Family Economics and Nutrition Review [Volume 15, Number 1]

              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.
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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
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Department of Agriculture, Washington, DC.
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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
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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
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American Dietetic Association. (1996). Position of the American Dietetic
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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,
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C2KBR/OJ-10. U.S. Census Bureau.
Krista!, A.R., Glanz, K., Curry, S.J., & Patterson, R.E. (1999). How can stages
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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.
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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,
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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
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Wellman, N.S., Weddle, D.O., Kranz, S., & Brain, C.T. (1997). Elder insecurities:
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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
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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:
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600-602.
Gordis, L. (2000). Epidemiology (2nd ed.). Philadelphia: W.B. Saunders Company.
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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
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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).
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children. Journal of Nutrition Education, 24, 36S-45S.
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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