NASA food experience and technology provided the basis for development of a convenient, shelfstable meal system for the elderly. Survey results and health-nutritional assessments from 163 to 168 volunteer elderly participants show the meal system to be feasible, user-acceptable, and an effective method for meeting many of the special nutrition needs of the elderly. Large-scale implementation of a NASA type system should be a jointly coordinated undertaking of the public and private sectors.
NASA Food Technology A Method for Meeting the Nutritional Needs of the Elderly1
Attempts to fashion a coherent national nutrition policy are notable for their singular lack of success. Since the height of the War on Poverty of the mid-1960s, citizen advocates, health and nutrition experts, and a small group of elected officials have called for a consistent and progressive policy. Their call came in the wake of poignant revelations of the ravaging effects of hunger in this country, especially its impact on the very young and old (Citizens Board of Inquiry, 1969). Although important nutrition initiatives have been undertaken, they have not been particularly successful in upgrading the nutritional status of their intended target groups (Clarkson, 1975). While the marginal success of domestic nutrition programs is disturbing, it is also understandable. A number of studies (Clarkson, 1975; DHEW, Office of Economic Opportunity, 1971; Kotz, 1969; Senate Select Committee on Nutrition & Human Needs, 1975; USDA, Economic Research Service, 1973) reveal that most nutrition programs emerged as corollaries of farm price support or cash transfer policies. Ironically, the primary objective of nutrition programs has been something other than improved nutrition. It, therefore, is not surprising that these programs have met with marginal success and that significant service gaps exist which can'The NASA Meal Project was a joint effort of the Lyndon B. Johnson Space Center (NASA), Lyndon B. Johnson School of Public Affairs of the Univ. of Texas at Austin (LBJ School), the Texas Research Institute of Mental Sciences, United Action for the Elderly, Inc., and the Univ. of Texas Medical Branch at Calveston (UTMBC), LBJ School participation in the project was supported in part by the Texas Dept. of Public Welfare through a Purchase of Service Agreement and was directed by Dr. Jurgen Schmandt. A comprehensive evaluation of the project is contained in Research Report 76, Meal System for the Elderly: Conventional Food in Novel Form, 1977, Lyndon B. Johnson School of Public Affairs, Univ. of Texas at Austin. 'Assistant Professor, LBJ School of Public Affairs, Univ. of Texas, Austin 70712.
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not be closed by means of program expansion alone. The demonstration project reported on here was an attempt to find a method for closing a portion of that gap with respect to the special nutrition needs of the elderly. It sought to test whether or not the food technology and experience which grew out of the manned space program of the National Aeronautics and Space Administration (NASA) could serve as a basis for developing a nutritionally sound and acceptable meal system for the elderly. The specific objective was to develop and test a pleasant-tasting, easily transportable, shelf-stable meal system which required few utensils and minimal skills to prepare and which would complement existing congregate meal and meals-on-wheels programs. The intent was to design a meal service for the rural, small-town, and urban elderly who cannot participate in group meal programs because they are ill, handicapped, homebound, or otherwise prevented from doing so. It has been estimated that 3 to 4 million elderly who are eligible to participate in the more 700 Title VII programs fit into this category (Weekly Compilation of Presidential Documents, 1976). System Development
The meal service system3 developed by NASA, in cooperation with the LBJ School of Public Affairs, used NASA food experience and technology as a basis for providing, by mail or personal delivery, packages of seven J NASA meal system refers to the combined technologies of preservation, packaging, and delivery methods used in new ways to introduce hot meals into the homes of project participants.
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Lodis Rhodes, PhD2
individual, self-contained meals. The rationale underlying d e v e l o p m e n t of the NASA system was based on the following considerations:
The NASA meal system was tested in seven
locations over a 3-month period by a group of 209 elderly volunteers: 41 in a 2-week pilot test and 168 in a 3-month field demonstration of the system. Development and testing of the system was carried out in four phases. Phase I was devoted to establishing the technical specifications for food items and producing or acquiring an initial food inventory of 149 items from commercial food processors. Specific activities conducted during Phase I included: (1) a food preference and attitude survey of a sample of elderly persons; (2) a technical taste test of all food items under consideration for use in the meal system; (3) a user taste test whereby a group of elderly persons provided sensory ratings of those food items which met technical specifications; (4) development of technical requirements for the meal packaging system. Phase II involved field testing a prototype of the system, including the delivery and field service-support network. The findings from this phase provided the basis for modifying the composition of single meal units and making changes in the packaging of the units. Phase III entailed the major field test of the system. The final phase involved an extended test period for 25 of the original 168 participants who took part in the major field test and an assessment of the policy implications of the NASA meal system.
Each criterion and its related assumptions were verified during Phase I and II. The first five items listed above established the technical requirements for the meal system; the others set the field service-support requirements. With respect to the latter requirements, the specification (6) that individuals on special diets not be included in the demonstration was for economic reasons. While, from a technical standpoint, it would have been possible to adapt meals to meet special dietary restrictions, the increased production costs for such small-scale food processing ruled out the option of including special diets or food preferences for this demonstration project. Item 8 was deemed necessary so that baseline data could be established concerning the type of assistance, if any, participants might require in the preparation of meals. Although there was recognition that meal preparation would require limited motor skills and dexterity, it was our intent to develop a packaging and preparation procedure geared to those elderly who have rather severe limitations in these areas (arthritis, impaired vision, mobility with mechanical assistance, etc.). More will be said on this when participant characteristics are discussed. The assumptions and criteria established The end result of the technical developfor development of the system specified that: ment phases was 21 different single meal units. These were assembled from an inven(1) All meals meet one-third of the daily recom- tory of 95 items which passed a two-step taste mended dietary requirements for males 51 years or test evaluation. Seven NASA technicians older;4 trained in sensory evaluation conducted the 'These dietary requirements were established by the Food and Nutrition first round of tests on the initial inventory of Board of the National Research Council of the National Academy of Sciences. Requirements for males for the age cohort of interest meet or exceed 149 food items. They evaluated each item for those for females.
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(1) The spiraling cost of institutionalization requires a reassessment of this method as the chief mechanism for delivering long-term care to the elderly; (2) Adequate and proper nutrition is a key factor in maintaining the elderly in their own homes and communities; (3) There is a need to increase the financial and technological capability of existing meal programs to serve a higher proportion of those elderly persons eligible for service but not being reached.
(2) All food items have a minimum shelf life of 1 year; (3) Food preservation methods must exclude freezing and give particular emphasis to thermostabilized (can), freeze-dried, dehydration, and foil-polyethylene layered pouches; (4) Meal preparation be possible with minimal kitchen equipment and cooking skills (utensils to open, measure, stir, dip and serve, and the capacity to boil water and heat or cool food items); (5) All single meal units include an entree, two side dishes, dessert, and beverage; (6) No special dietary restrictions or food preferences be included in the demonstration project; (7) Written instructions on meal preparation be in English and Spanish; (8) Demonstration project participants have sufficient mobility and dexterity to perform the simple motor tasks required to unpack, open, and prepare meals.
Areas of Inquiry
The major field demonstration was designed to provide information in three key areas: (1) cost of a NASA-type meal system; (2) user acceptability of the meal system; and (3) health-nutritional impact of meals on the user population. Meal cost was evaluated in terms of its competitiveness with existing congregate and meals-on-wheels programs. User acceptability was gauged in two ways. First, attention was focused on user reaction to the appearance, texture, and taste of the prepared food. This was accomplished by means of participant ratings on a three-point scale of "good," "fair," and "poor" for all food items and meals for each dimension. The second aspect of user acceptability involved determinVol. 17, No. 4,1977
ing if, and to what extent, participants found meal delivery, packaging, and preparation satisfactory to their particular needs. A health-nutritional assessment was undertaken as a screening and protective measure and to determine the nutritional impact, if any, of the NASA meals. Site/Participant Characteristics
Seven test sites and 168 volunteers were selected for participation in the field demonstration. Prospective participants were identified by social service agencies at each site. The use of volunteer participants was in line with assurances given to the Committee on Human Rights of the University to the effect that participation in the project was to be on a voluntary and written "informed consent" basis. While this procedure may raise questions about the representative of "volunteer" participants and the possible appearance of a "Hawthorne effect," the case can be made that participants were typical of those elderly already either receiving some services of known to service agencies. This is precisely the 3 to 4 million population which cannot be reached or serviced adequately by existing meal programs. As for a possible "Hawthorne effect," the fact that participants had on-going contact with social service agencies prior to the introduction of the meal system and that delivery techniques were designed to take such an effect into account minimized the chance that it would go undetected. Sites were selected based on the willingness of a community-based agency to serve as a coordinating center and the need to ensure that sites included an urban-rural mix with significant variation in the type and range of social services available to the elderly. The objective of the participant selection process was to secure a test population which reflected differentials in terms of income, service utilization, degree of self-sufficiency, age, sex, and ethnicity. As previously discussed, two factors automatically ruled out participation: (1) need for a special, health-related diet —prospective participants had to be able to tolerate a normal diet; and (2) prospective participants could not be bedridden. While mobility and physical capability were not screened beyond determining if these two requirements were met, medical histories and case notes revealed the range of chronic health problems one would expect to encounter in an elderly population of this kind. 335
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taste, texture, and appearance. Their ninepoint hedonic ratings resulted in 96 items being deemed acceptable for further testing—to be acceptable an item had to score an average of 5.0 on the 9.0 scale for each dimension. These 96 items were then subjected to a second taste test by a 70 member panel of elderly persons (55 females, 15 males; 56 black, 14 Anglo). Again, each item, to be acceptable for inclusion in the pilot and demonstration field tests, had to average 5.0 on the 9.0 hedonic scale for each dimension. Each food item was packaged in singleserve units of approximately 5 oz. Combinations of these single-serve units made up the 21 different meals. The majority of the single meal units (15) included canned food items; the remaining units used dehydration or freeze-dried methods. Cans could be opened by means of a pull-tab device in the case of aluminum cans and/or a can opener for those made of steel. Foil packages had perforated edges as an aid in opening them by means of cutting or tearing. Instructions, written and graphic, were placed on each item. Each meal was placed in an individual box and labeled with the menu number and list of menu items. The dimensions of the individual boxes were 9.5 x 6.5 x 3.5 inches. They ranged in weight from 7.4 oz. for an all freeze-dryed, dehydrated combination to 26.1 oz. for one made up primarily of steel and aluminum cans. A 1week supply of seven meals was packaged in a larger box which measured 22 x 10.5 x 7.5 inches. This box weighed less than 10 pounds and was designed for mailing. It was the basic service unit used throughout the demonstration.
72%
51%
46%
59 35% 54 32%
47
were eligible for reimbursement for services rendered to income-eligible participants. This was an attractive inducement in securing the participation of the agencies in the project. Second, and more importantly, since the clientele of existing meal programs have limited incomes, the intent was to have a lowincome elderly population test the NASA system. All but five of the 168 participants met the income allowable limit of 65% of the state median income for those 65 and older, or $392.12 per month for one person and $512.87 for a family of two. Five of the seven sites can best be described as rural (less than 1,500) or small town (1,501-10,000). As might be expected, regular social or meal services in these areas were limited or nonexistent. Three of the seven sites offered some form of meal program for the elderly. In addition, two sites were being serviced by home-health and alternate care programs: one was an urban site, the other rural. For the bulk of rural-small town participants, the daily meal service provided by the NASA system was the only direct assistance they received. Home health and alternate care participants were receiving a broader array of services ranging from visiting nurses and homemaker helpers to congregate meal programs and coordination of social activities.
28% 38
Meal Service Conditions
22%
24 14%
3-70
Female
7180
Male
Anglo
AGE
Black
Mex-Am
ETHNICITY
Fig. 1. Age, sex, and ethnicity of the participant population (N = 168). 85 65% 73 54%
52
38
39%
28%
06 34%
22 16%
18 13%
10 7%
SSA
SSI&SSA
SSI
Pension
Other
Medicaid
Medicare Food Stamps
Fig. 2. Income sources and supplements (N = 136).
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Since one objective of the demonstration was to determine the feasibility of incorporating a NASA-type meal system into existing meal and social service programs, a testing scheme was devised to include those who participated in existing home-based care services and meal programs, either congregate or meals-on-wheels. Since participants in this category had contact with a service network, part of the NASA delivery system was fashioned to build on that network. The basic meal service conditions for the 168 participants included three categories. First, 127 participants were scheduled to receive 63 meals—three cycles of 21 meals. This service condition was based on the assumption that participants (41) were grouped as "week-end supplement." These participants were scheduled to receive two meals per week. All those in this category were participating in 5-day a week congregate meal or meals-on-wheels programs which did not provide service on Saturday or Sunday. This servThe Gerontologist
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Physical capabilities ranged from being homebound to those who were quite active, owned their own cars, and drove them on a regular basis. Fig. 1 provides a breakdown of participant characteristics by age, sex, and ethnicity. Of the 168 participants, 124 lived alone. The others lived in 22 two-person households. Fig. 2 depicts a numerical breakdown of income sources for participants and their utilization of income supplement programs. Participants had to meet the income eligibility requirements of the Texas Department of Public Welfare (TDPW) for service under Title XX guidelines of the Social Security Act. There were two reasons for this stipulation. First, the community-based service agencies which provided much of the field support were TDPW contractors and, as such,
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testing the compatibility of the NASA system with existing meal and home-based care programs, participants would pick up their meals at congregate eating locations, or have meals delivered to their residence by a service provider who was already entering the home to provide other services (home-health, chore, or meals-on-wheels). Contact under this condition was to be within the framework of existing social relationships so as to minimize the chance of it being viewed as "special attention" by the participant. The third technique used the U.S. mail as an impersonal means of delivering meals. Beyond the orientation session, this method involved contact only to the extent it was necessary to confirm that participants received their meals and that they were not experiencing difficulty in preparing them. Where possible, this confirmation was done by phone contact. Also, the feasibility of mail delivery represents a significant departure from the prevailing notions of getting nutritious meals to the elderly.
Assessment Framework
The chief objective of the assessment phase (IV) of the project was to establish whether or not the meal system was economically feasible, nutritionally sound, user-acceptable, shelf-stable, convenient, and easily transportable in multiple units. The variables under study were: (1) length of participation in the program; (2) income level; (3) geographic location; (4) method of delivery; (5) utilization of social services; (6) extent of social contact. If differences with respect to user acceptability were to be revealed, it was anticipated that they would emerge on these six variables. Given that many questions related to the appropriateness of the package design and ease of meal preparation were resolved during the system development phase and the pilot field test, questions and problems in these areas were secondary considerations during the major field demonstration period. A health-nutrition assessment of the NASA meal system was conducted by a medical-nutritional team composed of physicians, biochemists, and dieticians from the University of Texas Medical Branch at Galveston. The medical evaluation included a medical history, physical examination, and biochemical screen of 20 metabolic and physiologic items; the nutritional evaluation, a dietary history,
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ice condition was to determine if the NASA system could be used to provide participants with meal service on those days when the other programs do not operate. The third service condition involved extending participation in the project for 25 participants in the 3-cycle (63 days) component of the program for an additional 2 cycles. This group of 25, at the conclusion of the project, would have received 105 days of meal service. This extended service period was included to provide additional time within which nutritional impact, if any, might be observed and to determine whether participants might become bored with the meals after a period of extended system utilization. The major distinction in the delivery techniques was that some emphasized personal contact through a pattern of regular social interaction between participants and field service-support volunteers whereas others minimized such contact. The concern with social interaction stemmed from the need to determine the minimum level of assistance necessary to ensure proper utilization of the meals. In this sense, the delivery system was intended to provide a relatively unobtrusive way of observing the life styles of the test population and to make sure participants did not encounter problems in using the meals. Also, since the development of congregate meal programs under Title VII of the Older Americans Act rests heavily on the need to respond to the perceived social isolation of the elderly, the delivery system allowed a means to gauge the degree of social-psychological isolation experienced by participants. The "personal" method of meal delivery entailed volunteers personally delivering the basic 7-day meal unit to the participant at his or her residence once a week. On these occasions, volunteers were to spend as much time as seemed appropriate visiting with participants. This usually amounted to 10 to 30 minutes. In addition to meal delivery, volunteers were to make themselves available to participants at other times during the week by phone or home visits to "chat" and to assist participants with small tasks or errands. Dependent on participant responsiveness, contact under the personal delivery system ranged from 2 to 5 episodes per week. The intermediate system of personal contact involved the participant as an active element in the delivery of meals. In this case, and consistent with the objective of
Date Name Please circle the right answer for each question. 1. This meal was: Breakfast Lunch Supper On: Mon. 2. A. Chicken a la King B. Peas C. D. E 3. 4. 5. 6.
GOOD GOOD GOOD GOOD GOOD
Tasted FAIR FAIR FAIR FAIR FAIR
Corn Peanuts Chocolate Drink The whole meal was: GOOD FAIR POOR Did this meal give you enough to eat? YES NO Was there any food left over? YES NO WHY? Make any comments about the food here, if you want to.
Meal# Tues. Wed. Thurs.
POOR POOR POOR POOR POOR
Fri.
Opening It Was EASY HARD EASY HARD EASY HARD EASY HARD EASY HARD
Sat. Sun. Instructions Were COOD FAIR POOR GOOD FAIR POOR COOD FAIR POOR COOD FAIR POOR GOOD FAIR POOR
8. What else will you eat today? Fig. 3. Meal evaluation —field demonstration.
clinical examination, and nutritional biochemical assessment. These data were gathered at three points: (1) prior to initial feeding; (2) at the conclusion of the 63-day basic test period; and (3) at the end of the 105-day period for the 25 participants in the extended-service component. The team evaluated 75 of the 168 participants. All participants were medically certified to take part in the project by either the medical-nutritional team or their private physician. Written certification from a private physician was to the effect that a prospective participant could tolerate a normal diet and had no medical condition such as a colostomy or diverticulosis which contraindicted participation. Information, in addition to the health-nutrition assessment and related to the six variable identified, was obtained by means of personal interviews and meal-evaluation rating sheets. The four instruments5 used included (1) ,a drop-out interview schedule; (2) a postdemonstration interview schedule; (3) an extended-demonstration interview schedule; and (4) a meal-evaluation questionnaire. With minor variation, all the interview schedules were a combination of open- and closed-end inquiries aimed at eliciting detailed information from participants concerning all aspects of the meal system, their dietary habits, use of services, and degree of social interaction. A meal-evaluation questionnaire, Fig. 3, was
•The interview schedules are reproduced in Research Report 76, "Meal System for the Elderly: Conventional Food in Novel Form," 1977, Lyndon B. Johnson School of Public Affairs, University of Texas at Austin.
completed by each participant in the 63-day component for each of the 21 meals. Under all delivery conditions, field servicesupport personnel were trained or alerted to observe and record participant reaction and adjustment to the meal system. These data provided the basis for several in-depth case studies on the impact of the NASA system on the food habits and daily routine of participants. Participant Reaction to the Meal System
Of the 168 persons who began the program, 150 completed it as planned, and the analysis was based on information from 163 participants. Dropout interviews were administered to 13 of the 18 individuals who did not complete the program. Data were lacking for 5 persons because of death (2), inappropriateness of conducting an interview with the spouse of one of the deceased (1), relocation of participant (1), and lack of success in scheduling an interview (1). The data consisted of participant responses to postdemonstration and dropout interviews, meal evaluation questionnaires, and case records based on researcher observations. Participant reaction to the NASA meal system was overwhelmingly favorable; 77% reported they "liked the program very much." Respondents found the meals convenient, easy to prepare, and tasty. In order of preference, participants indicated that they "liked most" the food (51%), method of preparation (21%), and delivery method (6%). Another measure of system acceptability to partici-
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7. What else have you eaten today?
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cans increased the unit costs from $.25 for a standard size can to $1.46 for the specially produced 5-oz. size. Second, packaging and labeling costs were higher than under normal conditions because of the design, test, and redesign process. Because of this, packaging and labeling had to be done manually and as a task separate from the production sequence of commercial processors. Third, costs of assembling the meals could have been eliminated or reduced had volunteers or lessskilled personnel been used to complete this task. Adjustments for these factors reduced the NASA per meal cost to approximately $1.60, T a b l e ! NASA/Average Per Meal Cost (Unadjusted).1 Per Meal Cost
Item Food/primary packaging Labeling/instructions Secondary packaging Seven-day meal box Meal assembly
$2.88 .75 .03
.035 .20
Total
$3.90
'The unadjusted totals for average and high-and lowcost meals do not take into account cost reductions which can be achieved through use of economies of scale measures and lower cost personnel. When these allowances are made, the average per meal cost is $1.60.
Table 2. Unadjusted Low- and High-Cost Meals.1 Menu #6 (Low Cost) Beef and rice w/onions Creamed peas Cottage cheese Chocolate Crunch Bar Instant vanilla drink Labels
Item Cost $ .59 .38 .45 .20 30 .41
Total$2.33 (unadjusted) Menu #9 (High Cost) Corn Beans w/tomato sauce Chicken a la King Applesauce Instant vanilla drink Labels
Item Cost $1.46 1.46 1.46
.50 .30 .40
Total$5.58 (unadjusted) 'The unadjusted totals for average and high- and lowcost meals do not take into account cost reductions which can be achieved through use of economies of scale measures and lower cost personnel. When these allowance were made, the average per meal cost is $T>60.
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pants was that 75% of the participants expressed the desire to continue in the program, and 85% suggested they would buy the meals if they were available and comparable in cost to their normal food purchases. The quality of the food also received high marks from participants; 60% of the respondents rated the NASA meals equal to or superior in quality to the hot meals they prepared for themselves or received in their meal program. Less than 10% of the participants indicated they experienced any difficulty with meal packaging or preparation. As mentioned earlier, many of the problems with package design and instructions on food preparation were solved as a result of the pilot test. The favorable responses of participants were expected in these two areas. The critical factor in any decision to adopt a NASA system is program cost. The economic analysis of the NASA system 'revealed it to be competitive with congregate and meals-on-wheels programs. The average per meal cost for the NASA system was calculated and compared with the per meal cost of a locally based meal program and the per meal cost for each congregate meal program in Texas. The latter costs were calculated from data provided by the Texas Governor's Committee on Aging. Congregate per meal costs in Texas ranged from $1.97 to $2.97 with factors of geographic area and number of meals served accounting for most of the variation. Put differently, costs were lower for urban programs and those which served a relatively large number of meals (individuals). The per meal cost of the NASA system was based on the expense of producing 10,000 meals. Table 1 gives a cost breakdown for production of the NASA meals. Table 2 shows the high- and low-cost meals. Several important factors must be considered when evaluating the per meal cost of the NASA system. First, economies of scale in meal production were impossible to achieve because of the small number of total meals and individual food items which were processed for the project. These special size production runs translated into significant increases in food costs. For example, 12 of the 96 food items accounted for over 50% of the total food costs. The 12 items were those packaged in cans as single-serve (5 oz.) units. Three of the 5 items in the high-cost meal were single-serve cans. The use of single-serve
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Policy Implications
All information and data collected during the pilot test and field demonstration indicated that the NASA meal system was feasible from the standpoint of user acceptability, nutritional soundness, and cost. Moreover, the evidence showed that the system could work independently or in conjunction with other care services. These results should not be surprising, since the system introduces nothing new; it merely pulled together existing technology in a novel form. All elements of the system are readily available, including the food technology. The NASA system can be used to close a part of the 3- to 4-million person gap represented by those elderly in need of meal and other care services beyond the reach of current programs. More importantly, advances can be made in this area within the framework of existing legislation and service programs and at a lower incremental cost than mere expansion of these programs. It appears that what is lacking is a recognition by policymakers in the public sector and food processors and market analysts in the private sphere that there is a need and available market for nutritionally balanced, shelf-stable, individually proportioned, and easy to prepare hot meals.
References
Clarkson, K. W. Food stamps and nutrition. American Enterprise Institute for Public Policy Research, Washington, 1975. Citizens' Board of Inquiry. Hunger, U.S.A. Beacon Press, Boston, 1969. DHEW, Office of Economic Opportunity. The food stamp program and how it works. OEO Pamphlet 6132-4, USCPO, Washington, Feb., 1971. Kotz, N. Let them eat promises. Prentice Hall, Eriglewood Cliffs, NJ, 1969. Senate Select Committee on Nutrition & Human Needs. Nutrition and health with an evaluation of nutritional surveillance in the United States. USCPO, Washington, Dec, 1975. USDA, Economic Research Service. Impacts of domestic and foreign food programs on the U.S. agricultural economy. USGPO, Washington, Oct., 1973. Weekly Compilation of Presidential Documents. Older Americans. Vol. 12, No. 7, Feb. 16,1976.
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excluding delivery, and assuming a production base of 50,000 meals per menu. The $1.60 figure is less than the per meal cost of existing programs. When the delivery cost of $.17 per meal for both personal and impersonal meal delivery are added, the total cost of the NASA system is still competitive with existing meal programs in Texas. The health-nutritional assessment revealed that the system had no harmful effects on participants, although the 3-month monitoring period was an extremely short time for health or nutritional changes to stabilize. However, the data point to favorable trends for hemoglobin values, serum vitamin A and C, and serum calcium and cholesterol levels. The trends, while favorable, did fluctuate within the test group. Because of the short test period and the small number (18) of participants who were tested at three points, it is impossible to say with certainty whether the variations reflect group of individual differences or would remain within acceptable limits. With respect to dietary habits, there was no difference in participant weights as measured before and after the test period. Most reported improved eating habits and feelings of general well-being as a result of the meals. Differences did not emerge along those dimensions where it was anticipated that they might occur. These variables included sex, age, ethnicity, site, and delivery method. However, there were indications, although not significant in the statistical sense, that participants who were in greatest need of services in terms of income supplement, health, and mobility viewed the meal system as a more critical factor in their continued ability to remain in their own home. This was particularly true of those participants who were receiving home-health services, and others experiencing a decreasing capacity to be self-sufficient. The case records and participant comments tended to support the notion that participants viewed the provision of meals as an important service which enhanced their self-reliance.
NASA Food Technology A Method for Meeting the Nutritional Needs of the Elderly1
Attempts to fashion a coherent national nutrition policy are notable for their singular lack of success. Since the height of the War on Poverty of the mid-1960s, citizen advocates, health and nutrition experts, and a small group of elected officials have called for a consistent and progressive policy. Their call came in the wake of poignant revelations of the ravaging effects of hunger in this country, especially its impact on the very young and old (Citizens Board of Inquiry, 1969). Although important nutrition initiatives have been undertaken, they have not been particularly successful in upgrading the nutritional status of their intended target groups (Clarkson, 1975). While the marginal success of domestic nutrition programs is disturbing, it is also understandable. A number of studies (Clarkson, 1975; DHEW, Office of Economic Opportunity, 1971; Kotz, 1969; Senate Select Committee on Nutrition & Human Needs, 1975; USDA, Economic Research Service, 1973) reveal that most nutrition programs emerged as corollaries of farm price support or cash transfer policies. Ironically, the primary objective of nutrition programs has been something other than improved nutrition. It, therefore, is not surprising that these programs have met with marginal success and that significant service gaps exist which can'The NASA Meal Project was a joint effort of the Lyndon B. Johnson Space Center (NASA), Lyndon B. Johnson School of Public Affairs of the Univ. of Texas at Austin (LBJ School), the Texas Research Institute of Mental Sciences, United Action for the Elderly, Inc., and the Univ. of Texas Medical Branch at Calveston (UTMBC), LBJ School participation in the project was supported in part by the Texas Dept. of Public Welfare through a Purchase of Service Agreement and was directed by Dr. Jurgen Schmandt. A comprehensive evaluation of the project is contained in Research Report 76, Meal System for the Elderly: Conventional Food in Novel Form, 1977, Lyndon B. Johnson School of Public Affairs, Univ. of Texas at Austin. 'Assistant Professor, LBJ School of Public Affairs, Univ. of Texas, Austin 70712.
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not be closed by means of program expansion alone. The demonstration project reported on here was an attempt to find a method for closing a portion of that gap with respect to the special nutrition needs of the elderly. It sought to test whether or not the food technology and experience which grew out of the manned space program of the National Aeronautics and Space Administration (NASA) could serve as a basis for developing a nutritionally sound and acceptable meal system for the elderly. The specific objective was to develop and test a pleasant-tasting, easily transportable, shelf-stable meal system which required few utensils and minimal skills to prepare and which would complement existing congregate meal and meals-on-wheels programs. The intent was to design a meal service for the rural, small-town, and urban elderly who cannot participate in group meal programs because they are ill, handicapped, homebound, or otherwise prevented from doing so. It has been estimated that 3 to 4 million elderly who are eligible to participate in the more 700 Title VII programs fit into this category (Weekly Compilation of Presidential Documents, 1976). System Development
The meal service system3 developed by NASA, in cooperation with the LBJ School of Public Affairs, used NASA food experience and technology as a basis for providing, by mail or personal delivery, packages of seven J NASA meal system refers to the combined technologies of preservation, packaging, and delivery methods used in new ways to introduce hot meals into the homes of project participants.
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Lodis Rhodes, PhD2
individual, self-contained meals. The rationale underlying d e v e l o p m e n t of the NASA system was based on the following considerations:
The NASA meal system was tested in seven
locations over a 3-month period by a group of 209 elderly volunteers: 41 in a 2-week pilot test and 168 in a 3-month field demonstration of the system. Development and testing of the system was carried out in four phases. Phase I was devoted to establishing the technical specifications for food items and producing or acquiring an initial food inventory of 149 items from commercial food processors. Specific activities conducted during Phase I included: (1) a food preference and attitude survey of a sample of elderly persons; (2) a technical taste test of all food items under consideration for use in the meal system; (3) a user taste test whereby a group of elderly persons provided sensory ratings of those food items which met technical specifications; (4) development of technical requirements for the meal packaging system. Phase II involved field testing a prototype of the system, including the delivery and field service-support network. The findings from this phase provided the basis for modifying the composition of single meal units and making changes in the packaging of the units. Phase III entailed the major field test of the system. The final phase involved an extended test period for 25 of the original 168 participants who took part in the major field test and an assessment of the policy implications of the NASA meal system.
Each criterion and its related assumptions were verified during Phase I and II. The first five items listed above established the technical requirements for the meal system; the others set the field service-support requirements. With respect to the latter requirements, the specification (6) that individuals on special diets not be included in the demonstration was for economic reasons. While, from a technical standpoint, it would have been possible to adapt meals to meet special dietary restrictions, the increased production costs for such small-scale food processing ruled out the option of including special diets or food preferences for this demonstration project. Item 8 was deemed necessary so that baseline data could be established concerning the type of assistance, if any, participants might require in the preparation of meals. Although there was recognition that meal preparation would require limited motor skills and dexterity, it was our intent to develop a packaging and preparation procedure geared to those elderly who have rather severe limitations in these areas (arthritis, impaired vision, mobility with mechanical assistance, etc.). More will be said on this when participant characteristics are discussed. The assumptions and criteria established The end result of the technical developfor development of the system specified that: ment phases was 21 different single meal units. These were assembled from an inven(1) All meals meet one-third of the daily recom- tory of 95 items which passed a two-step taste mended dietary requirements for males 51 years or test evaluation. Seven NASA technicians older;4 trained in sensory evaluation conducted the 'These dietary requirements were established by the Food and Nutrition first round of tests on the initial inventory of Board of the National Research Council of the National Academy of Sciences. Requirements for males for the age cohort of interest meet or exceed 149 food items. They evaluated each item for those for females.
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(1) The spiraling cost of institutionalization requires a reassessment of this method as the chief mechanism for delivering long-term care to the elderly; (2) Adequate and proper nutrition is a key factor in maintaining the elderly in their own homes and communities; (3) There is a need to increase the financial and technological capability of existing meal programs to serve a higher proportion of those elderly persons eligible for service but not being reached.
(2) All food items have a minimum shelf life of 1 year; (3) Food preservation methods must exclude freezing and give particular emphasis to thermostabilized (can), freeze-dried, dehydration, and foil-polyethylene layered pouches; (4) Meal preparation be possible with minimal kitchen equipment and cooking skills (utensils to open, measure, stir, dip and serve, and the capacity to boil water and heat or cool food items); (5) All single meal units include an entree, two side dishes, dessert, and beverage; (6) No special dietary restrictions or food preferences be included in the demonstration project; (7) Written instructions on meal preparation be in English and Spanish; (8) Demonstration project participants have sufficient mobility and dexterity to perform the simple motor tasks required to unpack, open, and prepare meals.
Areas of Inquiry
The major field demonstration was designed to provide information in three key areas: (1) cost of a NASA-type meal system; (2) user acceptability of the meal system; and (3) health-nutritional impact of meals on the user population. Meal cost was evaluated in terms of its competitiveness with existing congregate and meals-on-wheels programs. User acceptability was gauged in two ways. First, attention was focused on user reaction to the appearance, texture, and taste of the prepared food. This was accomplished by means of participant ratings on a three-point scale of "good," "fair," and "poor" for all food items and meals for each dimension. The second aspect of user acceptability involved determinVol. 17, No. 4,1977
ing if, and to what extent, participants found meal delivery, packaging, and preparation satisfactory to their particular needs. A health-nutritional assessment was undertaken as a screening and protective measure and to determine the nutritional impact, if any, of the NASA meals. Site/Participant Characteristics
Seven test sites and 168 volunteers were selected for participation in the field demonstration. Prospective participants were identified by social service agencies at each site. The use of volunteer participants was in line with assurances given to the Committee on Human Rights of the University to the effect that participation in the project was to be on a voluntary and written "informed consent" basis. While this procedure may raise questions about the representative of "volunteer" participants and the possible appearance of a "Hawthorne effect," the case can be made that participants were typical of those elderly already either receiving some services of known to service agencies. This is precisely the 3 to 4 million population which cannot be reached or serviced adequately by existing meal programs. As for a possible "Hawthorne effect," the fact that participants had on-going contact with social service agencies prior to the introduction of the meal system and that delivery techniques were designed to take such an effect into account minimized the chance that it would go undetected. Sites were selected based on the willingness of a community-based agency to serve as a coordinating center and the need to ensure that sites included an urban-rural mix with significant variation in the type and range of social services available to the elderly. The objective of the participant selection process was to secure a test population which reflected differentials in terms of income, service utilization, degree of self-sufficiency, age, sex, and ethnicity. As previously discussed, two factors automatically ruled out participation: (1) need for a special, health-related diet —prospective participants had to be able to tolerate a normal diet; and (2) prospective participants could not be bedridden. While mobility and physical capability were not screened beyond determining if these two requirements were met, medical histories and case notes revealed the range of chronic health problems one would expect to encounter in an elderly population of this kind. 335
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taste, texture, and appearance. Their ninepoint hedonic ratings resulted in 96 items being deemed acceptable for further testing—to be acceptable an item had to score an average of 5.0 on the 9.0 scale for each dimension. These 96 items were then subjected to a second taste test by a 70 member panel of elderly persons (55 females, 15 males; 56 black, 14 Anglo). Again, each item, to be acceptable for inclusion in the pilot and demonstration field tests, had to average 5.0 on the 9.0 hedonic scale for each dimension. Each food item was packaged in singleserve units of approximately 5 oz. Combinations of these single-serve units made up the 21 different meals. The majority of the single meal units (15) included canned food items; the remaining units used dehydration or freeze-dried methods. Cans could be opened by means of a pull-tab device in the case of aluminum cans and/or a can opener for those made of steel. Foil packages had perforated edges as an aid in opening them by means of cutting or tearing. Instructions, written and graphic, were placed on each item. Each meal was placed in an individual box and labeled with the menu number and list of menu items. The dimensions of the individual boxes were 9.5 x 6.5 x 3.5 inches. They ranged in weight from 7.4 oz. for an all freeze-dryed, dehydrated combination to 26.1 oz. for one made up primarily of steel and aluminum cans. A 1week supply of seven meals was packaged in a larger box which measured 22 x 10.5 x 7.5 inches. This box weighed less than 10 pounds and was designed for mailing. It was the basic service unit used throughout the demonstration.
72%
51%
46%
59 35% 54 32%
47
were eligible for reimbursement for services rendered to income-eligible participants. This was an attractive inducement in securing the participation of the agencies in the project. Second, and more importantly, since the clientele of existing meal programs have limited incomes, the intent was to have a lowincome elderly population test the NASA system. All but five of the 168 participants met the income allowable limit of 65% of the state median income for those 65 and older, or $392.12 per month for one person and $512.87 for a family of two. Five of the seven sites can best be described as rural (less than 1,500) or small town (1,501-10,000). As might be expected, regular social or meal services in these areas were limited or nonexistent. Three of the seven sites offered some form of meal program for the elderly. In addition, two sites were being serviced by home-health and alternate care programs: one was an urban site, the other rural. For the bulk of rural-small town participants, the daily meal service provided by the NASA system was the only direct assistance they received. Home health and alternate care participants were receiving a broader array of services ranging from visiting nurses and homemaker helpers to congregate meal programs and coordination of social activities.
28% 38
Meal Service Conditions
22%
24 14%
3-70
Female
7180
Male
Anglo
AGE
Black
Mex-Am
ETHNICITY
Fig. 1. Age, sex, and ethnicity of the participant population (N = 168). 85 65% 73 54%
52
38
39%
28%
06 34%
22 16%
18 13%
10 7%
SSA
SSI&SSA
SSI
Pension
Other
Medicaid
Medicare Food Stamps
Fig. 2. Income sources and supplements (N = 136).
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Since one objective of the demonstration was to determine the feasibility of incorporating a NASA-type meal system into existing meal and social service programs, a testing scheme was devised to include those who participated in existing home-based care services and meal programs, either congregate or meals-on-wheels. Since participants in this category had contact with a service network, part of the NASA delivery system was fashioned to build on that network. The basic meal service conditions for the 168 participants included three categories. First, 127 participants were scheduled to receive 63 meals—three cycles of 21 meals. This service condition was based on the assumption that participants (41) were grouped as "week-end supplement." These participants were scheduled to receive two meals per week. All those in this category were participating in 5-day a week congregate meal or meals-on-wheels programs which did not provide service on Saturday or Sunday. This servThe Gerontologist
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Physical capabilities ranged from being homebound to those who were quite active, owned their own cars, and drove them on a regular basis. Fig. 1 provides a breakdown of participant characteristics by age, sex, and ethnicity. Of the 168 participants, 124 lived alone. The others lived in 22 two-person households. Fig. 2 depicts a numerical breakdown of income sources for participants and their utilization of income supplement programs. Participants had to meet the income eligibility requirements of the Texas Department of Public Welfare (TDPW) for service under Title XX guidelines of the Social Security Act. There were two reasons for this stipulation. First, the community-based service agencies which provided much of the field support were TDPW contractors and, as such,
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testing the compatibility of the NASA system with existing meal and home-based care programs, participants would pick up their meals at congregate eating locations, or have meals delivered to their residence by a service provider who was already entering the home to provide other services (home-health, chore, or meals-on-wheels). Contact under this condition was to be within the framework of existing social relationships so as to minimize the chance of it being viewed as "special attention" by the participant. The third technique used the U.S. mail as an impersonal means of delivering meals. Beyond the orientation session, this method involved contact only to the extent it was necessary to confirm that participants received their meals and that they were not experiencing difficulty in preparing them. Where possible, this confirmation was done by phone contact. Also, the feasibility of mail delivery represents a significant departure from the prevailing notions of getting nutritious meals to the elderly.
Assessment Framework
The chief objective of the assessment phase (IV) of the project was to establish whether or not the meal system was economically feasible, nutritionally sound, user-acceptable, shelf-stable, convenient, and easily transportable in multiple units. The variables under study were: (1) length of participation in the program; (2) income level; (3) geographic location; (4) method of delivery; (5) utilization of social services; (6) extent of social contact. If differences with respect to user acceptability were to be revealed, it was anticipated that they would emerge on these six variables. Given that many questions related to the appropriateness of the package design and ease of meal preparation were resolved during the system development phase and the pilot field test, questions and problems in these areas were secondary considerations during the major field demonstration period. A health-nutrition assessment of the NASA meal system was conducted by a medical-nutritional team composed of physicians, biochemists, and dieticians from the University of Texas Medical Branch at Galveston. The medical evaluation included a medical history, physical examination, and biochemical screen of 20 metabolic and physiologic items; the nutritional evaluation, a dietary history,
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ice condition was to determine if the NASA system could be used to provide participants with meal service on those days when the other programs do not operate. The third service condition involved extending participation in the project for 25 participants in the 3-cycle (63 days) component of the program for an additional 2 cycles. This group of 25, at the conclusion of the project, would have received 105 days of meal service. This extended service period was included to provide additional time within which nutritional impact, if any, might be observed and to determine whether participants might become bored with the meals after a period of extended system utilization. The major distinction in the delivery techniques was that some emphasized personal contact through a pattern of regular social interaction between participants and field service-support volunteers whereas others minimized such contact. The concern with social interaction stemmed from the need to determine the minimum level of assistance necessary to ensure proper utilization of the meals. In this sense, the delivery system was intended to provide a relatively unobtrusive way of observing the life styles of the test population and to make sure participants did not encounter problems in using the meals. Also, since the development of congregate meal programs under Title VII of the Older Americans Act rests heavily on the need to respond to the perceived social isolation of the elderly, the delivery system allowed a means to gauge the degree of social-psychological isolation experienced by participants. The "personal" method of meal delivery entailed volunteers personally delivering the basic 7-day meal unit to the participant at his or her residence once a week. On these occasions, volunteers were to spend as much time as seemed appropriate visiting with participants. This usually amounted to 10 to 30 minutes. In addition to meal delivery, volunteers were to make themselves available to participants at other times during the week by phone or home visits to "chat" and to assist participants with small tasks or errands. Dependent on participant responsiveness, contact under the personal delivery system ranged from 2 to 5 episodes per week. The intermediate system of personal contact involved the participant as an active element in the delivery of meals. In this case, and consistent with the objective of
Date Name Please circle the right answer for each question. 1. This meal was: Breakfast Lunch Supper On: Mon. 2. A. Chicken a la King B. Peas C. D. E 3. 4. 5. 6.
GOOD GOOD GOOD GOOD GOOD
Tasted FAIR FAIR FAIR FAIR FAIR
Corn Peanuts Chocolate Drink The whole meal was: GOOD FAIR POOR Did this meal give you enough to eat? YES NO Was there any food left over? YES NO WHY? Make any comments about the food here, if you want to.
Meal# Tues. Wed. Thurs.
POOR POOR POOR POOR POOR
Fri.
Opening It Was EASY HARD EASY HARD EASY HARD EASY HARD EASY HARD
Sat. Sun. Instructions Were COOD FAIR POOR GOOD FAIR POOR COOD FAIR POOR COOD FAIR POOR GOOD FAIR POOR
8. What else will you eat today? Fig. 3. Meal evaluation —field demonstration.
clinical examination, and nutritional biochemical assessment. These data were gathered at three points: (1) prior to initial feeding; (2) at the conclusion of the 63-day basic test period; and (3) at the end of the 105-day period for the 25 participants in the extended-service component. The team evaluated 75 of the 168 participants. All participants were medically certified to take part in the project by either the medical-nutritional team or their private physician. Written certification from a private physician was to the effect that a prospective participant could tolerate a normal diet and had no medical condition such as a colostomy or diverticulosis which contraindicted participation. Information, in addition to the health-nutrition assessment and related to the six variable identified, was obtained by means of personal interviews and meal-evaluation rating sheets. The four instruments5 used included (1) ,a drop-out interview schedule; (2) a postdemonstration interview schedule; (3) an extended-demonstration interview schedule; and (4) a meal-evaluation questionnaire. With minor variation, all the interview schedules were a combination of open- and closed-end inquiries aimed at eliciting detailed information from participants concerning all aspects of the meal system, their dietary habits, use of services, and degree of social interaction. A meal-evaluation questionnaire, Fig. 3, was
•The interview schedules are reproduced in Research Report 76, "Meal System for the Elderly: Conventional Food in Novel Form," 1977, Lyndon B. Johnson School of Public Affairs, University of Texas at Austin.
completed by each participant in the 63-day component for each of the 21 meals. Under all delivery conditions, field servicesupport personnel were trained or alerted to observe and record participant reaction and adjustment to the meal system. These data provided the basis for several in-depth case studies on the impact of the NASA system on the food habits and daily routine of participants. Participant Reaction to the Meal System
Of the 168 persons who began the program, 150 completed it as planned, and the analysis was based on information from 163 participants. Dropout interviews were administered to 13 of the 18 individuals who did not complete the program. Data were lacking for 5 persons because of death (2), inappropriateness of conducting an interview with the spouse of one of the deceased (1), relocation of participant (1), and lack of success in scheduling an interview (1). The data consisted of participant responses to postdemonstration and dropout interviews, meal evaluation questionnaires, and case records based on researcher observations. Participant reaction to the NASA meal system was overwhelmingly favorable; 77% reported they "liked the program very much." Respondents found the meals convenient, easy to prepare, and tasty. In order of preference, participants indicated that they "liked most" the food (51%), method of preparation (21%), and delivery method (6%). Another measure of system acceptability to partici-
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7. What else have you eaten today?
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cans increased the unit costs from $.25 for a standard size can to $1.46 for the specially produced 5-oz. size. Second, packaging and labeling costs were higher than under normal conditions because of the design, test, and redesign process. Because of this, packaging and labeling had to be done manually and as a task separate from the production sequence of commercial processors. Third, costs of assembling the meals could have been eliminated or reduced had volunteers or lessskilled personnel been used to complete this task. Adjustments for these factors reduced the NASA per meal cost to approximately $1.60, T a b l e ! NASA/Average Per Meal Cost (Unadjusted).1 Per Meal Cost
Item Food/primary packaging Labeling/instructions Secondary packaging Seven-day meal box Meal assembly
$2.88 .75 .03
.035 .20
Total
$3.90
'The unadjusted totals for average and high-and lowcost meals do not take into account cost reductions which can be achieved through use of economies of scale measures and lower cost personnel. When these allowances are made, the average per meal cost is $1.60.
Table 2. Unadjusted Low- and High-Cost Meals.1 Menu #6 (Low Cost) Beef and rice w/onions Creamed peas Cottage cheese Chocolate Crunch Bar Instant vanilla drink Labels
Item Cost $ .59 .38 .45 .20 30 .41
Total$2.33 (unadjusted) Menu #9 (High Cost) Corn Beans w/tomato sauce Chicken a la King Applesauce Instant vanilla drink Labels
Item Cost $1.46 1.46 1.46
.50 .30 .40
Total$5.58 (unadjusted) 'The unadjusted totals for average and high- and lowcost meals do not take into account cost reductions which can be achieved through use of economies of scale measures and lower cost personnel. When these allowance were made, the average per meal cost is $T>60.
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pants was that 75% of the participants expressed the desire to continue in the program, and 85% suggested they would buy the meals if they were available and comparable in cost to their normal food purchases. The quality of the food also received high marks from participants; 60% of the respondents rated the NASA meals equal to or superior in quality to the hot meals they prepared for themselves or received in their meal program. Less than 10% of the participants indicated they experienced any difficulty with meal packaging or preparation. As mentioned earlier, many of the problems with package design and instructions on food preparation were solved as a result of the pilot test. The favorable responses of participants were expected in these two areas. The critical factor in any decision to adopt a NASA system is program cost. The economic analysis of the NASA system 'revealed it to be competitive with congregate and meals-on-wheels programs. The average per meal cost for the NASA system was calculated and compared with the per meal cost of a locally based meal program and the per meal cost for each congregate meal program in Texas. The latter costs were calculated from data provided by the Texas Governor's Committee on Aging. Congregate per meal costs in Texas ranged from $1.97 to $2.97 with factors of geographic area and number of meals served accounting for most of the variation. Put differently, costs were lower for urban programs and those which served a relatively large number of meals (individuals). The per meal cost of the NASA system was based on the expense of producing 10,000 meals. Table 1 gives a cost breakdown for production of the NASA meals. Table 2 shows the high- and low-cost meals. Several important factors must be considered when evaluating the per meal cost of the NASA system. First, economies of scale in meal production were impossible to achieve because of the small number of total meals and individual food items which were processed for the project. These special size production runs translated into significant increases in food costs. For example, 12 of the 96 food items accounted for over 50% of the total food costs. The 12 items were those packaged in cans as single-serve (5 oz.) units. Three of the 5 items in the high-cost meal were single-serve cans. The use of single-serve
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Policy Implications
All information and data collected during the pilot test and field demonstration indicated that the NASA meal system was feasible from the standpoint of user acceptability, nutritional soundness, and cost. Moreover, the evidence showed that the system could work independently or in conjunction with other care services. These results should not be surprising, since the system introduces nothing new; it merely pulled together existing technology in a novel form. All elements of the system are readily available, including the food technology. The NASA system can be used to close a part of the 3- to 4-million person gap represented by those elderly in need of meal and other care services beyond the reach of current programs. More importantly, advances can be made in this area within the framework of existing legislation and service programs and at a lower incremental cost than mere expansion of these programs. It appears that what is lacking is a recognition by policymakers in the public sector and food processors and market analysts in the private sphere that there is a need and available market for nutritionally balanced, shelf-stable, individually proportioned, and easy to prepare hot meals.
References
Clarkson, K. W. Food stamps and nutrition. American Enterprise Institute for Public Policy Research, Washington, 1975. Citizens' Board of Inquiry. Hunger, U.S.A. Beacon Press, Boston, 1969. DHEW, Office of Economic Opportunity. The food stamp program and how it works. OEO Pamphlet 6132-4, USCPO, Washington, Feb., 1971. Kotz, N. Let them eat promises. Prentice Hall, Eriglewood Cliffs, NJ, 1969. Senate Select Committee on Nutrition & Human Needs. Nutrition and health with an evaluation of nutritional surveillance in the United States. USCPO, Washington, Dec, 1975. USDA, Economic Research Service. Impacts of domestic and foreign food programs on the U.S. agricultural economy. USGPO, Washington, Oct., 1973. Weekly Compilation of Presidential Documents. Older Americans. Vol. 12, No. 7, Feb. 16,1976.
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excluding delivery, and assuming a production base of 50,000 meals per menu. The $1.60 figure is less than the per meal cost of existing programs. When the delivery cost of $.17 per meal for both personal and impersonal meal delivery are added, the total cost of the NASA system is still competitive with existing meal programs in Texas. The health-nutritional assessment revealed that the system had no harmful effects on participants, although the 3-month monitoring period was an extremely short time for health or nutritional changes to stabilize. However, the data point to favorable trends for hemoglobin values, serum vitamin A and C, and serum calcium and cholesterol levels. The trends, while favorable, did fluctuate within the test group. Because of the short test period and the small number (18) of participants who were tested at three points, it is impossible to say with certainty whether the variations reflect group of individual differences or would remain within acceptable limits. With respect to dietary habits, there was no difference in participant weights as measured before and after the test period. Most reported improved eating habits and feelings of general well-being as a result of the meals. Differences did not emerge along those dimensions where it was anticipated that they might occur. These variables included sex, age, ethnicity, site, and delivery method. However, there were indications, although not significant in the statistical sense, that participants who were in greatest need of services in terms of income supplement, health, and mobility viewed the meal system as a more critical factor in their continued ability to remain in their own home. This was particularly true of those participants who were receiving home-health services, and others experiencing a decreasing capacity to be self-sufficient. The case records and participant comments tended to support the notion that participants viewed the provision of meals as an important service which enhanced their self-reliance.
