Nutritional Programming for the Elderly Thurmon W. Myers, MS East Orange, New Jersey

It is impossible to talk about nutrition and the elderly without reviewing related factors such as program funding levels, income and purchasing power, education, medical implications, and resulting social costs. Although we have witnessed a tremendous increase in federal appropriations for Title VII programs, many senior citizens have not and will not benefit from nutrition programs. As the ratio of elderly citizens to total population increases, we may expect: (1) an increase in program budgets with a concomitant decrease in the proportion of senior citizens served; and (2) a regressed government attitude toward income-related support programs, causing decreased purchasing power, ineffective nutrition programs, and little relative improvement in the health of our elderly population. Types of Programs Currently, a range of nutrition programs are scattered through our communities. In New York City, the majority of programs are sponsored under Title VII of the Older Americans Act, Title XX of the Social Security Act (formerly Title VI), and Department of Social Service sponsorship. In combination, the three sources give a handsome image of senior citizens in receipt of govemment-sponsored nutrition services. This writer's comments

Presented to the Second Annual ITTContinental Baking Company Symposium on Nutrition at the Sixth Annual Convention and Scientific Assembly of Region of the National Medical Association and the Empire State Medical Association, Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to: Mr. Thurmon W. Myers, Washington Heights West Harlem Inwood Mental Health Council's CMHC, 1727 Amsterdam Avenue, New York, NY 10031.

will be limited to Title VII programs as an attempt to review and comment on all programs would prove a Herculean task that time and resources do not permit and because the largest number of programs come under Title VII. Section 701(a) of Title VII gives one a surge of great optimism on first reading. The intent of the act states the need to establish: . . .permanent nationwide projects to assist in meeting the nutritional and social needs of millions of persons aged sixty or older "because" many elderly persons do not eat adequately because (1) they cannot afford to do so; (2) they lack the skills to select and prepare nourishing and well-balanced meals; (3) they have limited mobility which may impair their capacity to shop and cook for themselves; and (4) they have feelings of rejection and loneliness which obliterate the incentive necessary to prepare and eat a meal alone. .I

These high intentions prompt senior citizens to have high expectations and, thus, a feeling of disappointment if their expectations of services to be delivered


are not commensurate with the benefits of the Act.

Level of Funding Although we have witnessed a tremendous increase in the amount of federal appropriations, less than two percent of our seniors benefited from the programs in 1975. For fiscal years 1973 and 1974, $98.6 million was allocated by the Administration on Aging under Title VII. The allotments increased to $148.75 million, $185.625 million, and $203 million for fiscal years 1975, 1976, and 1977, respectively.2 If the 1973 allotment level is used as a comparative base, we see very noticeable percentage increases in the dollar amounts. Rough calculations yield a 66.2 percent increase in 1975, 124.87 percent in 1976, and 136.47 percent in 1977 as compared to 1973-1974 allotment levels. Yet, in 1976 nearly $200 million provided congregate meals for only 240,000 seniors or 0.8 percent of approximately 30 million3 eligible seniors. Initial feelings of 335

Table 1. Monthly Income (54 Senior Citizens, Harlem Hospital Outpatient Service)

Type of Income

Percent of Total Population

Average Income

SSA SSI Combined SSA/SSI Pension Pension plus other

57.4 66.6 31.4 12.9 11.1

$151.29 126.65 209.61 * 160.07 251.38**

*17 persons were recipients of both SSA and SSI, and have been included in those individual categories. **These persons had other sources of income such as railroad retirement and veteran's benefits.

elation have been smothered by the apparent low level of service in spite of the large appropriations. If $185.625 million feeds only 240,000 seniors, how few will receive help from $203 million? Thoughts about low service levels are particularly disturbing as only $203.525 million of $401.6 million (50.67 percent of budget), appropriated for programs under the Administration on Aging programs, went to Title VII Nutrition Programs for the Elderly. Of further concern is that most reports forecast an increase in our aged population.

The Senior Population: Profile and Prospects The ratio of the elderly to the total population has increased in the recent past and is expected to increase at least until the year 2000. "The proportion of the population that was 60 years old and over increased from 14.1 to 14.7 percent during 1970-1974. For persons 65 years old and over, this proportion increased from 9.8 to 10.3 percent."4 A similar picture surfaces when we look at the elderly population of New York State and New York City. New 336

York City realized a 17 percent increase in its over-65 population between 1960 and 1970. At the same time, the younger population was either "leveling off' or decreasing. An end of the baby-boom era, lower fertility rates, and other variables have been reported as related or causative factors. Whichever hypothesis is adopted by federal, state, local, or private sources, each seems to agree that the number of elderly citizens is increasing faster than the general population. Social security authorities are anxious because they anticipate an inadequate number of working citizens to contribute to the benefit system. The May 10, 1977 edition of the New York Times reported that "the future ratio of workers to social security recipients is expected to fall and that long-term financing problems" are expected. The "inter-generational financing system" discussed in the May 10, 1977 edition of the New York Times may sound inviting, but may promise fightor-flight behavior. As dollars become tighter, we may see increasing antagonism between the aged and our more youthful population. In 1975 a senior citizen stood and proudly asserted that he had a right to social security benefits. A younger man, who appeared to be in his early thirties, later stood to protest having to support the

retired and other social security recipients via payroll deductions. This vignette occurred at a conference sponsored by Seniors for Adequate Social Security (SASS), and provided the author with discomfort and concern.

Income and Purchasing Power Senior citizens, because they live on fixed incomes, have a limited power of purchase (Tables 1-5). Even though the federal government has allowed cost of living increases since the early 1970s, many of our seniors still fall below nationally established poverty levels. If $30 million is taken as a base, about 9.9 million live at or below poverty level. Government-generated figures clearly tell us that at least seven million (23.3 percent) of our aged live at or below the current poverty level. However, the Post-White House Conference on Aging Report stated that "The Administration does not concur in the recommendation. . .that the intermediate budget developed by the Bureau of Labor Statistics become the national goal in this area."5 In other words, the Administration took the position that it would not help seniors to realize an adequate income base.


The dollars received by our seniors do not allow for much "fat" in their pocketbooks. For instance, 54 senior citizens participated in an outpatient service program at Harlem Hospital. Less than 12 percent had incomes at or above $251.38 per month in 1975. The others had one of the following monthly dollar-support bases: $151.29 from SSA, $126.65 from SSI, $209.61 from SSA and SSI, and/or $160.07 from pension, SSA, and SSI. Such stipends are not great amounts of money. The ability of the recipients to purchase goods and services was made more difficult because the corresponding percentages of dollars required toward rent were 35.7, 59.3, 70.8, 42.8 and 56 percent,6 respectively. Clearly, the majority had to use more than one half of their income for rent. The ability of such senior citizens to survive is amazing. A system which says it will provide aid only to those who contribute to the "kitty" makes one angry. This anger would be tempered if the seniors were among those who contributed at a higher level because they would be eligible for a higher rate of return. However, as the Selected Findings on the Black Elderly reported in 1974, the elderly black had: The most restricted job life, the lowest income. (And The lowest social security benefit. was) left in the most disadvantaged position economically in their old age.7

According to a study by the New York City Office for the Aged, over 82 percent of the studied population reported they "could not make ends meet" or "just about managed to get by." It would be surprising if the aged were not bitter. The elderly pay large rents for poor housing. Data source and scope may vary, but a consistent picture emerges indicating that our older residents will have a "tough row to hoe" in future years.

Education and Effective Nutrition Programs Nutrition programs have not been effective in re-educating the elderly in selecting and preparing "nourishing and well-balanced meals" or in learning related skills. A national survey of Title VII programs revealed that some projects did not have nutrition education as a component. The report further stated

Table 2. Average Rent as Percentage of Monthly Income* (54 Senior Citizens, Harlem Hospital Outpatient Service) Type of Income

Average Income

Rent Percent of Income

SSA SSI Combined SSA/SSI Pension Pension plus other

$151.29 126.65 209.61 160.07 251.38

59.3 70.8 42.8 56.0 35.7

*The average rent of all participants was calculated to be $89.77.

Table 3. Marital Status (54 Senior Citizens, Harlem Hospital Outpatient Service)


Single Married Widowed Divorced Separated Total

that "over half were unable to report any measurable impact from nutrition education."8 The inference is that nutrition education is approached in a rather haphazard fashion, if at all. The provision of a "nourishing and wellbalanced diet" is not necessarily to be equated with teaching about proper nutrition. As the chairman of the advisory committee of one center, the author is fully aware that we must frequently battle with the numbers game. The sponsoring agency says that we must provide "X" number of hot meals per day. At the same time, an 85-centper-meal allotment, based on a calculation made on or about 1971, has not increased and we have suffered a cut in the budget line for food. The cutting of budget lines for food and staff make it difficult to provide a nourishing meal within budget limits, especially when there is also a decrease in the number of staff. However, inadequately budgeted lines represent only part of the picture. The adequacy of the nutrition requirements is also questionable.




11 6 35 1 1 54

3.7 11.1 81.5 1.8 1.8 99.9

Medical Implications The intentions of the Food and Nutrition Board of the National Academy of Sciences are presumably honorable. On the other hand, that the recommended daily allowance (RDA) is established at "one third"9 of the daily nutritional requirements is baffling. The author is not a physician, nor trained in nutrition or related sciences. Nevertheless, might not the established RDA pose "severe risks unless justified by careful individual analysis."9 Furthermore, it is possible that 310,000 seniors, combined congregate and homebound, are "at risk" of: (1) undernutrition, the failure to obtain necessary amounts of essential nutrients; and (2) excessive caloric intake and its impact on the level of obesity.9 Physicians and other health professionals, of course, have thoughts about nutrition, caloric intake, and resultant or associated implications. Perhaps all would agree, at least in principle, that "without such adequately nutritious diets, poorly nourished people of all 337

Table 4. Sex (54 Senior Citizens, Harlem Hospital Outpatient





M F Total

8 46 54

14.8 85.1 99.9

ages are at greater health risk."9 Non-clinical nutrition factors advise us of the heavy burden of ill health. Since there appears to be a relationship between aging and the need for medical attention and possible ill health, it seems that the provision of a healthy meal is related to independence and, therefore, of general concern. Inadequate nutrition contributes to poorer health, more frequent visits to the hospital or physician, and an increased drain on dollars, social and other services. Mass media and the literature continue to point to the increasing cost of hospitalization. The February 27, 1977 edition of the New York Times reported that health care costs totaled $140 billion nationally in 1976, a 19 percent increase over the 1975 cost of $118 billion. The article further stated that New York's total health care budget was $14 billion and that this state's health care inflation rate is rising five times as fast as the general inflation rate. We are paying a great deal in order to provide medical services in general, and since the aged make more visits for medical care than the younger population, efforts should be exhausted to abort factors that contribute to escalating costs.

Regressed titudes



In spite of a decision by the federal government to allow cost-of-living increases, a number of situations have prevented the aged from seeing real differences in dollars passed to them. For instance, when the federal government increased its share of SSI support, the state decreased theirs, and older people saw little increase in monies passed to them. It seems as if money is given by one hand and taken by the other. With the advent of increasing media 338

Table 5. Living Arrangements (54 Senior Citizens, Harlem Hospital Outpatient Service)




Alone With spouse With child With non-relative Unknown Total

30 6 10 6 2 54

55.5 11.1 18.5 11.1 3.7 99.9

coverage about the shrinking support base for the social security system, we hear President Carter intimating that we may have been too generous in approving cost-of-living increases for SSA and SSI benefit services. At the same time seniors had to pay a greater price through premium and copayment contribution for Medicare coverage. Will the government repeal or smother PL 94-569 because it is too liberal? PL 94-569 does not include the value of a home when determining SSI eligibility. It requires states which supplement the SSI program to pass along federal cost-of-living increases but will not subject SSI recipients to loss of Medicaid solely due to cost-ofliving increases. There is a question as to the probability that the federal government will appropriate $80 million to provide home-delivered meals for 125,000 to 175,000 homebound seniors of the over four million seniors in need. If programs are cut back, the elderly will suffer and the black single female, living alone, will suffer a high proportion of stress than her white female counterpart.

Resulting Social Costs The intertwined relationship of nutrition to: (1) program funding levels, (2) income, (3) purchasing power, (4) education programs, (5) medical costs, and (6) implementation necessarily mean that we will pay a high price for any deficiency. With inflation, taxes, payroll deductions, and hospital costs will increase and the elderly will not see any real increase in their purchasing power if nutrition programs with the education component remain as narrow in scope and limited in effectiveness as they are currently. If there is a breakdown in any of the interconnected links, more

social workers will be needed to make home visits, and to help make hospital discharge plans. They are needed to help family members maintain the relative's household during periods of hospitalization and/or aid to family members as they pass through various phases of grief when a family member dies. The social costs of inefficient and/or ineffective nutrition efforts are not meager by any means. Although the programs do not operate for profit, our present system dictates that professionals receive payment for services. Doctors, nurses, social workers, psychiatrists, psychologists, hospital administrators, and social security people do not totally volunteer their services. If we plan to limit controllable cost increases, we must demand effective services or redefine program objectives so that they are attainable and thereby diminish past disappointment and frustration.

Literature Cited 1. Section 701A, Title VIl, The Older American Act. PL92-258, US Code, 1972 2. HEW Fact Sheet AoA, No. (OHD) 7620230. Revised April 1976, p 2 3. Proceedings of the Select Committee on Nutrition and Human Needs of the United

States Senate. Congressional Record, June 17, 1976, p 18 4. Statistical Memo No. 31, Department of Health, Education, and Welfare Publication No. (OHD) 75-20013, May 1975, p 1 5. Report of the Post/White House Conference on Aging. 1973, p 21 6. Myers T: Geriatric psychiatry-some movement, some constraints. Presented to the Social Service Department at Harlem Hospital, New York, January 1976, unpublished 7. New York City Office For the Aging: Selected findings of the black elderly in the inner city: A Study Conducted by the Research Department of the New York City Office for the Aging, p 4, 1974 8. Title VIl Survey-Select Committee on Nutrition and Human Needs. United States Senate, April 1976, p 11 9. The Homebound Elderly: The Need For a National Meals-on-Wheels Program. Special Report of the Food and Nutrition Board, National Academy of Sciences, Washington, D.C., November 1976, pp 19,22


Nutritional programming for the elderly.

Nutritional Programming for the Elderly Thurmon W. Myers, MS East Orange, New Jersey It is impossible to talk about nutrition and the elderly without...
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