This article was downloaded by: [University of North Texas]On: 21 November 2014, At: 06:41Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Journal of Nutrition For theElderlyPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wjne20

Food Practices, Service Use,and Dietary Quality in ElderlyBlacksNancy L. Cohen PhD, RD a , Penny A. Ralston PhD b ,Mary Jane Laus MS a , Odilia Bermudez PhD c & RitaBrennan Olson MS aa Department of Nutrition , University ofMassachusetts , Amherst, MA, 01003-1420, USAb College of Human Sciences, and ResearchAffiliate , Pepper Institute on Aging, Florida StateUniversity , Tallahassee, FL, 32306-2033, USAc USDA , Tufts , Boston, MA, 02111, USAPublished online: 12 Oct 2008.

To cite this article: Nancy L. Cohen PhD, RD , Penny A. Ralston PhD , Mary Jane LausMS , Odilia Bermudez PhD & Rita Brennan Olson MS (1998) Food Practices, ServiceUse, and Dietary Quality in Elderly Blacks, Journal of Nutrition For the Elderly, 17:4,17-34, DOI: 10.1300/J052v17n04_02

To link to this article: http://dx.doi.org/10.1300/J052v17n04_02

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Food Practices, Service Use, and Dietary Quality in Elderly Blacks

Nancy L. Cohen, PhD, RD Penny A. Ralston, PhD Mary Jane Laus, MS

Odilia Berrnudez, PhD Rita Brennan Olson, MS

ABSTRACT. Nutr ient intake, food practices, service use, and their relationship to dietary qual i ty in b lack elder ly is described. A health and food questionnaire and three 24-hour food recalls were administered. D ie ts were very low in energy, ca lc ium and v i tamin B-6, sl ight ly low in protein, thiamin, r ibof lav in and iron, and adequate in v i tamins A, C and niacin. Men consumed more energy, fat, and cholesterol than women, and less v i tamins C , B-6 and thiamin. Food stamps and home health aides (HHAs) were used more than other services. Dietary qual i ty was

Nancy L. Cohen is Associate Professor, and Mary Jane Laus and Rita Brennan Olson are Project Managers, Department o f Nutrition, University o f Massachusetts, Amherst, MA 01003-1420. Penny A. Ralston is Professor and Dean, College of Human Sciences, and Research Affiliate, Pepper Institute on Aging, Florida State University, Tallahassee, FL 32306-2033. Odil ia Bermudez i s Scientist, USDA, Tufts, Boston, MA 02111.

Address correspondence to Nancy L. Cohen, Associate Professor, Department of Nutrition, University of Massachusetts, Amherst, MA 01003-1420.

This research was supported i n part by the AARP Andrus Foundation and Massa- chusetts Agriculture Experiment Station project #666.

of American Societies for Experimental Biology, New Orleans, LA (Cohen, N. L., Ralston, P. A,, Laus, M. J., Bermudez, O., Olson, R. B. and Robinson, F. (1993) Factors related to dietary quality i n elderly blacks. FASEB J . 7:A204) and the 1993 Annual Meet ing or the Gerontological Society of America, N e w Orleans, LA (Cohen, N. L., Ralston, P. A,, Laus, M. J . , Bermudez, O., Olson, R. B. and Robinson, F. (1993) Food practices, service use and dietary qual i ly i n elderly blacks).

Journal o f Nutrit ion for the Elderly, Vol. 17(4) 1998 0 1998 by The Haworth Press, Inc. All rights reserved.

This paper was presented in part a t the 1993 Annual Meet ing o f the Federation

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18 JOURNAL OF NUTRITION FOR THE ELDERLY

related to gcndcr, number of meals, and HHA use. [Arlicle copies avail- able fur a fee from The Haworth Ducrriiieiit Delivery Service: 1-800-342-9678. E-muil uddress: ge(iiifo@ha worthpressiiic. coin]

INTRODUCTION

The population of older minorities is rising in the U.S. (Weddle et al., 1996). Concurrent with this population growth is the concern regarding nutrition and health status of older blacks. Diet-related dis- eases such as diabetes, hypertension, certain cancers, and heart disease are more prevalent among older blacks than whites (Edmonds, 1993; Rubenstein and Kramer, 1994). Elderly blacks also score higher than whites in the Nutrition Screening Initiative ratings of risk (Miller et al., 1996).

Despite the documented health problems, little is known about the nutritional intake of elderly blacks. Data from the National Health and Nutrition Examination Survey (NHANES) I11 from 1988-91 indicate that older blacks consume less energy and fewer nutrients than older whites (Federation of American Societies for Experimental Biology, 1995). Information from the earlier NHANES I and I1 surveys showed that, in general, nutritional inadequacies were more often present in diets of black females, followed by black males, than in diets of whites (Jerome, 1988). Older black women were found to consume less pro- tein, calcium, iron, thiamin, and riboflavin than older white women, and older black men consumed less iron, thiamin and vitamin C than white men (Todhunter, 1976). Among congregate mealsite partici- pants, blacks consumed less calcium, thiamin, iron, fat, carbohydrates, fiber, niacin, and vitamin C than whites, but most nutrients were close to the Recommended Dietary Allowance (RDA) (Holahan and Kun- kel, 1987). Similarly, a study of the elderly in their 60s, 80s and 100s found that blacks consumed high-fiber foods and calcium-rich foods less frequently than whites (Houston et al., 1994).

There is also little information regarding food practices of older blacks that may be related to nutrient intake. Results from national data show that, compared to whites, fewer blacks cook meat or poultry without added fat or use skim milk (Cypel et al., 1996). A similar proportion of blacks and whites report cutting the amount of sugar used in recipes (Cypel et al., 1996). However, there are few studies investigating food practices in older blacks addressing other areas of

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Cohm et al. 19

the US. Dietary Guidelines (US. Dept. of Agriculture and U S . Dept. of Health and Human Services, 1990). This information would be useful to guide nutrition education and services to incorporate dietary recommendations that are relevant to the older black population.

To best address the food and nutrient needs of older blacks, it is important to learn about variations within the population. Sociodemo- graphic and health factors may be related to dietary intake in elderly blacks, yet the literature suggests few findings. The NHANES data show that sex differences in dietary quality exist for older blacks (Jerome, 1988). A small longitudinal study of elderly blacks also showed that diets change with age (Jerome, 1988). Regarding income and education, dietary quality was found to be positively related (Tod- hunter, 1976; Houston et al., 1994), not related (Posner et al., 1987a), or related only to income (Learner and Kivett, 1981). Each of these studies utilized a racially mixed population; the relationship in elderly blacks is unclear.

Use of food and nutrition-related services by black elders also has implications for the dietary quality of this group. The literature that is available shows that older blacks use nutritional services such as home-delivered meals and congregate meals (Lawrence, 1989; Wal- lace et al., 1997). Moyer and Balsam (1996) report that, due to the 1987 amendments to the Older Americans Act, requiring state and local area aging plans to target minority populations, rates for minority elderly for both of these services are now double that of their represen- tation in the older population (i.e., 27% for congregate meals; 25% for home-delivered meals). Although participation rates have increased, there are few studies that cite the effectiveness of these programs for minority elderly populations. The studies that are available using el- derly blacks have shown no effects for food stamps (Posner et al., 1987a), and even a negative effect for home delivered meals (Steele and Bryan, 1985/86) for the black and white elderly investigated. Thus, further study is needed to determine the effect, if any, of formal supports on dietary quality of elderly blacks.

The purpose of this study was to describe the nutrient intake levels, food practices related to the U S . Dietary Guidelines (U.S. Dept. of Agriculture and US. Dept. of Health and Human Services, 1990), and food program use of blacks residing in public housing for the elderly in Springfield, Massachusetts. This population predominantly lives alone and is low income, many of whom are older than age 74; thus

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20 JOUWAL OF NUTKITION FOR THE ELDERLY

this sample may be at high nutritional risk (Posner et al., 1993). In addition, the relationship of dietary quality to sociodemographics and service use was explored. Results from this study may be of use to practitioners in designing nutrition and food interventions and services targeted to this population.

METHODS

Questionnaire Design

A health and food habits questionnaire was developed to include demographic information, eating practices, and use of home health aides, senior centers, food stamps, home delivered meals, and congre- gate meals (locally referred to as “hot meals”). Dietary guidelines practices were examined by nine 4-point Likert-type questions related to using fat and sodium in cooking, choosing high fiber, low sugar, and low fat alternatives, as well as reading labels. The survey was reviewed for content validity by the investigation team and two older blacks from Springfield, MA. After initial revisions, the question- naires were administered to eight elderly blacks in a Springfield elder- ly housing site. The questionnaires were again revised to be more appropriate to the population studied. The final questionnaires, along with a 24-hour food recall, were again pilot-tested and revised to improve clarity and ease of administration.

Subjects

Use of human subjects was approved by the University of Massa- chusetts human subjects review committee. Subjects in public housing for the elderly were randomly selected based on a multistage sampling design (Levy and Lemeshow, 1980). Individuals who were black, aged 55 and over, and able to comprehend their role in the study were eligible. Letters were sent to those included in the sample (n = 150), explaining the study and requesting their participation. Each potential subject was then contacted, by telephone or in-person. At that time, the interviewers explained the study again, obtained consent for par- ticipation and scheduled an interview appointment. After the initial list of 150 were contacted, an additional 45 individuals were randomly

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Coheir et al. 21

selected to increase the total number participating in the study. Of the total of 195 who were included in the study sample, 14.9% were unable to be contacted, 9.7% were ineligible and 34.4% declined to participate. This response rate was similar to one obtained in a nutri- tion study, also involving home visits with a representative sample of elderly in New England (Posner et al., 1994). Sample representative- ness was evaluated by comparing the age, sex, housing site, and source of income of respondents to nonrespondents using Springfield Housing Authority data. Respondents were similar to nonrespondents with respect to these variables.

Data Collection

The health and food habits questionnaires and the 24-hour food recall were administered, during in-person interviews, by interviewers from the Springfield black population who were trained to collect dietary and survey data as described previously (Laus et al., 1994). Second and third 24-hour food recalls were collected by telephone at approximately one-month intervals. An 8-ounce glass and measuring spoons were provided to each participant as aids in estimating portion size and used for each recall.

Data Analysis

Data from the questionnaires were entered into a microcomputer using Key Entry 111 (Southern Computer System, lnc., Birmingham, AL, 1986), double entered, and verified. Dietary data were analyzed using the University of Massachusetts Nutrient Data Bank, a comput- erized facility with over 6,000 foods. All diets were entered and checked for accuracy, then three-day mean values were calculated for the following nine nutrients: protein, niacin, thiamin, riboflavin, vita- min B-6, vitamin C, vitamin A, calcium, and iron, along with energy, fat, and cholesterol content, as well as sodium inherent in foods and added in preparation. No attempt was made to estimate salt added at the table, as this i s impractical to accomplish in a community-based setting. The contribution of supplements to nutrient intake values was not included. Values were expressed as a percentage of the 1989 Recommended Dietary Allowances (National Research Council, 1989). Dietary quality was defined two ways:

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-- 77 JOUKNAL OF NUTRITION FOR THE ELDERLY

1. A Mean Adequacy Ratio (MAR) score was computed by the fol- lowing formula: MAR = the sum of the percentage of the Rec- ommended Dietary Allowance (RDA) for each of nine nutrients listed above, truncated at 100% and divided by 9. Low dietary quality (DQ) was defined as a MAR of less than 50%, moderate DQ was defined as a MAR of 50-75%, and high DQ as a MAR of over 75%.

2. Each subject was also evaluated on the number of dietary goals achieved (GOALS). The dietary goals used were: less than or equal to 30% of the energy from fat, less than 300 mg of choles- terol, and less than 2400 mg of sodium per day (National Re- search Council, 1989). Low DQ was defined as only one goal achieved, moderate DQ as two goals achieved, and high DQ as three goals achieved.

Statistical Analysis

All statistics were performed using SAS (SAS Institute, Inc., Ver- sion 6.04, Cary, NC, 1990) on the personal computer. A simple fre- quencies procedure was used for descriptive data. Differences in nutri- ent intake between males and females were determined using the Student’s t test. The relationships between dietary quality and demo- graphics and service use were determined using the chi square statis- tic.

RESULTS

Sociodemographic characteristics of the sample are shown in Table 1. The largest percentage of the older blacks studied were 65-74 years of age, followed by 56-64 and 75-94 years of age. The majority of the respondents were female, with a sizeable percentage male. With re- gard to marital status, most subjects were widowed, divorced, or sepa- rated. Most of the respondents had not completed high school, with 28% completing high school or some college.

The majority of the older blacks studied indicated that they did not have enough money to meet their needs. Only about 18% of the respondents felt that they had enough money to meet their needs. Similarly, less than one quarter of the population responded that they

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Colrert et 01. 23

TABLE 1. Sociodemographic and Health Characteristics of Study Repsondents

Age (years) 56-64 65-74 75-94

Gender Female Male

Marital Status Single Married Divorced, Separated or Widowed

0-Grade 6 Grade 7-11 Grade 12+

Enough Somewhat Enough Not Enough

Can Always Buy Enough Can Usually Buy Enough Can Rarely Buy Enough Can Never Buy Enough

One Two Three Four or More

Food Stamps Hot Meals Home Delivered Meals Home Health Aides Senior Centers

Educational Level

Enough Money to Meet Needs

Ability to Buy Food

Frequency of Eating Daily (#of times)

Current Service Useb

Total Population (N = 80)

n percenta

25 31 36 45 19 24

51 64 29 36

5 6 5 6

70 88

31 39 27 34 22 28

14 18 21 27 44 56

18 23 43 54 14 18 4 5

10 13 36 45 25 31 9 11

30 38 10 13 8 10

27 34 14 18

asme frequencies may not add up lo 100%. due to missing values or rounding. bn = 79

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24 JOURNAL OFNUTRITION FOR THE ELDERLY

could always buy enough food. While most respondents mentioned that they could usually buy enough food, almost one-quarter re- sponded that they could rarely or never buy enough food to meet their needs.

When asked how many times they usually eat each day, almost half of the total population responded only two times per day, while about one-third of the group consumed three “meals.” Small proportions of the sample ate only once daily or four or more times per day.

Over 80% of subjects were aware of the five services studied (data not shown). The predominant services currently utilized were food stamps (38%) and home health aides (34%), with less than 15% using senior centers, hot meals, or home delivered meals.

The percentage of subjects reporting “always” or “sometimes” performing practices related to the US. Dietary Guidelines is shown in Table 2. Most respondents reported eating fresh fruits and vegeta- bles for snacks and desserts. About half of the sample used low calorie

TABLE 2. Dietary Guidelines-Related Practices of Black Elderly

Percentaae of Subiects Res~ndlnq “Ahvavs” or “Sometimes”

Practices Men In = 21) Women In = 59)

1, Eat Fresh Fruit or Vegatables for Snacks or Desserts

2. Use Low Calorie Salad Dressings

3. Read Labels to Find Out Fat, Sugar and/or

4. Taste Foods at the Table Before Adding Salt

5. Add Salt When Cooking Foods

6. Add Fat Such as Margarine, Oil, Bacon

7. Fry Foods Such as Meat, Chicken, Fish or Eggs

8. Eat White Bread and Rolls Instead of Wheat Rolls

and Mayonnaise

Sodium Content of Foods

or Lard When Cooking Vegetables

or Other Whole Grains

9. Select Fruit Canned in Heavy Syrup

79 02

45 57

52 51

28 33

83 63

72 73

72 57

66 65

31 33

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Colieti et al. 25

mayonnaise and salad dressings, and reported always or sometimes reading food labels. Only one-third of the sample tasted foods before adding salt. The majority of respondents reported adding salt to foods while cooking, adding fat when cooking vegetables, frying meats, and eating white breads and cereals instead of whole grain choices. Most subjects did not select fruit canned in heavy syrup. Intake of energy was very limited in both men and women, with an average of 1218 ( f 101) and 991 ( f 53) kilocalories, respectively. The mean percent- age of energy from fat was higher than the 30% recommended in the U S . Dietary Guidelines for Americans (U.S. Depts. of Agriculture and Health and Human Services, 1990); intake tended to be higher in men than women, with values of 37% and 33%, respectively. Men also consumed more cholesterol than women, averaging 332 ( f 36) mg and 188 ( f 18) rng, respectively. Sodium intakes contributed by food sources were below the 2400 mg maximum recommended level in both men and women, with values of 1944 ( f l 7 2 ) mg and 1654 ( f 105) mg, respectively. As the amount of salt added at the table was not included, the actual levels of consumption were higher.

Mean micronutrient intakes and comparison to the RDA are shown in Table 3. Mean intakes of vitamins A and niacin were above the RDA in both men and women. Vitamin C intake was above the RDA

TABLE 3. Mean Nutrient Intake and Percentage of RDA in Diets of Elderly Black Men and Women

Men (n = 29) Women (n = 51)

Nutrient Mean %RDA (.-SE) Mean %RDA (+SE)

Vitamin A (IU) Vitamin C (mg) Thiamin (mg) Riboflavin (mg) Niacin (mg) Vitamin 8-6 (mg) Calcium (rng) Iron (mg)

4700 ' 141 (28.7) 7735 289.3 58.8 97.9 (11.7) 91.9 153.1**

1.2 83.9 (9.0) 1.1 89.2 23.7 158.3 (11.3) 20.5 157.7 0.9 46.7 (4.5) 1 .o 65.3-

9.6 95.9 (9.5) 8.1 81.3

0.9 76.8 (6.2) 1 .o 98.4*

485 60.6 (7.4) 443 55.4

(79.8) (16.8) (8.5) (9.2)

(12.3) (6.4) (4.9)

(8.4)

Women signif cant y d Herent from men. p a 0 05 Women s gn f cantiy altferent lrom men. p a 0 01

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26 JOUIWAL OF NUTRITION FOR THE ELDERLY

in women, but not in men; this difference was significant. Mean con- sumption of thiamin, riboflavin and iron was only slightly below recommended levels; of these, only thiamin levels were higher in females than males. Mean intakes of vitamin B-6 and calcium were quite low, ranging from 5 5 6 5 % of the RDA; vitamin B-6 values were higher in women than men.

There was no relationship between age or education and dietary quality when measured by MAR or GOALS, as is shown in Table 4. Gender was significantly related to both MAR and GOALS. A high percentage of women consumed high quality diets, while most men had moderate quality diets when measured by MAR. With regard to the number of dietary goals achieved, most men consumed low quality diets, while most women consumed moderate quality diets. These findings are consistent with the lower cholesterol and percentage of energy from fat found in women compared to men.

There was no relationship between MAR or GOALS and percep- tions of having enough money to purchase food or meet one’s needs. However, MAR was significantly related to the frequency of eating. Fifty percent of subjects who ate only once per day had low MAR scores, while only 10% consumed diets with high MAR scores. Most subjects who ate two times per day consumed diets with moderate or high MAR scores, while the majority of subjects who consumed three or more meals per day consumed high MAR diets. A trend toward an opposite relationship between the number of meals consumed daily and GOALS is also apparent (p = 0.075). Subjects who ate only once daily consumed diets with moderate or high GOALS scores, while those who ate two or three times per day were more likely to have a low or moderate GOALS score.

Food stamp use was not related to dietary quality, as shown in Table 4. Home health aide use was significantly related to GOALS scores, as subjects who utilized this service had diets of moderate quality, while nonusers had diets of low quality. The relationship between dietary quality and use of the other services was not investigated, since partic- ipation rates were too low.

DISCUSSION

This study investigated nutrient intake in blacks residing in public housing for the elderly in a medium-sized city in the Northeast. How-

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TABLE 4. The Relationship Between Demographics and Service Use and Di- etary Quality in Black Elderly

Dietary Quality as MARa DIetary Ouallty as GOALSb

Variable Low Moderate High n % % %

Age 55-64 25 20 20 65-74 36 8 47 7% 19 21 37

Education 116 31 19 48 7-1 1 27 11 30 12t 22 14 27

Gender Male 29 7 55 Female 51 20 26

x 2 = 5.92 d f = 4

x* = 5.59 d f = 4

xz = 7.58 tn = 2 Money to Meet Needs Enough 14 29 21 Marginal 21 5 38

Enough Money to Buy Foods

NotEnough 44 14 41 x 2 = 4.93 d f = 4

Always 18 17 50 Usually 43 16 26 RarelyINever 18 6 50

Usually Eat 1 Meal 10 50 40 2 Meals 36 11 42 3 Meals 34 9 29

Food Stamps Yes 30 43 40 No 47 51 36

Home Health Aide Yes 27 52 26 No 45 57 38

x 2 = 6.05 d f = 4

X'Z 14.44 d f = 4

Xz = 0.49 df = 2

xz = 2.077 d f = 2

60 44 42

p = 0.205

32 59 59

p = 0.232

38 55

p = 0.023

50 57 46

p = 0.294

33 58 44

p = 0.195

10 47 62

p = 0.006

17 13

p = 0.781

22 11

p = 0.345

Low Moderate High % % o/,

40 32 2a 42 44 14 32 47 21

x2=2.60 d f = 4 p=O.626

48 29 23 33 48 19 32 50 18

x2 = 3.23 d f = 4 p = 0.520

66 24 10 24 51 26

Xz = 13.76 df = 2 p = 0.M)I

50 21 29 29 57 14 41 ' 39 21

X2 = 4.63 d f = 4 p = 0.327

50 28 22 37 42 21 33 50 17

X2 = 2.31 d f = 4 p = 0,729

10 40 50 47 36 17 .38 47 15

X2 = 8.49 df= 4 p = 0.075

50 27 23 34 49 17

Xz =3.79 d f = 2 p = 0.150

18 63 18 47 31 22

x 2 = 7.79 df = 2 p = 0.020

aMAR = the sum of the %RDA. truncated at loo%, for protein. niacin, thiamin, riboflavin, vitamin B-6. vitamin C, vitamin A, calcium and iron. divided by 9. bGOALS is a 3-point scale, based on the number of the foliowing three dietary goals achieved: < 30% of energy from fat. c 300 mg cholesterol, and c 2400 mg sodium.

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28 JOUKNAL OF NUTRITION FOR THE ELDERLY

ever, many characteristics of this population were similar to those found in general among elderly blacks. For example, the proportion of men and women and education levels are relatively similar to those of the general black population over age 65 (National Caucus and Center on Black Aged, 1991). Since most of the housing units in this study were designed for single adults, it is not surprising that very few subjects were married.

Age and education were not related to dietary quality in this study. In Jerome’s longitudinal study of elderly blacks (1988) and a crossec- tional investigation of sexagenarians and centegenarians (Houston et al., 1994), diets did change with age, but nutrient quality per se was not evaluated. It is possible that changes with age in an older person’s diet may not alter the quality indicators measured here. For example, choice of specific food products and variety of foods consumed may change over time without concomitant alterations in overall nutrient content of the diet. Age was negatively associated, and education was positively associated with dietary quality in both a predominantly white elderly population in New England (Posner et al., 1994), and in a racially mixed population of older noninstitutionalized adults (Sin- gleton et al., 1980). The positive relationship between education and diet quality was supported in the work of Houston and coworkers (1994). In contrast, neither age nor education was related to dietary quality or self-perceptions of dietary adequacy in racially mixed popu- lations (Learner and Kivett, 1981; Posner et al., 1987b). Clearly, fur- ther study is needed to clarify age and education relationships to dietary quality in a large representative sample of elderly blacks, ad- justing for potential confounding factors such as service use, mobility, and income.

The majority of respondents in this study felt that they did not have enough money to meet their needs, and one-quarter could rarely or never buy enough food to satisfy their needs. Although income data were not reported by many respondents, half of those that did respond in this study of residents of public housing, had incomes below pover- ty level. This is consistent with trends for elderly blacks in general, particularly those who live alone (National Caucus and Center on Black Aged, 1991). In this study, financial perceptions were not re- lated to dietary quality. The relationship between income and dietary quality shown in the literature is mixed, with positive findings (Learn- er and Kivett, 1981; Miller et al., 1996) and no effects seen (Caliendo

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Colrell el rrl. 29

and Batcher, 1980; Posner et al., 1987b). Since few subjects in the present study felt that they had enough money to meet their needs, it is possible that the relationship between income and dietary quality in elderly blacks, if any, is not apparent until income levels reach a certain threshold.

The largest percentage of the subjects in this study ate two times per day, with an additional thirty percent consuming three meals daily. A sizeable proportion ate only once per day. Meal skipping has been shown to occur in other studies of elderly blacks [Jerome, 1988). In this study, dietary quality, as measured by MAR, was related to the number of meals consumed per day, with mostly poor diets in those who ate only one meal, moderate diets in those who ate two meals, and higher dietary quality in those who consumed three or more meals per day. The number of meals was also positively related to dietary quality and energy intake in research using a national population (Murphy et al., 1990) and a southern rural sample (Lee and Templeton, 1993). When using the dietary goals as an indicator of dietary quality, the trend for higher quality in those consuming one meal per day is not surprising; it is more difficult to exceed the 2400 mg of sodium in foods or 300 mg of cholesterol levels when food intake is low.

The older blacks studied were highly aware of services in the com- munity. These results are surprising, because most surveys of black elderly show this population as being unaware of services (Crawley, 1986; Dancy, 1977). There was no relationship of current food stamp use to dietary quality in this study. In contrast, home health aide use was significantly related to GOALS scores. Previous studies have shown either no relationship or a negative relationship between ser- vice use and dietary quality (Steele and Bryan, 1985/86; Posner et al., 1987a). It is possible that home health aides purchase or prepare foods lower in fat, cholesterol and sodium for the elderly in their care. It is also possible that the health conditions necessitating home health care lead an older adult to choose foods lower in fat or sodium.

The food practices of study subjects reflected the recommendations of the U S . Dietary Guidelines with regard to avoiding too much sugar, but many subjects performed food behaviors that contribute to higher fat and sodium intakes and a lower fiber intake. By focusing nutrition education programs on appealing ways to cook meats and vegetables without adding too much fat or salt, such as that published by the National Cancer Institute (1993), practitioners can help the population

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30 JOURNAL OF NUTRITION FOR THE ELDERLY

to meet dietary guidelines in a culturally appropriate way. While the food practices investigated here build on the sparse national data avail- able, they were only indicators of numerous possible food behaviors; further research into Dietary Guidelines-related practices of older blacks is needed as well.

The black elderly in this study consumed, on average, low levels of energy, vitamin B-6 and calcium, with slightly low intakes of protein, thiamin, riboflavin and iron relative to the RDA. Subjects in this study, on average, consumed adequate levels of niacin and vitamins A and C. Similarly, the NHANES 111 data show that older blacks consume low levels of energy, calcium and vitamin B6 (Cypel et al., 1996). Howev- er, the intakes of energy and most nutrients investigated, except vita- min A and niacin, are even lower in this study than those of blacks aged 60 and above in the NHANES 111 study (Cypel et al., 1996). The present study includes subjects who are older and who live alone, and thus may have lower intakes than the general elderly black population that was surveyed by NHANES. Further, the group studied exhibited most of the factors identified with poor nutrition among the elderly, including eating alone, low education level, belonging to a racial minority, and living in a low income neighborhood (Tucker, 1993). Although efforts were made to collect as complete dietary information as possible, there still may have been a level of underreporting by subjects. Recalling dietary information with accuracy can be difficult for older adults (Dwyer and Coleman, 1994). In addition, it is difficult to identify the amounts of fat and kilocalories actually consumed from culturally-prepared foods, such as use of gravies and fatty meats as seasonings. It should be noted that the elderly black population studied here had twice the proportion of individuals reporting that they could rarely or never buy enough to eat than the low income black popula- tion surveyed nationally (Cypel et al., 1996). It is thus likely that the energy intakes reported in this study are truly lower than those re- ported in other studies.

Considering the very low levels of energy that the subjects in this study consumed, the average nutrient density of the diets was relative- ly high. For example, the high vitamin A intakes seen in this study resulted from consumption of green and orange vegetables, organ meats and other vegetables (Brennan Olson, 1992). These findings concur with Davis and coworkers (1990), who concluded “the in- creased risk of dietary inadequacy for older persons living alone is not

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Coheii et al. 31

a result of choosing poor-quality foods, but rather a result of consum- ing too little food.”

There were differences in dietary quality between males and fe- males in this study. Elderly black men consumed lower quality diets than women with respect to MAR scores and the dietary goals of fat, sodium and cholesterol. In contrast, research with elderly whites (Brown, 1976) and a national sample of elderly (Davis et a]., 1990) showed that men consume higher quality diets than women. Some of this difference may be attributed to the higher food intake of males in general, leading to higher nutrient intake and resultant higher quality diets. Since men in the present study consumed diets of limited energy, nutrient intake was also limited and did not result in higher quality intakes than women. Food choices and dietary guidelines practices of elderly black males were also higher in fat and cholesterol than those of the elderly black females studied.

Research presented in this paper was based on comparison to cur- rent national standards, such as the 1989 RDAs (National Research Council, 1989) and U.S. Dietary Guidelines (U.S. Departments of Agriculture and Health and Human Services, 1990). Yet there is de- bate regarding the suitability of some of these recommendations for older Americans. For example, Russell (1997) suggests that the RDAs for the elderly should be higher for riboflavin, vitamins B6 and B12, folate, vitamin D, and calcium. In this case, the data presented would imply that diets of older blacks are limited even further. In addition, some nutritionists note that the recommendation of 30% of energy from fat is not appropriate for all elderly, such as those who have difficulty maintaining weight (Gerontological Nutritionists, 1991). In this case, the fat levels seen in this study may not be as problematic as national recommendations imply, since the higher kilocalories carried by fat can be used to meet the energy needs in this low energy-con- suming population. Clearly, additional information is needed regard- ing dietary guidance for older adults.

Results from this study have several implications for researchers and service providers. There is a great need for increased energy intake among elderly blacks. Although there was no statistical rela- tionship between dietary quality and use of food stamps or senior meals programs in this study, participation rates were low. Efforts to tailor these programs to better meet the food and nutrient needs of elderly blacks, along with innovative ways to increase food intake, are

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32 JOURNAL OF NUTRITION FOR THE ELDERLY

needed. Since home health aide use was significantly related to dietary quality, it is important to ensure adequate nutritional training of this group. Future research should investigate whether coverage of and access to this program by elderly blacks is sufficient.

This study also points to many areas in which nutrition education can help reduce dietary problems. Nutrition education to achieve the US. Dietary Guidelines is necessary, particularly for elderly black men. Nutrition education should also encourage eating three or more times per day, and emphasize calcium-rich foods that are appropriate for this population. Further research is needed to determine the most effective methods of nutrition education for elderly blacks, as well as to further examine the relationships between dietary quality and de- mographics, health and service factors explored in this study.

Received: August 1997 Revised: February 1998 Accepted: March 1998

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