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Articles

Nutritional and Health Consequences Are Associated with Food Insecurity among U.S. Elderly Persons¹

Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853

²To whom correspondence should be addressed. E-mail: eaf1{at}cornell.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
The purpose of this study was to examine the consequences associated with food insecurity for the nutritional and health status of the elderly in the United States. The data analyzed were from the Third National Health and Nutrition Examination Survey (1988–1994) and the Nutrition Survey of the Elderly in New York State (1994). Multiple logistic and linear regression analyses were used to assess the extent to which food-insecure elderly were likely to have lower nutrient intake, skinfold thickness, self-reported health status and higher nutritional risk. Regardless of food insecurity status, older people consumed less than the recommended dietary allowance for eight nutrients. Food-insecure elderly persons had significantly lower intakes of energy, protein, carbohydrate, saturated fat, niacin, riboflavin, vitamins B-6 and B-12, magnesium, iron and zinc, as well as lower skinfold thickness. In addition, food-insecure elderly persons were 2.33 (95% confidence interval: 1.73–3.14) times more likely to report fair/poor health status and had higher nutritional risk. These results indicate that food-insecure elderly persons have poorer dietary intake, nutritional status and health status than do food-secure elderly persons. It is necessary to ensure the nutritional well-being of all elderly persons who are at nutritional and health risk, including those who are food insecure and have even poorer nutritional and health status than those who are food secure.

KEY WORDS: • food insecurity • elderly • consequence • humans

	INTRODUCTION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Food insecurity has been documented among U.S. elderly persons in several studies (Alaimo 1997 , Burt 1993 , Frongillo et al. 1992 , Parker 1992 , Quandt and Rao 1999 ). The first-ever national prevalence estimates of food insecurity confirmed that food insecurity exists among U.S. elderly persons and remains a persistent problem. Despite the great strength of the U.S. economy and the nation’s nutrition safety net, 5.5% of U.S. households with elderly persons struggle to meet their basic food needs (Bickel et al. 1998 , Hamilton et al. 1997 ).

Food insecurity can affect health and quality of life, either directly or indirectly through nutritional status (Anderson 1990 , Campbell 1991 ). For elderly persons, who already use substantially more health, medical and other services than the general population, food insecurity can bring further physical, emotional and economic burdens to the elderly persons themselves, their formal or informal caregivers, and the health care system. Thus, understanding the consequences of food insecurity is crucial to addressing the public health risks of hunger in elderly persons and providing complementary information to better tailor nutrition and health services for an ever-increasing and diverse older population in the United States.

The majority of studies examining the nutritional and health consequences of food insecurity have focused on younger adult women and children. The consequences include decreased dietary intake (Cristofar and Basiotis 1992 , Kendall et al. 1995 and 1996 , Rose and Oliveira 1997 , Tarasuk and Beaton 1999 ), decreased household food supply (Kendall et al. 1996 ), psychosocial dysfunction (Kleinman et al. 1998 , Murphy et al. 1998 ), increased body weight (Kendall et al. 1995 ), health problems (Nelson et al. 1998 , Roe 1990 , Wehler et al. 1992 ), decreased quality of life (Vailas et al. 1998 ) and sociofamiliar perturbations (Hamelin et al. 1999 ).

Separating out the consequences of food insecurity among elderly persons requires careful consideration of various determinants of nutritional and health status pertinent to that age group. In contrast to persons of younger age, a greater variety of factors are associated with nutritional and health status in elderly persons. Not only the aging process, but also health, psychological, social and economic factors, are closely related to nutritional and health status in elderly persons. Three studies have examined the consequences of food insecurity among elderly persons. One was a national study showing that food-insufficient elderly individuals had lower intakes of eight nutrients including energy and calcium, based on the 1989–1991 Continuing Survey of Food Intake by Individuals (Rose and Oliveira 1997 ). The other studies were local studies reporting that food-insecure elderly persons were more likely to have lower body weight and global quality of life (Roe 1990 , Vailas et al. 1998 ). These studies, however, have not fully accounted for various health problems and functional impairments affecting nutritional and health status among elderly persons in examining consequences of food insecurity.

The purpose of this study was to examine the nutritional and health consequences associated with food insecurity of the elderly, 60 y and older in the United States, using data from the Third Health and Nutrition Examination Survey (NHANES III,³ 1988–1994) and a state representative sample from the Nutrition Survey of the Elderly in New York State (NSENY, 1994 ). To separate out the consequences of food insecurity, we used a statistical approach, controlling for other significant confounders that affect nutritional and health status in elderly persons. Specifically, we assessed the extent to which food-insecure elderly persons are likely to have lower nutrient intakes, energy stores, self-reported health status and nutritional risk while considering a wide range of factors affecting nutritional and health status in elderly persons. The results will provide a better understanding of the consequences associated with food insecurity, and guidance for improving nutrition services for the elderly.

	SUBJECTS AND METHODS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Data and study sample

    NHANES III data and study sample. Elderly persons 60–90 y old (n = 6596) were sampled in the NHANES III (1988–1994). The survey was designed to obtain nationally representative information on health and nutritional status in the U.S. population through extensive interviews and an examination in the Mobile Examination Center (MEC). Specifically, the NHANES III included the aged and very old; home examination was used to monitor nonresponse at the time of data collection to provide reliable estimates in older persons for the first time (McDowell et al. 1991 ). More detailed information of the survey design and operation has been published elsewhere (U.S. Department of Health and Human Services National Center for Health Statistics 1996 ).

The final analytic sample included all individuals who had complete information on nutrient intakes, skinfold thickness and self-reported health status along with potential controlling variables. Different samples sizes were available for different nutrition and health outcomes, i.e., n = 5035 for nutrient intake analysis, n = 4386 for skinfold thickness and n = 6586 for self-reported health status. Preliminary analysis showed no significant differences in socioeconomic characteristics and prevalence of food insecurity across these samples.

    NSENY data and study sample. The data were taken from elderly persons 60–96 y old (n = 553) who were sampled in the supplemental survey to the NSENY (April 18–July 7, 1994). The NSENY was conducted by the New York State Department of Health in collaboration with the State Office for the Aging to obtain information to improve the effectiveness of services provided by the Elderly Nutrition Program (ENP) in New York State. This survey included a wide range of data related to eligibility for a home-delivered meals program, sociodemographic characteristics, nutritional risk, food insecurity and functional impairment variables. More detailed information of the survey design, operation and questionnaire has been published elsewhere (New York State Department of Health and Office for the Aging 1996 ). The analytic sample included all individuals who had complete information on food insecurity, nutritional risk, eligibility for a home-delivered meals program and potential controlling variables that are described in the following. Of the 484 elderly persons for whom food insecurity data were available, 477 had complete data sets and have been included in the final analysis.

Food insecurity

There have been significant efforts to understand and measure the nature and extent of food insecurity in the past decade, mainly among younger adults and children. By definition, food insecurity occurs whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain (Anderson 1990 ). Research to understand food insecurity specifically in elderly persons has recently begun. There has been no direct measurement of food insecurity in elderly persons who have different physical and socioeconomic conditions, perceptions, attitudes and experiences throughout their life concerning food problems. We used the best available food insecurity measures in both data sets, i.e., the food insufficiency question in the NHANES III and the three food insecurity items in the NSENY.

In NHANES III, food insufficiency was defined as "an inadequate amount of food intake due to lack of resources" (Briefel and Woteki 1992 ). The food-insufficiency question was a part of the family questionnaires in the NHANES III, and was designed to measure individual food insufficiency on basis of the reported adequacy of the family’s food resources. Several studies have confirmed the validity of the food-insufficiency question as a measure of food insecurity, mainly in younger adults and children (Alaimo 1997 , Alaimo et al. 1999 , Basiotis 1992 , Briefel and Woteki 1992 , Cristofar and Basiotis 1992 , Frongillo et al. 1997, Rose and Oliveira 1997 , Wolfe et al. 1998 ). An elderly person was classified as "food insufficient" if he/she reported that the family "sometimes or often did not get enough food to eat."

In the NSENY, the three-item food insecurity measure determined the presence of food insecurity status during the last 6 mo ("Do you have enough money to buy the food you need most of the time?"; "In the past 6 mo, have you skipped one or more meals because you had no food in the house or you thought that soon you might not have enough food?"; and "In the past 6 mo, have you had to choose between buying food or paying bills or buying something else you needed?"). Previous research established the content and construct validity of the items (Burt 1993 , Quandt and Rao 1999 ). An elderly person was classified as "food insecure" if he/she gave an affirmative response to at least one of the three items.

Nutrient intake

In NHANES III, detailed nutrient intake information was available based on a single 24-h dietary recall taken in the MEC. The NHANES III incorporated several strategies for improving dietary recall performance in both healthy and poor/frail older persons, such as memory enhancement techniques and proxy respondents. Also, intake of drinking water, vitamin/mineral supplements and medication usage data were included to estimate total nutrient intake (McDowell et al. 1991 , U.S. DHHS National Center for Health Statistics 1996 ). Energy and 19 nutrients were selected for the analysis on the basis of previous research reflecting concerns for excessive or deficient intake in the elderly (Barrocas et al. 1995 , Ponza et al. 1994 , Schlenker 1998 ).

Skinfold thickness

Anthropometric measurements provide information or estimation of the adequacy of an individual’s energy balance and body composition. Weight, arm circumference and skinfold thickness, including triceps, subscapular, suprailliac and thigh skinfold, were selected to assess energy stores in NHANES III.

Self-reported health status

Self-reported health status provides a simple, direct and global way of capturing perceptions of health criteria that are as broad and inclusive as the responding individuals choose to make them (Idler and Benyamini 1997 , Krause and Jay 1994 ). The validity of perceived health status has been shown by its strong predictive power for mortality, disability, survival and health care services use, especially in elderly persons (Idler and Benyamini 1997 , Kaplan 1988 , Mor et al. 1994 , Mossey and Shapiro 1982 ).

In the NHANES III, the following question was asked: "Would you say your health in general is excellent, very good, good, fair, or poor?" For analyses, the response was recoded into two categories, i.e., good, including excellent, very good and good, and poor, including fair and poor.

    Nutritional risk. The NSENY included a nutritional risk scale adopted from the ten-item Nutritional Screening Initiative checklist (NSIC). The NSIC was designed as a brief risk-appraisal questionnaire that could be self-administered and scored by older persons, family members or caregivers (Nutrition Screening Initiative 1991 ). Criticism on the validity of the NSIC has been reported (Rush, 1997 ). The construct and scoring system of NSIC, however, have been validated in the past (Joseph et al. 1997 , Posner et al. 1993 and 1994 ), and the NSIC has been used extensively for evaluating nutritional risk across various fields specializing in the care of elderly people.

In our study, a modified version of nutritional risk was used after excluding one item ("Do you have enough money to buy the food you need most of the time?") that was also included in the food-insecurity measure. The questions included in nutritional risk are 1 meal/d, consuming fruits/vegetable/milk every day, dietary change due to health problems, tooth and mouth problems, inability to shop/cook/feed self, weight loss/gain, using 3 drugs/d, 3 alcoholic drinks/d and eating alone. Each item had its own weight score, depending on attributable seriousness to nutritional and health risk in the elderly; total score was 17.

Controlling variables

To assess the relationship between food insecurity and nutritional and health consequences, it is crucial to control for potential confounding variables. Sociodemographic, economic, psychological, physical functioning, health and behavioral, and adverse health conditions have been known to influence nutrient intakes, anthropometry, self-reported health status and nutritional risk (Betts and Vivian 1985 , Bianchetti et al. 1990 , Garry et al. 1982 , Gilbride et al. 1998 , Gray-Donald et al. 1994 , Idler and Benyamini 1997 , Johnson and Wolinsky 1993 , Keller et al. 1997 , MacLellan 1997 , Marshall et al. 1999 , Murphy et al. 1990 , Neyman et al. 1996 , Payette et al. 1995 , Posner et al. 1987 , Ritchie et al. 1997 , Schlenker 1998 , Stevens et al. 1992 , Walker and Beauchene 1991 , Weimer 1998 ). After listing eligible confounding variables based on prior knowledge and research about the relationship of the dependent variable to each covariate under consideration, only variables known to be reasonably associated with the dependent variables and available in the data sets were considered as potential confounders.

    Physical functioning. The Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) have been the most frequently assessed indicators of disability (Hardley et al. 1993 , Kovar and Lawton 1994 ). The NHANES III included four items of ADL (dressing, eating, getting in or out of bed, and transferring) and two items of nutrition-related IADL (preparing own meals and managing money). The NSENY included five items of ADL (getting in/out of chair/bed, feeding self, getting dressed, taking bath/shower, toileting) and five items of IADL (getting around by car, using public transportation, doing light housework, managing money, taking medicine). A three-category indicator of physical function was constructed as follows: 1) no problem (having no difficulty in either ADL or IADL); 2) IADL problem (having at least one difficulty in IADL); and 3) ADL problem (having at least one difficulty in ADL).

    Chronic disease. A chronic disease variable reflected the presence (vs. absence) of serious health problems in NSENY or at least one of the self-reported clinically diagnosed diseases that are highly prevalent and affect nutritional and health status among elderly persons that were available in NHANES III, such as arthritis, hypertension, health failure, stroke, cataract, cancer, diabetes mellitus and emphysema.

    Sociodemographic and economic variables. Age was divided into the following three groups: 1) younger old (60–69 y); 2) older old (70–79 y); and 3) oldest old (80 y). Race-ethnicity was categorized into the following three groups: 1) non-Hispanic White; 2) non-Hispanic-Black; and 3) Hispanic. Although previous research reported different health appraisals due to different languages used in interviews (Idler and Benyamini 1997 ), we did not include language differences in race-ethnicity classification because we are interested in self-reported health status appraisal separated by race-ethnicity, not in comparing health status across race-ethnicity. Questions on marital status and household size were used to create a three-category living arrangement variable as follows: 1) living with spouse; 2) living with others; and 3) living alone. Educational status was broken down into two groups, i.e., high school graduate or less (12 y) and more than high school graduate (>12 y). A social support or social isolation variable was created with information about how often subjects got together with friends or relatives, such as going out together or visiting in each other’s homes. Location included two categories, metro or nonmetro in NHANES III, and New York City or non-New York City in NSENY. As an economic factor, the poverty index ratio (PIR), computed as the midpoint of the observed family income category in household interview divided by the poverty threshold, was divided into the following five groups in NHANES III: 1) <50%, 2) 50–100%, 3) 100–130%, 4) 130–200%, and 5) >200%; in NSENY, there were two categories (150% and >150%). For the purpose of aiding comparison of the economic factor across the two data sets, PIR for NHANES III was recoded into two categories (130% vs. > 130%). Food assistance program participation indicated whether respondents took part in such programs available in their community at that time. Programs for which information was available were the Food Stamp Program and ENP in NHANES III and ENP in NSENY. In addition, dichotomous variables were constructed to indicate gender, dietary change due to health problems and use of vitamin/mineral supplementation.

Statistical analysis

The General Linear Models procedure of SAS (SAS Institute, Cary, NC) for linear regression was used to assess the extent to which food-insecure elderly were likely to have lower nutrient intake and skinfold thickness and be at nutritional risk. Nutrient intake data were transformed by using the natural logarithm to approximate the normal distribution. This analysis compared relative means of nutrient intake and skinfold thickness between food insecure and secure groups while controlling for other confounding variables. The estimates for these variables were transformed back to the original units for presentation. To assess the association of food insecurity with self-reported health status, logistic regression was used with SAS PROC LOGISTIC.

Descriptive statistics were analyzed using sample weights and complex survey effects that take into account oversampling, noncoverage and nonresponse (Table 1 ). The complex sample design was taken into account when calculating variance estimates using SVY commands in STATA (Statacorp 1997 ).

	RESULTS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Sociodemographic, economic and health characteristics of food-insecure and food-secure elderly persons from the two data sets are presented in Table 1 . In the study population in NHANES III, the mean age was 70.8 y (range 60–90 y). More than 15% of elderly persons were in their 80s, 57% were female and 11% were minority. Of the 6558 elderly persons who answered the food-insufficiency question, 1.7% were food insufficient. Compared with food-sufficient elderly persons, food-insufficient elderly were more likely to be poor, minority, participants in food assistance programs, only a high school graduate and living alone. About 60% of food-insufficient elderly persons were functionally impaired, 48% for ADL (basic self-care activities) and 11% for IADL (activities for independent living). The study population from the NSENY had characteristics similar to those from the NHANES III. Mean age of the study sample was 67.7 y (SEM = 0.73), 19.9% were oldest old, 61.6% were female and 20.9% were minority. Almost half of them were widowed (42.5%), living alone (47.0%) and functionally impaired (21.9% for ADL and 30.37% for IADL). One third of them had low income (below 150% of the poverty line). In the NSENY, 22.7% participated in senior meals program, 4.4% received special transportation to go for shopping, 5.9% received homemaker services and 11.3% had tried to obtain long-term care services (nursing home care, home care services, home-delivered meals). Food-insecure elderly persons were more likely to be poor (53.0%), a minority (37.4%), living alone (53.7%), living in New York City, a senior meals program participant (34.0%) and socially isolated (23.1%). Two thirds of them were functionally impaired for both ADL and IADL, and 34.3% were homebound.

Nutrient intakes in food insufficient vs. food-sufficient elderly are displayed as means adjusted for confounding factors, i.e., age, gender, race-ethnicity, PIR, education, living arrangement, food program participation, disease, physical functioning, dietary change due to health problems, use of vitamin/mineral supplementation and medication use (Table 2 ). Food insufficient elderly had consistently lower mean intakes of 19 nutrients, significantly so for 12 nutrients, including energy, protein, iron, zinc, vitamins B-6, and B-12, riboflavin and niacin. We also estimated the adjusted nutrient intake as a percentage of recommended dietary allowances (RDA) to compare relative adequacy of nutrient intake in relation to current safe and adequate nutrition allowances for the maintenance of good health among relatively healthy elderly, despite its limitation (Fig. 1 ). Regardless of food insufficiency status, older people consumed less than the RDA for 8 nutrients including energy and calcium. Food-insufficient elderly persons had even lower intakes for those nutrients than did food-sufficient elderly persons. For example, energy and calcium intakes in food-insufficient elderly persons were about two thirds of RDA, 68.5 and 66.9%, respectively.

View larger version (45K): [in this window] [in a new window]   Figure 1. Nutrient intakes as a percentage of the recommended dietary allowances (RDA) of food-insufficient and food-sufficient elderly: NHANES III, 1988–1994. Nutrient intake as a percentage of RDA was calculated from unweighted linear regression analysis controlling for age, gender, race, Poverty Index Ratio, education, living arrangement, food program participation, disease, functional impairments, dietary change due to health problems, vitamin/mineral supplement and medication use. *Means significantly different at P < 0.05.

Food-insecure elderly persons had on average a 1.59 point higher nutritional risk score than did food-secure elderly persons (P < 0.001), even after controlling for confounding factors affecting nutritional and health status in the elderly.

	DISCUSSION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
The elderly population will grow dramatically during the 21st century. Although overall economic and educational attainments of the elderly have improved with time, there have always been subgroups with multiple risks for poorer nutritional and health status. This study reveals that food insecurity is another risk factor associated with poorer nutritional and health status among older persons.

Food-insufficient or food-insecure elderly persons had lower nutrient intakes than those that were food secure. This result is consistent with previous research (Cristofar and Basiotis 1992 , Kendall et al. 1995 and 1996 , Rose and Oliveira 1997 , Tarasuk and Beaton 1999 ) and further confirms the negative association of food insecurity with nutrient intakes in elderly persons independent of poverty, disease, functional impairments, age, gender, race-ethnicity and education. A single 24-h dietary recall from a cross-sectional survey cannot provide detailed information on the extent and duration of inadequate nutrient intake among food-insecure elderly persons. However, significantly lower skinfold thickness measures and inadequate eating habits as indicated by nutritional risk in food-insecure elderly persons suggests that they had had lower and poorer nutrient intake for an extended time than did those who were food secure, which led to the existence of cumulative effects on their energy stores and nutritional risk status. In other words, persistent (or intermittent) food insecurity that existed in the past among elderly persons may have led them to consume lower nutrient intakes, and even change their body composition and eating habits.

Moreover, food insecurity has a negative association with self-reported health status in elderly persons. It is not possible to determine whether this relationship found between food insecurity and self-reported health status is causal because the data sets used in this study do not provide information on the severity and duration of food insecurity, or the coping mechanisms of the food-insecure elderly. In addition, there is a potential for reverse causality between food insecurity and self-reported health among elderly persons because poorer health status may contribute to food insecurity through high medical bills and higher costs for medications. Demonstration of an association between food insecurity and poor self-reported health status, however, irrespective of the causal direction, indicates that the food-insecure elderly are at the risk of poorer nutritional and health status.

The two data sets for this study used different operational definitions and measurements to determine food insecurity in elderly persons; consequently, they may reflect different aspects of food insecurity. Food-insufficient elderly persons in the NHANES III were determined mainly by the availability of family food resources, whereas in the NSENY, food-insecure elderly persons were determined by both economic resources and the health problems that elderly persons might have. Indeed, several studies estimating food insecurity in elderly persons using different operational definitions and measurements in the past yielded varying prevalence rates from 1.7 to 22% (Wolfe et al. 1996 ), which was due mainly to limited understanding of the nature and extent of food insecurity, specifically in elderly persons. Until now, no direct measurement of food insecurity in the elderly has been developed; such a measurement should be based on a conceptual framework pertinent to elderly persons because of their different physical and socioeconomic conditions, perceptions, attitudes, and experiences throughout their life toward food problems. Also, there has been concern with the potential underestimation of the prevalence of food insecurity among elderly persons, particularly in the national surveys. Only 1.7% of elderly persons from NHANES III, and 5.5% from the Current Population Survey were food insecure, which was lower than the figure for younger adults (Alaimo et al. 1998, Hamilton et al. 1997 , Rose and Oliveira 1997 ). A likely explanation for these findings is the limited concepts and measures that do not reflect the special characteristics of food insecurity in elderly persons. Irrespective of limitations in using potentially different aspects of food-insecure elderly samples from the two data sets, however, our results showed a negative association between food insecurity and nutritional and health status that was consistent in both data sets. These results documented adverse effects on nutritional and health status associated with food insecurity, whether it is determined by food insufficiency or the three-item food-insecure measure. These results suggest the need for more research to understand fully the nature, extent and prevention of food insecurity in elderly persons.

Optimal nutritional status is an important component of good health and requires particular attention in elderly persons (Reuben et al. 1995 ). Malnutrition exacerbates diseases, increases disability, decreases resistance to infection and extends hospital stays among elderly persons. Malnutrition results in increased costs to care-givers by increasing care-giving demands, and inflates national health care costs due to increased complication rates. Given the unprecedented increase in the aging population, demand for health care and social services by elderly persons will increase national health care costs (Schneider and Guralnik 1990 ). Health care costs may be greatly reduced by improving the nutritional well-being of elderly persons, especially those who are at the risk of poorer health status (Rowe and Kahn 1998 ). A decline in nutritional status is not an inevitable part of the aging process or of disease; rather, it is environmentally determined and frequently results from inattention to risk factors that can be improved by appropriate nutrition intervention (American Dietetic Association 1993 ). Prevention of poor nutritional status among elderly people makes an important contribution to their overall well-being.

Given that the average nutrient consumption was below the RDA, more attention is required to ensure that elderly persons have adequate nutrient intake. Food assistance programs as a food safety net to reduce malnutrition in the elderly should be provided to elderly persons to prevent adverse nutritional and health status, and to provide health care cost saving for the nation. Careful attention should be given in particular to food-insecure elderly persons because their nutritional and health status was poorer than that of the average elderly.

With an increasing aging population, ensuring that every elderly person has enough food to eat to meet his or her nutritional needs may be one important way to help our elderly enjoy healthy, active and successful aging. Food-insecure elderly persons need more attention because food insecurity is an undesirable phenomenon, not only because of its relationship to poorer nutritional and health status, but also its ethical unacceptability.

	ACKNOWLEDGMENTS

 
Christine M. Olson provided valuable comments on a previous draft of the manuscript.

	FOOTNOTES

 
¹ Funded in part by the 1999 Small Grants Program sponsored by the Food and Nutrition Research Program at the Economic Research Service, U.S. Department of Agriculture and administered by the University of California at Davis (Research Agreement Number K-981834–01).

³ Abbreviations used: ADL, Activities of Daily Living; ENP, Elderly Nutrition Program or participant of Elderly Nutrition Program; IADL, Instrumental Activities of Daily Living; MEC, mobile examination center; NHANES III, Third National Health and Nutrition Examination Survey; NSENY, Nutrition Survey of the Elderly in New York State; NSIC, Nutritional Screening Initiative checklist; PIR, Poverty Index Ratio; RDA, recommended dietary allowances.

Manuscript received June 13, 2000. Initial review completed August 24, 2000. Revision accepted February 15, 2001.

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