July/August 2017

Research Review: The Powerful Impact of Meals on Wheels
By Brian Polzner, MS, RDN, LD
Today's Geriatric Medicine
Vol. 10 No. 4 P. 28

Older adult malnutrition has become an area of growing concern in America. The cost of disease-associated malnutrition is estimated to be $51.3 billion per year.1 This issue is only going to increase in importance as the aging population continues to grow and live longer. According to the Centers for Disease Control and Prevention, life expectancy for all races increased from 73.7 to 78.8 between 1980 and 2013. By the year 2030 there will be 74 million adults aged 65 and older.2 Although Americans are living longer, physiologic, functional, and social changes associated with aging can exert an impact on the nutrition status of the aging adult population that puts them at risk. One of two older adults is either malnourished or at risk of becoming malnourished.3 Older adults are at increased risk for malnutrition for a variety of reasons that include but are not limited to poverty, food insecurity, mental health, social isolation, depression and chronic disease, and repeated hospitalization.

This increased risk for malnutrition creates a costly problem for our health care system. Those adults who are malnourished experience 50% higher rates of hospital readmissions. Malnutrition increases risks of complications and mortality during the hospital stay and can lead to increased length of stay, poor recovery, and repeated health care-related visits. This combination of more frequent admissions and increased complications during treatment results in costs up to 300% greater for malnourished individuals than for older adults with adequate nutrition status.4

There are, however, programs in place to help address these needs through the Older Americans Act (OAA) established in 1965.5 As supported by the Administration on Aging, the OAA established an Aging Services Network made up of State Units on Aging, Area Agencies on Aging (AAAs), and local service providers. These programs provide a range of community-based services for older adults aged 60 and over (and their caregivers) from visiting nurses, homemaking, and transportation, among others.

A major focus of these programs lies in supportive nutrition services. The most well known among these is the home-delivered meal program often referred to as Meals on Wheels (MOW). Many people are familiar with the program and may have a relative who receives meals or know someone who is a volunteer delivering meals. However, many are not familiar with the impact this program has on the aging population.

Who Uses MOW?
Programs like MOW are designed to reach the most vulnerable older adults with the greatest social and economic need and help them remain in their homes. MOW participants tend to be more vulnerable than the general population over the age of 60. In 2013, the average age of MOW participants was 79.53 years. Those older adults were also four times as likely to be aged 85 and older, compared with the general population aged 60 and older. Home-delivered meal participants experienced increased isolation and were 55% more likely to live alone. They were also 52% more likely to report being in poor or fair health.6

Activities of daily living (ADLs), a measure of an individual's functional status, have a major impact on his or her ability to remain at home longer.7 Home-delivered meal participants were 34% more likely than the general population aged 60 and older to have difficulty with three or more ADLs.6 A 2015 Brown University study led by Kali S. Thomas, PhD, found that 58% of individuals on waitlists for MOW services reported needing someone to help with personal care needs due to a physical, mental, or emotional condition. The study found that 85% of waitlisted older adults reported having a chronic illness, and 72% indicated that chronic illness impacted their ability to leave their homes.8

A Multifactorial Function
Older adults' access to nutritious meals through MOW helps reduce hunger and food insecurity by providing meals to individuals who might otherwise struggle to acquire them, while also helping elders improve their nutrient intake. MOW programs must adhere to strict guidelines as established by OAA. Each meal must meet one-third of the Dietary Reference Intakes (DRIs) reported in the 2015-2020 Dietary Guidelines for Americans. A registered dietitian must approve these menus. MOW participants have been found to have between a 4% and 31% higher mean daily nutrient intake than nonparticipants and had improved nutrient intakes on days they received meals compared with days they did not.7,9

Improved nutrient intake is critical. However, MOW is about more than a meal. Other factors contribute significantly to the quality of life, ability of older adults to remain in their homes, and decrease in malnutrition risk, as identified in the Thomas study. Providers who deliver the meals often administer other OAA services, such as help at home or visiting nurses, or are connected with local area health care providers who offer those services. The process of qualifying for service requires an in-depth assessment to be conducted at intake and at least yearly thereafter. Factors such as nutrition risk, ADLs, home environment, and mental health are assessed during these evaluations. A positive consequence of these assessments and daily meal deliveries is that MOW providers are positioned to become sources of referrals to other needed services as well as serving as a daily check-in to ensure everything is satisfactory with respect to a client's needs. These daily check-ins may be the only contact MOW participants have with other people each day. The smiling face at the front door each day can make a world of difference in an older adult's life.

Effectiveness and Efficiency
The Thomas study examined the impact of MOW on the health and well-being of adults aged 60 and older. Older adults in this study receiving daily delivered meals self-reported improvements in many risk factors for malnutrition: improvements in mental health and self-rated health, reductions in the rate of falls, improvements in feelings of isolation and loneliness, and reductions in worrying about being able to remain in their homes. They also reported that the meals helped them eat more healthfully and feel safer.8

MOW providers operate efficiently with respect to costs. Providers utilize a large base of volunteers for deliveries, helping to dramatically lower the costs of daily deliveries. Through partnerships with local and state agencies, as well as a large focus on external fundraising, for every federal dollar provided for the MOW program, nearly $3.55 was leveraged.7 A 2014 study shows that about 69% of total expenditures for MOW programs come from sources other than OAA funding.10

Identifying Qualifying Older Adults
This is relatively easy and shouldn't be intrusive for any health care professionals, from hospital discharge coordinators to primary care physicians. The place to start is determining that an individual in question is aged 60 or older. Looking for signs of problems with mobility, food security, mental health, and transportation is also helpful. At this point, there is plenty of information on which to act. If a provider wants to incorporate a standardized protocol, a nutrition risk assessment like the DETERMINE Your Nutrition Health (established by the Nutrition Screening Initiative) or a simple nutrition screen such as the Mini-Nutritional Assessment (MNA) is relatively simple. However, these assessments are conducted through the application process, so there is no need to take on any extra work, which may be a concern.

Connecting Elders With MOW and Other Services
Making the connection is actually very easy. Providers, family members, and caregivers can contact the local AAA. Each state is divided into regions, with each region represented by an individual AAA as designated by the State Department of Aging. For example, Ohio has 12 AAAs covering all of its 88 counties. Local AAAs are the organizations most familiar with the needs of and services for older adults in the immediate area. Representatives will be able to set up a family member or referred client with MOW and other service for which he or she qualifies.

Another great resource is Meals on Wheels America, an advocacy and support organization for home-delivered meal providers across the country. A simple tool on its website helps locate MOW programs near specific search locations. This is a great resource for individuals interested in becoming volunteers, as the organization can help to find a local program for which to volunteer via a similar search tool.

It's well known that older adults are living longer lives, creating longer periods of increased risk of age-related malnutrition and the costly outcomes associated with it. There are many vital services in place to help assist those elders at greatest risk. MOW is one of those critical services that can help lower malnutrition risk, promote health and well-being, delay adverse health conditions, and help keep older adults in their homes.

— Brian Polzner, MS, RDN, LD, is a registered dietitian nutritionist at LifeCare Alliance, an elder care nonprofit organization in Columbus, Ohio, where he manages menus for the Meals on Wheels program.

References
1. Snider JT, Linthicum MT, Wu Y, et al. Economic burden of community-based disease-associated malnutrition in the United States. JPEN J Parenter Enteral Nutr. 2014;38(2 Suppl):77S-85S.

2. The Malnutrition Quality Collaborative. National blueprint: achieving quality malnutrition care for older adults. http://defeatmalnutrition.today/files/1614/9027/0221/MQC_Blueprint.pdf. Published March 2017.

3. Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-1738.

4. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235-239.

5. Kowlessar N, Robinson K, Schur C. Older Americans benefit from Older Americans Act nutrition programs. http://nutritionandaging.org/wp-content/uploads/2015/10/2015_0928_AoA_Brief_September.pdf. Published September 2015. Accessed May 24, 2017.

6. Banaszak-Holl J, Fendrick AM, Foster NL, et al. Predicting nursing home admission: estimates from a 7-year follow-up of a nationally representative sample of older Americans. Alzheimer Dis Assoc Disord. 2004;18(2):83-89.

7. Millen BE, Ohls JC, Ponza M, McCool AC. The elderly nutrition program: an effective national framework for preventive nutrition interventions. J Am Diet Assoc. 2002;102(2):234-240.

8. Thomas KS, Dosa DM. More than a meal: evaluating the effectiveness of a home-delivered meals program. Gerontologist. 2015;55(Suppl 2):574-574.

9. Walden O, Hayes PA, Lee DY, Montgomery DH. The provision of weekend home delivered meals by state and a pilot study indicating the need for weekend home delivered meals. J Nutr Elder. 1988;8(1):31-43.

10. Sahyoun NR, Vaudin A. Home-delivered meals and nutrition status among older adults. Nutr Clin Pract. 2014;29(4):459-465.