To our knowledge, this is the first study focused on nutrition-related terms described in state/territorial units on aging plans. Nutrition was mentioned frequently in the overall plans, but unexpectedly it was mentioned only infrequently in plans’ goals/objectives and strategies/actions. Moreover, nutrition was rarely defined operationally, making it difficult to know whether the term referred to a program description, the type/amount of food provided by OAA programs, or to participants’ nutrition status.
There were few mentions of the other nutrition terms searched for, whether they referred specifically to nutrition-related conditions or to possible nutrition interventions. The limited mentions and rare inclusions in goals/objectives or strategies/actions are disappointing but not surprising, because the terms were not explicitly included in ACL’s guidance at the time. No statistically significant associations were found between number of term mentions, percent of state populations who were 65+, percent of state populations who were obese, or state’s region of the country. This finding suggests the need to more closely link these conditions or interventions to preventive health needs and public health goals.
The results reveal several additional opportunities for both federal and state/territorial agencies to enhance impact of OAA programs on healthy aging. First, provision of operational definitions in future federal guidance for all nutrition-related terms along with strategies and actions associated with them would be helpful. Lack of a clear operational definition for nutrition in ACL guidance may have led to confusion at the state/territorial level and a failure to more frequently include nutrition in state/territorial plan goals/objectives and strategies/actions. Operational definitions are needed for both the goal of maintaining/improving nutrition status of OAA program participants as well as for meeting participants’ nutrition needs by serving high quality, healthy food. ACL guidance could assist in providing uniform definitions for various ways nutrition contributes to OAA programs and outcomes. More direct federal guidance on how OAA programs potentially have an impact on nutrition-related conditions is another opportunity for further development. At the time, ACL guidance available on state/territorial aging plans did not explicitly address malnutrition, sarcopenia, frailty, or obesity; all common conditions among older adults . ACL has since moved to include malnutrition in its guidance for state/territorial 2022 plans . This is a positive step, but other nutrition-related conditions/interventions are not addressed. It is still too early to know how ACL’s new guidance may influence state/territorial plans. Further, it does not appear ACL has issued any new guidance on Title VI grants.
Second, better prevalence estimates of nutrition-related conditions are necessary. The paucity of information on prevalence of malnutrition, sarcopenia, and frailty among OAA program participants may have partly accounted for their low number of mentions in state/territorial aging plans. The national prevalence of malnutrition among community-living older Americans is unknown, although it may be substantial. A systematic review, meta-analysis and meta-regression of protein-energy malnutrition by region estimated a North American prevalence of 6.1% among community living older adults . Rates of sarcopenia are also not clearly defined in the US; internationally sarcopenia estimates for community-dwelling older adults are 1-29% or greater, depending on definitions used . Similarly, US frailty rates are not tracked; globally frailty community prevalence in older adults can vary significantly from 4-59% .
OAA agencies may have assumed all participants were at risk and there was no need for further focus since many older adults exhibit at least one nutrition-related condition. However, better data on prevalence and overlap of malnutrition, sarcopenia, and frailty, as well as obesity among OAA participants are essential because interventions to prevent/treat these conditions vary greatly depending on underlying causes . Failure to screen/direct appropriate interventions to those OAA participants most likely to respond may dilute program effectiveness.
State/territorial units on aging could consider greater integration of screening, assessment, and intervention for these conditions within OAA’s network of disease prevention/health promotion services. Both malnutrition and obesity were among the chronic conditions identified in a report on OAA participation’s effect on health care utilization, but there was no analysis specific to OAA programs and malnutrition and obesity outcomes; sarcopenia and frailty were not even identified . Technical assistance and additional resource allocation could make this more likely as the aging services network is already stretched thin  and even the recent further funding allocated to OAA programs through COVID-19 relief legislation had no additional funding for malnutrition. There is also an important role for ACL’s National Resource Center on Nutrition and Aging, including in surveys and in prevalence/outcomes research for nutrition-related conditions.
Third, it may be that the limited mentions of nutrition-related conditions and interventions in plans reflected lack of input by registered dietitian nutritionists (RDNs) at state/territorial-levels. The 2020 OAA reauthorization specified an RDN must federally administer OAA nutrition programs and in the future nutrition’s impact on healthy aging will likely be given more attention at the federal level. States/territories could adopt a similar approach by requiring an RDN administer state/territorial OAA nutrition programs.
Fourth, there are opportunities to enhance community awareness and attention to nutrition-related problems among community dwelling older adults, potentially including working closer with state public health and social service agencies. More guidance on/attention to malnutrition, sarcopenia, frailty, and obesity screening, assessment, and interventions in state/territorial aging plans could influence state master plans on aging and cascade down to local agencies’ plans. This is of particular concern for 3 states (California, Florida, Texas) where 25% of all older Americans will reside by decade’s end, and 7 additional states (Georgia, Illinois, Michigan, New York, North Carolina, Ohio, Pennsylvania) which will account for another 25% of the older adult population . The potential community-level public health need is underscored by a recent county-specific study of malnutrition among older Texans (65+); household poverty status, low food access, low educational level, and rurality were all significantly associated with crude death rates from malnutrition .
Fifth, our findings suggest there may be opportunities to help improve nutrition and health equity. Native Americans represent less than 2% of the US population, but nationally have some of the highest rates of food insecurity, poverty, diet-related diseases, and other socioeconomic challenges [28, 29]. Malnutrition, frailty, and the social determinants of nutritional health are areas of particular concern among Native Americans [30, 31]. This provides an area for future development and collaboration at the federal level between ACL and other agencies engaged in nutrition and health services for this population.
Finally, our experience suggests scrutiny of state/territorial units on aging plans may provide opportunities for future public health and prevention research, particularly as OAA programs have been identified as helping community-dwelling older adults age in place . This research could focus on the intersection of nutrition and other areas related to healthy aging and federally funded community programs and services.
Strengths and Limitations
One strength of our study is that, to our knowledge, it is the first to review state/territorial aging plans to identify mentions of specific nutrition terms, including conditions with potential impact on healthy aging. It also provides a benchmark for evaluating state/territorial aging plans and ACL guidance going forward, as 2019 GAO report recommendations, 2020-2025 DGAs, and 2020 OAA Reauthorization provisions become fully implemented.
Our study had several limitations. The method for identifying defined nutrition terms in aging plans was a simple count and may have been subject to error. Yet when investigators initially independently reviewed a small sample of the same aging plans, differences in counts were limited. The use of the ADvancing States website was a logical, publicly available resource. More current aging plans may have been available on state/territorial websites, but a search of these 50+ individual websites was beyond the investigation’s scope.