incidence of age-adjusted fracture rates for non-Hispanic White women is greater than twice the rate for African Americans. But low risk does not translate into no risk. A fact sheet from the National Institutes of Health (1998) states that [A]pproximately 300,000 African-American women currently have osteoporosis; between 80 and 95 percent of fractures in African-American women over 64 are due to osteoporosis; AfricanAmerican women are more likely than White women to die following a hip fracture; as African-American women age, their risk of hip fractures doubles approximately every 7 years; [and] diseases more prevalent in the AfricanAmerican population, such as sickle-cell anemia and systemic lupus erythematosus, are linked to osteoporosis. Some researchers have developed a prudent approach to this dichotomy. One group concluded that the "higher values of bone densities in AfricanAmerican women, compared with White women are caused by a higher peak bone mass, as a slower rate of loss from skeletal sites comprised predominantly of trabecular bone. Low-risk strategies to enhance peak bone mass and to lower bone loss, such as calcium and vitamin D augmentation of the diet, should be examined for African-American women" (Aloia, Vaswani, Yeh, &Flaster, 1996). To promote higher intakes of calcium more effectively, researchers and nutrition educators need to know more about food practices in relationship to dietary calcium. However, little information is available on the effect that food practices of older African Americans may have on nutrient intake, particularly calcium (Cohen, Ralston, Laus, Bermudez, & Olson, 1998). The Council on Aging's congregate meal feeding program is an excellent means of studying the problem of dietary calcium barriers among AfricanAmerican elders. Even though the Council's meals provide one-third of the RDA for all nutrients, AfricanAmerican participants consumed less calcium, thiamin, iron, fat, carbohydrate, Family Economics and Nutrition Review fi ber, niacin, and vitamin C than did White participants (Holahan & Kunkel, 1986). The purpose of the current pilot study was to examine the barriers to adequate calcium intake, through focus group discussions, among the AfricanAmerican elderly population that participates in the congregate meal program. The information from this study is needed to prepare effective, relevant, and appropriate nutritional education presentations and materials. Methods Participant Recruitment In the mid-South region of the United States, researchers recruited participants from a congregate meal site in a large urban senior center. Researchers held a recruitment session during which they explained the project's focus, time conmlitment, and purpose to potential participants; scheduled participants for the focus group sessions; and distributed appointment cards. Upon completing all focus group sessions, participants received a $15 gift certificate to a local grocery store. The researchers completed the official recruitment process in 1 day; however, the participants, without prompting, recruited others. Only African-American elders 60 years and older participated in this study. Assessment Instruments The assessment instruments consisted of the Demographic and Calcium Intake Questionnaire (DCIQ) (Fleming & Heimbach, 1994) and the focus group questions (box 1). In addition to collecting demographic data, researchers used the DCIQ to assess participants' food preferences in relationship to dairy and calciumcontaining foods. To make the focus group procedures and questions more reliable and while taking into account 2003 Vol. 15 No.1 the age and cultural differences of elderly African Americans, the researchers used a dietary calcium intake questionnaire developed for low-income Vietnamese mothers (Reed, Meeks, Nguyen, Cross, & Ganison, 1998). Forexan1ple, where Reed and colleagues emphasized Asian cultural references, the researchers substituted African-American cultural references and maintained the theoretical framework of the original template, which was based on the PRECEDEPROCEED model (Green & Kreuter, 1991). This model has tlu:ee central components related directly to the types of questions raised during a focus group discussion that seeks to understand how to address, in a better fashion, dairy calcium needs through nutrition education: (I) predisposing (knowledge, attitudes, and motivations), (2) enabling (resources and skills), and (3) reinforcing (praise and perceived benefits). Based on the recommendations of Krueger (1998), the researchers interspersed these questions within the procedural framework described in box 1. Procedures for Data Collection and Data Analysis Each of the six focus groups was limited to no more than 12 participants, and each session lasted no longer than 1 Y2 hours. A total of 56 African Americans participated. At the beginning of each focus group session, the researchers obtained a written consent from each participant. Before group discussions began, the researchers administered the DCIQ to participants and offered assistance if needed. To help participants become comfortable, theresearchers asked each to "tell us your name, and tell us what your favorite food is." To transition to the discussion, the researchers asked participants to talk about some of the good points about their diet and how they would improve their diet. Participants considered milk good for bones and teeth and were concerned about bone health and disease prevention in spite of being unable to describe calcium-related deficiency diseases. 5 Box 1. Focus group transition statements and questions 1 Transition The USDA Food Guide Pyramid recommends that adults consume milk and dairy products every day. Key Questions #1 What dairy products do you commonly consume? How often do you have foods in this group? Which of the dairy foods do you select when you eat away from home? What things hinder you from eating these foods more often? What keeps you from ordering milk and dairy products when you eat away from home? As you see it, what is the relationship of milk and health? What people or materials helped you develop your viewpoint? Key Questions #2 Foods in the milk and dairy group are high in calcium. Calcium helps prevent several diseases: thinning of the bones or osteoporosis; high blood pressure or hypertension; and weak bones or rickets. What have you heard about these diseases? What would you like to know about these diseases? How does knowing about diseases related to poor calcium intake impact your diet choices? What would motivate you to eat more of the foods in the dairy group? Transition So, you are saying that milk is important because of the nutrients it provides such as calcium. Key Questions #3 Here is a list of foods with their calcium content. What are your impressions of this list? So you eat several of these foods, what keeps you from purchasing/eating other foods on the list? What would motivate you to eat other foods that contain calcium? Think about the last time you tried something you never tried before. How did you go from never eating it to having tried it? How do your friends and family influence the foods you buy or prepare? Transition So, what I am hearing is that your friends and family impact your food choices. When you think back on it, how much does your family influence the foods you buy or prepare? Key Questions #4 What are your thoughts about what your grandchildren need in terms of milk and dairy foods? Where do you like to get nutrition information? What is your impression about food labels? Are there places or people who don't provide nutrition information that you would like to hear from? What nutrition information do you get from the following materials or places: brochures, reading materials, recipes high in calcium, grocery store lists, foods to select in a restaurant, signs, community classes-in the library, community center, and/or church? What are appealing and convenient ways for us to provide you with information about foods and nutrition? What is your impression of the "Got Milk" signs? What is your family and grandchildren's impressions of the posters? What would you like to know about calcium, milk, and dairy foods? How much time would you like to spend learning about calcium? 1 Krueger, 1998; Reed et al., 1998. Researchers used the focus group discussion questions to identify the barriers to calcium intake. This discussion was followed by a transition to this combined set focused on participants' opinion about their grandchildren's need for milk and dairy products. To close the discussion, researchers asked the participants to give any advice that would help African Americans increase the calcium content of their diets. frequencies were determined for food preferences and the demographic variables. The models were used to analyze the qualitative data: (1) the inductive data analysis model identified topics, categories, themes, and concepts as a means of bringing forth knowledge (McMillan & Schumacher, 1997)and(2)thePRECEDE-PROCEED model was used to subdivide the knowledge gained into categories (Green&Kreuter, 1991). the key questions. The first and second sets of key questions focused on current dietary behavior and predisposing factors, respectively; the third set focused on reinforcing factors. Finally, the fourth set of key questions focused on enabling factors. Researchers combined the last two sets of questions to determine educational strategies. One additional question in 6 Both quantitative and qualitative procedures were used to analyze the data. The Statistical Package for the Social Sciences (SPSS, 1999) was used to analyze the descriptive data; Family Economics and Nutrition Review Researchers completed and compiled the qualitative data in the form of tape recordings and handw1itten notes. During analysis, the researchers reviewed both the notes and the tapes from each focus group session and then used the tape recordings to complete the notes. Next, researchers identified barriers, placed the individual baniers into categories, and organized the categories into patterns or themes and concepts (e.g., related to a predisposing or an enabling factor). Results and Discussion The focus group attendance was excellent, with only six no-shows. Six other participants attended a focus group session other than the one they had original ly planned to attend. By casual observation, we noted that all but two of the participants appeared to be able-bodied: one revealed a hearing Joss and one used a walker. Even though over half (n=28) of the AfricanAmerican seniors in this study reported income below the poverty index (Annual Update of the HHS Poverty Guidelines, 1999), fmances were rarely mentioned as a banier to adequate calcium intake in the focus groups. These seniors seemed adept at managing their finances, and 40 percent used resources other than congregate meals, freq uently citing commodity foods as supplements to their food budgets. Most African-American participants (84 percent) agreed to provide demographic information (table 1). Six often participants had less than a high school education, about 6 of 10 had a monthly income of Jess than $700, and about 6 of 10 were not receiving food assistance. Almost three-quarters of the participants were single, separated, divorced, or widowed; over half (57 percent) lived alone. Most of the 56 participants (n=47) completed the food preference survey, which indicated that greater 2003 Vol. 15 No. 1 than 90 percent of the respondents liked and ate milk and dairy products as well as some other foods with moderate or high amounts of calcium (e.g., salmon with bones). However, some participants, while reviewing a list of calcium-containing foods, noted unfamiliarity with relatively new products such as tofu. In terms of general categories of calcium-containing supplements (calcium, antacids, or vitanlins and minerals), 83 percent of the participants reported using supplements of various types daily, weekly, or seldom. Fifty-five percent reported taking at least one of the calciumcontaining supplements daily, 13 percent reported using calcium supplements or other antacids (e.g., Turns), and 49 percent reported using vitaminmineral supplements (data not shown). Focus group discussions revealed a list of barriers to calcium intake among African-American seniors: • concern for health and disease states • Jack of nutrition knowledge • behaviors related to dairy products • limited food preferences • concerns about finances • lack of food variety • concerns about food sanitation • limited food availability Two subcategories represented the barriers: predisposing factors and enabling factors . Researchers identified four types of barriers related to predisposing factors: customs and beliefs, food handling/sanitation, nutrition knowledge, and health reasons/disease state/food intolerance. Researchers also identified four types of barriers related to enabling factors: food preferences, financial issues, food variety and availability, and behaviors. In terms of food preferences, the participants discussed the need to learn to eat and learn to like new foods to increase calcium intake. Participants identified Table 1. Demographic characteristics of African-American seniors Variables EducationalleveP <8th grade 9th-11th grade 12th grade Technical school Some college College degree Monthly income $687 or less $688-$922 $923 or more Food assistance2 Yes No Marital status Single, separated, divorced, widowed Married Gender Male Female Living situation Lives alone Lives with spouse Lives with other Percent 40.4 19.1 31 .9 12.7 4.3 4.3 55.3 23.4 21.3 40.4 59.6 72.3 27.7 13.0 87.0 57.4 27.7 14.9 1 Participants selected all that applied. For example, a participant that completed 12th grade and technical school may have selected both categories. 2Participants' most frequently reported food assistance was commodity foods. n = 47. 7 several marketing and educational strategies to improve the calcium nutrition knowledge of the AfricanAmerican population. Although most participants had less than a high school education, they were articulate and participated actively in the focus group discussions. The only physical banier mentioned in the focus groups was digestive problems, which is different from the findings of others (Fischer & Johnson, 1990; Skaien, 1982). These researchers had shown physical barriers to be a substantial cause of nutritional deficiencies. Demographic Data and Food Preference For these participants, fruits, vegetables, grains, and desserts were the favorite foods. The frequency data derived from the demographic survey supported these statements and revealed that almost 90 percent of these participants liked and ate food from all food groups. Several of the participants stated that collard or mustard greens were a favorite food. Of those that mentioned greens as a favorite food, several said they not only ate greens for dinner but sometimes for breakfast or lunch as well. Because salmon was the only meat mentioned in the frequency data, meat preferences were not determined. On the frequency checklist, the participants indicated whether they liked or ate dairy products, but these items were not mentioned as favorite foods in the focus group discussions. When the moderators probed about dairy foods, many participants indicated they did not like the taste of the foods or they had been instructed to eliminate them from their diet for health/disease reasons. These participants did not mention total avoidance of calcium-rich foods. 8 Barriers to Calcium Intake One of the challenges for understanding and discussing the baniers to calcium intake among the urban African-American elders is the interaction among factors. For example, lack of nutritional knowledge may interact with health status and disease state. Alternatively, concern for food handling and sanitation can interact with food preferences and selections. Overall, baniers discovered during this investigation are similar to the baniers identified by Zablah, Reed, Hegsted, and Keenan (1999) when they interviewed 90 African-American women who were either pregnant or had children 5 years old or younger. Zablah and colleagues found that participants perceived they consumed enough calcium, disliked the taste of some calcium-rich foods, experienced digestion problems, had a perceived lack of knowledge of products containing calcium, and were concerned about cholesterol and the high-calorie content of these foods. Thus, both the mothers of young children and elderly African Americans have concerns related to dietary calcium intake and food sources of calcium. Barriers Related to Predisposing Factors Customs and beliefs. In general, participants considered milk a healthful food, connected with cows and wonderful family memories. For example, one participant stated," ... [B]eing raised on the farm, we had to milk the cows. So we knew that was good. We always knew. My daddy insisted that we drink milk." A participant even considered milk a healing food, having recommended milk as a food to a convalescing friend. This friend, a member of the same focus group as the participant, testified that she now drinks milk daily. However, participants discussed the image of milk as a child's food as well, associati ng the "Got Milk" campaign with children. Calcium requirements were not mentioned in the context of a chronic disease state or as a religious dietary restriction. (In a similar focus group held with Women, Infants, and Children Program participants, one mother mentioned her plans to eliminate milk from the diet of an elementary school-age child because of her religious beliefs [unpublished data].) Participants suggested milk as an aid for acute problems, such as ankle problems and "popping bones," described as "bones that don' t act right." Food and nutrition knowledge. Participants in the focus group di scussions wanted information about nutrition and calcium. Participants considered milk good for bones and teeth and were concerned about bone health and disease prevention in spite of being unable to describe calciumrelated deficiency diseases. However, one participant discussed her bout with osteoporosis, and the pain and discomfort involved with this debilitating disease. Additional examples of basic lack of knowledge included calcium content of foods and complications related to poor calcium intake. Participants also confused eggs with dairy products. In addition, although participants correctly identified milk and cheese products as containing cholesterol, they failed to identify lowfat milk and cheese products as appropriate dietary modification for those concerned with dietary cholesterol. For example, one participant stated, "Well, I like cheese, but you know they say cheese is so bad for you now for cholesterol. So I don't eat too much cheese." The discussions revealed that participants were surprised that greens were a source of calcium. When moderators provided the participants with a list of calcium-rich foods that included greens (100 mg calcium per Y2 cup serving), many said they were unaware that Family Economics and Nutrition Review greens were a good source of dietary calcium. One participant commented, "I didn't know [turnip greens] had calcium. I know I love them." In addition to greens, participants seemed surprised to learn about the high calcium content of many foods, such as sardines with bones, prunes, broccoli, spinach, and tofu. Although the basis of such confusion may be lack of nutrition knowledge, the confusion may also relate to how health care professionals organize nutrition knowledge. It is possible that the issue of food categories in terms of nutrients may represent a difference in the organizational schema of nutritional sciences based on nutrients, while that of the participants' knowledge may be based on other factors. Krall, Dwyer, and Coleman ( 1988) said it this way: [A] person's memory is likely to follow personal schemes such as food combinations, time, location, etc. The categorization scheme, such as nutrient-related groups, is not well understood by most lay persons, [and is] therefore, alien to the manner in which [their] information was stored, [and] imposes an arbitrary structure which potentially leads to inefficient recall. In addition, concerns about food handling and sanitation practices of food service establishments served as a deterrent to ordering milk as a beverage when eating out. "Now, I wouldn't order milk out-because I use to work at a restaurant .... If they bring [milk] to me in a glass, I wouldn't drink it. [Researcher: How come?]. .. Well, we had a keg. And, everyone would dip their hand down in that keg, and they'd want the 2003 Vol. 15 No. 1 employees to drink that milk, ... Well, we could get milk [from] the dining room, but the other help had to get milk from ... that keg, and I didn't think that was right." Health reasons, disease state, and food intolerance. Many of the participants were concerned about health and disease-related issues. They were especially concerned with heart disea e, high blood pressure, high cholesterol, and arthritis. Previous resear·ch also found similar health concerns in rural African-American elderly (Lee, Templeton, Marlette, Walker, & Fahm, 1998; Wallace, Fox, & Napier, 1996). As one participant in the 1996 study commented: "I drink a little milk, ... I can't handle milk too good unless I'm at home." Thus, participants in the 1996 study sometimes tied these concerns to food restrictions, especially when their physician instructed them to eliminate certain foods from their diets. The participants reported being educated by their physician or nurse (none mentioned a dietitian) about which foods to avoid. Participants often followed medical recommendations to avoid or restrict a food group that was a calcium source without any instruction on how to replace the calcium in their diet. In terms of lactose intolerance, symptoms mentioned included flatulence, and stomach problems. Participants also mentioned that dairy products, such as milkshakes, were "too rich for the system," although this could be related to the fat or sugar content. Generally, participants did not specifically mention dietary strategies for managing lactose intolerance, such as consuming yogurt or acidophilus milk or using lactase tablets. However, one participant mentioned the lack of lactose-free products as a barrier to purchasing dairy products in food service establishments. The focus group participants expressed an interest in all types of educational media including direct mail, television, radio, newspapers, and magazines. 9 Among the elderly, the perception of milk intolerance appears to vary with ethnicity and gender. Elbon, Johnson, Fisher, and Searcy ( 1999), in a national telephone survey of 475 older Ametican participants, including 27 African Americans, found that 35 percent of the African-American respondents considered themselves milk intolerant, whereas only 17 percent of the Whites did so. Twice as many women (21 percent) considered themselves milk intolerant than did the men (1 0 percent). Others found similar avoidance based on perception (Buchowski, Semenya, & Johnson, 2002). Barriers Related to Enabling Factors The barriers related to enabling factors were food preferences, financial issues, food variety and availability, and behaviors related to calcium-containing foods. In terms of food preferences, to help improve calcium intake, the participants discussed the need to learn to eat and enjoy new foods and learn how relatives, friends, and interactions at social gatherings (e.g., at church) influenced their food choices by introducing new foods . (Participants demonstrated a willingness to try the calcium-fortified juice provided as a snack during all focus group discussions.) Subjects participated in the tradition of extended family members influencing food choices by encouraging their grandchildren to drink milk. One subject told the story of how she learned to eat broccoli: 10 "This broccoli, I never was too fond of it, but my son-in-law, when they were living here in town, use to cook dinner on Sundays and invite me over. And he would fix the broccoli. I didn' t want to hurt his feelings. So I started eating broccoli, and Table 2. Marketing and educational strategies for promoting calcium intake suggested by African-American seniors Strategies Direct mail Media Informal educational sessions Location Desired tactics n = 56. sometimes I get it ... when I go out, 'cause I don't do too much cooking at home. But, I' ll eat the broccoli especiall y, you know, with some cheese on it." In addition, the participants seemed to categorize foods into good and bad foods as well as in terms of a diseasebased model, that is, to eliminate foods due to a disease. Some participants mentioned fmancial concerns as a barrier to intake of milk products. Financial issues related to the cost of food are not onl y a concern among the urban southern elderly African Americans, but also among the rural southern African Americans. Lee and colleagues (1998) found that more than 70 percent of rural AfricanAmerican elders considered food (and medical) costs to be a se1ious issue. Recommendations Brochures Newsletters Magazines Television Radio Newspapers Tasting parties Focus group discussions Peer education Senior citizens' center schools Library Grocery store School or family reunions Large print text Colorful with pictures Diet-appropriate ethnic foods For example, focus group participants mentioned cost issues as reasons for not ordering milk at a food service establishment. Participants indicated that availability of some calcium-containing foods might infl uence consumption (e .g., calciumcontaining j uice). In terms of behaviors, participants mentioned postponing drinking milk to avoid fl atulence during social engageme nts. This behavior appears to indicate that participants were struggling with how to maintain consumption of dairy products in spite of symptoms of lactose intolerance. In such cases, nutrition education could help the elderly develop more effective strategies for managing lactose intolerance. Family Economics and Nutrition Review Marketing and education strategies The focus group participants expressed an interest in all types of educational media including direct mail, television, radio, newspapers, and magazines (table 2). They found it enjoyable to learn in social settings, such as community center classes, church meetings, family and class reunions, and the senior citizens' center. Tastetesting sessions in any setting were particularly appealing to the group. Other routes of nutrition education delivery included sessions at the library, food bank, and the commodity food distribution centers. The input from the participants involved in the present study clearly shows that a number of strategies might be successful in increasing AfricanAmerican seniors' knowledge about adequate calcium intake. One strategy that has benefitted elders is church-based health promotion. Ransdell (1995) discussed why such promotional strategies have been successful and are appropriate for many elderly. In addition, the comments of African-American caregivers that spiritual activities promote health, as reported in a recent study (McDonald, Fink, & Wykle, 1999), probably reflect the sentiment of many others in the community. While working with urbandwelling minority elders, Wieck (2000) found that health promotion activities work best when the focus is on small, achievable goals in the context of short-focused educational sessions. Hurdle (2001) discussed the importance of social support as a component of health promotion activities. Hurdle's report helps, in part, to explain the positive response of the elders to the focus group approach used by this study. The focus group may have helped support "connectedness" (Belenky, Clinchy, Goldberger, & Tarule, 1986), and may help with the 2003 Vol. 15 No. 1 sense of community fostered by the center at which the focus groups were conducted. Furthermore, others found that women were more like! y than men to participate in health-promoting activities and relaxation, while men were more likely than women to participate in exercise (Felton, Parsons, & Bartoces, 1997). Therefore, gender patterns of response to health promotion should be considered when planning healthpromoting activities. Summary and Recommendations In this pilot study, focus group interactions were excellent means to elicit African-American elders' opinions about barriers and educational strategies related to calcium intake. The results may not be generally applicable, because they pinpoint the existence of barriers to adequate calcium intake among one group of African-American seniors. Within this group, health/disease states and lack of knowledge appeared to be the primary and secondary barriers reported, respectively. Although similar studies quantify calcium intake in this population, they provide only limited insight of the barriers. Therefore, further studies are necessary to validate the current findings. A future research plan could include correlating calcium intake data with results from focus group discussions. The participants in the present study provided suggestions that are beneficial for educators who develop materials and methods for nutrition instruction. Specifically, the elderly participants requested disease-specific calcium education directed to their level of learning and that would be provided in a community-based and socially centered environment. The seniors in this study wanted the following information: linkage between calcium sources and specific disease states, calcium content of foods, high-calcium recipes provided in grocery stores at the point of purchase, cooking demonstrations or taste-testing parties featuring calcium-rich foods, and strategies for managing dairy-related food intolerance. Health care providers, social workers, food assistance program managers, volunteers who work with the elderly, and family members must also be educated on adequate calcium intake for these seniors. Educational programs should concentrate on introducing new foodstuffs into seniors' diets and teaching them to substitute item that have been omitted from their diets for medical reasons with alternative calcium-containing foods. Identification and recognition of calcium barriers should be determined across cultures and age groups, if educators hope to promote adequate calcium intakes. 11 12 References Alaimo, K., McDowell, M.A., Briefel, R.R., Bischof, A.M., Caughman, C.R., Loria, C.M. et al. (1994, November 14). Dietary Intake of Vitamins, Minerals, and Fiber of Persons Ages 2 Months and Over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91. Advance Data No. 258. Hyattsville, MD: National Center for Health Statistics. Aloia, J.F., Vaswani, A., Yeh, J.K., & Flaster, E. ( 1996). Risk for osteoporosis in black women. Calcified Tissue International, 59(6), 415-423. Annual Update of the HHS Poverty Guidelines, 7 Federal Register 13428-13430 (1999) (codifiedat42CFR 124). Belenky, M.F., Clinchy, B.M., Goldberger, N.R., & Tarule, J.M. (1986). Women's Ways of Knowing: The Development of Self, Voice, and Mind. New York: Basic Books. Buchowski, M.S., Semenya, J., &Johnson, A.O. (2002). Dietarycalciumintakein lactose maldigesting intolerant and tolerant African American women. Journal of the American College of Nutrition, 21(1 ), 47-54. Cohen, N.L., Ralston, P.A.,Laus,M.J., Bermudez, 0., & Olson, R.B. (1998). Food practices, service use, and dietary quality in elderly Blacks. Journal of Nutrition fortheElderly, 17(4), 17-34. Elbon, S.M., Johnson,M.A.,Fisher,J.G., & Searcy, C.A. (1999). The influence of perceived milk intolerance on dairy product consumption in older American adults. Journal of Nutrition for the Elderly, 19(1), 25-39. Felton, G.M., Parsons, M.A., & Bartoces, M.G. (1997). Demographic factors: Interaction effects on health-promoting behaviors and health related factors. Public Health Nursing, 14(6), 361-367. Fischer, J., & Johnson, M.A. (1990). Low body weight and weight lose in the aged. Journal of the American Dietetic Association, 90( 12), 1697-1706. Fleming, K.H., & Heimbach, J.T. (1994). Consumption of calcium in the U.S.: Food sources and intake levels. Journal of Nutrition, 124(8), 1426S-1430S. Green, L.W., & Kreuter, M.W. (1991). Health Promotion Planning: An Educational and Environmental Approach (2"d ed.). Mountain View, CA: Mayfield Pub. Co. Holahan, K.B., & Kunkel, M.E. ( 1986). Contribution of the Title ill meals program to nutrient intake of participants. Journal of Nutrition for the Elderly, 6( I), 45-54. Hurdle, D.E. (2001). Social support: A critical factor in women's health and health promotion. Health & Social Work, 26(2), 72-79. Family Economics and Nutrition Review Jackson, K.A., & Savaiano, D.A. (200 1). Lactose maldigestion, calcium intake and osteoporosis in African-, Asian-, and Hispanic-Americans. Journal of the American College ofNutrition, 20(Suppl. 2), 198S-207S. Johnson, A. 0 ., Semenya, J. G., B uchowski, M.S., Enwonwu, C. 0., & Scrimshaw, N.S. (1993). Correlation oflactose mal digestion, lactose intolerance, and milk intolerance. The American Journal of Clinical Nutrition, 57(3), 399-401. Joint National Committee. (1993). The Fifth Report oftheJointNational Committee on Detection, Evaluation and Treatment on High Blood Pressure (JNCV). Archives oflnternalMedicine, 153(2), 154-183. Koh, E.T., & Chi, M.S. (1981). Clinical signs found in association with nutritional deficiencies as related to race, sex, and age of adults. The American Journal of Clinical Nutrition, 34(8), 1562-1568. Krall, E., Dwyer, J., & Coleman, K. (1988). Factors influencing accuracy of dietary recall. Nutrition Research, 8, 829-841. Krueger, R.A. (1998). Developing Questions for Focus Groups: Focus Group Kit 3. Thousand Oaks, CA: Sage Publications. Lee, C.J., Templeton, S.B., Marlette, M., Walker, R.S., & Fahm, E.G. (1998). Diet quality and nutrient intakes of Black southern rural elderly. Journal of Nutrition for the Elderly, 17(4), 1-15. Luckey, M.M., Meier, D.E., Mandeli, P.J., Decosta, M.C., Hubbard, M.L., & Goldsmith, S.J. (1989). Radial and vertebral bone density in White and Black women: Evidence for racial differences in premenopausal bone homeostasis. The Journal of Clinical Endocrinology and Metabolism, 69(4), 762-770. McDonald, P.E., Fink, S.V., & Wykle, M.L. (1999). Self-reported healthpromoting behaviors of Black and White caregivers. Western Journal of Nursing Research, 21(4), 538-548. McMillan, J.H., & Schumacher, S. (1997). Research in Education: A Conceptual Introduction. New York: Harper Collins College Publishers. National Academy Press. (1997). Dietary Reference Intakes: For Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Washington, DC: Author. National Institutes of Health. (1998). Osteoporosis and African American women. Retrieved February 23, 2001, from http://www.osteo.org. National Research Council. (1989). Recommended Dietary Allowances, (lOth ed.). Washington, DC: National Academy Press. Pollitzer, W.S., & Anderson, J.J. (1989). Ethnic and genetic differences in bone mass: A review with a hereditary vs environmental perspective. American Journal ofClinicalNutrition, 50(6), 1244-1259. 2003 Vol. 15 No. 1 13 Ransdell, L.B. (1995). Church-based health promotion: An untapped resource for women 65 and older. American Journal of Health Promotion, 9(5), 333-336. Reed, D.B., Meeks, P.M., Nguyen, L., Cross, E.W., & Garrison, M.E.B. (1998). Assessment of nutrition education needs related to increasing dietary calcium intake in low-income Vietnamese mothers using focus group discussions. Journal ofNutritionEducation, 30(3), 155-163. Riggs, B.L., Peck, W.A., &Bell, N.H. (1991). Physician's Resource Manual on Osteoporosis: A Decision-Making Guide (2"d ed.). Washington, DC: National Osteoporosis Foundation. Shimakawa, T., Sorlie, P., Carpenter, M.A., Dennis, B., Tell, G.S., Watson, R., et al. (1994). Dietary intake patterns and sociodemographic factors in the atherosclerosis risk in communities study: ARlC study investigators. Preventive Medicine, 23(6), 769-780. Silverman, S.L., & Madison, R.E. (1988). Decreased incidence of hip fracture in Hispanics, Asians, and Blacks: California hospital discharge data. American Journal of Public Health, 78(11), 1482-1483. Skaien, P. (1982). Inadequate nutrition in the elderly: A stumbling block to good health. InT. J. Wells, (Ed.), Aging and Health Promotion. Rockville, MD: Aspen Publishers, Inc. Slesinski, M.J., Subar, A. F., & Kahle, L.L. ( 1996). Dietary intake off at, fiber and other nutrients is related to the use of vitamin and mineral supplements in the United States: The 1992 National Health Interview Survey. Journal of Nutrition, 126(12), 3001-3008. SPSS Reference Guide, Windows Version 10. (1999). Chicago, IL: SPSS Inc. Wallace, D.C., Fox, T.A., &Napier, E. (1996). Community-based service utilization among African American elderly. Journal of Gender, Culture, and Health, 1(4), 295-308. Wieck, K.L. (2000). Health promotion for inner-city minority elders. Journal of Community Health Nursing, 17(3), 131-139. Yates, A.A., Schliker, S.A., & Suitor, C.W. (1998). Dietary Reference Intakes: The new basis for recommendations for calcium and related nutrients, B vitamins, and cholene. Journal of the American Dietetic Association, 98(6), 699-706. Zablah, E.M., Reed, D.B., Hegsted, M., & Keenan, M.J. (1999). Barriers to calcium intake in African American women. Journal of Human Nutrition and Dietetics, 12(2), 123-132. 14 Family Economics and Nutrition Review Cynthia A. Long, MS, RD Ohio State University ExtensionCrawford County Alma Montano Saddam, PhD, RD The Ohio State University Nikki L. Conklin, PhD Ohio State University Extension Scott D. Scheer, PhD The Ohio State University and Ohio State University Extension 2003 Vol. 15 No. I The Influence of the Healthy Eating for Life Program on Eating Behaviors of Nonmetropolitan Congregate Meal Participants Current research indicates that when older adults increase their consumption of fruits and vegetables, they maintain or improve their health. Thus, their quality of life can be improved and health care costs lowered. A purposive sample of older adults (treatment group, n=50; control group, n=51) attending congregate meals participated in this study, with the treatment group receiving four lessons on fruits and vegetables over 4 weeks. The Stages of Change construct of the Transtheoretical Model was used to identify separate stages of change related to fruit- and vegetable-eating behaviors. Pre- versus post-test results showed that the treatment group's consumption of vegetables changed significantly, a positive movement from a lower stage of change (e.g., from Precontemplation, which was 30 percent at pre-test and 12 percent at post-test) to a higher category at posttest (e.g., taking action to change, or maintaining, their fruit- and vegetable-eating behaviors). Based on findings of this study, lessons on fruits and vegetables that include the Healthy Eating for Life Program (HELP) may promote positive changes in eating behaviors of nonmetropolitan participants of congregate meals and should be considered for study with similar older adult populations. T he older adult population in the United States is growing quickly (Price, 2001). The older adult population is projected to increase throughout the next several decades. In 2000, for example, 35.0 million Americans (12.4 percent) were 65 years old and older (Hetzel & Smith, 2001 ). By 2010,39.7 million Americans (13.2 percent) will be 65 years old and over, and by 2030, up to 20 percent of the U.S. population will be over age 65 (U.S. Census Bureau, 2000a; U.S. Census Bureau, 2000b). Along with this redistribution of the U.S. population, concerns related to aging may increase, including those related to the health and well-being of the older generation (Rogers, 1999). For example, the U.S. Department of Agriculture reported that Americans' diets need to improve, including those of the elderly (Basiotis, Carlson, Gerrior, Juan, & Lino, 2002). Although aging is not itself a cause of malnutrition, related risk factors can affect older adults' nutritional intake, contribute to malnutrition (Wellman, Weddle, Kranz, & Brain, 1997), and be "multiple and synergistic" (American Dietetic Association [ADA], 2000). Other factors that may contribute to the dietary status of the members of this growing older population are the types of nutrition messages they receive and their readiness to change diet-related behaviors. 15 Background A 1996 report by the American Dietetic Association discussed the increased challenges of competing with conflicting nutrition messages that consumers receive from a variety of sources. The public needs sciencebased information that not only educates, but also encourages the adoption of more healthful nutritionrelated behaviors. An update of this Association's report notes that research is needed to develop and test costeffective methods for evaluating the efficacy of nutrition education programs. For effective behavior change, nutrition education programs must be based on the target audience's needs, behaviors, motivations, and desires. And the gap between knowledge of nutrition and actual healthful eating practices must be narrowed by providing nutrition information in a usable form to consumers (ADA, 1996). In the 1970s, Prochaska and colleagues began studying how people make changes. Their efforts led to the development of the Transtheoretical Model, ofwhich the Stages of Change is a construct (Prochaska, Norcross, & DiClemente, 1994). Prochaska, attempting to bring together the components of the major psychotherapy theories regarding how people acquire successful behavior change, found that the many theories could be summarized by principles called the "processes of change." He was especially interested in how "selfchangers" progress along a continuum of change-from Precontemplation to Contemplation, Preparation, Action, Maintenance, and Terminationwithout therapy or a professional program (box I). According to this construct, successful change requires that self-changers 16 know the stage in which they are located and subsequently use appropriately timed strategies. Initial thoughts were that self-changers moved linearly from one stage to the next. In reality, successful selfchangers may recycle through the Stages of Change several times before successfully reaching the Maintenance or Termination stage (Prochaska, Norcross, & DiClemente, 1994). In studies of health behaviors, older adults have been found to fall primarily into the Precontemplation or Maintenance stage, therefore, calling for nutrition education efforts to be targeted at the Precontemplation stage (Nigg eta!., 1999), where people do not perceive there is a need to change. The assumption is that people at the Precontemplation stage for adoption of a healthful diet need information that assists them in becoming aware of the personal benefits of healthful eating behaviors (Laforge, Greene, & Prochaska, 1994). Persons in the Maintenance stage-where behavior changes have occurred for more than 6 months-may experience some relapse (Krista!, Glanz, Curry, & Patterson, 1999), may need infor-mation about local resources, and may need strategies to help them deal with barriers to maintaining their dietary changes. Implications for nutrition education programs for older adults include understanding and applying successful program elements, providing a clear plan for education and having that education based on segmented needs of the older population, adapting locally, and using existing services to provide education. These implications point to the need for research of behavior-based nutrition education for older adults (Contento eta!., 1995). Thus, this study examines the influence of a nutrition education intervention- the Healthy Eating for Life Program (HELP)-on the eating behaviors of a select group of older adults that participated in congregate meal programs. Because the scientific evidence supporting the healthful benefits of fruit and vegetable consumption is significant (U.S. Department ofHealth and Human Services [DHHS], 2000; Tate & Patrick, 2000; Gerrior, 1999), we focus on behavior changes related to the consumption of these food items. According to current research, older adults may maintain or improve their health by increasing their intake of fruits and vegetables, thus possibly lowering health care costs and increasing their quality of life (ADA, 2000; Gerrior, 1999). Nutrition education curricula for older adults are available for use, but the ability of these curricula to increase the servings of fruits and vegetables consumed by older adults is uncertain (Clarke & Mahoney, 1996; Contento et al, 1995). Hence, more evaluation studies are needed of the influence of nutrition education programs that are designed for older adults at congregate meal sites. Methods Subjects The target population for this study consisted of community-dwelling, nonrnetropolitan older adults who attended congregate meal sites. The participants were at least 60 years old (as required for attendance at the congregate meals), with the exception of spouses under 60 years old who could attend meals when accompanying their older spouse. The treatment group was chosen from three Ohio counties; the control group, Family Economics and Nutrition Review Box 1 - Basic definitions of the Stages of Change Construct of the Transtheoretical Model and operational definitions used in this study Basic definition Operational definition Precontemplation No intention of changing behavior and does not see a need Participant consumed fewer than 3 to 4 servings of fruits (vegetables) to change. each day and did not say he or she was seriously thinking about eating more servings of fruits (vegetables) during the next 6 months. Contemplation Acknowledge need to change behavior and begins to think Participant conswnedfewer than 3 to 4 sen1ings of fruits (vegetables) seriously about doing so during the next 6 months or so. each day and said he or she was seriously thinking about eating more servings of fruits (vegetables) during the next 6 months. Preparation Plans to take action during the next month to change Participant consumed fewer than 3 to 4 servings of fruits (vegetables) a behavior. each day and was planning to eat more servings of fruits (vegetables) during the next 30 days. Action Takes action to change behavior but action has lasted for Participant consumed 3 to 4 or more servings of fruits (vegetables) 6 months or less. each day and has been consuming this amount of frui ts (vegetables) for 6 months or less. Maintenance Has been practicing a changed behavior for more than Participant consumed 3 to 4 or more servings of fruits (vegetables) 6 months. each day and has been consuming this amount of fruits (vegetables) for more than 6 months. Termination Has reached ultimate goal of behavior change, with no concern for relapse. Note: Stages of change definitions are by Prochaska, Norcross, and DiClemente (1994). from another Ohio county. 1 The Area Agency on Aging, county offices of Ohio State University Extension, and coordinators of the congregate meal sites assisted with site selection, which needed to be more rural than urban or nonrnetropolitan.2 Fifty treatment and 51 control participants were selected. 3 1The data for this study were collected as part of the multi-State effort to test the lesson plans of the HELP. 20hio was selected to provide data from a nonurban population, as part of a coordinated effort to compare data among States. 2003 Vol. 15 No. 1 Survey Instruments Three instruments were used in this study: a demographics instrument, a questionnaire entitled Checkup on Your Good Eating Practices, and a Stages of Change instrument that consisted of Yrhe size of the sample was based on guidance from the HELP Elderly Nutrition Education Coordinating Group: Mary P. Clarke, PhD, RD, Kansas State University; Sherrie M. Mahoney, MS, Kansas Extension Service; Jacquelyn McClelland, PhD, RD, North Carolina State University; William D. Hart, PhD, RD, St. Louis University; Denise Brochetti, PhD, Virginia Polytechnic Institute and State University; Alma Montano Saddam, PhD, RD, The Ohio State University. two subscales-one for fruits and another for vegetables. These instruments were developed by Extension nutrition professionals of the HELP Elderly Nutrition Education Coordinating Group that developed the HELP instructor's manual. The demographics instrument collected information on gender, age, race, number in household, educational level, income, how often meals were eaten with someone else, and how often meals and snacks were eaten. Checkup on Your Good Eating Practices consisted of seven questions related to eating fruits and vegetables, 17 and the Stages of Change instrument consisted of eight separate questions, four each for fruits and for vegetables (box 2). Questions on the Stages of Change instrument asked older adults the number of servings of fruits and vegetables they were eating, how long they had been eating that number of servings, and whether they were seriously thinking of increasing this number either in the next 30 days or in the next 6 months. These questions were based on the criteria of the Transtheoretical Model Stages of Change construct (W.D. Hart, personal communication, October 19, 2001). Thus, the questions were based on a standardized length of time individuals had been working on, or intended to implement, a behavior change. The Extension nutrition specialists, dietetic nutrition professionals, and county Extension agents (who also field tested the teaching materials) tested the instruments for content and face validity. The instruments were reviewed for content accuracy and suitability for the older adult target audience, after which appropriate adjustments were made. Extensive field testing addressed any issues related to reliability. Cronbach's Alpha was used to test internal consistency of the instruments. The instrument Checkup on Your Good Eating Practices tested at an alpha of .77. The subscale for Stages of Change for fruit-related behaviors tested at an alpha of .53, and the subscale for Stages of Change for vegetable-related behaviors tested at an alpha of .63. Research in applying the Stages of Change construct to measurement of behavior change of nutritional behaviors is relatively new. Therefore, the alpha levels were considered acceptable (Nunnally, 1967). 18 Box 2 - Major Survey Instruments 1 t- Checkup on Your Good Eating Practices: Example questions (Answer choices: Almost never, Seldom, Often, Almost always, and Doesn't apply.) What do you do? Include at least three food groups in my breakfast (e.g., milk, fruit, and grains such as bread and cereal)? Eat 3 or more servings of different vegetables daily? Eat at least l serving of vitamin A-rich foods daily (e.g., dark green, leafy [spinach, kale, broccoli] and deep yellow [sweet potatoes, cantaloupe, apricots])? Choose potatoes prepared in lower fat ways (not fried)? Eat 2 or more servings of different fruits daily? Choose at least 1 serving of vitamin C-rich foods daily (e.g., orange juice, grapefruit, broccoli, cabbage, tomatoes)? Include at least 1 serving from each of the five food groups (i.e., grains, fruits, vegetables, meat group, and milk products)? Stages of Change: Questions Separate questions were asked for fruit- and vegetable-eating behaviors. How many servings of fruits (vegetables) do you eat each day? 0 I or 2 3 or4 5 or more Don't know About how long have you been eating this amount of fruits (vegetables)? Less than 1 month 1 to 3 months 4 to 6 months Longer than 6 months Don't know Are you seriously thinking about eating more servings of fruits (vegetables) starting sometime in the next 6 months? Yes No I already eat enough Undecided Are you planning to eat more servings of fruits (vegetables) during the next 30 days? Yes No I already eat enough Undecided 1HELP evaluation instruments developed by Mary P. Clarke, PhD, RD; Jacquelyn McClelland, PhD, RD; William D. Hart, PhD, RD; and Alma Montano Saddam, PhD, RD of the Elderly Nutrition Education Coordinating Group. Family Economics and Nutrition Review Treatment and Analysis The HELP was developed as a joint project of the Cooperative Extension Services at Kansas State University, The Ohio State University, North Carolina State University, and St. Louis University. The program 's theme foc used on having participants depend primarily on food for good nutritional health and encouraging them to eat a variety of nutritious foods even though the adults' calorie needs may have declined. HELP lessons were designed to facilitate movement of nutrition behaviors along a continuum-from being unaware of eating habits and health connections to applying skills to maintain healthful eating behaviors (Clarke & Mahoney, 1996). The HELP lessons specifically addressed nutritional needs of older adults. The connection between good health and healthful eating habits was emphasized. The fruit and vegetable lessons also presented practical ways for small households to purchase and store fruits and vegetables. Suggestions were shared for preparing fruits and vegetables that are easier to chew; lower in salt, sugar, and fat; and preserve other nutrients. The recipes, varying in texture, flavor, and temperature, were chosen because of their ability to appeal to the changing taste buds of many older adults. The treatment group was taught a series of four HELP nutrition lessons. The lessons for the first 2 weeks focused on vegetables, with a Jesson on potatoes included, while the second 2 weeks focused on fruits. The objectives of the lessons related to the following: suggested number and sizes of servings; vegetables and fruits as sources of various nutrients and few calories; links between eating vegetables and fruits and decreased risk for some diseases; cost-effective purchasing, storage, and preparation 2003 Vol. 15 No. 1 of vegetables and fruits; and vegetables and fruit with less fat, salt, and sugar. A dish featuring vegetables or fruits was brought to each class for participants to taste. Also, at each of the four sessions, the participants were given handouts of the lessons, "challenges" for planning behavior changes, copies of recipes (including those tasted in class) in the HELP, and educational aids (e.g., refrigerator magnets of vegetables and fruits). For each group (one each from three counties), all lessons were taught in the same order by the researcher who used the same visuals, dishes to taste, and style of presentation. The control group did not receive the weekly lessons. However, after completing the post-test, they were offered a set of handouts and the HELP recipes. Pre- and post-tests, respectively, were administered to the control group from September through December 1998, with these results being used to test and retest the study instruments. The instruments tested reliably below .05, with the exception of the question that dealt with how long the reported number of vegetables had been eaten. This question, however, was accepted as reliable because of the slightly lower number of participants answering the question. To consider this study quasiexperimental and a nonequivalent control-group design, we made efforts to select similar treatment and control groups. Analysis of the demographics conducted on treatment and control groups was only significantly different on one variable: how often they ate meals with someone else. For the questionnaire Checkup on Your Good Eating Practices, we summed a score for each treatment and control group participant by using answers from seven questions related to fruit and vegetable behavior (total possible For vegetable-eating behaviors, the treatment groups' pre-test responses were mostly indicative of Precontemplation, followed closely by Maintenance, and then Preparation ... . 19 score of 28, after eliminating "doesn't apply"). A paired-sample t-test was used to compare the means of the preand post-test scores for each group. Post- and pre-test matched summed scores were also measured with a sign test. This test determined whether significant differences exist between positive and negative changes from the pre-test to the post-test. These changes, derived by subtracting pretest from post-test results, were placed into three categories: negative differences, positive differences, or ties (i.e., no change). For the Stages of Change instrument, we used sign tests to measure differences of matched cases from pre-test to post-test administration, excluding "don't know" for the number of servings, how long this amount of fruits and vegetables had been eaten, and for computed stages of change for fruit- and vegetable-eating behaviors for participants in both groups. An algorithm was used to calculate a separate stage of change for eating fruits and vegetables (box 1). Pre- and post-test fruit and vegetable stages were calculated for the treatment and control participants, except for those without sufficient data to categorize. Results Sample Characteristics Overall, the older adults in the treatment and control groups were similar. Seventy-six percent of the 50 participants in the treatment group were women, and 92 percent were White. Sixty-seven percent of the 51 participants in the control group were women, and 94 percent were White (data not shown). 20 Table 1. Post-test/pre-test sign test for Checkup on Your Good Eating Practices regarding fruit- and vegetable-eating behaviors of elderly participants Treatment group 1 Control group2 Negative differences Positive differences Ties 1n = 44. 2n = 49. Eating Practices Results from the questionnaire entitled Checkup on Your Good Eating Practices showed that, compared with the control group, a significant difference existed between the means for the treatment group from the pretest to the post-test. From the pre-to the post-test, mean scores by the treatment group increased from 20.86 to 22.73 (p~.05). For the control group, the means were 19.46 at the pre-test and 20.67 at the post-test (data not shown). For the sign test, although two-tailed significance levels did not show a significant difference in either group's summed scores, the percentages of negative and positive differences and the ties for the treatment group were noteworthy (table 1). From the pre-test to the post-test, for example, 59 percent of changes by the treatment group were positive, compared with 43 percent of the changes by the control group that were positive. The percentage of ties (no change) was low for the groups (9 vs. 26 percent). These results imply that some type of change took place from pre-test to post-test administration, particularly in how members of the treatment group viewed their eating behaviors. Stages of Change Members of the treatment group categorized their fruit-eating behavior most often as Maintenance at the Percent 32 31 59 43 9 26 pre-test and post-test (32 percent each), followed closely by Precontemplation at pre-test and post-test (24 and 28 percent, respectively) and Preparation (20 percent each at pre-test and post-test) (table 2). Changes that could not be categorized dropped from 20 percent at pre-test to 4 percent at post-test. Responses reflective of behaviors in the Action category increased from 0 at pre-test to 8 percent at post-test; that is, at post-test, members of the treatment group consumed 3 to 4 or more servings of fruits each day and had been consuming this amount for no more than 6 months. Among the control group members, pre-test responses regarding their fruiteating behaviors fell most frequently into Precontemplation, followed by Preparation and Maintenance (43, 25, and 20 percent, respectively). For this group, pre-test and post-test differences were minor among all categories. For vegetable-eating behaviors, the treatment groups' pre-test responses were mostly indicative ofPrecontemplation, followed closely by Maintenance, and then Preparation (30, 28, and 24 percent, respectively). That is, some members of the treatment group had not considered changing their vegetable-eating behavior, some had practiced changing their behavior, and Family Economics and Nutrition Review Table 2. Pre-test and post-test computed Stages of Change for fruit- and vegetableeating behaviors of elderly participants Treatment group 1 Fruits Stage of change Pre-test Maintenance 32 Action 0 Preparation 20 Contemplation 4 Precontemplation 24 Cannot categorize 20 Control group2 Fruits Stage of change Pre-test Maintenance 20 Action 2 Preparation 25 Contemplation 2 Precontemplation 43 Cannot categorize 8 1n =50. 2n =51. others planned to take action during the next month to change their vegetable-eating behavior. At the posttest, members of the treatment group most frequently characterized their vegetable-eating behavior as being related to Maintenance, followed by Preparation, and Precontemplation (46, 26, and 12 percent, respectively), a different pattern than was the case at the pre-test phase. The control group's responses at pre-test were mostly in two categories: Maintenance (47 percent) and Precontemplation (33 percent). The post-test category for Precontemplation remained at 33 percent, but the Preparation category was 18 percent, a change from the pretest (8 percent). Also, control group participants categorizing their behavior as Maintenance dropped to 33 percent at the post-test phase. 2003 Vol. 15 No. 1 Vegetables Post-test Pre-test Post-test Percent 32 28 46 8 4 10 20 24 26 8 0 0 28 30 12 4 14 6 Vegetables Post-test Pre-test Post-test Percent 18 47 33 6 0 4 19 8 18 4 2 2 49 33 33 4 10 10 Results from the sign tests revealed no significant difference between pre-test and post-test results for neither the treatment group nor the control group for stage of change related to fruiteating behaviors nor for the control group for stage of change related to vegetable-eating behaviors (table 3). However, a significant positive change for stage of change for the treatment group's vegetable-eating behaviors existed. This positive change shows movement from a lower stage of change category to a higher category from the pre-test to the post-test. Limitations of the Study Findings were limited to the older adults in this study. Participants were not randomly selected because they were attendees of pre-arranged class sites, and some self-selection occurred. Our findings indicate that the HELP nutrition lessons made a difference ... in how some older adults in the treatment group thought about changes, planned for changes, or made changes in their fruit- and vegetable-eating behaviors. 21 Measurable behavior change may have been limited because of the short span of weeks in which treatment took place. Other considerations were (1) the environments of the congregate meal sites that varied in lighting, seating arrangements, distractions, and participant attentiveness and (2) the nutrition education on fruits and vegetables that the control group may have received from other sources prior to this study. Conclusions This study specifically examined the influence of nutrition education on the eating behaviors of older adults who resided in nonmetropolitan or semirural geograpruc areas and who were also participants of congregate meal programs. Based on recent trends, the nonmetropolitan or semi-rural older adult population is an important group to focus on because of factors such as the out-migration of younger persons in these areas and the sometimessegmented nutrition and health care services (ADA, 2000; Rogers, 1999). Further study is recommended of not only this geographic audience but also of a comparison of this audience with urban older adults who participate in congregate meal programs. Our findings indicate that the HELP nutrition lessons made a difference, measured by real and statistical significance, in how some older adults in the treatment group thought about changes, planned for changes, or made changes in their fruit- and vegetableeating behaviors. Additionally, there is merit to the use and further study of the questions on the Stages of Change instrument for fruit- and vegetableeating behaviors; that is, for the categorization of older adults ' behaviors into the Precontemplation, Contemplation, Preparation, Action, or Maintenance stages. 22 Table 3. Post-test/pre-test sign test for Stages of Change computed for fruit- and vegetable-eating behaviors of elderly participants Treatment1 Control2 Negative differences Positive differences Ties 24 22 54 Fruits Percent 16 20 64 Treatment1 Control2 Negative differences Positive differences Ties 8 41* 51 Vegetables Percent 17 5 78 1n = 37 for fruit-eating behaviors, and n = 37 for vegetable-eating behaviors. 2n = 45 for fruit-eating behaviors, and n = 41 for vegetable-eating behaviors. *Differences in behavior changes from the pre-test to the post-test are significant, at p $.05. Realistically, diets vary over time because of a number of factors-one being changes in foods that are available. Therefore, a more relevant application of the Stages of Change construct, compared with simply measuring eating behavior, may be to measure cognitive and behavioral engagement. This approach allows researchers to focus more on what people are thinking about eating during the process of changing their diet, compared with measuring specific foods and nutrients consumed (Krista), Glanz, Curry, & Patterson, 1999). This approach also may be more empowering to individuals who are working toward more healthful eating behaviors. Acknowledgments This educational program was mainly funded by a grant from USDA's Extension Service and by partial support from the North Carolina Institute of Nutrition, Chapel Hill. This research also was supported by funds from the Dean's Research Incentive Fund of the College of Human Ecology, The Ohio State University. We acknowledge the assistance of the staff of Ohio State University Extension in participating counties; those who assisted at the congregate meal sites; and M.A. (Annie) Berry, PhD, senior statistician of Ohio State University Extension. Family Economics and Nutrition Review References American Dietetic Association. (2000). Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. Journal of the American Dietetic Association, 1 00(5), 580-595. American Dietetic Association. (1996). Position of the American Dietetic Association: Nutrition education for the public. Journal of the American Dietetic Association, 96(11), 1183-1187. Basiotis, P.P., Carlson, A., Gerrior, S.A., Juan, W.Y., & Lino, M. (2002). The Healthy Eating Index: 1999-2000. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. CNPP-12. Clarke, M.P., & Mahoney, S.M. (1996). A Healthy Eating for Life Program for Mature Adults. Kansas State University Agricultural Experiment Station and Cooperative Extension Service. Contento, 1., Balch, G.I., Bronner, Y.L., Lytle, L.A., Maloney, S.K., Olson, C.M., et al. (1995) . Nutrition education for older adults. Journal of Nutrition Education, 27, 339-346. Gerrior, S.A. (1999). Dietary changes in older Americans from 1977 to 1996: Implications for dietary quality. Family Economics and Nutrition Review, 12(2), 3-14. Hetzel, L. & Smith, A. (2001). The 65 Years and Over Population: 2000. Brief C2KBR/OJ-10. U.S. Census Bureau. Krista!, A.R., Glanz, K., Curry, S.J., & Patterson, R.E. (1999). How can stages of change be best used in dietary intervention? Journal of the American Dietetic Association, 99(6), 679-684. Laforge, R.G, Greene, G.W., & Prochaska, J.O. (1994). Psychological factors influencing low fruit and vegetable consumption. Journal of Behavioral Science, 17(4), 361-374. Nigg, C.R., Burbank, P.M., Padula, C., Dufresne, R., Rossi, J.S., Velicir, W.F., et at. (1999). Stages of change across ten health risk behaviors for older adults. The Gerontologist, 39(4), 473-482. Nunnally, J.C. (1967). Psychometric Theory. New York, NY: McGraw-Hill. Price, C. A. (2001). The Impact of Demographic Changes on Society. Presentation at Northwest District Family Nutrition Program In-Service on Aging. Columbus, Ohio. Prochaska, J.O., Norcross, J.C., & DiCJemete, C. C. (1994). Changing for Good. New York, NY: William Morrow and Company, Inc./ Avon Books. 2003 Vol. 15 No. 1 23 Rogers, C. C. (1999). Changes in the Older Population and Implications for Rural Areas. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Rural Development Research Report Number 90. Tate, M.J., & Patrick, S. (2000). Healthy People 2010 targets healthy diet and healthy weight as critical goals. Journal of the American Dietetic Association, 100(3), 300. U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC. U.S. Census Bureau. (2000a). Projections of the Total Resident Population by 5-Year Age Gro.ups, and Sex with Special Age Categories: Middle Series, 2006 to 2010. Retrieved July 29, 2003, from www.census.gov/population/projections/ nation/summary/np-t3-c.txt. U.S. Census Bureau. (2000b). Projections of the Total Resident Population by 5-Year Age Groups, and Sex with Special Age Categories: Middle Series, 2025 to 2045. Retrieved July 29, 2003, from www.census.gov/population/projections/ nation/summary/np-t3-f.txt. Wellman, N.S., Weddle, D.O., Kranz, S., & Brain, C.T. (1997). Elder insecurities: Poverty, hunger, malnutrition. Journal of the American Dietetic Association, 97(10 Suppl.), S120-Sl22. 24 Family Economics and Nutrition Review Edward A. Frongillo, PhD Cornell University Pascale Valois, MSc Fonds de Ia Recherche en Sante du Quebec Wendy S. Wolfe, PhD Cornell University 2003 Vol. 15 No. 1 Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders This study tested a concurrent events approach to understand better the relationships between social support and food insecurity of a sample (n=9) of low-income elders that had participated in an earlier study (n=53) in Upstate New York. This approach involved the use of time-intensive telephone interviews over a span of 4 months. Results indicated that the concurrent events approach provided a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. The researchers found that the telephone interviews helped with obtaining a better understanding of the elders' "monthly cycle" of food insecurity and the importance of food exchange as a source of social and food support among elders, a finding that had not been captured in the two in-depth retrospective interviews of the earlier study. M any elders experience hunger and food insecurity because of low incomes, limited mobility, or poor health (Cook & Brown, 1992; Cohen, Burt, &Schulte, 1993; Lee& Frongillo, 200la; Nord etal. , 2002). Food insecurity among elders contributes to poor diet and malnutrition, which exacerbates disease, increases disability, decreases resistance to infection, and extends hospital stays (Adminisu·ation on Aging, 1994; Torres-Gil, 1996; Lee & Frongillo, 200lb). Food insecurity is defined as "the inability to acquire or consume an adequate quality or suffic ient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so" (Radimer, Olson, Greene, Campbell, & Habicht, 1992). Food insecurity among the elderly also includes the inability to obtain and use food in the household (e.g ., to gain access to, prepare, and eat available food) because of functional impair-ments, health problems, or lack of social support (Lee & Frongillo, 200 1a). Social support affects whether an elderly person with financial or physical limitations or both experiences food insecurity. This support can result from informal social networks, such as family and friends, or more formal programs, such as food programs (Wolfe, Olson, Kendall, & Frongillo, 1996). Functional impairments, health problems, and lack of social support have significant relations with food insecurity (Burt, 1993; Frongillo, Rauschenbach, Roe, & Williamson, 1992; New York State Department of Health and Office for the Aging, 1996;Quandt&Rao, 1999;Roe, 1990; Wolfe et al., 1996). Social support and food insecurity interact in complex ways. At least partly due to methodological limitations, these interactions are neither well understood nor easy to study (Lee& Frongillo, 2001c). For example, equivocal evidence has revealed the buffering effect of social 25 support among elders (Newsom & Schulz, 1996; Lee & Frongillo, 200la). For some elders, family or friendseven if needed routinely--cannot always help as planned, resulting sometimes in hunger or food insecurity. Although it is impot1ant to understand these types of situations, it is difficult to obtain adequate details about these experiences from one or even two indepthinterviews (Wolfeetal., 1996). When experiences such as these occur, participants tend to talk in general terms about what they did and suggest that they are okay. However, they often do not mention exactly what they consumed or mention the anxiety they experienced. In addition, they tend to talk more about one or two problematic times that resulted in greater anxiety or more severe food insecurity rather than including other less severe examples of lack of suppot1 or of the variability or precariousness of their support. Thus, it has been difficult to obtain the details that are needed to understand more fully the relation of social support to food insecurity in this population. Many low-income elders also experience a monthly financial cycle that results in a food insecurity cyclehaving less food insecurity and anxiety at the beginning of the month when they receive their monthly checks and experiencing greater food insecurity and anxiety at the end of the month when their money has been spent (Wolfeetal., 1996). Some low-income elders are so accustomed to this monthly cycle that they do not talk about these difficulties (even when asked) unless they happen to be interviewed during that time. It is unclear, however, how various management strategies relate to this monthly cycle. Thus, the ways that both formal and informal social support serve to improve the food security of elders are not well understood, partly because of 26 methodological limitations in research designs. In general, understanding the biological, psychological, and social dynamics of events, needs, practices, and help-seeking and other behaviors of elders is important to assessing and interpreting their experiences. It is, as well, important to understanding how food assistance programs and other formal actions might contribute to improving food security. For example, 1 of the 10 recommendations about health outcomes developed by an Institute of Medicine (1996) committee was to determine "the impact on health outcomes when older individuals make transitions between types of care, treatment settings, and health plans." Acquiring such understanding requires new research approaches that allow for describing and sorting out complex, dynamic patterns of each elder's experience across an approptiate timeframe (Lee &Frongillo, 2001c). For similar reasons, and in the absence of randomized intervention trials, new research approaches are also needed for assessing the effect of programs, such as home-delivered meals and home-care services. Time-intensive, event-focused approaches may be particularly valuable for understanding complex, dynamic patterns (Tuma & Hannan, 1984; Blossfeld & Rohwer, 1995), because they are used to study transitions across a set of discrete states, including the length of time intervals between entry into and exit from specific states (e.g., well vs. ill). The transitions are studied in relation to other discrete events and changes in continual states. These event-focused approaches hold advantages for causal inference over both cross-sectional and traditional longitudinal approaches because of the detailed knowledge of the occunence and timing of events. These approaches are particularly suited for research with elders because of the highly dynamic nature of factors that affect their nutrition and health (Lee & Frongillo, 2001 c). This study tested an innovative, events-focused, qualitative research approach to understand better the relationships between social support and food insecurity of low-income elders. This new concunent events approach involved studying a small group of food-insecure elders intensively for a prolonged period to help understand the intricacies of the variability and uncertainty of social support as well as other events experienced in relation to food insecurity. The approach is refetTed to as "concunent" because the researchers monitored study participants frequently over time (Gordis, 2000). Methods We previously conducted a study of 53 food-insecure low-income elderly men and women who lived in their own homes in three large cities in Upstate New York. In this earlier study, we completed two in-depth interviews with each elder. The purpose of the earlier study was to understand better the experience of elderly food insecurity and thus contribute to previous research of food insecurity among elders (Wolfe eta!., 1996, 1998). For the study reported here, we selected a subset of nine of these elders. When we conducted the earlier study, six of the nine elders in the study reported here were food insecure and three, relying heavily on social support strategies for food, were marginally food secure. The sample consisted of seven Caucasian women, one Caucasian man, and one AfricanAmerican man whose ages ranged from 59 to 76 (an average of68 years). Four had impaired mobility (two in wheelchairs) and one had occasional dizzy spells. Six lived alone; one with Family Economics and Nutrition Review her daughter and husband, who died during the study; one, with her elderly boyfriend; and one, with her teenaged grandson. Two received both food stamps and home-delivered meals. Three of the elders received homedelivered meals only-one, not because she needed them, but because she he) ped deliver these meals. Of the nine elders, only two participated in congregate meals and received food from food pantries; two did not participate in any food programs. Monthly incomes of the elderly participants ranged from $400 to $900, averaging $738 each month. Six lived in subsidized housing; all had been employed most of their lives; two had not completed high school, five were high school graduates, and two attended some college. Each participant was interviewed weekly by telephone for 4 months (December 2000 to March 2001) by one of the authors who performed all of the interviews by using an interview guide and a tape recorder. Participants were asked about the past week: their food situation (i.e., how they obtain their groceries, whether they had any help with meals, whether they attended any food programs, or whether they had problems accessing food), their use of social networks, frequency of family contacts, changes in their health or social support, and events of the past week. Rapport was established quickly during the telephone conversations, because the same interviewer had interviewed each participant twice in his or her home during the previous year. The weekly contact helped to increase rapport further, which is important for gathering this type of sensitive information. Informed consent (to participate and to tape record the telephone interviews) was obtained in the first interview. Analysis was ongoing: Each week prior to the next telephone interview, the 2003 Vol. 15 No.1 interviewer listened to, took detailed notes from, and analyzed the interview of the previous week. From this analysis, the interviewer developed follow-up questions to probe more fully for emerging issues. Following the final interviews, these records were further analyzed, summarized, reviewed, and discussed by all three authors. Results and Discussion Usefulness of the Concurrent Events Approach for Understanding Social Support and Food Insecurity As expected, the time-intensive telephone interviews produced a fuller understanding of some issues that arose in our earlier research with this population. One finding was the surprising extent and importance of food exchange as a source of social and food support among elders, a finding that had not been captured in the in-depth interviews. For example, one woman took home-delivered meals to others in her building and sold Avon products, both of which placed her in situations where people gave her food they had received from the homedelivered meal program, food pantries, or restaurants. These food gifts, plus the free home-delivered meals she received for working for them, were important to her food security. Another woman, with very low mobility, lived alone and relied on her family for support. Becau e this was not always reliable, this participant became a member of a food network in her apartment building for seniors. This network included elaborate food-trade and food-access strategies. For example, in addition to receiving halfpint carton of milk from a neighbor' s home-delivered meals, this study participant received food from a woman who did not use all the food that her The weekly telephone calls provided good rapport between the elderly food-insecure participants and the interviewer and a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. 27 children brought to her. In return, our participant made homemade soup and brought portions to others. Another person received food from the "bread fairy ," an elderly neighbor who went regularly to the food pantry to get and then distribute loaves of day-old bread to various needy residents. A fourth elderly woman was diabetic and had recently begun sharing the food she prepared with others. The foods included items such as diabetic desserts that she shared with a diabetic neighbor whom she also took food shopping. Extensive food-sharing among elders has been elucidated by others (e.g., Quandt, Arcury, Bell, McDonald, & Vitolins, 2001). The study was intended to produce a better understanding of the variability and uncertainty of social support in relation to food insecurity, since the findings from the earlier in-depth interviews suggested that social support was important for food security but often was not consistent or reliable in many cases. What we found, however, was that at least in this group, the social support of most participants did not change over the 4 months of the study (e.g., elders maintained routine patterns regarding who took them shopping). In fact, having non-changing situations was important to these elders. The only exception was the elderly participant who reported both in the in-depth and telephone interviews that her daughter took her shopping once a month. However, this supposed routine help did not occur during the first 2 months of our weekly telephone interviews. As a result, this participant had to borrow food from her neighbors and had to order canned food from a drug store that delivered-although she preferred fresh food. This situation also made her home-delivered meals more vital than ever. Another participant who 28 experienced a major life event during the study-the loss of her husbanddid not lose her social support or food insecurity as might have been expected because she also lived with her daughter. Results such as these suggest that a longer follow-up period may be needed to understand the effects of variability in social support for most elders. Perhaps, when changes in social support occur for most elders, the changes are over a longer petiod, such as those associated with climatic seasons. Usefulness of the Concurrent Events Approach for Understanding Other Events and Experiences Related to Food Insecurity The weekly telephone interviews were valuable for gaining a fuller understanding of the daily lives of these food-insecure elders. By talking with the participants weekly, the researchers found that the interviews also helped with obtaining a better understanding of the elders' "monthly cycle" of food insecurity and also allowed good rapport and confidence to be established. The telephone interviews also allowed the researcher to ask more direct questions and the elderly participants to share additional personal information. Some examples follow. (1) One elderly woman was not classified as food insecure based on the earlier study, but the weekly contacts helped to elucidate how much she actually relied on food stampsparticularly at the end of the month. Her food money began to be depleted during the third week of the month; during the end of the month, her food situation actually changed. For example, she had to substitute foods like french toast for dinner rather than eating meals that included meat. Because of the rapport established between the interviewer and another participant, the elderly woman making these substitutions was comfortable enough to describe one of her food-access strategies: smuggling food from the congregate lunches to be eaten for her dinner. Although this was not allowed (because of concerns for food safety), she regularly brought containers for extra food. (2) The weekly interviews helped researchers understand the support system of one African-American man who had very little family support, but he seemed to have a number of friends that took him shopping. Later in the study, however, he revealed that he often paid these friends for rides and therefore was reluctant to call them as much as he needed. (3) The concurrent events approach was intended to allow us to understand and describe what and how events occuned on a week-to-week basis, as well as how these events affect elders' food insecurity. We previously found that major sicknesses and other stressful events affected the food situation of the elders and, thus, their food insecurity (Wolfe et al., 1996). Although few participants endured very stressful events during the 4 months of study, Christmas turned out to be one such event. The weekly interviews provided an understanding of the importance of Christmas and the stress it may cause because of the need to have extra money to buy special food, presents for grandchildren, and other items. Christmas, therefore, sometimes resulted in greater food insecurity. For example, one woman who wanted to bake for her family and friends bought extra staple foods and saved some money during the fall so that she could purchase extra baking supplies. Unfortunately, she was forced to use this stocked food when her Family Economics and Nutrition Review money started to become depleted becau e of extra Christmas expenses. The interviews also highlighted the importance of charitable food baskets at Christmas for some participants. (4) Another event occun·ed when the Caucasian male participant-on the recommendation of others in his building-decided to try food shopping rather than eating out at a snack bar each evening. By following this recommendation, he spent more money than he would have spent otherwise. The result: Before the end of the month, this elderly participant needed to borrow money and use credit to eat. Perhaps this was because he was not used to shopping for groceries. (5) One elderly woman's health, social support, and food situation changed dramatically during the 4-month study. This participant was on a diet described as lowfat, low-cholesterol, low-sugar, low-sodium, and limited-greens. (The latter was due to a history of blood clots and medication for it. Based on her interpretations, she believed she was not allowed to eat anything "green.") The weekly telephone contact produced a greater understanding of how complicated it was for this participant to follow her dietespecially given her low income. In addition, during the time that the telephone interviews were conducted, this elderly participant experienced several major life changes. After having heart surgery, she moved in with her elderly boyfriend so that he could take care of her. At the same time, she continued to pay for her own house, which caused financial difficulties. (She did not feel secure enough with her new situation to sell her house.) Living with her boyfriend who had no diet limitation made it even more difficult for her to follow her fairly strict diet. Our previous work showed that the ability to eat the "right foods for health" was an important aspect of food 2003 Vol. 15 No. 1 security among the elderly, and her new social situation seemed to make this woman even more food in ecure. Then, just before our study ended, she was diagnosed with breast cancer. This new life-altering event-plus the negative effect of living with someone with very different food habits-cau ed her to conclude that her diet really did not matter anyway. As a result, he stopped following her diet. It' likely that her food situation changed further after her cancer surgery, which was cheduled after the end of our study. Thus, using the new concurrent events approach, compared with the two indepth interviews alone, produced a fuller understanding of changes as they occurred. This fuller understanding probably would not have been achieved with retrospective indepth interviews or event histories (Tum a & Hannan, 1984; Blossfeld & Rohwer, 1995). During the 4-month timeframe, however, there were not many substantial changes. The approach was relatively easy and inexpensive to implement, requiring only about 10 minutes to interview each participant each week. Conclusions The weekly telephone calls provided good rapport between the elderly foodinsecure participants and the interviewer and provided a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. These calls added to what was achieved in the two ptior in-depth interviews. The concurrent events approach was not efficient for understanding the variability of social support or the effect of stressful events on food insecurity, however, because these events did not occur very often. The approach might be more efficient (for the same amount of interviewer time input) by first The concurrent events approach is likely to be useful for investigation following an event or transition such as participating in the home-delivered meals program, moving into senior housing, loss of a spouse, moves by family members, or a change in health condition. 29 interviewing a new person in his or her home once or twice, followed by weekly telephone calls for a month, and then monthly telephone calls for at least several months or up to a year. When an important event or change is identified, weekly telephone calls can be made for several weeks to investigate that event or change. The concurrent events approach is likely to be useful for investigation following an event or a transition such as participating in the home-delivered meals program, moving into senior housing, losing a spouse, moves by family members, or a change in health condition. The concurrent events approach could identify the early effects of programs and provide muchneeded evidence about whether and how being a program participant (e.g., Meals on Wheels recipient) is helpful. For example, one could investigate whether elders receiving homedelivered meals eat the meals, establish a relationship with the delivery person, or have changes in their mental state. Participants could be recruited by using either a formal or an informal surveillance system (such as through contacts in housing offices or through home-delivered meals programs) that provides prompt notification when someone is making a transition. Soon after this notification, the participant could be interviewed, as frequently as once a week or once a month, to obtain a more detailed and accurate assessment of any changes in food status and social support. This study has demonstrated the usefulness of an innovative, feasible, and inexpensive concurrent events research approach for investigating nutrition issues in the elderly. The two key elements of the approach are the initial establishment of rapport by using one or two in-depth, in-person, qualitative interviews and then frequent follow-up qualitative interviews via 30 telephone. Variants of this approach might involve brief in-person follow-up interviews or incorporation of some quantitative questions. Acknowledgments We thank Elizabeth Conrey, Amy Terhune, and the anonymous reviewers for helpful comments on an earlier draft. This research was ptimarily funded by a grant from the Cornell Gerontology Research Institute, an Edward R. Roybal Center supported by the National Institute on Aging ( 1 P50 AG 11711-01 ). This research was also supported in part by a grant (99-34324- 8120) from the Cooperative State Research, Education, and Extension Service (CSREES), United States Department of Agriculture (USDA); and by Cornell University Agricultural Experiment Station Federal formula funds, Project No. NYC-399425 received from CSREES, USDA. Family Economics and Nutrition Review References Administration on Aging, U.S. Department of Health and Human Services, National Aging Information Center. (1994). Food and Nutrition for Life: Malnutrition and Older Americans. Report No. NAIC-12 (December). Washington, DC. Blossfeld, H., & Rohwer, G. (1995). Techniques of Event History Modeling: New Approaches to Causal Analysis. Manhwa, NJ: Lawrence Erlbaum Association. Butt, M.R. (1993). Hunger Among the Elderly: Local and National Comparison. Washington, DC: The Urban Institute. Cohen, B.E., Burt, M.R., & Schulte, M.M. (1993). Hunger and Food Insecurity Among the Elderly. Washington, DC: The Urban Institute. Cook, J.T., & Brown, J.L. (1992). Estimating the Number of Hungry Americans. Tufts University, Medford, MA: Center for Hunger, Poverty and Nutrition Policy Working Paper No. HEO 1-090292. Frongillo,E.A., Rauschenbach,B.S ., Roe, D.A., & Williamson, D.F. (1992). Characteristics related to elderly persons' not eating for 1 or more days: Implications for meal programs. American Journal of Public Health, 82(4), 600-602. Gordis, L. (2000). Epidemiology (2nd ed.). Philadelphia: W.B. Saunders Company. Institute of Medicine. (1996). Health Outcomes for Older People: Questions for the Coming Decade. Committee to Develop an Agenda for Health Outcomes Research for Elderly People. Division of Health Care Services. Washington, DC: National Academy Press. Lee, J.S., & Frongillo, E.A. (2001a). Factors associated with food insecurity among US elderly: Importance offunctional impairments. Journal of Gerontology: Social Sciences, 56B, S94-S99. Lee, J.S. , & Frongillo, E. A. (2001 b). Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. Journal of Nutrition, 131, 1503-1509. Lee, J.S., & Frongillo, E.A. (2001c). Understanding needs is important for assessing the impact of food assistance program participation on nutritional and health status in U.S. elderly persons. Journal of Nutrition, 131, 765-773. New York State Department of Health and Office for the Aging. (1996). Nutrition Survey of the Elderly in New York State. Albany, NY. Newsom, J.T., & Schulz, R. (1996). Social support as a mediator in the relation between functional status and quality of life in older adults. Psychology and Aging, 11,34-44. 2003 Vol. 15 No. 1 31 Nord, M., Kabbani, N., Tiehen, L., Andrews, M., Bickel, G., & Carlson, S. (2002). Household Food Security in the United States, 2000: Measuring Food Security in the United States. Wa hlngton, DC: U.S. Department of Agriculture, Economic Research Service. Quandt, S.A., Arcury, T.A., Bell, R.A., McDonald, J., & Vitolins, M.Z. (2001). The social and nutritional meaning of food sharing among older rural adults. Journal of Aging Studies, 15,145-162. Quandt, S.A., & Rao, P. (1999). Hunger and food security among older adults in a rural community. Human Organizations, 58(1), 28-35. Radimer, K.L., Olson, C.M., Greene, J.C. , Campbell, C. C., & Habicht, J.P. ( 1992). Understanding hunger and developing indicators to assess it in women and children. Journal of Nutrition Education, 24, 36S-45S. Roe, D.A. (1990). In-home nutritional assessment of inner-city elderly. Journal of Nutrition, 120(Suppl. 11), 1538-1543. Torres-Gil, F.M. (1996). Malnutrition and hunger in the elderly. Nutrition Reviews, 54(1), S7-S8. Tuma, N., & Hannan, M. (1984). Social Dynamics: Models and Methods. San Diego, CA: Academic Press. Wolfe, W.S., Olson, C.M., Kendall, A., & Frongillo, E.A. (1996). Understanding food insecurity in the elderly: A conceptual framework. Journal of Nutrition Education, 28, 92-100. Wolfe, W.S., Olson, C.M., Kendall, A., & Frongillo, E.A. (1998). Hunger and food insecurity in the elderly: Its nature and measurement. Journal of Aging and Health, 10,327-350. 32 Family Economics and Nutrition Review Mark Nord, PhD Economic Research Service U.S. Department of Agriculture 2003 Vol. 15 No. 1 Measuring the Food Security of Elderly Persons This study assessed the appropriateness of the U.S. Food Security Scale for measuring the food security of elderly persons and, in particular, whether measured prevalence rates of food insecurity and hunger among the elderly were likely to be biased, relative to those of the nonelderly. The findings, based on analysis of 3 years of data from the Current Population Survey Food Security Supplement, consistently indicated that the Food Security Scale fairly represented the food security status of elderly persons, compared with the food security status of nonelderly persons. Statistical analysis of the multiple-indicator scale found no indication that the scale underrepresented the prevalence of food insecurity or hunger among the elderly because they interpreted or responded to questions in the Food Security Scale differently than did the nonelderly. Responses to questions other than those in the scale indicated that some elderly did face food-access problems other than insufficient resources to buy food-most notably problems getting to a food store. However, these problems were no more likely for the elderly than for the nonelderly to be so serious that desired eating patterns were disrupted or food intake was insufficient. A small proportion of elderly households classified as food-secure obtained food assistance from Federal and community programs, suggesting that some of these households were less than fully food-secure and that some may, indeed, be food-insecure. However, foodsecure elderly-only households were less likely than the food-secure nonelderly households to rely on food assistance programs that are accessible to both. Elderly persons are more foodsecure than are nonelderly persons, according to recent nationally representative food security surveys sponsored by the U.S. Department of Agriculture (USDA) (Nord, 2002; Nord et al., 2002; Gutluie & Lin, 2002; Andrews, Nord, Bickel, & Carlson, 2000; Bickel, Carlson, & Nord, 1999). In these surveys, food security-defined as access at all times to enough food for an active, healthy I ife for all household members-is measured by a series of questions about behaviors and experiences known to characterize households that are having difficulty meeting their food needs (Fitchen, 1981; Fitchen, 1988; Radirner, Olson, & Campbell, 1990; Radimer, Olson, Green, Campbell & Habicht, 1992; Wehler, Scott, & Anderson, 1992). The U.S. Food Security Scale, calculated from responses to these questions, measures the food security of the household and classifies each as food-secure, food-insecure without hunger, or foodinsecure with hunger (Bickel, Nord, Price, Hamilton, & Cook, 2000; Hamilton etal., 1997a; 1997b).Concernshave been raised about whether this measurement method, based on selfreported food-access conditions and behaviors, fairly represents the food security of elderly persons, compared with that of non-elderly persons. Food insecurity is known to be associated with poor nutrition and health 33 outcomes for elderly people, and age aggravates the negative effects of poor nutrition on the elderly; so accurate, reliable measurements of the food security of the elderly are important both for monitoring and research purposes (Sahyoun & Basi otis, 2000; Guthrie & Lin, 2002).ln this study, I assess the appropriateness of the U.S. Food Security Scale for measuring the food security of elderly persons and, in particular, whether prevalence rates of food insecurity and hunger are comparable between households with and without elderly persons present. Statistics based on the September 2000 Food Security Survey Module-the most recent food security data available-indicate that 94 percent of households with an elderly person (i.e., age 65 or over) present were food-secure throughout the year (Nord, 2002). Thus, the remaining 6 percent of households with elderly persons were food-insecure, meaning that at some time during the previous year, these households were either uncertain of having or unable to acquire enough food to meet basic needs of all their member because they had insufficient money or other resources for food. One in four of the food-insecure elderly households (1.5 percent of all elderly households) were food-insecure to the extent that one or more household members were hungry at least some time during the year because they could not afford enough food. The other three-fourths of food-insecure elderly households obtained enough food to avoid hunger by using a variety of coping strategies such as eating less varied diets, participating in Federal food assistance programs, or getting emergency food from community food pantries. These rates of food insecurity and hunger were about half those of households with no elderly members, and this relationship was observed at 34 all income levels, including household with incomes below the Federal poverty line. The extent of food insecurity and hunger among elderly households remained almost unchanged from that of 1995 (when the fir t nationally representative food security survey was conducted) through 2000. The corresponding prevalence rates for the nonelderly, on the other hand, declined substantially during this period of economic growth. There are two areas of greatest concern regarding application of the standard methods for measuring food security to the elderly. The first is whether the questions in the Food Security Scale are understood similarly by the elderly and the nonelderly and whether they experience and respond to food insecurity in similar ways. The standard method depends on self-reported conditions and behaviors related to food access and, as such, may be subject to differences in how people understand and interpret the questions and may be subject to biases in the direction of perceived social desirability. For example, ethnographic findings have suggested that the least severe question in the Food Security Scale, which asks whether respondents worried that their food would run out before they received money to buy more, might be less sensitive for elders. Some elderly persons, at least, report that they just do not worry about such things. The second area of concern is whether the ~~od Security Scale is appropriately sensitive to obstacles that particularly affect elders' ability to get adequate, nutritious meals. The Food Security Scale measures, specifically, food insecurity and hunger that are caused by insufficient money or other resources for food. Each question in the scale specifies this resource constraint as a reason for the behavior or condition-for example: "In the last 12 months, did you ever cut the size of your meals or skip meal because there wasn't enough money for food?" Factor other than economic resource constraints (e.g., health problem , mobility limitation , and lack of transportation) may be ob tacle to elders' ability to obtain adequate nutritious meals, and food-acces problems caused by uch factors might not be registered by the Food Security Scale (Guthrie & Lin, 2002). Data and Methods Data to as ess the e concern about measuring the food ecurity of elderly persons were drawn from the Augu t 1998, Aprill999, and September 2000 Current Population Survey Food Security Supplement (CPS-FSS). The CPS-FSS i an annual, nationally representative survey of about42,000 households, which i conducted as a supplement to the monthly CPS labor force survey. In each hou ehold, the person most knowledgeable about the food purchased and eaten in the home respond to the questions in the Food Security Supplement. Annual tatistic on household food ecurity in the United States are publi hed by the USDA and are based on data from the CPS-FSS. Separate analy is file were constructed for households in which all per on were age 65 or older (i.e., elderly-only hou eholds) and households in which no person was age 65 or older (i.e., nonelderly hou eholds). Hou ehold with mixed elderly and nonelderlyabout 7 percent of all hou ehold - were excluded from the analy is. Family Economics and Nutrition Review Scaling Analysis: Do the Elderly and Nonelderly Experience and Respond Similarly to Food Insecurity? To assess whether the questions in the Food Security Scale are understood similarly by the elderly and the nonelderly and whether they experience and respond similarly to food insecurity, I compared response patterns of elderly-only and nonelderly households. To do so, I used statistical methods based on the Rasch measurement model-the methods originally used to develop the Food Security Scale. This analysis exploits one of the strengths of multiple-indicator measures such as the Food Security Scale: associations among the indicators comprising the scale provide evidence of its validity and reliability. Furthermore, if the patterns of association among the items in a multipleindicator measure are similar in two populations, this suggests that the items relate similarly in the two populations to the underlying phenomenon that accounts for their interrelationships; that is, the items measure the same phenomenon in the two populations. These methods of scale assessment are more widely used in psychometric research and educational testing than in nutrition and economic research, so I present first a brief summary of the Rasch model and the scale assessment statistics based on it. More detailed information on the Rasch model and associated statistics is available elsewhere. 1 1 See Wright (1977; 1983), Wright & Ma ters (1982), Baker ( 1992), Hambleton, Swaminathan, & Rogers ( 1991 ), and Fischer & Molenaar ( 1995), and the Website of the MESA psychometric laboratory at the University of Chicago at www.rasch.org. Information about applications of Rasch methods to the development and assessment of food security scales is avai lable in Hamilton et al. ( 1997a; 1997b), Ohls, Radbi ll, & Schirm (200 I ), Bickel et al. (2000), and Nord (2000). 2003 Vol. 15 No. 1 An essential characteristic of the Food Security Scale is that the items comprising it vary across a wide range of severity of food insecurity. The precise severity level of each item (the "item calibration" or "item score") is estimated empirically from the overall pattern of response to the scale items by the interviewed households. However, the range of severity of the conditions identified by the items is also intuitively evident from inspection of the items. For example, not eating for a whole day is a more severe manifestation of food insecurity than is cutting the size of meals or skipping meals. These differences in severity are observed in two ways in the response patterns of surveyed households. First, more severe items are less frequently affirmed than less severe items. Second, households that affum a specific item are likely to have also affirmed all items that are less severe, while households that deny the item are likely to also deny all items that are more severe. These typical response patterns are not universal, but they are predominant, and among households that do deviate from the typical patterns, the extent of deviation tends to be slight. The Rasch model formalizes the concept of severity-ordering of items and provides standard statistical methods to estimate the sever
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Title | Family Economics and Nutrition Review [Volume 15, Number 1] |
Date | 2003 |
Contributors (group) | Center for Nutrition Policy and Promotion (U.S.) |
Subject headings | Home economics--United States--Periodicals;Nutrition policy--United State--Periodicals |
Type | Text |
Format | Pamphlets |
Physical description | v. : $b ill. ; $c 28 cm. |
Publisher | Washington, D.C. : U.S. Dept. of Agriculture |
Language | en |
Contributing institution | Martha Blakeney Hodges Special Collections and University Archives, UNCG University Libraries |
Source collection | Government Documents Collection (UNCG University Libraries) |
Rights statement | http://rightsstatements.org/vocab/NoC-US/1.0/ |
Additional rights information | NO COPYRIGHT - UNITED STATES. This item has been determined to be free of copyright restrictions in the United States. The user is responsible for determining actual copyright status for any reuse of the material. |
SUDOC number | A 77.245:15/1 |
Digital publisher | The University of North Carolina at Greensboro, University Libraries, PO Box 26170, Greensboro NC 27402-6170, 336.334.5482 |
Full-text | Special Issue Elderly Nutrition Research Articles 3 Improving Calcium Intake Among Elderly African Americans: Barriers and Effective Strategies TerraL. Smith, Susan J. Stephens, Mary Ann Smith, Linda Clemens, and Dianne K. Polly 15 The Influence of the Healthy Eating for Life Program on Eating Behaviors of Non metropolitan Congregate Meal Participants Cynthia A. Long, Alma Montano Saddam, Nikki L. Conklin, and Scott D. Scheer Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders Edward A. Frongil/o, Pascale Valois, and Wendy S. Wolfe 33 Measuring the Food Security of Elderly Persons Mark Nord A Statewide Educational Intervention to Improve Older Americans' Nutrition and Physical Activity M.A. McCamey, N.A. Hawthorne, S. Reddy, M. Lombardo, M.E. Cress, and M.A. Johnson 58 Estimation of Portion Sizes by Elderly Respondents Sandria Godwin and Edgar Chambers IV Healthy Eating Index Scores and the Elderly Michael S. Finke and Sandra J. Huston 7 4 Factors Affecting Nutritional Adequacy Among Single Elderly Women Deanna L. Sharpe, Sandra J. Huston, and Michael S. Finke 83 Reduction in Modifiable Osteoporosis-Related Risk Factors Among Adults in the Older Americans Nutrition Program J.M.K. Cheong, M.A. Johnson, R.D. Lewis, J. G. Fischer, and J. T. Johnson 'I\· Ann M. Veneman, Secretary U.S. Department of Agriculture Eric M. Bost, Under Secretary , Food, Nutrition, and Consumer Services " \\1'- '\ , ... ~ Eric J. Hentges, Executive Director Center for Nutrition Policy and Promotion 0'·•' Steven N. Christensen, Deputy Director Center for Nutrition Policy and Promotion P. Peter Basiotis, Director Nutrition Policy and Analysis Staff Center for Nutrition Policy and Promotion Mission Statement To improve the health of Americans by developing and promoting dietary guidance that links scientific research to the nutrition needs of consumers. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to al l programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250- 9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. Editor Uulia M. Dinkins Associate Editor David M. Herring Features Editor Mark Lino Managing Editor Jane W. Fleming Peer Review Coordinator Hazel Hiza Family Economics and Nutrition Review is written and published semiannually by the Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, DC. The Secretary of Agriculture has determined that publication of this periodical is necessary in the transaction of the public business required by law of the Department. ifhis publication is not copyrighted. Thus, contents may be reprinted without permission, but credit to Family Economics and Nutrition Review would be appreciated. Use of commercial or trade names does not imply approval or constitute endorsement by USDA. Family Economics and Nutrition Review is indexed in the following databases: AGRICOLA, Ageline, Economic Literature Index, ERIC, Family Studies, PAIS, and Sociological Abstracts. Family Economics and Nutrition Review is for sale by the Superintendent of Documents. Subscription price is $13 per year ($18.20 for foreign addresses}. Send subscription order and change of address to Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. (See subscription form on p. 103.} Original manuscripts are accepted for publication. (See "guidelines for submissions" on back inside cover.} Suggestions or comments concerning this publication should be addressed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion, USDA, 3101 Park Center Drive, Room 1034, Alexandria, VA 22302-1594. The Family Economics and Nutrition Review is now available at www.cnpp.usda.gov (See p. 104} CENTER FOR NUTRITION POLICY AND PROMOTION Research Articles 3 Terra L. Smith, Susan J. Stephens, Mary Ann Smith, Linda Clemens, and Dianne K. Polly 15 The Influence of the Healthy Eating for Life Program on Eating Behaviors of Nonmetropolitan Congregate Meal Participants Cynthia A. Long, Alma Montano Saddam, Nikki L. Conklin, and Scott D. Scheer 25 Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders Edward A. Frongillo, Pascale Valois, and Wendy S. Wolfe 33 Measuring the Food Security of Elderly Persons Mark Nord 47 A Statewide Educational Intervention to Improve Older Americans' Nutrition and Physical Activity M.A. McCamey, N.A. Hawthorne, S. Reddy, M. Lombardo, M.E. Cress, and M.A. Johnson 58 Estimation of Portion Sizes by Elderly Respondents Sandria Godwin and Edgar Chambers IV 67 Healthy Eating Index Scores and the Elderly MichaelS. Finke and Sandra J. Huston 7 4 Factors Affecting Nutritional Adequacy Among Single Elderly Women Deanna L. Sharpe, Sandra J. Huston, and MichaelS. Finke 83 Reduction in Modifiable Osteoporosis-Related Risk Factors Among Adults in the Older Americans Nutrition Program J.M.K. Cheong, M.A. Johnson, R.D. Lewis, J.G. Fischer, andJ. T. Johnson Regular Items 92 Federal Studies 100 Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, September 2003 101 Consumer Prices 102 U.S. Poverty Thresholds and Related Statistics Volume 15, Number 1 2003 Foreword W ith this issue, we here at the Center for Nutrition Policy and Promotion celebrate the 60'h anniversary of Family Economics and Nutrition Review. From its beginning as a monthly newsletter, to its transformation as a research journal, Family Economics and Nutrition Review has provided valuable information to the American public. Whether named Wartime Family Living (1943), Rural Family Living (1945), Family Economics Review (1957), or Family Economics and Nutrition Review (1995), this USDA publication has always provided information-based on current scientific knowledge-for Americans to make decisions about food, clothing, and shelter, as well as provided information about other aspects of daily living (e.g., energy prices, welfare reform, and population trends for quality of life). . Started during World War II, Wartime Family Living, a newsletter, kept Americans abreast of war-related food concerns: distribution, production and manufacturing quotas, and rationing. USDA Cooperative Extension agents, the audience that translated the information in Wartime Family Living into forms useful to the American public, found this helpful advice in the December 27, 1943, issue: "Wartime diets for good nutrition, presented in April's Wartime Family Living, has now been printed and is called Family food plans for good nutrition. These plans, a low-cost and a moderate-cost one, have been revised slightly since their earlier release. Both will be helpful in planning diets that will measure up to the yardstick of good nutrition." We have produced several special issues: the Special Economic Problems of Low-Income Families (1965), the Economic Role of Women in Family Life (1973), Promoting Family Economic and Nutrition Security (1998), and the Food Guide Pyramid for Young Children (1999). The USDA's 60th anniversary edition of Family Economics and Nutrition Review, a special issue, focuses on our elderly population: By focusing on this growing population, we are not only addressing some important implications of aging in relation to nutrition and well-being, we are also continuing our tradition of linking "scientific research to the nutrition needs of consumers" and thus improving the well-being of American families and consumers. On the 25th anniversary, Family Economics Review was recognized as having helped the USDA reach its goal of providing Americans with a flow of information on problems affecting their welfare: "Today, Family Economics Review brings together and interprets economic data affecting consumers from USDA and many Government sources, for use by [Cooperative] Extension workers, college and high school teachers, social welfare workers, and other leaders working with farm and city people." On this 60th anniversary, Family Economics and Nutrition Review reflects the USDA's goal to improve the Nation's nutrition and health through nutrition education and promotion. It is our wish here at the Center for Nutrition Policy and Promotion that Family Economics and Nutrition Review will continue to serve the needs of the American public. Julia M. Dinkins Editor TerraL. Smith, PhD, RD The University of Memphis Susan J. Stephens, MS, RD Central North Alabama Health Services, Inc. Huntsville, AL Mary Ann Smith, PhD, RD The University of Memphis Linda Clemens, EdD, RD The University of Memphis Dianne K. Polly, MS, JD Metropolitan Inter-Faith Association 2003 Vol. 15 No. 1 Research Articles Improving Calcium Intake Among Elderly African Americans: Barriers and Effective Strategies The objectives of this pilot study were to identify barriers to and informed strategies for improving calcium intake among elderly African Americans. To accomplish these objectives, researchers recruited 56 seniors (age 60 or older) from a congregate meal site in a large urban senior center in the mid-South region of the United States. In focus group discussions, participants answered questions related to food preferences, calcium intake, motivations, and barriers to calcium intake, as well as recommended educational strategies. Researchers used both quantitative and qualitative methods to evaluate the data. The study revealed eight barriers to dietary calcium intake: concern for health and disease states, lack of nutrition knowledge, behaviors related to dairy products, limited food preferences, financial concerns, lack of food variety, food sanitation concerns, and limited food availability. Participants suggested several educational strategies, including group discussions, taste-testing sessions, and peer education at various locations. Other suggestions were direct mail, television, and newspapers with large print text and colorful depictions of diet-appropriate ethnic foods. Focus group interactions are excellent means of eliciting nutritionrelated opinions from African-American elders. T he resu lts of the Third National Health and Nutrition Examination Survey (NHANES III) (Alaimo et al., 1994) agree with the conclusions of other studies that the calcium intake of many African Americans is below recommended levels (National Research Council, 1989) and especially below the new calcium goals (Dietary Reference Intakes) for the American population (National Academy Press, 1997; Yates, Schliker, & Suitor, 1998). The limited intake of calcium by African Americans places this subgroup of the American population at risk for chronic diseases that may be alleviated by achieving adequate calcium. Although many African Americans consume milk, the consumption of dairy products-a major source of calcium in the United States-by African-American men and women is significantly lower than that of White men and women (Shirnakawa et al., 1994; Koh & Chi, 1981). Osteoporosis associated with calcium-intake deficiencies and possibly hypertension contributes to the high cost of medical care in the United States (Riggs, Peck, & Bell, 1991 ; Joint National Committee, 1993). Prevalence of deficiencies in lactase, an enzyme required to metabolize the primary milk sugar lactose, is blamed for the low intake of dairy products among African Americans (Pollitzer & Anderson, 1989). Although the consumption of milk and dairy products is inadequate in terms of calcium intake, nutrient supplementation is not a solution for many African Americans. Results from the 1992 National Health Interview Survey Epidemiology 3 Supplement (Slesinski, Subar, & Kahle, 1996) indicate that of the 1,353 Blacks surveyed, three-fourths (77 .2 percent) seldom or never used any vitan1in and mineral supplement, less than 5 percent (4.4 percent) used supplements occasionally, and 18.4 percent used them daily. Commonly called the "silent disease" because pain or symptoms are not experienced until a fracture occurs, osteoporosis is a metabolic bone disease characterized by low bone mass, which makes bones fragile and susceptible to fracture. While AfricanAmerican women tend to have higher bone mineral density than White women have, they are still at significant risk of developing osteoporosis. Furthermore, as African-American women age, their risk of developing osteoporosis more closely resembles the risk among White women. So, as the number of older women in the United States increases, an increasing number of African-American women with osteoporosis can be expected (National Institutes of Health, 1998). Background The literature is replete with studies indicating that calcium intakes of African Americans are below the recommended dietary guidelines (e.g., Alaimo et al., 1994 ), as well as the new calcium intake standards set by the Institute of Medicine (National Academy Press, 1997). In addition to verifying the poor status of calcium intake among African-American adults, much of the literature focuses on the dichotomy of lactose intolerance and bone densities of African Americans. Lactose intolerance is thought to be the primary barrier to consumption of milk and dairy products among African Americans (Buchowski, Semenya, & Johnson, 2002). The empirical work on lactose intolerance among African 4 Americans, however, does not establish that African Americans choose not to consume milk because of gastrointestinal distress. Researchers have found that lactose intolerance among some African Americans may be overestimated because of lactose digesters ' belief that consumption of milk leads to this distress (Johnson, Semenya, Buchowski, Enwonwu, & Scrimshaw, 1993). Even with lactose intolerance, small quantities of milk can be consumed with little or no discomfort, and specialty milk products and lactase tablets are available to ameliorate the symptoms related to lactose consumption. In addition, promising dietary management strategies are available, such as consuming lactose-containing dairy foods more frequently and in smaller amounts as well as with meals, eating live culture yogurt, using lactose-digestive aids, and the consumption of calciumfortified foods (Jackson & Savaiano, 2001). The other side of the dichotomy is bone mineral density and osteoporosis. A major reason for the sense of security regarding calci urn-intake research may be the higher bone mineral density of African-American women (e.g., Luckey et al. , 1989) coupled with their lower rates of osteoporosis. The implications are that high bone mineral density will protect African Americans from osteoporosis and symptoms of calcium deficiency. Silverman and Madison (1988) found that the incidence of age-adjusted fracture rates for non-Hispanic White women is greater than twice the rate for African Americans. But low risk does not translate into no risk. A fact sheet from the National Institutes of Health (1998) states that [A]pproximately 300,000 African-American women currently have osteoporosis; between 80 and 95 percent of fractures in African-American women over 64 are due to osteoporosis; AfricanAmerican women are more likely than White women to die following a hip fracture; as African-American women age, their risk of hip fractures doubles approximately every 7 years; [and] diseases more prevalent in the AfricanAmerican population, such as sickle-cell anemia and systemic lupus erythematosus, are linked to osteoporosis. Some researchers have developed a prudent approach to this dichotomy. One group concluded that the "higher values of bone densities in AfricanAmerican women, compared with White women are caused by a higher peak bone mass, as a slower rate of loss from skeletal sites comprised predominantly of trabecular bone. Low-risk strategies to enhance peak bone mass and to lower bone loss, such as calcium and vitamin D augmentation of the diet, should be examined for African-American women" (Aloia, Vaswani, Yeh, &Flaster, 1996). To promote higher intakes of calcium more effectively, researchers and nutrition educators need to know more about food practices in relationship to dietary calcium. However, little information is available on the effect that food practices of older African Americans may have on nutrient intake, particularly calcium (Cohen, Ralston, Laus, Bermudez, & Olson, 1998). The Council on Aging's congregate meal feeding program is an excellent means of studying the problem of dietary calcium barriers among AfricanAmerican elders. Even though the Council's meals provide one-third of the RDA for all nutrients, AfricanAmerican participants consumed less calcium, thiamin, iron, fat, carbohydrate, Family Economics and Nutrition Review fi ber, niacin, and vitamin C than did White participants (Holahan & Kunkel, 1986). The purpose of the current pilot study was to examine the barriers to adequate calcium intake, through focus group discussions, among the AfricanAmerican elderly population that participates in the congregate meal program. The information from this study is needed to prepare effective, relevant, and appropriate nutritional education presentations and materials. Methods Participant Recruitment In the mid-South region of the United States, researchers recruited participants from a congregate meal site in a large urban senior center. Researchers held a recruitment session during which they explained the project's focus, time conmlitment, and purpose to potential participants; scheduled participants for the focus group sessions; and distributed appointment cards. Upon completing all focus group sessions, participants received a $15 gift certificate to a local grocery store. The researchers completed the official recruitment process in 1 day; however, the participants, without prompting, recruited others. Only African-American elders 60 years and older participated in this study. Assessment Instruments The assessment instruments consisted of the Demographic and Calcium Intake Questionnaire (DCIQ) (Fleming & Heimbach, 1994) and the focus group questions (box 1). In addition to collecting demographic data, researchers used the DCIQ to assess participants' food preferences in relationship to dairy and calciumcontaining foods. To make the focus group procedures and questions more reliable and while taking into account 2003 Vol. 15 No.1 the age and cultural differences of elderly African Americans, the researchers used a dietary calcium intake questionnaire developed for low-income Vietnamese mothers (Reed, Meeks, Nguyen, Cross, & Ganison, 1998). Forexan1ple, where Reed and colleagues emphasized Asian cultural references, the researchers substituted African-American cultural references and maintained the theoretical framework of the original template, which was based on the PRECEDEPROCEED model (Green & Kreuter, 1991). This model has tlu:ee central components related directly to the types of questions raised during a focus group discussion that seeks to understand how to address, in a better fashion, dairy calcium needs through nutrition education: (I) predisposing (knowledge, attitudes, and motivations), (2) enabling (resources and skills), and (3) reinforcing (praise and perceived benefits). Based on the recommendations of Krueger (1998), the researchers interspersed these questions within the procedural framework described in box 1. Procedures for Data Collection and Data Analysis Each of the six focus groups was limited to no more than 12 participants, and each session lasted no longer than 1 Y2 hours. A total of 56 African Americans participated. At the beginning of each focus group session, the researchers obtained a written consent from each participant. Before group discussions began, the researchers administered the DCIQ to participants and offered assistance if needed. To help participants become comfortable, theresearchers asked each to "tell us your name, and tell us what your favorite food is." To transition to the discussion, the researchers asked participants to talk about some of the good points about their diet and how they would improve their diet. Participants considered milk good for bones and teeth and were concerned about bone health and disease prevention in spite of being unable to describe calcium-related deficiency diseases. 5 Box 1. Focus group transition statements and questions 1 Transition The USDA Food Guide Pyramid recommends that adults consume milk and dairy products every day. Key Questions #1 What dairy products do you commonly consume? How often do you have foods in this group? Which of the dairy foods do you select when you eat away from home? What things hinder you from eating these foods more often? What keeps you from ordering milk and dairy products when you eat away from home? As you see it, what is the relationship of milk and health? What people or materials helped you develop your viewpoint? Key Questions #2 Foods in the milk and dairy group are high in calcium. Calcium helps prevent several diseases: thinning of the bones or osteoporosis; high blood pressure or hypertension; and weak bones or rickets. What have you heard about these diseases? What would you like to know about these diseases? How does knowing about diseases related to poor calcium intake impact your diet choices? What would motivate you to eat more of the foods in the dairy group? Transition So, you are saying that milk is important because of the nutrients it provides such as calcium. Key Questions #3 Here is a list of foods with their calcium content. What are your impressions of this list? So you eat several of these foods, what keeps you from purchasing/eating other foods on the list? What would motivate you to eat other foods that contain calcium? Think about the last time you tried something you never tried before. How did you go from never eating it to having tried it? How do your friends and family influence the foods you buy or prepare? Transition So, what I am hearing is that your friends and family impact your food choices. When you think back on it, how much does your family influence the foods you buy or prepare? Key Questions #4 What are your thoughts about what your grandchildren need in terms of milk and dairy foods? Where do you like to get nutrition information? What is your impression about food labels? Are there places or people who don't provide nutrition information that you would like to hear from? What nutrition information do you get from the following materials or places: brochures, reading materials, recipes high in calcium, grocery store lists, foods to select in a restaurant, signs, community classes-in the library, community center, and/or church? What are appealing and convenient ways for us to provide you with information about foods and nutrition? What is your impression of the "Got Milk" signs? What is your family and grandchildren's impressions of the posters? What would you like to know about calcium, milk, and dairy foods? How much time would you like to spend learning about calcium? 1 Krueger, 1998; Reed et al., 1998. Researchers used the focus group discussion questions to identify the barriers to calcium intake. This discussion was followed by a transition to this combined set focused on participants' opinion about their grandchildren's need for milk and dairy products. To close the discussion, researchers asked the participants to give any advice that would help African Americans increase the calcium content of their diets. frequencies were determined for food preferences and the demographic variables. The models were used to analyze the qualitative data: (1) the inductive data analysis model identified topics, categories, themes, and concepts as a means of bringing forth knowledge (McMillan & Schumacher, 1997)and(2)thePRECEDE-PROCEED model was used to subdivide the knowledge gained into categories (Green&Kreuter, 1991). the key questions. The first and second sets of key questions focused on current dietary behavior and predisposing factors, respectively; the third set focused on reinforcing factors. Finally, the fourth set of key questions focused on enabling factors. Researchers combined the last two sets of questions to determine educational strategies. One additional question in 6 Both quantitative and qualitative procedures were used to analyze the data. The Statistical Package for the Social Sciences (SPSS, 1999) was used to analyze the descriptive data; Family Economics and Nutrition Review Researchers completed and compiled the qualitative data in the form of tape recordings and handw1itten notes. During analysis, the researchers reviewed both the notes and the tapes from each focus group session and then used the tape recordings to complete the notes. Next, researchers identified barriers, placed the individual baniers into categories, and organized the categories into patterns or themes and concepts (e.g., related to a predisposing or an enabling factor). Results and Discussion The focus group attendance was excellent, with only six no-shows. Six other participants attended a focus group session other than the one they had original ly planned to attend. By casual observation, we noted that all but two of the participants appeared to be able-bodied: one revealed a hearing Joss and one used a walker. Even though over half (n=28) of the AfricanAmerican seniors in this study reported income below the poverty index (Annual Update of the HHS Poverty Guidelines, 1999), fmances were rarely mentioned as a banier to adequate calcium intake in the focus groups. These seniors seemed adept at managing their finances, and 40 percent used resources other than congregate meals, freq uently citing commodity foods as supplements to their food budgets. Most African-American participants (84 percent) agreed to provide demographic information (table 1). Six often participants had less than a high school education, about 6 of 10 had a monthly income of Jess than $700, and about 6 of 10 were not receiving food assistance. Almost three-quarters of the participants were single, separated, divorced, or widowed; over half (57 percent) lived alone. Most of the 56 participants (n=47) completed the food preference survey, which indicated that greater 2003 Vol. 15 No. 1 than 90 percent of the respondents liked and ate milk and dairy products as well as some other foods with moderate or high amounts of calcium (e.g., salmon with bones). However, some participants, while reviewing a list of calcium-containing foods, noted unfamiliarity with relatively new products such as tofu. In terms of general categories of calcium-containing supplements (calcium, antacids, or vitanlins and minerals), 83 percent of the participants reported using supplements of various types daily, weekly, or seldom. Fifty-five percent reported taking at least one of the calciumcontaining supplements daily, 13 percent reported using calcium supplements or other antacids (e.g., Turns), and 49 percent reported using vitaminmineral supplements (data not shown). Focus group discussions revealed a list of barriers to calcium intake among African-American seniors: • concern for health and disease states • Jack of nutrition knowledge • behaviors related to dairy products • limited food preferences • concerns about finances • lack of food variety • concerns about food sanitation • limited food availability Two subcategories represented the barriers: predisposing factors and enabling factors . Researchers identified four types of barriers related to predisposing factors: customs and beliefs, food handling/sanitation, nutrition knowledge, and health reasons/disease state/food intolerance. Researchers also identified four types of barriers related to enabling factors: food preferences, financial issues, food variety and availability, and behaviors. In terms of food preferences, the participants discussed the need to learn to eat and learn to like new foods to increase calcium intake. Participants identified Table 1. Demographic characteristics of African-American seniors Variables EducationalleveP <8th grade 9th-11th grade 12th grade Technical school Some college College degree Monthly income $687 or less $688-$922 $923 or more Food assistance2 Yes No Marital status Single, separated, divorced, widowed Married Gender Male Female Living situation Lives alone Lives with spouse Lives with other Percent 40.4 19.1 31 .9 12.7 4.3 4.3 55.3 23.4 21.3 40.4 59.6 72.3 27.7 13.0 87.0 57.4 27.7 14.9 1 Participants selected all that applied. For example, a participant that completed 12th grade and technical school may have selected both categories. 2Participants' most frequently reported food assistance was commodity foods. n = 47. 7 several marketing and educational strategies to improve the calcium nutrition knowledge of the AfricanAmerican population. Although most participants had less than a high school education, they were articulate and participated actively in the focus group discussions. The only physical banier mentioned in the focus groups was digestive problems, which is different from the findings of others (Fischer & Johnson, 1990; Skaien, 1982). These researchers had shown physical barriers to be a substantial cause of nutritional deficiencies. Demographic Data and Food Preference For these participants, fruits, vegetables, grains, and desserts were the favorite foods. The frequency data derived from the demographic survey supported these statements and revealed that almost 90 percent of these participants liked and ate food from all food groups. Several of the participants stated that collard or mustard greens were a favorite food. Of those that mentioned greens as a favorite food, several said they not only ate greens for dinner but sometimes for breakfast or lunch as well. Because salmon was the only meat mentioned in the frequency data, meat preferences were not determined. On the frequency checklist, the participants indicated whether they liked or ate dairy products, but these items were not mentioned as favorite foods in the focus group discussions. When the moderators probed about dairy foods, many participants indicated they did not like the taste of the foods or they had been instructed to eliminate them from their diet for health/disease reasons. These participants did not mention total avoidance of calcium-rich foods. 8 Barriers to Calcium Intake One of the challenges for understanding and discussing the baniers to calcium intake among the urban African-American elders is the interaction among factors. For example, lack of nutritional knowledge may interact with health status and disease state. Alternatively, concern for food handling and sanitation can interact with food preferences and selections. Overall, baniers discovered during this investigation are similar to the baniers identified by Zablah, Reed, Hegsted, and Keenan (1999) when they interviewed 90 African-American women who were either pregnant or had children 5 years old or younger. Zablah and colleagues found that participants perceived they consumed enough calcium, disliked the taste of some calcium-rich foods, experienced digestion problems, had a perceived lack of knowledge of products containing calcium, and were concerned about cholesterol and the high-calorie content of these foods. Thus, both the mothers of young children and elderly African Americans have concerns related to dietary calcium intake and food sources of calcium. Barriers Related to Predisposing Factors Customs and beliefs. In general, participants considered milk a healthful food, connected with cows and wonderful family memories. For example, one participant stated" ... [B]eing raised on the farm, we had to milk the cows. So we knew that was good. We always knew. My daddy insisted that we drink milk." A participant even considered milk a healing food, having recommended milk as a food to a convalescing friend. This friend, a member of the same focus group as the participant, testified that she now drinks milk daily. However, participants discussed the image of milk as a child's food as well, associati ng the "Got Milk" campaign with children. Calcium requirements were not mentioned in the context of a chronic disease state or as a religious dietary restriction. (In a similar focus group held with Women, Infants, and Children Program participants, one mother mentioned her plans to eliminate milk from the diet of an elementary school-age child because of her religious beliefs [unpublished data].) Participants suggested milk as an aid for acute problems, such as ankle problems and "popping bones" described as "bones that don' t act right." Food and nutrition knowledge. Participants in the focus group di scussions wanted information about nutrition and calcium. Participants considered milk good for bones and teeth and were concerned about bone health and disease prevention in spite of being unable to describe calciumrelated deficiency diseases. However, one participant discussed her bout with osteoporosis, and the pain and discomfort involved with this debilitating disease. Additional examples of basic lack of knowledge included calcium content of foods and complications related to poor calcium intake. Participants also confused eggs with dairy products. In addition, although participants correctly identified milk and cheese products as containing cholesterol, they failed to identify lowfat milk and cheese products as appropriate dietary modification for those concerned with dietary cholesterol. For example, one participant stated, "Well, I like cheese, but you know they say cheese is so bad for you now for cholesterol. So I don't eat too much cheese." The discussions revealed that participants were surprised that greens were a source of calcium. When moderators provided the participants with a list of calcium-rich foods that included greens (100 mg calcium per Y2 cup serving), many said they were unaware that Family Economics and Nutrition Review greens were a good source of dietary calcium. One participant commented, "I didn't know [turnip greens] had calcium. I know I love them." In addition to greens, participants seemed surprised to learn about the high calcium content of many foods, such as sardines with bones, prunes, broccoli, spinach, and tofu. Although the basis of such confusion may be lack of nutrition knowledge, the confusion may also relate to how health care professionals organize nutrition knowledge. It is possible that the issue of food categories in terms of nutrients may represent a difference in the organizational schema of nutritional sciences based on nutrients, while that of the participants' knowledge may be based on other factors. Krall, Dwyer, and Coleman ( 1988) said it this way: [A] person's memory is likely to follow personal schemes such as food combinations, time, location, etc. The categorization scheme, such as nutrient-related groups, is not well understood by most lay persons, [and is] therefore, alien to the manner in which [their] information was stored, [and] imposes an arbitrary structure which potentially leads to inefficient recall. In addition, concerns about food handling and sanitation practices of food service establishments served as a deterrent to ordering milk as a beverage when eating out. "Now, I wouldn't order milk out-because I use to work at a restaurant .... If they bring [milk] to me in a glass, I wouldn't drink it. [Researcher: How come?]. .. Well, we had a keg. And, everyone would dip their hand down in that keg, and they'd want the 2003 Vol. 15 No. 1 employees to drink that milk, ... Well, we could get milk [from] the dining room, but the other help had to get milk from ... that keg, and I didn't think that was right." Health reasons, disease state, and food intolerance. Many of the participants were concerned about health and disease-related issues. They were especially concerned with heart disea e, high blood pressure, high cholesterol, and arthritis. Previous resear·ch also found similar health concerns in rural African-American elderly (Lee, Templeton, Marlette, Walker, & Fahm, 1998; Wallace, Fox, & Napier, 1996). As one participant in the 1996 study commented: "I drink a little milk, ... I can't handle milk too good unless I'm at home." Thus, participants in the 1996 study sometimes tied these concerns to food restrictions, especially when their physician instructed them to eliminate certain foods from their diets. The participants reported being educated by their physician or nurse (none mentioned a dietitian) about which foods to avoid. Participants often followed medical recommendations to avoid or restrict a food group that was a calcium source without any instruction on how to replace the calcium in their diet. In terms of lactose intolerance, symptoms mentioned included flatulence, and stomach problems. Participants also mentioned that dairy products, such as milkshakes, were "too rich for the system" although this could be related to the fat or sugar content. Generally, participants did not specifically mention dietary strategies for managing lactose intolerance, such as consuming yogurt or acidophilus milk or using lactase tablets. However, one participant mentioned the lack of lactose-free products as a barrier to purchasing dairy products in food service establishments. The focus group participants expressed an interest in all types of educational media including direct mail, television, radio, newspapers, and magazines. 9 Among the elderly, the perception of milk intolerance appears to vary with ethnicity and gender. Elbon, Johnson, Fisher, and Searcy ( 1999), in a national telephone survey of 475 older Ametican participants, including 27 African Americans, found that 35 percent of the African-American respondents considered themselves milk intolerant, whereas only 17 percent of the Whites did so. Twice as many women (21 percent) considered themselves milk intolerant than did the men (1 0 percent). Others found similar avoidance based on perception (Buchowski, Semenya, & Johnson, 2002). Barriers Related to Enabling Factors The barriers related to enabling factors were food preferences, financial issues, food variety and availability, and behaviors related to calcium-containing foods. In terms of food preferences, to help improve calcium intake, the participants discussed the need to learn to eat and enjoy new foods and learn how relatives, friends, and interactions at social gatherings (e.g., at church) influenced their food choices by introducing new foods . (Participants demonstrated a willingness to try the calcium-fortified juice provided as a snack during all focus group discussions.) Subjects participated in the tradition of extended family members influencing food choices by encouraging their grandchildren to drink milk. One subject told the story of how she learned to eat broccoli: 10 "This broccoli, I never was too fond of it, but my son-in-law, when they were living here in town, use to cook dinner on Sundays and invite me over. And he would fix the broccoli. I didn' t want to hurt his feelings. So I started eating broccoli, and Table 2. Marketing and educational strategies for promoting calcium intake suggested by African-American seniors Strategies Direct mail Media Informal educational sessions Location Desired tactics n = 56. sometimes I get it ... when I go out, 'cause I don't do too much cooking at home. But, I' ll eat the broccoli especiall y, you know, with some cheese on it." In addition, the participants seemed to categorize foods into good and bad foods as well as in terms of a diseasebased model, that is, to eliminate foods due to a disease. Some participants mentioned fmancial concerns as a barrier to intake of milk products. Financial issues related to the cost of food are not onl y a concern among the urban southern elderly African Americans, but also among the rural southern African Americans. Lee and colleagues (1998) found that more than 70 percent of rural AfricanAmerican elders considered food (and medical) costs to be a se1ious issue. Recommendations Brochures Newsletters Magazines Television Radio Newspapers Tasting parties Focus group discussions Peer education Senior citizens' center schools Library Grocery store School or family reunions Large print text Colorful with pictures Diet-appropriate ethnic foods For example, focus group participants mentioned cost issues as reasons for not ordering milk at a food service establishment. Participants indicated that availability of some calcium-containing foods might infl uence consumption (e .g., calciumcontaining j uice). In terms of behaviors, participants mentioned postponing drinking milk to avoid fl atulence during social engageme nts. This behavior appears to indicate that participants were struggling with how to maintain consumption of dairy products in spite of symptoms of lactose intolerance. In such cases, nutrition education could help the elderly develop more effective strategies for managing lactose intolerance. Family Economics and Nutrition Review Marketing and education strategies The focus group participants expressed an interest in all types of educational media including direct mail, television, radio, newspapers, and magazines (table 2). They found it enjoyable to learn in social settings, such as community center classes, church meetings, family and class reunions, and the senior citizens' center. Tastetesting sessions in any setting were particularly appealing to the group. Other routes of nutrition education delivery included sessions at the library, food bank, and the commodity food distribution centers. The input from the participants involved in the present study clearly shows that a number of strategies might be successful in increasing AfricanAmerican seniors' knowledge about adequate calcium intake. One strategy that has benefitted elders is church-based health promotion. Ransdell (1995) discussed why such promotional strategies have been successful and are appropriate for many elderly. In addition, the comments of African-American caregivers that spiritual activities promote health, as reported in a recent study (McDonald, Fink, & Wykle, 1999), probably reflect the sentiment of many others in the community. While working with urbandwelling minority elders, Wieck (2000) found that health promotion activities work best when the focus is on small, achievable goals in the context of short-focused educational sessions. Hurdle (2001) discussed the importance of social support as a component of health promotion activities. Hurdle's report helps, in part, to explain the positive response of the elders to the focus group approach used by this study. The focus group may have helped support "connectedness" (Belenky, Clinchy, Goldberger, & Tarule, 1986), and may help with the 2003 Vol. 15 No. 1 sense of community fostered by the center at which the focus groups were conducted. Furthermore, others found that women were more like! y than men to participate in health-promoting activities and relaxation, while men were more likely than women to participate in exercise (Felton, Parsons, & Bartoces, 1997). Therefore, gender patterns of response to health promotion should be considered when planning healthpromoting activities. Summary and Recommendations In this pilot study, focus group interactions were excellent means to elicit African-American elders' opinions about barriers and educational strategies related to calcium intake. The results may not be generally applicable, because they pinpoint the existence of barriers to adequate calcium intake among one group of African-American seniors. Within this group, health/disease states and lack of knowledge appeared to be the primary and secondary barriers reported, respectively. Although similar studies quantify calcium intake in this population, they provide only limited insight of the barriers. Therefore, further studies are necessary to validate the current findings. A future research plan could include correlating calcium intake data with results from focus group discussions. The participants in the present study provided suggestions that are beneficial for educators who develop materials and methods for nutrition instruction. Specifically, the elderly participants requested disease-specific calcium education directed to their level of learning and that would be provided in a community-based and socially centered environment. The seniors in this study wanted the following information: linkage between calcium sources and specific disease states, calcium content of foods, high-calcium recipes provided in grocery stores at the point of purchase, cooking demonstrations or taste-testing parties featuring calcium-rich foods, and strategies for managing dairy-related food intolerance. Health care providers, social workers, food assistance program managers, volunteers who work with the elderly, and family members must also be educated on adequate calcium intake for these seniors. Educational programs should concentrate on introducing new foodstuffs into seniors' diets and teaching them to substitute item that have been omitted from their diets for medical reasons with alternative calcium-containing foods. Identification and recognition of calcium barriers should be determined across cultures and age groups, if educators hope to promote adequate calcium intakes. 11 12 References Alaimo, K., McDowell, M.A., Briefel, R.R., Bischof, A.M., Caughman, C.R., Loria, C.M. et al. (1994, November 14). Dietary Intake of Vitamins, Minerals, and Fiber of Persons Ages 2 Months and Over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91. Advance Data No. 258. Hyattsville, MD: National Center for Health Statistics. Aloia, J.F., Vaswani, A., Yeh, J.K., & Flaster, E. ( 1996). Risk for osteoporosis in black women. Calcified Tissue International, 59(6), 415-423. Annual Update of the HHS Poverty Guidelines, 7 Federal Register 13428-13430 (1999) (codifiedat42CFR 124). Belenky, M.F., Clinchy, B.M., Goldberger, N.R., & Tarule, J.M. (1986). Women's Ways of Knowing: The Development of Self, Voice, and Mind. New York: Basic Books. Buchowski, M.S., Semenya, J., &Johnson, A.O. (2002). Dietarycalciumintakein lactose maldigesting intolerant and tolerant African American women. Journal of the American College of Nutrition, 21(1 ), 47-54. Cohen, N.L., Ralston, P.A.,Laus,M.J., Bermudez, 0., & Olson, R.B. (1998). Food practices, service use, and dietary quality in elderly Blacks. Journal of Nutrition fortheElderly, 17(4), 17-34. Elbon, S.M., Johnson,M.A.,Fisher,J.G., & Searcy, C.A. (1999). The influence of perceived milk intolerance on dairy product consumption in older American adults. Journal of Nutrition for the Elderly, 19(1), 25-39. Felton, G.M., Parsons, M.A., & Bartoces, M.G. (1997). Demographic factors: Interaction effects on health-promoting behaviors and health related factors. Public Health Nursing, 14(6), 361-367. Fischer, J., & Johnson, M.A. (1990). Low body weight and weight lose in the aged. Journal of the American Dietetic Association, 90( 12), 1697-1706. Fleming, K.H., & Heimbach, J.T. (1994). Consumption of calcium in the U.S.: Food sources and intake levels. Journal of Nutrition, 124(8), 1426S-1430S. Green, L.W., & Kreuter, M.W. (1991). Health Promotion Planning: An Educational and Environmental Approach (2"d ed.). Mountain View, CA: Mayfield Pub. Co. Holahan, K.B., & Kunkel, M.E. ( 1986). Contribution of the Title ill meals program to nutrient intake of participants. Journal of Nutrition for the Elderly, 6( I), 45-54. Hurdle, D.E. (2001). Social support: A critical factor in women's health and health promotion. Health & Social Work, 26(2), 72-79. Family Economics and Nutrition Review Jackson, K.A., & Savaiano, D.A. (200 1). Lactose maldigestion, calcium intake and osteoporosis in African-, Asian-, and Hispanic-Americans. Journal of the American College ofNutrition, 20(Suppl. 2), 198S-207S. Johnson, A. 0 ., Semenya, J. G., B uchowski, M.S., Enwonwu, C. 0., & Scrimshaw, N.S. (1993). Correlation oflactose mal digestion, lactose intolerance, and milk intolerance. The American Journal of Clinical Nutrition, 57(3), 399-401. Joint National Committee. (1993). The Fifth Report oftheJointNational Committee on Detection, Evaluation and Treatment on High Blood Pressure (JNCV). Archives oflnternalMedicine, 153(2), 154-183. Koh, E.T., & Chi, M.S. (1981). Clinical signs found in association with nutritional deficiencies as related to race, sex, and age of adults. The American Journal of Clinical Nutrition, 34(8), 1562-1568. Krall, E., Dwyer, J., & Coleman, K. (1988). Factors influencing accuracy of dietary recall. Nutrition Research, 8, 829-841. Krueger, R.A. (1998). Developing Questions for Focus Groups: Focus Group Kit 3. Thousand Oaks, CA: Sage Publications. Lee, C.J., Templeton, S.B., Marlette, M., Walker, R.S., & Fahm, E.G. (1998). Diet quality and nutrient intakes of Black southern rural elderly. Journal of Nutrition for the Elderly, 17(4), 1-15. Luckey, M.M., Meier, D.E., Mandeli, P.J., Decosta, M.C., Hubbard, M.L., & Goldsmith, S.J. (1989). Radial and vertebral bone density in White and Black women: Evidence for racial differences in premenopausal bone homeostasis. The Journal of Clinical Endocrinology and Metabolism, 69(4), 762-770. McDonald, P.E., Fink, S.V., & Wykle, M.L. (1999). Self-reported healthpromoting behaviors of Black and White caregivers. Western Journal of Nursing Research, 21(4), 538-548. McMillan, J.H., & Schumacher, S. (1997). Research in Education: A Conceptual Introduction. New York: Harper Collins College Publishers. National Academy Press. (1997). Dietary Reference Intakes: For Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Washington, DC: Author. National Institutes of Health. (1998). Osteoporosis and African American women. Retrieved February 23, 2001, from http://www.osteo.org. National Research Council. (1989). Recommended Dietary Allowances, (lOth ed.). Washington, DC: National Academy Press. Pollitzer, W.S., & Anderson, J.J. (1989). Ethnic and genetic differences in bone mass: A review with a hereditary vs environmental perspective. American Journal ofClinicalNutrition, 50(6), 1244-1259. 2003 Vol. 15 No. 1 13 Ransdell, L.B. (1995). Church-based health promotion: An untapped resource for women 65 and older. American Journal of Health Promotion, 9(5), 333-336. Reed, D.B., Meeks, P.M., Nguyen, L., Cross, E.W., & Garrison, M.E.B. (1998). Assessment of nutrition education needs related to increasing dietary calcium intake in low-income Vietnamese mothers using focus group discussions. Journal ofNutritionEducation, 30(3), 155-163. Riggs, B.L., Peck, W.A., &Bell, N.H. (1991). Physician's Resource Manual on Osteoporosis: A Decision-Making Guide (2"d ed.). Washington, DC: National Osteoporosis Foundation. Shimakawa, T., Sorlie, P., Carpenter, M.A., Dennis, B., Tell, G.S., Watson, R., et al. (1994). Dietary intake patterns and sociodemographic factors in the atherosclerosis risk in communities study: ARlC study investigators. Preventive Medicine, 23(6), 769-780. Silverman, S.L., & Madison, R.E. (1988). Decreased incidence of hip fracture in Hispanics, Asians, and Blacks: California hospital discharge data. American Journal of Public Health, 78(11), 1482-1483. Skaien, P. (1982). Inadequate nutrition in the elderly: A stumbling block to good health. InT. J. Wells, (Ed.), Aging and Health Promotion. Rockville, MD: Aspen Publishers, Inc. Slesinski, M.J., Subar, A. F., & Kahle, L.L. ( 1996). Dietary intake off at, fiber and other nutrients is related to the use of vitamin and mineral supplements in the United States: The 1992 National Health Interview Survey. Journal of Nutrition, 126(12), 3001-3008. SPSS Reference Guide, Windows Version 10. (1999). Chicago, IL: SPSS Inc. Wallace, D.C., Fox, T.A., &Napier, E. (1996). Community-based service utilization among African American elderly. Journal of Gender, Culture, and Health, 1(4), 295-308. Wieck, K.L. (2000). Health promotion for inner-city minority elders. Journal of Community Health Nursing, 17(3), 131-139. Yates, A.A., Schliker, S.A., & Suitor, C.W. (1998). Dietary Reference Intakes: The new basis for recommendations for calcium and related nutrients, B vitamins, and cholene. Journal of the American Dietetic Association, 98(6), 699-706. Zablah, E.M., Reed, D.B., Hegsted, M., & Keenan, M.J. (1999). Barriers to calcium intake in African American women. Journal of Human Nutrition and Dietetics, 12(2), 123-132. 14 Family Economics and Nutrition Review Cynthia A. Long, MS, RD Ohio State University ExtensionCrawford County Alma Montano Saddam, PhD, RD The Ohio State University Nikki L. Conklin, PhD Ohio State University Extension Scott D. Scheer, PhD The Ohio State University and Ohio State University Extension 2003 Vol. 15 No. I The Influence of the Healthy Eating for Life Program on Eating Behaviors of Nonmetropolitan Congregate Meal Participants Current research indicates that when older adults increase their consumption of fruits and vegetables, they maintain or improve their health. Thus, their quality of life can be improved and health care costs lowered. A purposive sample of older adults (treatment group, n=50; control group, n=51) attending congregate meals participated in this study, with the treatment group receiving four lessons on fruits and vegetables over 4 weeks. The Stages of Change construct of the Transtheoretical Model was used to identify separate stages of change related to fruit- and vegetable-eating behaviors. Pre- versus post-test results showed that the treatment group's consumption of vegetables changed significantly, a positive movement from a lower stage of change (e.g., from Precontemplation, which was 30 percent at pre-test and 12 percent at post-test) to a higher category at posttest (e.g., taking action to change, or maintaining, their fruit- and vegetable-eating behaviors). Based on findings of this study, lessons on fruits and vegetables that include the Healthy Eating for Life Program (HELP) may promote positive changes in eating behaviors of nonmetropolitan participants of congregate meals and should be considered for study with similar older adult populations. T he older adult population in the United States is growing quickly (Price, 2001). The older adult population is projected to increase throughout the next several decades. In 2000, for example, 35.0 million Americans (12.4 percent) were 65 years old and older (Hetzel & Smith, 2001 ). By 2010,39.7 million Americans (13.2 percent) will be 65 years old and over, and by 2030, up to 20 percent of the U.S. population will be over age 65 (U.S. Census Bureau, 2000a; U.S. Census Bureau, 2000b). Along with this redistribution of the U.S. population, concerns related to aging may increase, including those related to the health and well-being of the older generation (Rogers, 1999). For example, the U.S. Department of Agriculture reported that Americans' diets need to improve, including those of the elderly (Basiotis, Carlson, Gerrior, Juan, & Lino, 2002). Although aging is not itself a cause of malnutrition, related risk factors can affect older adults' nutritional intake, contribute to malnutrition (Wellman, Weddle, Kranz, & Brain, 1997), and be "multiple and synergistic" (American Dietetic Association [ADA], 2000). Other factors that may contribute to the dietary status of the members of this growing older population are the types of nutrition messages they receive and their readiness to change diet-related behaviors. 15 Background A 1996 report by the American Dietetic Association discussed the increased challenges of competing with conflicting nutrition messages that consumers receive from a variety of sources. The public needs sciencebased information that not only educates, but also encourages the adoption of more healthful nutritionrelated behaviors. An update of this Association's report notes that research is needed to develop and test costeffective methods for evaluating the efficacy of nutrition education programs. For effective behavior change, nutrition education programs must be based on the target audience's needs, behaviors, motivations, and desires. And the gap between knowledge of nutrition and actual healthful eating practices must be narrowed by providing nutrition information in a usable form to consumers (ADA, 1996). In the 1970s, Prochaska and colleagues began studying how people make changes. Their efforts led to the development of the Transtheoretical Model, ofwhich the Stages of Change is a construct (Prochaska, Norcross, & DiClemente, 1994). Prochaska, attempting to bring together the components of the major psychotherapy theories regarding how people acquire successful behavior change, found that the many theories could be summarized by principles called the "processes of change." He was especially interested in how "selfchangers" progress along a continuum of change-from Precontemplation to Contemplation, Preparation, Action, Maintenance, and Terminationwithout therapy or a professional program (box I). According to this construct, successful change requires that self-changers 16 know the stage in which they are located and subsequently use appropriately timed strategies. Initial thoughts were that self-changers moved linearly from one stage to the next. In reality, successful selfchangers may recycle through the Stages of Change several times before successfully reaching the Maintenance or Termination stage (Prochaska, Norcross, & DiClemente, 1994). In studies of health behaviors, older adults have been found to fall primarily into the Precontemplation or Maintenance stage, therefore, calling for nutrition education efforts to be targeted at the Precontemplation stage (Nigg eta!., 1999), where people do not perceive there is a need to change. The assumption is that people at the Precontemplation stage for adoption of a healthful diet need information that assists them in becoming aware of the personal benefits of healthful eating behaviors (Laforge, Greene, & Prochaska, 1994). Persons in the Maintenance stage-where behavior changes have occurred for more than 6 months-may experience some relapse (Krista!, Glanz, Curry, & Patterson, 1999), may need infor-mation about local resources, and may need strategies to help them deal with barriers to maintaining their dietary changes. Implications for nutrition education programs for older adults include understanding and applying successful program elements, providing a clear plan for education and having that education based on segmented needs of the older population, adapting locally, and using existing services to provide education. These implications point to the need for research of behavior-based nutrition education for older adults (Contento eta!., 1995). Thus, this study examines the influence of a nutrition education intervention- the Healthy Eating for Life Program (HELP)-on the eating behaviors of a select group of older adults that participated in congregate meal programs. Because the scientific evidence supporting the healthful benefits of fruit and vegetable consumption is significant (U.S. Department ofHealth and Human Services [DHHS], 2000; Tate & Patrick, 2000; Gerrior, 1999), we focus on behavior changes related to the consumption of these food items. According to current research, older adults may maintain or improve their health by increasing their intake of fruits and vegetables, thus possibly lowering health care costs and increasing their quality of life (ADA, 2000; Gerrior, 1999). Nutrition education curricula for older adults are available for use, but the ability of these curricula to increase the servings of fruits and vegetables consumed by older adults is uncertain (Clarke & Mahoney, 1996; Contento et al, 1995). Hence, more evaluation studies are needed of the influence of nutrition education programs that are designed for older adults at congregate meal sites. Methods Subjects The target population for this study consisted of community-dwelling, nonrnetropolitan older adults who attended congregate meal sites. The participants were at least 60 years old (as required for attendance at the congregate meals), with the exception of spouses under 60 years old who could attend meals when accompanying their older spouse. The treatment group was chosen from three Ohio counties; the control group, Family Economics and Nutrition Review Box 1 - Basic definitions of the Stages of Change Construct of the Transtheoretical Model and operational definitions used in this study Basic definition Operational definition Precontemplation No intention of changing behavior and does not see a need Participant consumed fewer than 3 to 4 servings of fruits (vegetables) to change. each day and did not say he or she was seriously thinking about eating more servings of fruits (vegetables) during the next 6 months. Contemplation Acknowledge need to change behavior and begins to think Participant conswnedfewer than 3 to 4 sen1ings of fruits (vegetables) seriously about doing so during the next 6 months or so. each day and said he or she was seriously thinking about eating more servings of fruits (vegetables) during the next 6 months. Preparation Plans to take action during the next month to change Participant consumed fewer than 3 to 4 servings of fruits (vegetables) a behavior. each day and was planning to eat more servings of fruits (vegetables) during the next 30 days. Action Takes action to change behavior but action has lasted for Participant consumed 3 to 4 or more servings of fruits (vegetables) 6 months or less. each day and has been consuming this amount of frui ts (vegetables) for 6 months or less. Maintenance Has been practicing a changed behavior for more than Participant consumed 3 to 4 or more servings of fruits (vegetables) 6 months. each day and has been consuming this amount of fruits (vegetables) for more than 6 months. Termination Has reached ultimate goal of behavior change, with no concern for relapse. Note: Stages of change definitions are by Prochaska, Norcross, and DiClemente (1994). from another Ohio county. 1 The Area Agency on Aging, county offices of Ohio State University Extension, and coordinators of the congregate meal sites assisted with site selection, which needed to be more rural than urban or nonrnetropolitan.2 Fifty treatment and 51 control participants were selected. 3 1The data for this study were collected as part of the multi-State effort to test the lesson plans of the HELP. 20hio was selected to provide data from a nonurban population, as part of a coordinated effort to compare data among States. 2003 Vol. 15 No. 1 Survey Instruments Three instruments were used in this study: a demographics instrument, a questionnaire entitled Checkup on Your Good Eating Practices, and a Stages of Change instrument that consisted of Yrhe size of the sample was based on guidance from the HELP Elderly Nutrition Education Coordinating Group: Mary P. Clarke, PhD, RD, Kansas State University; Sherrie M. Mahoney, MS, Kansas Extension Service; Jacquelyn McClelland, PhD, RD, North Carolina State University; William D. Hart, PhD, RD, St. Louis University; Denise Brochetti, PhD, Virginia Polytechnic Institute and State University; Alma Montano Saddam, PhD, RD, The Ohio State University. two subscales-one for fruits and another for vegetables. These instruments were developed by Extension nutrition professionals of the HELP Elderly Nutrition Education Coordinating Group that developed the HELP instructor's manual. The demographics instrument collected information on gender, age, race, number in household, educational level, income, how often meals were eaten with someone else, and how often meals and snacks were eaten. Checkup on Your Good Eating Practices consisted of seven questions related to eating fruits and vegetables, 17 and the Stages of Change instrument consisted of eight separate questions, four each for fruits and for vegetables (box 2). Questions on the Stages of Change instrument asked older adults the number of servings of fruits and vegetables they were eating, how long they had been eating that number of servings, and whether they were seriously thinking of increasing this number either in the next 30 days or in the next 6 months. These questions were based on the criteria of the Transtheoretical Model Stages of Change construct (W.D. Hart, personal communication, October 19, 2001). Thus, the questions were based on a standardized length of time individuals had been working on, or intended to implement, a behavior change. The Extension nutrition specialists, dietetic nutrition professionals, and county Extension agents (who also field tested the teaching materials) tested the instruments for content and face validity. The instruments were reviewed for content accuracy and suitability for the older adult target audience, after which appropriate adjustments were made. Extensive field testing addressed any issues related to reliability. Cronbach's Alpha was used to test internal consistency of the instruments. The instrument Checkup on Your Good Eating Practices tested at an alpha of .77. The subscale for Stages of Change for fruit-related behaviors tested at an alpha of .53, and the subscale for Stages of Change for vegetable-related behaviors tested at an alpha of .63. Research in applying the Stages of Change construct to measurement of behavior change of nutritional behaviors is relatively new. Therefore, the alpha levels were considered acceptable (Nunnally, 1967). 18 Box 2 - Major Survey Instruments 1 t- Checkup on Your Good Eating Practices: Example questions (Answer choices: Almost never, Seldom, Often, Almost always, and Doesn't apply.) What do you do? Include at least three food groups in my breakfast (e.g., milk, fruit, and grains such as bread and cereal)? Eat 3 or more servings of different vegetables daily? Eat at least l serving of vitamin A-rich foods daily (e.g., dark green, leafy [spinach, kale, broccoli] and deep yellow [sweet potatoes, cantaloupe, apricots])? Choose potatoes prepared in lower fat ways (not fried)? Eat 2 or more servings of different fruits daily? Choose at least 1 serving of vitamin C-rich foods daily (e.g., orange juice, grapefruit, broccoli, cabbage, tomatoes)? Include at least 1 serving from each of the five food groups (i.e., grains, fruits, vegetables, meat group, and milk products)? Stages of Change: Questions Separate questions were asked for fruit- and vegetable-eating behaviors. How many servings of fruits (vegetables) do you eat each day? 0 I or 2 3 or4 5 or more Don't know About how long have you been eating this amount of fruits (vegetables)? Less than 1 month 1 to 3 months 4 to 6 months Longer than 6 months Don't know Are you seriously thinking about eating more servings of fruits (vegetables) starting sometime in the next 6 months? Yes No I already eat enough Undecided Are you planning to eat more servings of fruits (vegetables) during the next 30 days? Yes No I already eat enough Undecided 1HELP evaluation instruments developed by Mary P. Clarke, PhD, RD; Jacquelyn McClelland, PhD, RD; William D. Hart, PhD, RD; and Alma Montano Saddam, PhD, RD of the Elderly Nutrition Education Coordinating Group. Family Economics and Nutrition Review Treatment and Analysis The HELP was developed as a joint project of the Cooperative Extension Services at Kansas State University, The Ohio State University, North Carolina State University, and St. Louis University. The program 's theme foc used on having participants depend primarily on food for good nutritional health and encouraging them to eat a variety of nutritious foods even though the adults' calorie needs may have declined. HELP lessons were designed to facilitate movement of nutrition behaviors along a continuum-from being unaware of eating habits and health connections to applying skills to maintain healthful eating behaviors (Clarke & Mahoney, 1996). The HELP lessons specifically addressed nutritional needs of older adults. The connection between good health and healthful eating habits was emphasized. The fruit and vegetable lessons also presented practical ways for small households to purchase and store fruits and vegetables. Suggestions were shared for preparing fruits and vegetables that are easier to chew; lower in salt, sugar, and fat; and preserve other nutrients. The recipes, varying in texture, flavor, and temperature, were chosen because of their ability to appeal to the changing taste buds of many older adults. The treatment group was taught a series of four HELP nutrition lessons. The lessons for the first 2 weeks focused on vegetables, with a Jesson on potatoes included, while the second 2 weeks focused on fruits. The objectives of the lessons related to the following: suggested number and sizes of servings; vegetables and fruits as sources of various nutrients and few calories; links between eating vegetables and fruits and decreased risk for some diseases; cost-effective purchasing, storage, and preparation 2003 Vol. 15 No. 1 of vegetables and fruits; and vegetables and fruit with less fat, salt, and sugar. A dish featuring vegetables or fruits was brought to each class for participants to taste. Also, at each of the four sessions, the participants were given handouts of the lessons, "challenges" for planning behavior changes, copies of recipes (including those tasted in class) in the HELP, and educational aids (e.g., refrigerator magnets of vegetables and fruits). For each group (one each from three counties), all lessons were taught in the same order by the researcher who used the same visuals, dishes to taste, and style of presentation. The control group did not receive the weekly lessons. However, after completing the post-test, they were offered a set of handouts and the HELP recipes. Pre- and post-tests, respectively, were administered to the control group from September through December 1998, with these results being used to test and retest the study instruments. The instruments tested reliably below .05, with the exception of the question that dealt with how long the reported number of vegetables had been eaten. This question, however, was accepted as reliable because of the slightly lower number of participants answering the question. To consider this study quasiexperimental and a nonequivalent control-group design, we made efforts to select similar treatment and control groups. Analysis of the demographics conducted on treatment and control groups was only significantly different on one variable: how often they ate meals with someone else. For the questionnaire Checkup on Your Good Eating Practices, we summed a score for each treatment and control group participant by using answers from seven questions related to fruit and vegetable behavior (total possible For vegetable-eating behaviors, the treatment groups' pre-test responses were mostly indicative of Precontemplation, followed closely by Maintenance, and then Preparation ... . 19 score of 28, after eliminating "doesn't apply"). A paired-sample t-test was used to compare the means of the preand post-test scores for each group. Post- and pre-test matched summed scores were also measured with a sign test. This test determined whether significant differences exist between positive and negative changes from the pre-test to the post-test. These changes, derived by subtracting pretest from post-test results, were placed into three categories: negative differences, positive differences, or ties (i.e., no change). For the Stages of Change instrument, we used sign tests to measure differences of matched cases from pre-test to post-test administration, excluding "don't know" for the number of servings, how long this amount of fruits and vegetables had been eaten, and for computed stages of change for fruit- and vegetable-eating behaviors for participants in both groups. An algorithm was used to calculate a separate stage of change for eating fruits and vegetables (box 1). Pre- and post-test fruit and vegetable stages were calculated for the treatment and control participants, except for those without sufficient data to categorize. Results Sample Characteristics Overall, the older adults in the treatment and control groups were similar. Seventy-six percent of the 50 participants in the treatment group were women, and 92 percent were White. Sixty-seven percent of the 51 participants in the control group were women, and 94 percent were White (data not shown). 20 Table 1. Post-test/pre-test sign test for Checkup on Your Good Eating Practices regarding fruit- and vegetable-eating behaviors of elderly participants Treatment group 1 Control group2 Negative differences Positive differences Ties 1n = 44. 2n = 49. Eating Practices Results from the questionnaire entitled Checkup on Your Good Eating Practices showed that, compared with the control group, a significant difference existed between the means for the treatment group from the pretest to the post-test. From the pre-to the post-test, mean scores by the treatment group increased from 20.86 to 22.73 (p~.05). For the control group, the means were 19.46 at the pre-test and 20.67 at the post-test (data not shown). For the sign test, although two-tailed significance levels did not show a significant difference in either group's summed scores, the percentages of negative and positive differences and the ties for the treatment group were noteworthy (table 1). From the pre-test to the post-test, for example, 59 percent of changes by the treatment group were positive, compared with 43 percent of the changes by the control group that were positive. The percentage of ties (no change) was low for the groups (9 vs. 26 percent). These results imply that some type of change took place from pre-test to post-test administration, particularly in how members of the treatment group viewed their eating behaviors. Stages of Change Members of the treatment group categorized their fruit-eating behavior most often as Maintenance at the Percent 32 31 59 43 9 26 pre-test and post-test (32 percent each), followed closely by Precontemplation at pre-test and post-test (24 and 28 percent, respectively) and Preparation (20 percent each at pre-test and post-test) (table 2). Changes that could not be categorized dropped from 20 percent at pre-test to 4 percent at post-test. Responses reflective of behaviors in the Action category increased from 0 at pre-test to 8 percent at post-test; that is, at post-test, members of the treatment group consumed 3 to 4 or more servings of fruits each day and had been consuming this amount for no more than 6 months. Among the control group members, pre-test responses regarding their fruiteating behaviors fell most frequently into Precontemplation, followed by Preparation and Maintenance (43, 25, and 20 percent, respectively). For this group, pre-test and post-test differences were minor among all categories. For vegetable-eating behaviors, the treatment groups' pre-test responses were mostly indicative ofPrecontemplation, followed closely by Maintenance, and then Preparation (30, 28, and 24 percent, respectively). That is, some members of the treatment group had not considered changing their vegetable-eating behavior, some had practiced changing their behavior, and Family Economics and Nutrition Review Table 2. Pre-test and post-test computed Stages of Change for fruit- and vegetableeating behaviors of elderly participants Treatment group 1 Fruits Stage of change Pre-test Maintenance 32 Action 0 Preparation 20 Contemplation 4 Precontemplation 24 Cannot categorize 20 Control group2 Fruits Stage of change Pre-test Maintenance 20 Action 2 Preparation 25 Contemplation 2 Precontemplation 43 Cannot categorize 8 1n =50. 2n =51. others planned to take action during the next month to change their vegetable-eating behavior. At the posttest, members of the treatment group most frequently characterized their vegetable-eating behavior as being related to Maintenance, followed by Preparation, and Precontemplation (46, 26, and 12 percent, respectively), a different pattern than was the case at the pre-test phase. The control group's responses at pre-test were mostly in two categories: Maintenance (47 percent) and Precontemplation (33 percent). The post-test category for Precontemplation remained at 33 percent, but the Preparation category was 18 percent, a change from the pretest (8 percent). Also, control group participants categorizing their behavior as Maintenance dropped to 33 percent at the post-test phase. 2003 Vol. 15 No. 1 Vegetables Post-test Pre-test Post-test Percent 32 28 46 8 4 10 20 24 26 8 0 0 28 30 12 4 14 6 Vegetables Post-test Pre-test Post-test Percent 18 47 33 6 0 4 19 8 18 4 2 2 49 33 33 4 10 10 Results from the sign tests revealed no significant difference between pre-test and post-test results for neither the treatment group nor the control group for stage of change related to fruiteating behaviors nor for the control group for stage of change related to vegetable-eating behaviors (table 3). However, a significant positive change for stage of change for the treatment group's vegetable-eating behaviors existed. This positive change shows movement from a lower stage of change category to a higher category from the pre-test to the post-test. Limitations of the Study Findings were limited to the older adults in this study. Participants were not randomly selected because they were attendees of pre-arranged class sites, and some self-selection occurred. Our findings indicate that the HELP nutrition lessons made a difference ... in how some older adults in the treatment group thought about changes, planned for changes, or made changes in their fruit- and vegetable-eating behaviors. 21 Measurable behavior change may have been limited because of the short span of weeks in which treatment took place. Other considerations were (1) the environments of the congregate meal sites that varied in lighting, seating arrangements, distractions, and participant attentiveness and (2) the nutrition education on fruits and vegetables that the control group may have received from other sources prior to this study. Conclusions This study specifically examined the influence of nutrition education on the eating behaviors of older adults who resided in nonmetropolitan or semirural geograpruc areas and who were also participants of congregate meal programs. Based on recent trends, the nonmetropolitan or semi-rural older adult population is an important group to focus on because of factors such as the out-migration of younger persons in these areas and the sometimessegmented nutrition and health care services (ADA, 2000; Rogers, 1999). Further study is recommended of not only this geographic audience but also of a comparison of this audience with urban older adults who participate in congregate meal programs. Our findings indicate that the HELP nutrition lessons made a difference, measured by real and statistical significance, in how some older adults in the treatment group thought about changes, planned for changes, or made changes in their fruit- and vegetableeating behaviors. Additionally, there is merit to the use and further study of the questions on the Stages of Change instrument for fruit- and vegetableeating behaviors; that is, for the categorization of older adults ' behaviors into the Precontemplation, Contemplation, Preparation, Action, or Maintenance stages. 22 Table 3. Post-test/pre-test sign test for Stages of Change computed for fruit- and vegetable-eating behaviors of elderly participants Treatment1 Control2 Negative differences Positive differences Ties 24 22 54 Fruits Percent 16 20 64 Treatment1 Control2 Negative differences Positive differences Ties 8 41* 51 Vegetables Percent 17 5 78 1n = 37 for fruit-eating behaviors, and n = 37 for vegetable-eating behaviors. 2n = 45 for fruit-eating behaviors, and n = 41 for vegetable-eating behaviors. *Differences in behavior changes from the pre-test to the post-test are significant, at p $.05. Realistically, diets vary over time because of a number of factors-one being changes in foods that are available. Therefore, a more relevant application of the Stages of Change construct, compared with simply measuring eating behavior, may be to measure cognitive and behavioral engagement. This approach allows researchers to focus more on what people are thinking about eating during the process of changing their diet, compared with measuring specific foods and nutrients consumed (Krista), Glanz, Curry, & Patterson, 1999). This approach also may be more empowering to individuals who are working toward more healthful eating behaviors. Acknowledgments This educational program was mainly funded by a grant from USDA's Extension Service and by partial support from the North Carolina Institute of Nutrition, Chapel Hill. This research also was supported by funds from the Dean's Research Incentive Fund of the College of Human Ecology, The Ohio State University. We acknowledge the assistance of the staff of Ohio State University Extension in participating counties; those who assisted at the congregate meal sites; and M.A. (Annie) Berry, PhD, senior statistician of Ohio State University Extension. Family Economics and Nutrition Review References American Dietetic Association. (2000). Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. Journal of the American Dietetic Association, 1 00(5), 580-595. American Dietetic Association. (1996). Position of the American Dietetic Association: Nutrition education for the public. Journal of the American Dietetic Association, 96(11), 1183-1187. Basiotis, P.P., Carlson, A., Gerrior, S.A., Juan, W.Y., & Lino, M. (2002). The Healthy Eating Index: 1999-2000. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. CNPP-12. Clarke, M.P., & Mahoney, S.M. (1996). A Healthy Eating for Life Program for Mature Adults. Kansas State University Agricultural Experiment Station and Cooperative Extension Service. Contento, 1., Balch, G.I., Bronner, Y.L., Lytle, L.A., Maloney, S.K., Olson, C.M., et al. (1995) . Nutrition education for older adults. Journal of Nutrition Education, 27, 339-346. Gerrior, S.A. (1999). Dietary changes in older Americans from 1977 to 1996: Implications for dietary quality. Family Economics and Nutrition Review, 12(2), 3-14. Hetzel, L. & Smith, A. (2001). The 65 Years and Over Population: 2000. Brief C2KBR/OJ-10. U.S. Census Bureau. Krista!, A.R., Glanz, K., Curry, S.J., & Patterson, R.E. (1999). How can stages of change be best used in dietary intervention? Journal of the American Dietetic Association, 99(6), 679-684. Laforge, R.G, Greene, G.W., & Prochaska, J.O. (1994). Psychological factors influencing low fruit and vegetable consumption. Journal of Behavioral Science, 17(4), 361-374. Nigg, C.R., Burbank, P.M., Padula, C., Dufresne, R., Rossi, J.S., Velicir, W.F., et at. (1999). Stages of change across ten health risk behaviors for older adults. The Gerontologist, 39(4), 473-482. Nunnally, J.C. (1967). Psychometric Theory. New York, NY: McGraw-Hill. Price, C. A. (2001). The Impact of Demographic Changes on Society. Presentation at Northwest District Family Nutrition Program In-Service on Aging. Columbus, Ohio. Prochaska, J.O., Norcross, J.C., & DiCJemete, C. C. (1994). Changing for Good. New York, NY: William Morrow and Company, Inc./ Avon Books. 2003 Vol. 15 No. 1 23 Rogers, C. C. (1999). Changes in the Older Population and Implications for Rural Areas. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Rural Development Research Report Number 90. Tate, M.J., & Patrick, S. (2000). Healthy People 2010 targets healthy diet and healthy weight as critical goals. Journal of the American Dietetic Association, 100(3), 300. U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC. U.S. Census Bureau. (2000a). Projections of the Total Resident Population by 5-Year Age Gro.ups, and Sex with Special Age Categories: Middle Series, 2006 to 2010. Retrieved July 29, 2003, from www.census.gov/population/projections/ nation/summary/np-t3-c.txt. U.S. Census Bureau. (2000b). Projections of the Total Resident Population by 5-Year Age Groups, and Sex with Special Age Categories: Middle Series, 2025 to 2045. Retrieved July 29, 2003, from www.census.gov/population/projections/ nation/summary/np-t3-f.txt. Wellman, N.S., Weddle, D.O., Kranz, S., & Brain, C.T. (1997). Elder insecurities: Poverty, hunger, malnutrition. Journal of the American Dietetic Association, 97(10 Suppl.), S120-Sl22. 24 Family Economics and Nutrition Review Edward A. Frongillo, PhD Cornell University Pascale Valois, MSc Fonds de Ia Recherche en Sante du Quebec Wendy S. Wolfe, PhD Cornell University 2003 Vol. 15 No. 1 Using a Concurrent Events Approach to Understand Social Support and Food Insecurity Among Elders This study tested a concurrent events approach to understand better the relationships between social support and food insecurity of a sample (n=9) of low-income elders that had participated in an earlier study (n=53) in Upstate New York. This approach involved the use of time-intensive telephone interviews over a span of 4 months. Results indicated that the concurrent events approach provided a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. The researchers found that the telephone interviews helped with obtaining a better understanding of the elders' "monthly cycle" of food insecurity and the importance of food exchange as a source of social and food support among elders, a finding that had not been captured in the two in-depth retrospective interviews of the earlier study. M any elders experience hunger and food insecurity because of low incomes, limited mobility, or poor health (Cook & Brown, 1992; Cohen, Burt, &Schulte, 1993; Lee& Frongillo, 200la; Nord etal. , 2002). Food insecurity among elders contributes to poor diet and malnutrition, which exacerbates disease, increases disability, decreases resistance to infection, and extends hospital stays (Adminisu·ation on Aging, 1994; Torres-Gil, 1996; Lee & Frongillo, 200lb). Food insecurity is defined as "the inability to acquire or consume an adequate quality or suffic ient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so" (Radimer, Olson, Greene, Campbell, & Habicht, 1992). Food insecurity among the elderly also includes the inability to obtain and use food in the household (e.g ., to gain access to, prepare, and eat available food) because of functional impair-ments, health problems, or lack of social support (Lee & Frongillo, 200 1a). Social support affects whether an elderly person with financial or physical limitations or both experiences food insecurity. This support can result from informal social networks, such as family and friends, or more formal programs, such as food programs (Wolfe, Olson, Kendall, & Frongillo, 1996). Functional impairments, health problems, and lack of social support have significant relations with food insecurity (Burt, 1993; Frongillo, Rauschenbach, Roe, & Williamson, 1992; New York State Department of Health and Office for the Aging, 1996;Quandt&Rao, 1999;Roe, 1990; Wolfe et al., 1996). Social support and food insecurity interact in complex ways. At least partly due to methodological limitations, these interactions are neither well understood nor easy to study (Lee& Frongillo, 2001c). For example, equivocal evidence has revealed the buffering effect of social 25 support among elders (Newsom & Schulz, 1996; Lee & Frongillo, 200la). For some elders, family or friendseven if needed routinely--cannot always help as planned, resulting sometimes in hunger or food insecurity. Although it is impot1ant to understand these types of situations, it is difficult to obtain adequate details about these experiences from one or even two indepthinterviews (Wolfeetal., 1996). When experiences such as these occur, participants tend to talk in general terms about what they did and suggest that they are okay. However, they often do not mention exactly what they consumed or mention the anxiety they experienced. In addition, they tend to talk more about one or two problematic times that resulted in greater anxiety or more severe food insecurity rather than including other less severe examples of lack of suppot1 or of the variability or precariousness of their support. Thus, it has been difficult to obtain the details that are needed to understand more fully the relation of social support to food insecurity in this population. Many low-income elders also experience a monthly financial cycle that results in a food insecurity cyclehaving less food insecurity and anxiety at the beginning of the month when they receive their monthly checks and experiencing greater food insecurity and anxiety at the end of the month when their money has been spent (Wolfeetal., 1996). Some low-income elders are so accustomed to this monthly cycle that they do not talk about these difficulties (even when asked) unless they happen to be interviewed during that time. It is unclear, however, how various management strategies relate to this monthly cycle. Thus, the ways that both formal and informal social support serve to improve the food security of elders are not well understood, partly because of 26 methodological limitations in research designs. In general, understanding the biological, psychological, and social dynamics of events, needs, practices, and help-seeking and other behaviors of elders is important to assessing and interpreting their experiences. It is, as well, important to understanding how food assistance programs and other formal actions might contribute to improving food security. For example, 1 of the 10 recommendations about health outcomes developed by an Institute of Medicine (1996) committee was to determine "the impact on health outcomes when older individuals make transitions between types of care, treatment settings, and health plans." Acquiring such understanding requires new research approaches that allow for describing and sorting out complex, dynamic patterns of each elder's experience across an approptiate timeframe (Lee &Frongillo, 2001c). For similar reasons, and in the absence of randomized intervention trials, new research approaches are also needed for assessing the effect of programs, such as home-delivered meals and home-care services. Time-intensive, event-focused approaches may be particularly valuable for understanding complex, dynamic patterns (Tuma & Hannan, 1984; Blossfeld & Rohwer, 1995), because they are used to study transitions across a set of discrete states, including the length of time intervals between entry into and exit from specific states (e.g., well vs. ill). The transitions are studied in relation to other discrete events and changes in continual states. These event-focused approaches hold advantages for causal inference over both cross-sectional and traditional longitudinal approaches because of the detailed knowledge of the occunence and timing of events. These approaches are particularly suited for research with elders because of the highly dynamic nature of factors that affect their nutrition and health (Lee & Frongillo, 2001 c). This study tested an innovative, events-focused, qualitative research approach to understand better the relationships between social support and food insecurity of low-income elders. This new concunent events approach involved studying a small group of food-insecure elders intensively for a prolonged period to help understand the intricacies of the variability and uncertainty of social support as well as other events experienced in relation to food insecurity. The approach is refetTed to as "concunent" because the researchers monitored study participants frequently over time (Gordis, 2000). Methods We previously conducted a study of 53 food-insecure low-income elderly men and women who lived in their own homes in three large cities in Upstate New York. In this earlier study, we completed two in-depth interviews with each elder. The purpose of the earlier study was to understand better the experience of elderly food insecurity and thus contribute to previous research of food insecurity among elders (Wolfe eta!., 1996, 1998). For the study reported here, we selected a subset of nine of these elders. When we conducted the earlier study, six of the nine elders in the study reported here were food insecure and three, relying heavily on social support strategies for food, were marginally food secure. The sample consisted of seven Caucasian women, one Caucasian man, and one AfricanAmerican man whose ages ranged from 59 to 76 (an average of68 years). Four had impaired mobility (two in wheelchairs) and one had occasional dizzy spells. Six lived alone; one with Family Economics and Nutrition Review her daughter and husband, who died during the study; one, with her elderly boyfriend; and one, with her teenaged grandson. Two received both food stamps and home-delivered meals. Three of the elders received homedelivered meals only-one, not because she needed them, but because she he) ped deliver these meals. Of the nine elders, only two participated in congregate meals and received food from food pantries; two did not participate in any food programs. Monthly incomes of the elderly participants ranged from $400 to $900, averaging $738 each month. Six lived in subsidized housing; all had been employed most of their lives; two had not completed high school, five were high school graduates, and two attended some college. Each participant was interviewed weekly by telephone for 4 months (December 2000 to March 2001) by one of the authors who performed all of the interviews by using an interview guide and a tape recorder. Participants were asked about the past week: their food situation (i.e., how they obtain their groceries, whether they had any help with meals, whether they attended any food programs, or whether they had problems accessing food), their use of social networks, frequency of family contacts, changes in their health or social support, and events of the past week. Rapport was established quickly during the telephone conversations, because the same interviewer had interviewed each participant twice in his or her home during the previous year. The weekly contact helped to increase rapport further, which is important for gathering this type of sensitive information. Informed consent (to participate and to tape record the telephone interviews) was obtained in the first interview. Analysis was ongoing: Each week prior to the next telephone interview, the 2003 Vol. 15 No.1 interviewer listened to, took detailed notes from, and analyzed the interview of the previous week. From this analysis, the interviewer developed follow-up questions to probe more fully for emerging issues. Following the final interviews, these records were further analyzed, summarized, reviewed, and discussed by all three authors. Results and Discussion Usefulness of the Concurrent Events Approach for Understanding Social Support and Food Insecurity As expected, the time-intensive telephone interviews produced a fuller understanding of some issues that arose in our earlier research with this population. One finding was the surprising extent and importance of food exchange as a source of social and food support among elders, a finding that had not been captured in the in-depth interviews. For example, one woman took home-delivered meals to others in her building and sold Avon products, both of which placed her in situations where people gave her food they had received from the homedelivered meal program, food pantries, or restaurants. These food gifts, plus the free home-delivered meals she received for working for them, were important to her food security. Another woman, with very low mobility, lived alone and relied on her family for support. Becau e this was not always reliable, this participant became a member of a food network in her apartment building for seniors. This network included elaborate food-trade and food-access strategies. For example, in addition to receiving halfpint carton of milk from a neighbor' s home-delivered meals, this study participant received food from a woman who did not use all the food that her The weekly telephone calls provided good rapport between the elderly food-insecure participants and the interviewer and a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. 27 children brought to her. In return, our participant made homemade soup and brought portions to others. Another person received food from the "bread fairy " an elderly neighbor who went regularly to the food pantry to get and then distribute loaves of day-old bread to various needy residents. A fourth elderly woman was diabetic and had recently begun sharing the food she prepared with others. The foods included items such as diabetic desserts that she shared with a diabetic neighbor whom she also took food shopping. Extensive food-sharing among elders has been elucidated by others (e.g., Quandt, Arcury, Bell, McDonald, & Vitolins, 2001). The study was intended to produce a better understanding of the variability and uncertainty of social support in relation to food insecurity, since the findings from the earlier in-depth interviews suggested that social support was important for food security but often was not consistent or reliable in many cases. What we found, however, was that at least in this group, the social support of most participants did not change over the 4 months of the study (e.g., elders maintained routine patterns regarding who took them shopping). In fact, having non-changing situations was important to these elders. The only exception was the elderly participant who reported both in the in-depth and telephone interviews that her daughter took her shopping once a month. However, this supposed routine help did not occur during the first 2 months of our weekly telephone interviews. As a result, this participant had to borrow food from her neighbors and had to order canned food from a drug store that delivered-although she preferred fresh food. This situation also made her home-delivered meals more vital than ever. Another participant who 28 experienced a major life event during the study-the loss of her husbanddid not lose her social support or food insecurity as might have been expected because she also lived with her daughter. Results such as these suggest that a longer follow-up period may be needed to understand the effects of variability in social support for most elders. Perhaps, when changes in social support occur for most elders, the changes are over a longer petiod, such as those associated with climatic seasons. Usefulness of the Concurrent Events Approach for Understanding Other Events and Experiences Related to Food Insecurity The weekly telephone interviews were valuable for gaining a fuller understanding of the daily lives of these food-insecure elders. By talking with the participants weekly, the researchers found that the interviews also helped with obtaining a better understanding of the elders' "monthly cycle" of food insecurity and also allowed good rapport and confidence to be established. The telephone interviews also allowed the researcher to ask more direct questions and the elderly participants to share additional personal information. Some examples follow. (1) One elderly woman was not classified as food insecure based on the earlier study, but the weekly contacts helped to elucidate how much she actually relied on food stampsparticularly at the end of the month. Her food money began to be depleted during the third week of the month; during the end of the month, her food situation actually changed. For example, she had to substitute foods like french toast for dinner rather than eating meals that included meat. Because of the rapport established between the interviewer and another participant, the elderly woman making these substitutions was comfortable enough to describe one of her food-access strategies: smuggling food from the congregate lunches to be eaten for her dinner. Although this was not allowed (because of concerns for food safety), she regularly brought containers for extra food. (2) The weekly interviews helped researchers understand the support system of one African-American man who had very little family support, but he seemed to have a number of friends that took him shopping. Later in the study, however, he revealed that he often paid these friends for rides and therefore was reluctant to call them as much as he needed. (3) The concurrent events approach was intended to allow us to understand and describe what and how events occuned on a week-to-week basis, as well as how these events affect elders' food insecurity. We previously found that major sicknesses and other stressful events affected the food situation of the elders and, thus, their food insecurity (Wolfe et al., 1996). Although few participants endured very stressful events during the 4 months of study, Christmas turned out to be one such event. The weekly interviews provided an understanding of the importance of Christmas and the stress it may cause because of the need to have extra money to buy special food, presents for grandchildren, and other items. Christmas, therefore, sometimes resulted in greater food insecurity. For example, one woman who wanted to bake for her family and friends bought extra staple foods and saved some money during the fall so that she could purchase extra baking supplies. Unfortunately, she was forced to use this stocked food when her Family Economics and Nutrition Review money started to become depleted becau e of extra Christmas expenses. The interviews also highlighted the importance of charitable food baskets at Christmas for some participants. (4) Another event occun·ed when the Caucasian male participant-on the recommendation of others in his building-decided to try food shopping rather than eating out at a snack bar each evening. By following this recommendation, he spent more money than he would have spent otherwise. The result: Before the end of the month, this elderly participant needed to borrow money and use credit to eat. Perhaps this was because he was not used to shopping for groceries. (5) One elderly woman's health, social support, and food situation changed dramatically during the 4-month study. This participant was on a diet described as lowfat, low-cholesterol, low-sugar, low-sodium, and limited-greens. (The latter was due to a history of blood clots and medication for it. Based on her interpretations, she believed she was not allowed to eat anything "green.") The weekly telephone contact produced a greater understanding of how complicated it was for this participant to follow her dietespecially given her low income. In addition, during the time that the telephone interviews were conducted, this elderly participant experienced several major life changes. After having heart surgery, she moved in with her elderly boyfriend so that he could take care of her. At the same time, she continued to pay for her own house, which caused financial difficulties. (She did not feel secure enough with her new situation to sell her house.) Living with her boyfriend who had no diet limitation made it even more difficult for her to follow her fairly strict diet. Our previous work showed that the ability to eat the "right foods for health" was an important aspect of food 2003 Vol. 15 No. 1 security among the elderly, and her new social situation seemed to make this woman even more food in ecure. Then, just before our study ended, she was diagnosed with breast cancer. This new life-altering event-plus the negative effect of living with someone with very different food habits-cau ed her to conclude that her diet really did not matter anyway. As a result, he stopped following her diet. It' likely that her food situation changed further after her cancer surgery, which was cheduled after the end of our study. Thus, using the new concurrent events approach, compared with the two indepth interviews alone, produced a fuller understanding of changes as they occurred. This fuller understanding probably would not have been achieved with retrospective indepth interviews or event histories (Tum a & Hannan, 1984; Blossfeld & Rohwer, 1995). During the 4-month timeframe, however, there were not many substantial changes. The approach was relatively easy and inexpensive to implement, requiring only about 10 minutes to interview each participant each week. Conclusions The weekly telephone calls provided good rapport between the elderly foodinsecure participants and the interviewer and provided a fuller understanding of food insecurity, social support, other events, and experiences among these elderly participants. These calls added to what was achieved in the two ptior in-depth interviews. The concurrent events approach was not efficient for understanding the variability of social support or the effect of stressful events on food insecurity, however, because these events did not occur very often. The approach might be more efficient (for the same amount of interviewer time input) by first The concurrent events approach is likely to be useful for investigation following an event or transition such as participating in the home-delivered meals program, moving into senior housing, loss of a spouse, moves by family members, or a change in health condition. 29 interviewing a new person in his or her home once or twice, followed by weekly telephone calls for a month, and then monthly telephone calls for at least several months or up to a year. When an important event or change is identified, weekly telephone calls can be made for several weeks to investigate that event or change. The concurrent events approach is likely to be useful for investigation following an event or a transition such as participating in the home-delivered meals program, moving into senior housing, losing a spouse, moves by family members, or a change in health condition. The concurrent events approach could identify the early effects of programs and provide muchneeded evidence about whether and how being a program participant (e.g., Meals on Wheels recipient) is helpful. For example, one could investigate whether elders receiving homedelivered meals eat the meals, establish a relationship with the delivery person, or have changes in their mental state. Participants could be recruited by using either a formal or an informal surveillance system (such as through contacts in housing offices or through home-delivered meals programs) that provides prompt notification when someone is making a transition. Soon after this notification, the participant could be interviewed, as frequently as once a week or once a month, to obtain a more detailed and accurate assessment of any changes in food status and social support. This study has demonstrated the usefulness of an innovative, feasible, and inexpensive concurrent events research approach for investigating nutrition issues in the elderly. The two key elements of the approach are the initial establishment of rapport by using one or two in-depth, in-person, qualitative interviews and then frequent follow-up qualitative interviews via 30 telephone. Variants of this approach might involve brief in-person follow-up interviews or incorporation of some quantitative questions. Acknowledgments We thank Elizabeth Conrey, Amy Terhune, and the anonymous reviewers for helpful comments on an earlier draft. This research was ptimarily funded by a grant from the Cornell Gerontology Research Institute, an Edward R. Roybal Center supported by the National Institute on Aging ( 1 P50 AG 11711-01 ). This research was also supported in part by a grant (99-34324- 8120) from the Cooperative State Research, Education, and Extension Service (CSREES), United States Department of Agriculture (USDA); and by Cornell University Agricultural Experiment Station Federal formula funds, Project No. NYC-399425 received from CSREES, USDA. Family Economics and Nutrition Review References Administration on Aging, U.S. Department of Health and Human Services, National Aging Information Center. (1994). Food and Nutrition for Life: Malnutrition and Older Americans. Report No. NAIC-12 (December). Washington, DC. Blossfeld, H., & Rohwer, G. (1995). Techniques of Event History Modeling: New Approaches to Causal Analysis. Manhwa, NJ: Lawrence Erlbaum Association. Butt, M.R. (1993). Hunger Among the Elderly: Local and National Comparison. Washington, DC: The Urban Institute. Cohen, B.E., Burt, M.R., & Schulte, M.M. (1993). Hunger and Food Insecurity Among the Elderly. Washington, DC: The Urban Institute. Cook, J.T., & Brown, J.L. (1992). Estimating the Number of Hungry Americans. Tufts University, Medford, MA: Center for Hunger, Poverty and Nutrition Policy Working Paper No. HEO 1-090292. Frongillo,E.A., Rauschenbach,B.S ., Roe, D.A., & Williamson, D.F. (1992). Characteristics related to elderly persons' not eating for 1 or more days: Implications for meal programs. American Journal of Public Health, 82(4), 600-602. Gordis, L. (2000). Epidemiology (2nd ed.). Philadelphia: W.B. Saunders Company. Institute of Medicine. (1996). Health Outcomes for Older People: Questions for the Coming Decade. Committee to Develop an Agenda for Health Outcomes Research for Elderly People. Division of Health Care Services. Washington, DC: National Academy Press. Lee, J.S., & Frongillo, E.A. (2001a). Factors associated with food insecurity among US elderly: Importance offunctional impairments. Journal of Gerontology: Social Sciences, 56B, S94-S99. Lee, J.S. , & Frongillo, E. A. (2001 b). Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. Journal of Nutrition, 131, 1503-1509. Lee, J.S., & Frongillo, E.A. (2001c). Understanding needs is important for assessing the impact of food assistance program participation on nutritional and health status in U.S. elderly persons. Journal of Nutrition, 131, 765-773. New York State Department of Health and Office for the Aging. (1996). Nutrition Survey of the Elderly in New York State. Albany, NY. Newsom, J.T., & Schulz, R. (1996). Social support as a mediator in the relation between functional status and quality of life in older adults. Psychology and Aging, 11,34-44. 2003 Vol. 15 No. 1 31 Nord, M., Kabbani, N., Tiehen, L., Andrews, M., Bickel, G., & Carlson, S. (2002). Household Food Security in the United States, 2000: Measuring Food Security in the United States. Wa hlngton, DC: U.S. Department of Agriculture, Economic Research Service. Quandt, S.A., Arcury, T.A., Bell, R.A., McDonald, J., & Vitolins, M.Z. (2001). The social and nutritional meaning of food sharing among older rural adults. Journal of Aging Studies, 15,145-162. Quandt, S.A., & Rao, P. (1999). Hunger and food security among older adults in a rural community. Human Organizations, 58(1), 28-35. Radimer, K.L., Olson, C.M., Greene, J.C. , Campbell, C. C., & Habicht, J.P. ( 1992). Understanding hunger and developing indicators to assess it in women and children. Journal of Nutrition Education, 24, 36S-45S. Roe, D.A. (1990). In-home nutritional assessment of inner-city elderly. Journal of Nutrition, 120(Suppl. 11), 1538-1543. Torres-Gil, F.M. (1996). Malnutrition and hunger in the elderly. Nutrition Reviews, 54(1), S7-S8. Tuma, N., & Hannan, M. (1984). Social Dynamics: Models and Methods. San Diego, CA: Academic Press. Wolfe, W.S., Olson, C.M., Kendall, A., & Frongillo, E.A. (1996). Understanding food insecurity in the elderly: A conceptual framework. Journal of Nutrition Education, 28, 92-100. Wolfe, W.S., Olson, C.M., Kendall, A., & Frongillo, E.A. (1998). Hunger and food insecurity in the elderly: Its nature and measurement. Journal of Aging and Health, 10,327-350. 32 Family Economics and Nutrition Review Mark Nord, PhD Economic Research Service U.S. Department of Agriculture 2003 Vol. 15 No. 1 Measuring the Food Security of Elderly Persons This study assessed the appropriateness of the U.S. Food Security Scale for measuring the food security of elderly persons and, in particular, whether measured prevalence rates of food insecurity and hunger among the elderly were likely to be biased, relative to those of the nonelderly. The findings, based on analysis of 3 years of data from the Current Population Survey Food Security Supplement, consistently indicated that the Food Security Scale fairly represented the food security status of elderly persons, compared with the food security status of nonelderly persons. Statistical analysis of the multiple-indicator scale found no indication that the scale underrepresented the prevalence of food insecurity or hunger among the elderly because they interpreted or responded to questions in the Food Security Scale differently than did the nonelderly. Responses to questions other than those in the scale indicated that some elderly did face food-access problems other than insufficient resources to buy food-most notably problems getting to a food store. However, these problems were no more likely for the elderly than for the nonelderly to be so serious that desired eating patterns were disrupted or food intake was insufficient. A small proportion of elderly households classified as food-secure obtained food assistance from Federal and community programs, suggesting that some of these households were less than fully food-secure and that some may, indeed, be food-insecure. However, foodsecure elderly-only households were less likely than the food-secure nonelderly households to rely on food assistance programs that are accessible to both. Elderly persons are more foodsecure than are nonelderly persons, according to recent nationally representative food security surveys sponsored by the U.S. Department of Agriculture (USDA) (Nord, 2002; Nord et al., 2002; Gutluie & Lin, 2002; Andrews, Nord, Bickel, & Carlson, 2000; Bickel, Carlson, & Nord, 1999). In these surveys, food security-defined as access at all times to enough food for an active, healthy I ife for all household members-is measured by a series of questions about behaviors and experiences known to characterize households that are having difficulty meeting their food needs (Fitchen, 1981; Fitchen, 1988; Radirner, Olson, & Campbell, 1990; Radimer, Olson, Green, Campbell & Habicht, 1992; Wehler, Scott, & Anderson, 1992). The U.S. Food Security Scale, calculated from responses to these questions, measures the food security of the household and classifies each as food-secure, food-insecure without hunger, or foodinsecure with hunger (Bickel, Nord, Price, Hamilton, & Cook, 2000; Hamilton etal., 1997a; 1997b).Concernshave been raised about whether this measurement method, based on selfreported food-access conditions and behaviors, fairly represents the food security of elderly persons, compared with that of non-elderly persons. Food insecurity is known to be associated with poor nutrition and health 33 outcomes for elderly people, and age aggravates the negative effects of poor nutrition on the elderly; so accurate, reliable measurements of the food security of the elderly are important both for monitoring and research purposes (Sahyoun & Basi otis, 2000; Guthrie & Lin, 2002).ln this study, I assess the appropriateness of the U.S. Food Security Scale for measuring the food security of elderly persons and, in particular, whether prevalence rates of food insecurity and hunger are comparable between households with and without elderly persons present. Statistics based on the September 2000 Food Security Survey Module-the most recent food security data available-indicate that 94 percent of households with an elderly person (i.e., age 65 or over) present were food-secure throughout the year (Nord, 2002). Thus, the remaining 6 percent of households with elderly persons were food-insecure, meaning that at some time during the previous year, these households were either uncertain of having or unable to acquire enough food to meet basic needs of all their member because they had insufficient money or other resources for food. One in four of the food-insecure elderly households (1.5 percent of all elderly households) were food-insecure to the extent that one or more household members were hungry at least some time during the year because they could not afford enough food. The other three-fourths of food-insecure elderly households obtained enough food to avoid hunger by using a variety of coping strategies such as eating less varied diets, participating in Federal food assistance programs, or getting emergency food from community food pantries. These rates of food insecurity and hunger were about half those of households with no elderly members, and this relationship was observed at 34 all income levels, including household with incomes below the Federal poverty line. The extent of food insecurity and hunger among elderly households remained almost unchanged from that of 1995 (when the fir t nationally representative food security survey was conducted) through 2000. The corresponding prevalence rates for the nonelderly, on the other hand, declined substantially during this period of economic growth. There are two areas of greatest concern regarding application of the standard methods for measuring food security to the elderly. The first is whether the questions in the Food Security Scale are understood similarly by the elderly and the nonelderly and whether they experience and respond to food insecurity in similar ways. The standard method depends on self-reported conditions and behaviors related to food access and, as such, may be subject to differences in how people understand and interpret the questions and may be subject to biases in the direction of perceived social desirability. For example, ethnographic findings have suggested that the least severe question in the Food Security Scale, which asks whether respondents worried that their food would run out before they received money to buy more, might be less sensitive for elders. Some elderly persons, at least, report that they just do not worry about such things. The second area of concern is whether the ~~od Security Scale is appropriately sensitive to obstacles that particularly affect elders' ability to get adequate, nutritious meals. The Food Security Scale measures, specifically, food insecurity and hunger that are caused by insufficient money or other resources for food. Each question in the scale specifies this resource constraint as a reason for the behavior or condition-for example: "In the last 12 months, did you ever cut the size of your meals or skip meal because there wasn't enough money for food?" Factor other than economic resource constraints (e.g., health problem , mobility limitation , and lack of transportation) may be ob tacle to elders' ability to obtain adequate nutritious meals, and food-acces problems caused by uch factors might not be registered by the Food Security Scale (Guthrie & Lin, 2002). Data and Methods Data to as ess the e concern about measuring the food ecurity of elderly persons were drawn from the Augu t 1998, Aprill999, and September 2000 Current Population Survey Food Security Supplement (CPS-FSS). The CPS-FSS i an annual, nationally representative survey of about42,000 households, which i conducted as a supplement to the monthly CPS labor force survey. In each hou ehold, the person most knowledgeable about the food purchased and eaten in the home respond to the questions in the Food Security Supplement. Annual tatistic on household food ecurity in the United States are publi hed by the USDA and are based on data from the CPS-FSS. Separate analy is file were constructed for households in which all per on were age 65 or older (i.e., elderly-only hou eholds) and households in which no person was age 65 or older (i.e., nonelderly hou eholds). Hou ehold with mixed elderly and nonelderlyabout 7 percent of all hou ehold - were excluded from the analy is. Family Economics and Nutrition Review Scaling Analysis: Do the Elderly and Nonelderly Experience and Respond Similarly to Food Insecurity? To assess whether the questions in the Food Security Scale are understood similarly by the elderly and the nonelderly and whether they experience and respond similarly to food insecurity, I compared response patterns of elderly-only and nonelderly households. To do so, I used statistical methods based on the Rasch measurement model-the methods originally used to develop the Food Security Scale. This analysis exploits one of the strengths of multiple-indicator measures such as the Food Security Scale: associations among the indicators comprising the scale provide evidence of its validity and reliability. Furthermore, if the patterns of association among the items in a multipleindicator measure are similar in two populations, this suggests that the items relate similarly in the two populations to the underlying phenomenon that accounts for their interrelationships; that is, the items measure the same phenomenon in the two populations. These methods of scale assessment are more widely used in psychometric research and educational testing than in nutrition and economic research, so I present first a brief summary of the Rasch model and the scale assessment statistics based on it. More detailed information on the Rasch model and associated statistics is available elsewhere. 1 1 See Wright (1977; 1983), Wright & Ma ters (1982), Baker ( 1992), Hambleton, Swaminathan, & Rogers ( 1991 ), and Fischer & Molenaar ( 1995), and the Website of the MESA psychometric laboratory at the University of Chicago at www.rasch.org. Information about applications of Rasch methods to the development and assessment of food security scales is avai lable in Hamilton et al. ( 1997a; 1997b), Ohls, Radbi ll, & Schirm (200 I ), Bickel et al. (2000), and Nord (2000). 2003 Vol. 15 No. 1 An essential characteristic of the Food Security Scale is that the items comprising it vary across a wide range of severity of food insecurity. The precise severity level of each item (the "item calibration" or "item score") is estimated empirically from the overall pattern of response to the scale items by the interviewed households. However, the range of severity of the conditions identified by the items is also intuitively evident from inspection of the items. For example, not eating for a whole day is a more severe manifestation of food insecurity than is cutting the size of meals or skipping meals. These differences in severity are observed in two ways in the response patterns of surveyed households. First, more severe items are less frequently affirmed than less severe items. Second, households that affum a specific item are likely to have also affirmed all items that are less severe, while households that deny the item are likely to also deny all items that are more severe. These typical response patterns are not universal, but they are predominant, and among households that do deviate from the typical patterns, the extent of deviation tends to be slight. The Rasch model formalizes the concept of severity-ordering of items and provides standard statistical methods to estimate the sever |
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