The National Evaluation of the Older Americans Nutrition Program 1993-95 (8) found that the average OANP meal provided more than 50% of the 1989 Recommended Dietary Allowances (RDAs) for many nutrients based on adult male values. The National Evaluation concluded that both congregate and home-delivered meals contributed significantly to participants' daily nutrient intake, and therefore, their nutritional status. When comparing the nutrient content of OANP meals at the time of the National Evaluation to newer Dietary Reference Intakes (DRIs) (including RDA and other values described below), the meals would have been deficient in vitamins D, E, folate, and magnesium. Other nutrients met or exceeded the newer DRI/RDA values. See Table 2 Nutrient Availability of an Older Americans Nutrition Program Meal Relative to the Dietary Reference Intakes and Recommended Dietary Allowances compiled by the National Policy and Resource Center on Nutrition and Aging (Center).

The use of the newer DRI/RDA values to plan and evaluate OANP meals was addressed by an Issue Panel convened by the Center in February 2002 (reviewed later in this chapter). Recommendations from this and future Issue Panels will continue to shape OANP practice and guidelines.

B. NUTRITION RECOMMENDATIONS

Congress reauthorized the Older Americans Act (OAA) in 2000 for 5 years. OAA Section 339 requires that nutrition projects meet the Dietary Guidelines for Americans (9), published by the Secretaries of Health and Human Services and Agriculture and the RDAs (which are now included in the DRIs) established by the Food and Nutrition Board, Institute of Medicine of the National Academy of Sciences. The National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445) requires that the Secretaries of Health and Human Services and Agriculture contract with a scientific body, such as the National Academy of Sciences, to publish reports on nutrient requirements and status of the United States on a 2 to 5 year basis and to develop Dietary Guidelines every 5 years. The Act requires that all federal food, nutrition, and health programs promote the Dietary Guidelines. Thus, the most recent versions of the DRIs and Dietary Guidelines serve as the cornerstone for federal nutrition policy.

The new DRIs (10-15) provide values for men and women aged 51-70 and over 70 years. The DRI values include an RDA or an Adequate Intake for nutrients with no established RDA, and a Tolerable Upper Intake Level. Refer to Table 1 Dietary Reference Intakes for Older Adults compiled by the Center for current nutrient values established by the Food and Nutrition Board.

• The RDA is the average daily dietary intake level that is sufficient to meet the nutrient requirement for nearly all (97-98%) healthy individuals of a specified age range and gender.
• The Adequate Intake (AI) is the daily dietary intake level of healthy people assumed to be adequate when there is insufficient evidence to set an RDA. It is based on observed mean nutrient intakes and experimental data. The National Academy of Sciences recommends that the Adequate Intake be used if an RDA is not available.
• The Tolerable Upper Intake Level (UL) is the highest daily dietary intake that is likely to pose no risk of adverse health effects to almost all individuals of a specific age range.
• The Estimated Energy Requirement (EER) is defined as the dietary energy intake that is predicted (with variance) to maintain energy balance in a healthy adult of defined age, gender, weight, height and level of activity, consistent with good health.
• An Acceptable Macronutrient Distribution Range (AMDR) is defined as a range of intakes for a particular energy source (ie, carbohydrates, proteins, fats) that is associated with reduced risk of chronic disease while providing adequate intakes of essential nutrients. The AMDR is expressed as a percentage of total energy intake because its requirement is not independent of other energy fuel sources or of the total energy requirement of the individual.

The newer DRIs include RDAs for older adults that are higher than the 1989 RDAs for vitamins B-12, C, D, E, K, folate, calcium, and magnesium. The DRIs provide equations to calculate an individual's energy requirements based on activity level (the EER). To meet the body's daily nutritional needs while minimizing risk for chronic disease, an AMDR was established for carbohydrate to be 45-65% of total calories, for fat, 20-35% of total calories, and for protein, 10-35% of total calories. The DRIs also suggests that no more than 25% of total calories come from added sugars (those incorporated into foods and beverages during production and processing). The DRIs now emphasize the importance of physical activity and recommends that adults strive for an "active" lifestyle that is equivalent to 60 minutes of moderately intense physical activity throughout each day (15).

The 2000 Dietary Guidelines for Americans (5th ed.) are the most current guidelines to be followed when planning and serving OANP meals. These guidelines are incorporated in the selection of foods and serving sizes for meals as well as the basis for nutrition guidance for individuals and groups. The 3 main themes are:

1. Aim for Fitness

• Aim for a healthy weight. Choose a lifestyle that combines sensible eating with regular physical activity. To be at their best, adults need to avoid gaining weight, and many need to lose weight. Being overweight or obese increases your risk for high blood pressure, high blood cholesterol, heart disease, stroke, diabetes, certain types of cancer, arthritis, and breathing problems. A healthy weight is key to a long, healthy life.

Be physically active each day (a new recommendation). Being physically active and maintaining a healthy weight are both needed for good health, but they benefit health in different ways. Children, teens, adults, and the elderly—all can improve their health and well-being and have fun by including moderate amounts of physical activity in their daily lives.

2. Build a Healthy Base

• Let the pyramid guide your choices. Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need. For example, oranges provide vitamin C and folate but no vitamin B12; cheese provides calcium and vitamin B12; but no vitamin C. Choose the recommended number of daily servings from each of the five major food groups. If you avoid all foods from any of the five food groups, seek guidance to help ensure that you get all the nutrients you need.
• Choose a variety of grains, especially whole grains. They provide vitamins, minerals, carbohydrates (starch and dietary fiber), and other substances that are important for good health. Whole grains differ from refined grains in the amount of fiber and nutrients they provide, and different whole grain foods differ in nutrient content, so choose a variety of whole and enriched grains. Eating plenty of whole grains may help protect you against many chronic diseases.
• Choose a variety of fruits and vegetables daily. Eating plenty of fruits and vegetables of different kinds may help protect you against many chronic diseases. It also promotes healthy bowel function. Fruits and vegetables provide essential vitamins and minerals, fiber, and other substances that are important for good health. To promote your health, eat a variety of fruits and vegetables—at least 2 servings of fruits and 3 servings of vegetables—each day.
• Keep food safe to eat (a new recommendation). Foods that are safe from harmful bacteria, viruses, parasites, and chemical contaminants are vital for healthful eating. Safe means that the food poses little risk of foodborne illness. Farmers, food producers, markets, food service establishments, and other food preparers have a role to keep food as safe as possible. However, we also need to keep and prepare foods safely in the home, and be alert when eating out.
  
  

  3. Choose Sensibly
  
  

• Choose a diet that is low in saturated fat and cholesterol and moderate in total fat. Fats supply energy and essential fatty acids, and they help absorb the fat-soluble vitamins A, D, E, and K, and carotenoids. Some kinds of fat, especially saturated fats, increase the risk for coronary heart disease by raising the blood cholesterol. In contrast, unsaturated fats (found mainly in vegetable oils) do not increase blood cholesterol. Eating lots of fat of any type can provide excess calories.
• Choose beverages and foods to moderate your intake of sugars. Sugars are carbohydrates and a source of energy (calories). Dietary carbohydrates also include the complex carbohydrates starch and dietary fiber. Sugars and starches occur naturally in many foods that also supply other nutrients.
• Choose and prepare foods with less salt. Many people can reduce their chances of developing high blood pressure by consuming less salt. Many studies in diverse populations have shown that a high sodium intake is associated with higher blood pressure. At present, the firmest link between salt intake and health relates to blood pressure. High salt intake also increases the amount of calcium excreted in the urine. Eating less salt may decrease the loss of calcium from bone. Loss of too much calcium from bone increases the risk of osteoporosis and bone fractures.
• If you drink alcoholic beverages, do so in moderation. Alcoholic beverages supply calories but few nutrients. Current evidence suggests that moderate drinking is associated with a lower risk for coronary heart disease in some individuals. However, higher levels of alcohol intake raise the risk for high blood pressure, stroke, heart disease, certain cancers, accidents, violence, suicides, birth defects, and overall mortality (deaths). Older adults have a decreased ability to metabolize alcohol due to physiological changes and as a result may be at greater risk of adverse consequences.
  

SECTION 339 Nutrition
A State that establishes and operates a nutrition project under this chapter shall
(1) solicit the advise of a dietitian or individual with comparable expertise in the planning of nutritional services, and
(2) ensure that the project --
(A) provides meals that --
(i) comply with the Dietary Guidelines for Americans, published by the Secretary and the Secretary of Agriculture,
(ii) provide to each participating older individual
(I) a minimum of 33 1/3 percent of the daily recommended dietary allowances as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences, if the project provides one (1) meal per day,
(ll) a minimum of 66 2/3 percent of the allowances if the project provides two (2) meals per day, and
(III) 100 percent of the allowances if the project provides three (3) meals per day, and
(iii) to the maximum extent practicable, are adjusted to meet any special dietary needs of program participants.
(B) provides flexibility to local nutrition projects in designing meals that are appealing to program participants, …

The Center convened an Issue Panel: Dietary Reference Intakes and Dietary Guidelines in OANPs in February 2002. Panelists included nutrition and aging-related researchers, individuals involved in policy development, persons working at the federal, state, and local program level, and representatives from food industries. The Issue Panel Report includes a summary, backgrounder and working documents, and a directory of Issue Panelists (16).

The Issue Panel focused on the rationale for and the use of the most recent DRIs and Dietary Guidelines in the provision of OAA nutrition services, including nutrition education, nutrition counseling, and congregate and home-delivered meals. The Issue Panel Report was provided to the US Administration on Aging for consideration. These recommendations will assist in the development of guidance and technical assistance related to implementation of the DRIs and Dietary Guidelines in the OANP. State Units on Aging (SUAs), Area Agencies on Aging (AAAs), local service providers, and Title VI grantees can use these recommendations in the development of guidance and assistance for implementation. Recommendations from the report are included in applicable sections of the Older Americans Nutrition Program Toolkit.

The OAA states that a project shall provide a meal that complies with the Dietary Guidelines and a stated percentage of the RDAs which varies with the number of meals served to a participant. Because it is the responsibility of the SUA to implement the OAA, SUAs have incorporated these standards into their policies and procedures.

1. OANP meals should meet the current RDAs and AIs, and the 2000 Dietary Guidelines for Americans, as these reflect the most recent scientific evidence and provide the best-known guidance for meeting the nutrition needs of older adults in America.
2. OANPs should strive to ensure that each meal is reasonably well-balanced nutritionally and reflects the 2000 Dietary Guidelines since the meals provide a positive nutrition education model for participants. To best serve the nutrition and educational needs of participants, OANPs that serve 1 meal per day should ensure that each meal offers at least 33 1/3% of the RDAs/Adequate Intakes. OANPs that serve two meals per day should ensure that the sum of the two meals offers at least 66 2/3% of the RDAs/Adequate Intakes (but each meal itself does not have to be 33 1/3%) and those serving three meals per day should ensure that the sum of these three meals offers 100% of the RDAs/Adequate Intakes.
3. In addition to providing meals that meet the 2000 Dietary Guidelines and 1/3 of the RDAs/Adequate Intakes, OANPs should emphasize foods high in fiber, calcium, and protein. To the extent possible, programs should continue to target vitamins A and C, with vitamin A provided from vegetable-derived (carotenoid) sources. However, targeting specific nutrients such as those mentioned in this recommendation should not be misinterpreted as permission to ignore other nutrients. More specific recommendations regarding targeting nutrients should be addressed at a future Issue Panel.
4. OANPs should plan and evaluate meals for meeting the 2000 Dietary Guidelines and 1/3 RDA/Adequate Intake standards by computer-assisted analysis. Furthermore, Registered Dietitians (or individuals with comparable expertise) should be available at the SUA, AAA, and local provider level to assure nutrient adequacy of meals. If a meal pattern is used, it should be based on the food servings delineated in the Food Guide Pyramid that combined would meet 1/3 the RDAs/Adequate Intakes and the 2000 Dietary Guidelines, be tested for meeting standards, and include increased servings of fruits, vegetables, and whole grains.
5. Assuming culturally appropriate meals, OANPs should accommodate specific dietary needs to the extent possible. To better serve defined groups and individuals who require customization or therapeutic diets, OANPs would benefit from the availability of Registered Dietitians (or individuals with comparable expertise) -- who could also conduct needs assessments of the populations their programs serve.

The table below presents the most current DRIs and other nutrient values to use when planning and evaluating meals. Values are provided for serving 1, or a combination of 2 or 3 meals for 1 day's consumption for the average older adult population served by the OANP. The nutrients selected include those recommended for emphasis by the Issue Panel and those found in a number of studies to be deficient or of concern in the diets of older adults. (See "Enhancing the Nutritional Quality of the Meal" section of this chapter). Refer to Table 1 Dietary Reference Intakes for Older Adults compiled by the Center for all DRI values and footnotes.

* RDAs are in bold type and Adequate Intakes (AIs) are in ordinary type followed by an asterisk (*).
**Vitamin A should be provided from vegetable-derived (carotenoid) sources. See Issue Panel Report on Dietary Reference Intakes and Dietary Guidelines in Older Americans Act Nutrition Programs.
(1) Value for 75 year old male, height of 5'7", " low active" physical activity level (PAL). Using Table 5-22 Estimated Energy Requirements (EER) for Men and Women 30 Years of Age, calculated the median BMI and calorie level for men and subtracted 10 kcal/day (from 2504 kcal) for each year of age above 30.
(2) The RDA for protein equilibrium in adults is a minimum of 0.8g protein/kg body weight for reference body weight.
(3) Used highest DRI value for ages 51+ and male and female.
(4) Acceptable Macronutrient Distribution Ranges (AMDRs) for intakes of carbohydrates, proteins, and fats are expressed as percent of total calories. The AMDR for protein is 10-35%, carbohydrate is 45-65%, total fat is 20-35%.
(5) The RDA for carbohydrate is the minimum adequate to maintain brain function in adults.
(6) Because the percent of energy that is consumed as fat can vary greatly while still meeting daily energy needs, an AMDR is provided in the absence of an AI, EAR, or RDA for adults.
(7) Recommendations from the Dietary Guidelines for Americans 2000.
(8) Saturated fats, trans fatty acids, and dietary cholesterol have no known beneficial role in preventing chronic disease and are not required at any level in the diet. The recommendation is to keep intake as low as possible while consuming a nutritionally adequate diet, as many of the foods containing these fats also provide valuable nutrients. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academy Press; 2002.
(9) National Research Council, Food and Nutrition Board. Recommended Dietary Allowances. 10th ed. Washington, DC: National Academy Press; 1989.

Issue Panelists generally agreed that there might be circumstances when it is not always necessary for a single meal to meet the 1/3 requirement for every nutrient for which an RDA or Adequate Intake has been established. The idea of averaging nutrients over a longer period of time, such as a few days, or week was discussed. However, averaging was rejected overall by Panelists for periods longer than 1 day for the following reasons:

• The OANP meal can provide a good example of healthy food choices and balanced eating for participants, as well as demonstrate to federal policy makers the best that the OANPs offer;
• The availability of water-soluble nutrients, such as vitamin C, in foods may be reduced over long cooking or transporting times. Thus, participants may not be consuming the level of these nutrients that is planned; and
• The needs of congregate and home-delivered meal participants may not be equally met. Individuals who receive home-delivered meals five days per week may have better nutrient intakes over time than congregate participants that do not receive meals daily. Data indicate that only 60% of congregate participants attend a dining center 5 days a week. It is possible that participants might come on days when the meal contains less than requirements (16).

The Center plans to hold another Issue Panel (2003) regarding implementation of the DRIs. It is expected that the Panel will develop more specificity for energy (calories), the percentage of carbohydrate, protein, and fat to total calories, and key nutrients that should be included in computer-assisted menu analyses. The Issue Panel recommendations will be included in future modifications of the above table and other sections of this chapter.

C. MENU PLANNING

In order to ensure nutrient quality for the health of older Americans and to comply with the requirements of the OAA, SUAs establish written standards and guidelines detailing the specific requirements for menu planning and approval. Planning menus that includes input from participants is a best practice. Information may be obtained through focus groups, advisory councils, suggestion boxes, or surveys. Suggestions may also come from food production staff, site managers, home-delivered meal drivers, and food purveyors. SUAs, AAAs, and local providers should rely on professionals, preferably registered dietitians or nutritionists, to assist in the development, implementation, and approval of menus for OANPs. (Chapter 2 provides a description of a registered dietitian). Ideally, the menu will reflect local food preferences, provide variety in shape, color, temperature, texture, and flavor, consider food availability (foods in season), and costs. Well planned menus improve meal quality and increase client satisfaction (17).

The Issue Panel recommended that OANPs plan and evaluate meals for meeting nutritional requirements using computer-assisted nutrient analysis and that Registered Dietitians (or individuals with comparable expertise) be available at the state, area, and local provider levels to assure nutrient adequacy of meals (16).

A variety of nutrient analysis and meal production software products are available and used by SUAs, AAAs, and providers. Some simply provide analysis of foods, recipes, and menus. Others offer food production, inventory, and costing capabilities. The National Policy and Resource Center on Nutrition and Aging surveyed SUAs (12/02) concerning their use and requirements to use nutrient analysis software. (Click here for complete survey). Below is a summary of some of the responses. Additional responses are included in the "Menu Review and Approval" section of this chapter.

State Unit on Aging Respondents (N = 33)

• 10 SUAs use computer software to analyze the nutrient content of meals. These include Food Processor (6 SUAs), Nutritionist Pro (2 SUAs), FoodWorks (1), Computrition (1), and Nutritionist V (1).
• Factors influencing the selection of Food Processor software were cost, ease of use, ability to add to the data base, completeness of the database, and technical support. Nutritionist Pro and Foodworks were selected for similar reasons. Nutritionist V was selected because it provided quantity recipes. Computrition was used by a large vendor to do forecasting, inventory control, etc.
• 6 SUAs recommended a particular brand of nutrient analysis software for AAA and provider use: Food Processor (4 SUAs), NutritionistPro (1), and Nutritionist IV or more (1). Several SUAs indicated they provide no specific recommendations.
• SUAs identified nutrient analysis software commonly used by AAAs and providers: Food Processor (9 SUAs ), Nutritionist IV or V (5), Nutritionist Pro (4), Computrition (4), and Master cook (2).
  

The following list of nutrition software products was compiled by the Center:

• CALCMENU www.calcmenu.com/
• Computrition www.computrition.com/
• Dave Johnson Nutrition www.djsoft.com/
• DietAid www.shannonsoft.com/
• DietMaster www.lifestylestech.com/
• Dine Healthy www.dinesystems.com/
• Food Processor, Esha Research www.esha.com
• Food Smart www.food-smart.com/
• FoodWorks, Nutrition Company www.nutritionco.com
• Fuel Nutrition Software www.logiform.ca/fuel/pro_an.htm
• Mealformation Software www.mealformation.com/
• Nutribase 2001 Clinical, CyberSoft, Inc. www.nutribase.com
• Nutritionist Pro, First Databank www.firstdatabank.com
• SureQuest Software www.surequest.com/products.htm

A meal pattern is best used as a menu-planning tool (ensuring food plate coverage, and as a component of a catering contract) rather than as a standard for nutritional adequacy or as a compliance tool. Use of computerized nutrient analysis rather than a meal pattern helps ensure nutritional adequacy of meals and increases menu planning flexibility. Many SUAs require documentation that menus meet nutrient requirements using computer-assisted nutrient analysis. Some SUAs specify that meals must follow a meal pattern with no deviation.

Additional guidance is often provided for accompaniments such as desserts, condiments including margarine, salad dressings, and relishes, and beverages other than milk. Specific guidance is frequently included to ensure that foods high in key nutrients are provided. Recommendations for inclusion of foods high in vitamins A and C and fiber are common. In addition, information is typically provided in SUA guidelines to ensure that menus incorporate foods that are lower in sodium, fat, saturated fat, and cholesterol.

The 1972 meal pattern (still used by many OANPs today) first appeared in the Guide to Effective Project Operations, The Nutrition Program for the Elderly (the Oregon Guide, 1973). It was assumed that if a variety of foods were provided daily in the amounts indicated and proper food preparation and handling was practiced, the meal would provide at least 1/3 of the 1968 RDAs. The pattern became the quick checklist for determining the nutritional adequacy of a meal. Some SUAs added requirements that meals provide foods high in specific nutrients, such as vitamins A and C, as well as some others. This pattern does not ensure that the new DRI requirements are met for calories, carbohydrates, magnesium, folate, vitamin E, and fiber as noted in the Issue Panel Report: Table 4.1 Nutrient Composition of the 1972 Meal Pattern [page 53 of 62] (16). These variations in menu planning may be addressed in state guidelines.

The updated sample meal pattern below is based on the newer DRIs for energy as calculated for the table above, "Dietary Reference Intakes for Meal Planning and Evaluation." It provides approximately 685 calories per meal. The number of servings for each food group are based on USDA's Food Guide: Background and Development, Table 5 Nutrient profiles for food groups and subgroup composites. These profiles represent the quantities of nutrients and other components that one would expect to obtain on average from a serving of food in each group (18). Information from Table 5 Nutrient profiles... and from USDA's Agricultural Research Service, Home and Garden Bulletin No.72 (Revised October 2002) was used to determine the appropriate number of food group servings to best meet the new DRIs. See table, "Nutrient Composition of a Sample Meal Pattern."

The updated sample meal pattern includes 1 additional serving of bread or bread alternate and another serving of vegetable or fruit compared to the 1972 meal pattern. Serving sizes are based on the Food Guide Pyramid. The number of servings reflects an appropriate distribution of foods for the day, particularly for lunch or supper. Servings from a food group may be combined as one larger serving. For example, 2 servings from the bread or bread alternate food group may include 2 slices of bread for a sandwich or 1 cup of pasta or rice or it may include 1/2 cup pasta and 1 slice of bread. Likewise, 2 servings of vegetable may be 1/2 cup mashed potato and 1/2 cup green beans or 1 cup of either vegetable. The pattern provides the option for substituting 1 fruit serving for a vegetable serving and vice versa.

This updated sample meal pattern, although based on the food servings recommended in the Food Guide Pyramid, does not assure that meals meet 1/3 the DRIs and the 2000 Dietary Guidelines. Meals are likely to require specific types of fruits and vegetables, whole grains, and high fiber foods. Based on the information used from USDA's Food Guide: Background and Development, Table 5 Nutrient profiles for food groups and subgroup composites, the updated meal pattern may be deficient in vitamin E, requiring extra care in the selection of foods that are good sources of this nutrient (see "Sources of Key Nutrients" section of this chapter). Because of the increased nutrient requirements, it may be difficult for some participants to eat the amount of food for 1 meal at 1 sitting. The use of nutrient dense foods as well as fortified and enriched products should be a priority. In addition, calories from carbohydrates, fats, and/or proteins will require adjustment for underweight or overweight individuals. As appropriate for the weight status of participants, the provision of food supplements and modifications in serving sizes of particular food groups may be needed.

(1) The number of servings per meal provides for 1/3 of the DRIs as calculated in Table "Nutrient Composition of a Suggested Meal Pattern for Older Americans Nutrition Program Meals. This table is based on USDA's Food Guide Background and Development, Table 5, Nutrient Profiles for Food Group and Subgroup Composites. This meal pattern also relates to Table "Dietary Reference Intakes for Meal Planning and Evaluation" in this chapter.
(2) Caloric value (685 Kcal) based on a 75 year old male, height of 5'7", " low active" physical activity level (PAL). Using Table 5-22 Estimated Energy Requirements (EER) for Men and Women 30 Years of Age, calculated the median BMI and calorie level for men and substracted 10 kcal/day (from 2504 kcal) for each year of age above 30.
(3) The caloric requirement in the 2000 Dietary Guidelines is 1600-2200 calories.

The food group information below generally follows the 2000 Dietary Guidelines and Food Guide Pyramid. Although some foods are classified in more than 1 food group, a serving of a food can only be counted in 1 food group within the same meal. For example, dried beans may be counted as either a meat alternate serving or as a vegetable serving but not both in the same meal. Likewise, cottage cheese may be counted as either meat alternate serving or milk alternate serving but not both.

The Issue Panel recommended that OANPs emphasize foods that are high in fiber, calcium, and protein, and continue to target vitamins A and C, with vitamin A provided from vegetable-derived (carotenoid) sources. Targeting specific nutrients mentioned in this recommendation should not be misinterpreted as permission to ignore other nutrients (16). A number of studies found specific nutrients to be deficient in diets of older adults (8,19,20). While the National Evaluation revealed that OANP meals supplied over 33% of the 1989 RDAs for key nutrients. When compared to the newer DRIs, meals were inadequate in vitamins D and E, folate, calcium, and magnesium (8). The Continuing Survey of Food Intakes by Individuals 1994-1996 found older adults' dietary intake to be low in calories, total fat, fiber, carbohydrate, vitamin E, folate, calcium, and magnesium (19). The Third National Health and Nutrition Examination Survey (NHANES III) found older adults' dietary intake to be low in calories, total fat, fiber, calcium, magnesium, zinc, copper, folate, and vitamins B6, C and E (20). Therefore, the following require special attention: vitamins A, B-6, C, D, E, and folate; calcium, copper, magnesium, zinc; and calories, carbohydrates, total fat, protein, and fiber. More definitive guidance concerning targeting key nutrients will be developed as part of the next Issue Panel on the implementation of the DRIs.

Foods considered good sources of specific nutrients are shown in the following table prepared by the Center. Information provides "good" and "high" food sources of specific nutrients. A "high source" is defined as providing 20% or more of the Daily Value for a given nutrient per serving. A "good source" is federally defined as providing 10-19% of the Daily Value for a given nutrient per serving. See summary of the use and meaning of Daily Values that follows the table. Foods selected for the table meet the above parameters using typical serving sizes.

The USDA's National Nutrient Database for Standard Reference, Release 15 Nutrient List was used to develop the table (21). The database contains reports of selected food items and nutrients sorted by food description or in descending order by nutrient content in terms of common household measures. The food items and weights are adapted from Home and Garden Bulletin No. 72, Nutritive Value of Foods.

a High Source: 20% or more of Daily Value (DV) for given nutrient per serving.
b Good Source: 10-19% of Daily Value (DV) for given nutrient per serving.
c Daily Values (DV) for each nutrient based on RDA/AI.
d Based on DV for fiber of 35gm.

A number of SUAs and service providers have developed lists of foods considered good sources of specific nutrients but do not necessarily follow the federal food labeling definitions of good and high sources above. Such lists are commonly available for food sources of calcium, vitamins A and C, and fiber. An example from Colorado SUA is available. A number of websites provide lists of foods that are good sources of selected nutrients. Resources include Room 42 Health Tools, Nutrition Tools, Fitness Tools Resource Center and Healthcheck Systems.

Federal law requires that nutrition label information enable the public to readily comprehend the information and to understand its relative significance in the context of a total daily diet. Daily Values is the dietary reference labeling standard developed by the Food and Drug Administration (FDA) to help consumers plan a healthy overall diet. For various nutrients, it allows consumers to determine the percentage of the Daily Value provided by a serving of a food. It also provides a basis for defining descriptor terms, such as "high fiber" and "low fat" (22).

Daily Values include 2 sets of reference values for nutrients: Daily Reference Values (DRVs) and Reference Daily Intakes (RDIs). DRVs are for nutrients for which no set of standards previously existed, such as fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium. DRVs for the energy-producing nutrients (fat, carbohydrate, protein, and fiber) are based on the number of calories consumed per day. For labeling purposes, 2,000 calories was established as the reference for calculating percent Daily Values in 1990.

Because of the links between certain nutrients and certain diseases, DRVs for some nutrients represent the uppermost limit that is considered desirable. Eating too much fat or cholesterol, for example, has been linked to an increased risk of heart disease. Too much sodium can heighten the risk of high blood pressure in some people.

DRV Label Values for Fats and Sodium

RDIs replaced the term "US RDAs" (Recommended Daily Allowances). The US RDAs are a set of values, based on the 1968 RDAs, that are used as the food labeling standard by the FDA. These nutrient values are approximately equivalent to the highest number recommended in the 1968 RDAs for each of the included nutrients. US RDAs should not be confused with RDAs. The latter are short for Recommended Dietary Allowances, which are set by the National Academy of Sciences, and revised periodically. Food label definitions and nutrient values used generally lag behind the latest scientific knowledge. Plans are underway to revise the Nutrition Facts portion of the food label to comply with the newer DRI values.

D. SPECIAL DIETARY NEEDS

Today, menu planning is more challenging due to changes in the nutrient requirements as well as the need to accommodate the growing diversity of older adults. Increasing the number and variety of meal choices can help meet both the personal preferences of program participants and nutritional or special health needs. Meals should be adjusted to meet special dietary needs of program participants to the maximum extent possible (OAA, Section 339). The definition of "maximum extent practical" takes into consideration factors such as characteristics of the older adults served in the community, number of people with a specific need, capacity and capability of the provider, availability of different caterers/vendors, requirements of different funding sources, provider expertise, etc.

The term "special dietary needs" has been variously interpreted to mean: providing meals to meet cultural or ethnic preferences, ie, culturally appropriate; tailoring menus to conform to religious requirements (eg, Kosher, Hallal); and the provision of therapeutic or meals that are modified for health conditions (eg, 2 gm sodium, diabetic, renal, texture-modified). Other interpretations include meals that provide client "choice" or selection of different meal components (eg, 2 different entrees or 3 different vegetables, choice of milk).

To better serve defined populations and individuals who require menu customization or therapeutic diets, the Issue Panel recommended that OANPs utilize Registered Dietitians in conducting needs assessments of the program population and in developing appropriate interventions (16). The American Dietetic Association addressed the use of dietetics professionals in the assessment, planning and provision of liberalized diets for older individuals. When appropriate, such diets can enhance both quality of life and nutritional status, thus increasing the participants satisfaction with the meals provided and reducing noncompliance to their special dietary needs as well as any risks of malnutrition and weight loss (23).

Wisconsin
Using the knowledge and expertise of a consultant dietitian or qualified nutritionist, programs should determine the need, feasibility, and cost effectiveness in establishing a service for special menus using the following criteria:

• there are sufficient number of persons who need the special menus to make this service a practical and cost effective use of funds;
• the food and skills necessary to prepare the special menus are available in the planning and service area; and
• the type of special diet considered for service can be produced and delivered safely and cost effectively.

Modified meals meet the regular menu pattern, but contain modifications to one or more menu items. The types and amounts of all items must conform to the regular menu pattern. A health professional's authorization is not needed for a participant to receive a modified meal. However, a nutrition program may wish to prioritize the requests for modified meals. The following are examples of modified meals that a nutrition program may provide:

• meal with a lower sodium entrée if the regular entrée is of significantly higher sodium content than usually served;
• meal with fresh fruit, or juice-packed canned fruit in place of a concentrated sweet dessert;
• a modified meal may have an altered texture to accommodate the needs of an individual with problems chewing or swallowing. Examples of such meals include ground meat, thickened liquids or all pureed foods. "Clear liquid" meals are not allowed.

A therapeutic meal changes the meal pattern significantly by either limiting or eliminating one or more menu items, or by limiting the types of foods allowed and resulting in a meal that does not meet the nutrition guidelines of the Program.

Nutrition programs may obtain complex therapeutic meals from a local hospital or other facility under the supervision of a registered dietitian.

New York
General modifications to the regular menu should be provided (eg, substitutions for high sodium foods, substitutions for high concentrated carbohydrates, and texture modifications) for those individuals who do not require a more defined therapeutic diet.

Therapeutic diets, such as two grams sodium, 40 grams protein, 1200 Calories, and/or 40 grams fat, may be provided, if feasible, under the supervision of a registered dietitian. A written physician's order may be required to provide such diets. Overly restrictive diet prescriptions with less than these amounts or with multiple restrictions should be discouraged.

The use of medical foods, foods for special dietary uses, dietary supplements and functional foods is increasing. See definitions of "Supplements" at the end of this chapter. These products can play a positive role in people's health and may help improve the poor nutritional status of needy older adults. Many older adults are at nutrition risk because of low calorie intakes, poor food choices, economic reasons, chronic diseases (eg, osteoporosis), and/or special needs (eg, dysphasia). Also, many congregate and home delivered meal participants are unable to consume a complete meal when served or delivered. Therefore, greater flexibility in what constitutes a meal and other ways to provide meals that, to the maximum extent practical, are adjusted to meet special dietary needs of program participants may be allowed when prescribed by a registered dietitian (RD) or physician in conjunction with an individualized nutrition care plan.

Dietary supplements encompass a wide range of products, including vitamins, minerals, amino acids, herbs, and other botanicals. Although some older adults may need dietary supplements for health enhancement and/or to assist in meeting daily nutrient needs, the OAA cannot be used to pay for them. Funds from the OAA can be used for food as a part of a conventional meal.

The use of medical foods, foods for special dietary uses, and/or functional foods may allow OANPs to appropriately address individual nutrition needs in a comprehensive individualized nutrition care plan under the direction of an RD or MD. By using functional foods, the OANP may be able to more directly address public nutrition issues commonly seen in later years, such as osteoporosis. Functional foods should not be used as a replacement for important conventional foods, for example, replacing dairy products with calcium-fortified orange juice. Because of interrelationships among DRIs, Dietary Guidelines for Americans, and the Food Guide Pyramid, meals should include appropriate numbers of servings from each food group. To appropriately address the use of medical foods, foods for special dietary uses, and/or functional foods, SUAs and/or AAAs need to establish policies and procedures for their use. Such policies may reflect different program and funding requirements such as the Medicaid Waiver program.

New York
Nutrition supplements (eg, canned formulas, powdered mixes, food bars) may be made available to participants based on documented, assessed need as determined by a registered dietitian. Such products cannot replace conventional meals unless a physical disability warrants their sole use.

Wisconsin
Follow-up by health professionals is essential to follow progress, monitor nutrient intake, and to measure the success of the therapy. Health professionals who may make a written referral to the nutrition program for supplement meals include physicians, registered or certified dietitians, nurses, and public health nurses. A nutrition program participant's diet order may require a nutrition supplement to:

• replace a meal for an individual with profound dietary needs. The professional making the referral, or program dietitian must determine how much supplement would constitute 1 meal;
• in addition to a complete meal, or to replace 1 item in the meal pattern. (This is counted as 1 meal.); and
• provide a supplement-only meal in addition to a regular meal (To be counted as 2 meals, together they must provide 66% of the RDA).

Products not to be funded under the OAA include those used for weight loss and have reduced calories and/or fat; single or multiple vitamin or mineral supplements in tablets, capsules, liquids or any form, whether prescribed or over-the-counter; herbal remedies, teas, medicinal oils, laxatives, fiber supplement, etc; and products that require preparation such as powdered mixes or concentrated liquids.

The following products are not allowed for use in the OANP:

• Liquid supplement products which are used for weght lossk, have reduced calories and/or fat. Examples include "SlimFast", "Ensure light", "Boost", and "Carnation Instant Breakfast".
• Single or multiple vitamin or mineral supplements in tablets, capsules, liquids or any form, whether prescription or over-the-counter. Examples include "One-A-Day", "Geritol", vitamin B-6 and iron supplement.
• Herbal remedies, teas medicinal oils, laxatives, fiber supplements, etc...
• Supplemental nutrition products that require preparation such as powdered mixes or concentrated liquids.

Modifying food texture and consistency may help older adults with chewing and swallowing problems. Chopping, grinding, pureeing or blending foods are common ways to modify food textures. Texture modified food has the same nutritive value of solid foods and it can be just as tasty and appealing. Serving sizes should account for any dilution to the food item during the preparation process. Texture modified foods can be purchased in a variety of forms, may be prepared by the production kitchen, or may possibly be modified in an older adult's home. Thickened liquids are often required for individuals with dysphasia. The provision of such foods should be planned and prepared under the advice of a Registered Dietitian or other appropriate professional, such as an Occupational Therapist or Speech Pathologist.

Meeting the food preferences of program participants can be challenging. Nonetheless, making adaptations to menus is essential. Today's menus often contains common ethnic foods like spaghetti and lasagna, chow mein and stir-fry beef and broccoli, corned beef and cabbage, and fried chicken and sweet potatoes. However, there may be many entrees and side dishes representative of other cultures that are often overlooked. The good feeling that participants have when served favorite ethnic foods partly comes from the recognition that their cultural preferences are important and respected. Providing culturally appropriate, nutritious, high quality, and tasty meals can be effective as outreach to bring in the target population, improve customer satisfaction, promote health and reduce health disparities.

An Ask the Experts: Providing Food Services to Meet the Needs of Your Culturally Diverse Participants offers guidance and suggestions such as:

• Include community input when developing programs and planning menus.
• Target outreach to specific ethnic, cultural, or religious communities. Many programs have an advisory or community council with participants of various ethnicities to assist with menu planning.
• Employ staff and volunteers who reflect the diversity of the community served. Use bilingual staff, volunteers and/or interpreters to solicit menu and program ideas.
• Provide authentic ethnic cuisine. Although programs may do their best to provide ethnic meals, providing authentic ethnic cuisine may be difficult for cooks without such native experience. Having a cook "experienced" with traditional ethnic cooking be a "guest" cook or use an ethnic restaurant in the community as a caterer. This is particularly important during special occasions and holidays to carry on cultural traditions.
• Use an ethnic caterer or restaurant to serve specific ethnic and/or religious communities. The restaurants follow a meal pattern provided by the nutrition provider and the caterer develops the actual menu based on the known preferences of the group.
• Offer a variety of meals and/or foods from different ethnic groups. Introduce new foods to coincide with ethnic and religious holidays and nutrition education activities. Offer cultural food items as side dishes, desserts, or snacks, if not the entrée on a regular basis.

E. MENU REVIEW AND APPROVAL

Reviewing menus at State, AAA, or local levels involves verifying that they conform to nutrition standards and menu policies. Computer analysis ensures that menus conform to the Dietary Guidelines and provide at least minimal levels of RDAs for older adults. Reviews may also include recommending changes when menus contain errors, discouraging the use of extra items to avoid added food costs, and commenting on the variety of foods, color appeal, texture, consistency, and use of seasonal foods. States may or may not require submission of menus for review at that level, but no matter what level, a registered and/or licensed dietitian (or individual of comparable expertise) is usually required to complete the review and approval of menus - or certify the menus (17).

New York
The AAA shall ensure that menus are certified by a Registered Dietitian that each meal offers at least 33 1/3% of the RDAs, for two meals per day, the sum of the two meals is at least 66 2/3% of the RDAs (but each meal itself does not have to be 33 1/3%) and for three meals per day the sum of these three meals is 100% of the RDA; a nutrient analysis is available for all meals provided to participants; any deviation from the planned menu is noted and approved by a Registered Dietitian, project director or other designated person(s).

Massachusetts
Programs that prepare their own meals (and not using a set of rotating menus) must submit the nutrition analysis for three days meals once per fiscal year quarter to the SUA. Programs that use a set of rotating menus (such as frozen meals under state contract, catered Kosher or ethnic meals), must submit the nutrition analysis for all menus once per year to the SUA. (edited)

A complete nutritional analysis of the menu shall contain a minimum of: macronutrients:

• macronutrients: calories, protein, fat (including the % of total calories from fat).
• vitamins: A, B-6, B-12, C, and D, thiamin, riboflavin, niacin, and folate.
• minerals: calcium, iron, zinc, and magnesium.

The nutritional analysis form or equivalent computer analysis sheet should be used for the submission of the nutritional analysis. Nutrition projects are encouraged to utilize the nutritional information of the actual food products. However, if sources of food products vary, an average nutritional analysis may be used (ie, USDA Handbook No. 8).

If a 2nd (and 3rd) meal is provided to any clients for consumption on the same day as the meals mentions above, nutrient analysis shall be performed on the same Nutritional Analysis Form. For example, if an evening, multiple meal or breakfast menu is provided to clients in addition to a noon, regular meal, the 2nd (and 3rd) meal(s) should be submitted along with the "main" meals even if these meals are considered limited selection.

The specific meals that are analyzed may be chosen by the Nutrition Project. Different meals should be selected each quarter (ie, analyzed meals may not be identical to those chosen previously). The SUA may request that a nutritional analysis be performed on any meal which appears not to meet State requirements or for "spot-checking" purposes.

Nutritional analysis and/or full product descriptions for individual items used within Title III meals must be provided or made available by caterers. For consortium or joint menus, only one menu/nutritional analysis is required per menu cycle. It is the decision of the Nutrition Projects which agency(s) shall submit this information to Elder Affairs. If more than one Nutrition Project provides the same frozen/limited selection meal, only one nutritional analysis needs to be submitted. It is the decision of the Nutrition Projects which agency(s) shall submit this information to the SUA.

Menu substitutions should be comparable in nutrient content to the original menu item. SUAs often provide guidance as to the type of substitutions allowed, number of substitutions allowed during a given period of time, and the process to approve such menu changes by nutrition projects and caterers. Some states require that the nutrition program and/or a dietitian approve substitutions before they are served. Other states may also require that menu changes not only be documented and on file with the program but be submitted to the SUA within a certain time after the meal was served. Alabama requires that all menu deliveries to a dining center include an official notice of a menu change. Otherwise, the item must not be served for food safety reasons.

Some States or AAAs have written lists of acceptable food substitutions for each food group on a meal pattern. These list are similar to those in this Chapter: "Suggested Food Group Components and Serving Size," "Some High and Good Sources of Selected Nutrients," and those developed by SUAs and service providers. For example, substitute a high vitamin C source for a fruit; use a high vitamin A source for a vegetable substitute; and replace a meat with cottage cheese or peanut butter. Using a substitution list limits the need for staff to contact the dietitian each and every time there is a need to make a menu change.

F. MEAL SERVICE OPTIONS

It is common to provide a combination of 2 or 3 meals including breakfast, lunch and/or dinner, to participants receiving home-delivered meals. Multiple meal packages are typically delivered with the noon meal. Breakfast, a popular meal with older adults, contributes to their health and well being by increasing intakes of critical nutrient-dense foods associated with positive health outcomes: cereals and grains, complex carbohydrates, fruits, fiber, milk, and dairy products (24). Congregate nutrition programs may also serve breakfast and/or dinner in addition to or instead of lunch.

A number of nutrition programs offer weekend meals to higher risk congregate participants or to frail, homebound participants receiving meals on weekdays. Table IV.9 of the Mathematica Report indicates that 11% of congregate nutrition programs offer weekend meals and 35% of home-delivered nutrition programs offer weekend meals.

Frozen meals are often provided in areas where daily delivery is limited, for weekend meal services, or to enable home delivered meal programs to offer more menu choices. Frozen meals may also be used at congregate sites in rural areas where participation is low and other food service options are not feasible. Such meals are heated and served at the site.

Menu choice using a selective menu can increase participant satisfaction by offering choices for 1 or more food items. For example, nutrition programs may offer 1 entrée but several vegetable or dessert choices. There may be ethnic and religious-based alternatives to choose from or a choice of hot, cold, or ready-to-heat entrees. Home-delivered meal participants may be offered choices of hot meals or frozen meals delivered in advance. Menu choices may also be provided by offering participants a choice of 2 distinct and complete menus. The menus may vary in their ethnic offering (ie, choice of an American or Asian menu), be based on religious custom (eg, Kosher or Hallal), or vegetarian observance.

Emergency meals generally consist of shelf-stable items. Meal packages are provided to participants determined to need at times when the program is unable to deliver meals due to weather or other problems.

Medical food, as defined in Public Law 100-290, The Orphan Drug Amendment of 1988, is food which is formulated to be consumed or administered enterally under supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.

Medical foods are known by a variety of names, such as nutrition supplements, "liquid meals," and oral supplements. However, the most appropriate statutory term is medical food. It is interesting to note that the very same product, depending on where it is used (and how it is labeled), may at times qualify as a medical food (eg, in an institutional setting) and at other times, if purchased at retail, does not qualify as a medical food. "Non-medical" foods sold at retail always have the mandatory "Nutrition Facts" label.

Food for special dietary uses, according to Section 201 of the Federal Food, Drug, and Cosmetic Act, as the term is applied to food for humans, means particular (as distinguished from general) uses of food, as follows: (i) uses for supplying particular dietary needs which exist by reason of a physical, physiological, pathological or other condition, including but not limited to the conditions of diseases, convalescence, … underweight and overweight; (ii) uses for supplying particular dietary needs which exist by reason of age, …; (iii) uses for supplementing or fortifying the ordinary or usual diet with any vitamin, mineral or other dietary property.

Food for special dietary uses are often useful when there are chewing and swallowing problems and to speed recovery when there is illness-related cachexia and/or to halt unintended weight loss.

A dietary supplement is defined in Section 201 of the Federal Food, Drug, and Cosmetic Act as a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following ingredients: (A) a vitamin; (B) a mineral; (C) an herb or other botanical; (D) an amino acid; (E) a dietary substance for use by man to supplement the diet by increasing the total dietary intake; or (F) a concentrate, metabolic, constituent, extract, or combination of any ingredient described in clause (A), (B), (C), (D), or (E).

In the 2000 Dietary Guidelines for Americans, older adults are mentioned specifically as a group who may benefit from dietary supplements to meet specific nutrient needs. Older adults and people with little exposure to sunlight may need a vitamin D supplement. People who seldom eat dairy products or other rich sources of calcium need a calcium supplement, and people who eat no animal foods need to take a vitamin B12 supplement. The Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences recommends that adults over age 50 get their vitamin B12 from a supplement or from fortified foods.

Functional foods have no universally accepted definition. However, 2 definitions provide insight into this category. The American Dietetic Association broadly defines functional foods to include whole foods and fortified, enriched, or enhanced foods that have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis (25). The Institute of Medicine defines functional foods as those foods in which the concentrations of one or more ingredients have been manipulated or modified to enhance their contribution to a healthful diet (26).

Menu Planning Resources listed by the Center

Use of Medical Food and Food for Special Dietary Uses In Elderly Nutrition Programs: Backgrounder. Prepared for the AoA by the Center, May 1996.

PowerPoint Presentations from the AoA Nutritionists / Administrators Conference (June 2002):

• Dietary Reference Intakes & Dietary Guidelines in Older Americans Act Nutrition Programs (Nancy Wellman and Jean Lloyd)
• Dietary Reference Intakes and Dietary Guidelines: Nutrition Standards for Today’s Older Americans (Nancy Wellman and Jean Lloyd)
• Computer-assisted Menu Analysis for the Elderly Nutrition Program (Kathy Stroh)
  
  

American Dietetic Association: Related Position Statements

Brewer MS, Kendall P. Biotechnology and the future of food -- Position of ADA. J Am Diet Assoc. 1995;95:1429-1432. (reaffirmed and update to be published, 2000).

Dorner B, Niedert KC, Welch PK. Liberalized diets for older adults in long-term care -- Position of ADA. J Am Diet Assoc. 2002;102:1316-1323.

Duffy VB, Anderson GH. Use of nutritive and nonnutritive sweeteners -- Position of ADA. J Am Diet Assoc. 1998;98:580-587.

Hunt J, Dwyer J. Food fortification and dietary supplements. J Am Diet Assoc. 2001;101:115.

Marlett JA, McBurney MI, Slavin JL. Health implications of dietary fiber -- Position of ADA. J Am Diet Assoc. 2002;102:993-1000.

Mattes RD. Fat replacers -- ADA position. J Am Diet Assoc. 1998;98:463-468.

Messina VK, Kenneth I. Burke KI. Vegetarian Diets -- Position of ADA. J Am Diet Assoc. 1997;97:1317-1321.

Thomson C, Bloch AS, Hasler CN. American Dietetic Association Position Paper: Functional foods. J Am Diet Assoc. 1999;99:1278-1285.

Weddle DO, Fanelli-Kuczmarski M. Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. J Am Diet Assoc. 2000:100;580-595

1. National Academy of Sciences, Institute of Medicine (1999). The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Executive Summary, Washington, DC.

2. Weddle DO, Fanelli-Kuczmarski M. Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. J Am Diet Assoc. 2000:100;580-595.

3. Webber CB, Splett PL. Nutrition risk factors in a home health population. Home Health Care Services Quarterly. 1995:15;97-110.

4. Ryan C. Role of the dietitian in home care of the elderly. Home Healthcare Consultant. 1998:5;8-15.

5. Rowe JW, Kahn RL. Successful Aging. New York, NY: Pantheon; 1998.

6. Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998 May;98(5):548-53.

7. Smith R, Mullins L, Mushel M, Roorda J, Colquitt R. An examination of demographic, socio-cultural, and health differences between congregate and home diners in a senior nutrition program. J Nutr Elder. 1994;14(1):1-21

8. Mathematica Policy Research, Inc. Serving Elders at Risk, the Older Americans Act Nutrition Programs: National Evaluation of the Elderly Nutrition Program 1993-1995, Volume I: Title III Evaluation Findings. Washington, DC: US Department of Health and Human Services; 1996.

9. Dietary Guidelines for Americans, 2000. USDA. USDHHS. 5 Ed, 2000. Home and Garden Bulletin No. 232.

10. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997.

11. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998.

12. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press; 2000.

13. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academy Press; 2000.

14. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press; 2001.

15. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein and Amino Acids (Macronutrients). Washington, DC: National Academy Press; 2002.

16.Dietary Reference Intakes and Dietary Guidelines in Older Americans Act Nutrition Programs: An Issue Panel Report. (2002) Florida International University, Miami, FL.

17. Rhodes SS, ed. Effective Menu Planning for the Elderly Nutrition Program. Chicago, IL: American Dietetic Assoc.; 1991.

18. US Department of Agriculture, Human Nutrition Information Services. USDA Food Guide: Background and Development. Table 5. Nutrient profiles for food groups and subgroup composites. Misc. Pub. No. 1514; Hyattsville, MD: US Government Printing Office; 1993.

19. US Department of Agriculture, Food Survey Research Group. (1998) Continuing Survey of Food Intakes by Individuals 1994-1996.

20. National Center for Health Statistics. (Series 11, #1, SETS Version 1.22a) [CD-ROM]. Washington, DC: US Government Printing Office; 1997.

21. US Department of Agriculture National Nutrient Database for Standard Reference, Release 15 Nutrient List.

22. US Food and Drug Administration. Kurtzweil P. Daily Values' Encourage Healthy Diet.

23. Dorner B, Niedert KC, Welch PK. Liberalized diets for older adults in long-term care -- Position of ADA. J Am Diet Assoc. 2002;102:1316-1323.

24. Weddle DO, Gollub E, Stacey SS, Wellman NS. Final Report: The Morning Meals on Wheels Program Pilot Program: The Benefits to Elderly Nutrition Program Participants and Nutrition Projects. Florida International University, Miami, FL. 1998.

25. Thomson C, Bloch AS, Hasler CN. American Dietetic Association Position Paper: Functional foods. J Am Diet Assoc. 1999;99:1278-1285.

26. Committee on Opportunities in the Nutrition and Food Sciences, Food and Nutrition Board, Institute of Medicine. Thomas PR, Earl R, eds. Opportunities in the Nutrition and Food Sciences: Research Challenges for the Next Generation of Investigators. Washington, DC: National Academy Press; 1994.

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