Fall 2004
Featured Article

Hunger and Aging

By Edward A. Frongillo and Claire M. Horan

The United States is a wealthy country, but among older people, hunger and what nutrition scholars call “food insecurity” persist and are important underlying causes of or contributors to many of the nutrition-related difficulties today’s elders face.

As the other articles in this issue attest, optimal nutritional status is an important component of good health and requires particular attention in elderly people, with under-nutrition contributing to frailty and poor health by exacerbating medical conditions and increasing disability and extending hospital stays. These and other aspects of nutritional status also have economic consequences, for example, increased costs for caregivers because of increased need, and increased healthcare costs for the nation.

Yet, despite the health and monetary consequences as well as the ethical unacceptability of hunger and food insecurity, as we have noted, they persist in the United States today (Lee and Frongillo, 2001a). As a result, significant eVorts have been made in the past fifteen years to understand and measure household food insecurity and its determinants and consequences. Although most of this work has focused on food insecurity in younger families, specific efforts have also been made to understand hunger and food insecurity in elders.

What Is Food Insecurity?

Food insecurity refers to problems with the availability, accessibility, and utilization of food. In the United States, it has been assumed that younger people who have economic access to food can also acquire it and make effective use of it. But among elders, economic access to food does not guarantee that it will be utilized because of physical health and other problems (Lee and Frongillo, 2001a).

Food insecurity is determined by economic and social resources, functional status, and environmental context. Food insecurity can limit dietary intake and lead to hunger, distress, alienation, and changes in familial and social behaviors and interactions, thereby negatively affecting well-being in a number of ways. Food insecurity in older people can lead to exhaustion and weakness that may contribute to reducing physical activity and physical performance and increasing frailty and disability (Fried et al., 2001).

Since 1990, the consensus definitions of food insecurity and hunger that have emerged among professionals in the field are as follows: Food insecurity exists whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain. Hunger, defined as the uneasy or painful sensation caused by a lack of food, is a potential, although not necessary, consequence of food insecurity (Anderson, 1990). Nutritionists use this more narrow definition of hunger as one possible consequence of food insecurity, whereas in the media and among some advocates and concerned citizens, “hunger” is used to refer to the whole problem of households and individuals having difficulty with the availability, accessibility, and utilization of food.

The Extent of Food Insecurity

What is the extent of food insecurity among elders? The U.S. Household Food Security Survey Module (HFSSM) (Bickel et al., 2000) is a set of questions developed by the federal government to measure food security. According to the Current Population Survey using the HFSSM, 6.3 percent of all elder households were “food-insecure” in 2002, with 1.9 percent being food-insecure with hunger (Nord, Andrews, and Carlson, 2003). When compared with the percentages for other age groups, these numbers imply that the elders as a group are less food-insecure than other age groups. Some say that this difference is attributable to many elders having pensions or fixed incomes and thus being less affected by changes in the economy (Nord, 2002). This idea is consistent with poverty rates in the United States, which show that in 1999, some 9.7 percent of elders were poor, while 17 percent of children were poor (Clark et al., 2004).

Another explanation, however, is that the HFSSM may underestimate food insecurity among elders because they experience food insecurity differently compared to the rest of the population (Wolfe, Frongillo, and Valois, 2003). The HFSSM focuses on food insecurity that is a result of not having enough money for food, but some elders also experience food insecurity because of access or utilization problems due to their limited mobility or transportation options.

In addition, elders tend to understate their own problems more than other groups. Since elders are on a monthly financial cycle more often than other age groups, they may not be thinking of their end-of-month difficulties when answering questions about food insecurity. Their life experiences, such as living through significant economic depression, also affect their perceptions of their food insecurity (Quandt et al., 2001; Wolfe, Frongillo, and Valois, 2003).

Quandt and colleagues (2001) identified in their research a few specific themes that elders related to food insecurity. For example, many rural elders said they felt pride in the self-sufficiency and ability to weather hard times instilled in them by their parents. They also expressed a belief that either God or luck would come to their aid; they believed that food security was largely out of their own control. Quandt and colleagues inferred that it was pride that kept many elders from considering themselves food-insecure. The rural elders in the study preferred to rely on home food production or informal support from neighbors rather than using credit or taking advantage of senior nutrition programs, which they perceived as “welfare” and thus unacceptable. Many elders chose to merely regulate their food intake during periods of food insecurity rather than to seek help.

A Complex Experience

Wolfe and colleagues (2003) developed a framework for describing the complex experience of food-insecure elders. The framework has four components: quantitative, qualitative, social, and psychological. Each component includes a range from mildly to severely negative, and any one individual can experience one level of severity for one component and a different level for another.

Quantitative component. According to the framework, the experience of food insecurity can be quantified according to the relative amount of food available. At the least severe level, there is less food available in the home than would be desired or expected. At the intermediate level, the individual actually consumes an insufficient amount of food or less food than usual. The most severe level of the quantitative experience is hunger, when an individual goes one or more days without food.

Qualitative component. Qualitative aspects form another component of the experience. At the least severe level, this means having to buy or eat less-desired foods. For example, an individual may buy canned food rather than more expensive fresh food. Quandt and colleagues (2001) found such compromises to be common and even accepted by many rural elders. A more severe level of qualitative food insecurity is eating food that is nutritionally inadequate. For instance, many elders in the study by Wolfe and colleagues (1998) could afford only two chicken wings or no meat at all for a meal.

Sometimes elders who require costly medical care and prescriptions must choose between spending money on medication and spending it on healthy foods. Furthermore, some individuals require special types of food for health that may be more expensive. In a study of elders living in upstate New York (Frongillo, Valois, and Wolfe, 2003), one woman struggled to maintain her prescribed diet of foods that were low fat, low cholesterol, and low sugar, and with limited greens. Her low income made following this diet especially difficult.

Social component. According to the framework, the social component of food insecurity has two important aspects. The first is individuals obtaining food in ways that many see as socially unacceptable. Examples include buying food on credit, using food pantries, and, in severe cases, asking friends or relatives for money or food.

The second aspect is engaging in culturally unusual patterns of eating -- including eating meals at unusual times or skipping meals altogether. For example, one rural man described in the study by Wolfe and colleagues said, “Oatmeal, you can eat that for breakfast, lunch, and dinner, and sometimes we do.” The food eaten may be unusual as well. Members of ethnic minorities may not be able to obtain culturally appropriate food from a community food assistance program, often leaving them with food that seems strange or unappealing.

Psychological component. The quantitative, qualitative, and social components of food insecurity all have an important psychological effect on the individual. Although each food-insecure elder doubtless experiences somewhat different feelings, two emotional reactions to food insecurity have been found to be most common. First, uncertainty as to whether one will have enough food or nutritionally adequate food leads to anxiety. Second, especially in a social setting, the necessity to compromise about food choices (disregarding wishes or needs) leads to feelings of deprivation, anger, and embarrassment. Ravina, an urban elder, described her experience of asking friends for food: “It just makes me feel lost . . . lost and all alone by yourself and you ain't got nothing . . . I don't [like to ask], oh no. If I'm hungry I'll have to ask them” (Wolfe et al., 1998).

Reasons for Food Insecurity

The reasons for food insecurity among elders include financial difficulties, poor health, limited mobility, and lack of social support (e.g., Cook and Brown, 1992; Cohen, Burt, and Schulte, 1993). Whereas poverty is the most important cause of food insecurity at all ages, health-related problems such as physical and cognitive impairment that frequently occur with aging are additional important causes for elders.

Financial difficulties. The financial difficulties of elders are somewhat different from those of the general population. The monthly financial cycle of many elders leads to a monthly cycle of food insecurity. In other words, they may have enough money to buy food at the beginning of the month but run out of funds toward the end of the month (Frongillo, ffalois, and Wolfe, 2003).

Poor health. The poor health of many elders often contributes to the financial difficulties that lead to food insecurity. When elders need to spend their money on expensive healthcare or prescription medications, they have less money to spend on food. It is common for some elders to first pay the bills and buy medications, then buy food out of whatever money is left over (Quandt et al., 2001).

Limited mobility. Limited mobility is sometimes related to financial difficulties. For example, money may be available for food but not for transportation to a store or to pay someone to go food shopping as often as necessary. Another problem caused by limited mobility is that even if there is enough money and food in the house, the elder may not have access to it or be able to prepare or eat the food because of health problems or functional impairments (Lee and Frongillo, 2001b).

Social support. In this situation, social support is very important. Many elders have informal arrangements with friends or relatives who help them obtain or prepare food. However, such support is not always consistent or reliable (Frongillo, Valois, and Wolfe, 2003). Social support is also important in encouraging elders to eat. For many people, eating is a social activity, and being alone may result in decreased motivation to eat or cook. Elders may not eat because they are tired, lonely, or depressed. A reliable social support network can be of help in such situations.

Within the population of older people, differences in the prevalence of food insecurity do exist. Elders have different problems depending on where they live, their marital status, and their ethnicity. Nord (2002) found that elders living in the South had a higher rate of food insecurity and hunger than those in other regions of the country. The study also found that elders living in inner-city areas were twice as likely to be food-insecure as elders living in other urban areas. Rural elders had food insecurity levels that fell between the two other groups.

The factors that predict food insecurity differ in important ways between rural and urban elders. In rural areas, distance and the lack or shortage of public transportation is often a problem that limits formal assistance programs. The available stores are often small, with limited shopping selection and high prices. Supermarkets, which offer a large selection and cheaper food, are most common in suburban areas. Urban elders have disadvantages as well. They are less likely than their rural counterparts to be married or have family living nearby (Quandt et al., 2001).

Marital status is an important factor in food insecurity of elders. Married couples living together are the most secure group (Nord, Andrews, and Carlson, 2003). Although both unmarried men and unmarried women are at higher risk for food insecurity, men have a slightly higher risk. Differences in food insecurity by ethnicity amount to differences in income and marital status. Hispanic and black elders have higher poverty rates and are less likely to live in married-couple homes than are non-Hispanic white elders (Nord, 2002).

Consequences of Food Insecurity

While older individuals experience many of the general health and social consequences of food insecurity, which include decreased household food supply, poor health, and social and family problems, some consequences of food insecurity are specific to elders. Lee and Frongillo (2001b) found that, although older people in general consumed less than the recommended dietary allowance for eight important nutrients, including energy, food-insecure elders had intakes that were even lower -- to a significant degree. They were also found to have comparatively lower skin-fold thickness, a measure of energy stores. They had a higher nutritional risk and were twice as likely to report fair or poor health than were their counterparts. Food-insecure elders have also been found to have lower body weight and overall quality of life (Roe, 1990; Vailas et al., 1998).

Public and Private Food Assistance

Although both public and private food assistance programs are often available, elders rely heavily on private assistance to help alleviate food insecurity. For example, elders are more likely to choose the food pantry system of private charities than the government Food Stamp Program (Daponte, 2000). Whereas the general population is more comfortable using Food Stamps (Martin et al., 2003), the older population is more comfortable with private food assistance. In fact, elder households are less than half as likely to receive food stamps as younger households (Martin et al., 2003).

Studies have shown different subpopulations of elders to have different preferences for assistance. For example, Wolfe and colleagues (1998) found that urban black elders, in contrast to urban white elders, were more likely to use government programs providing congregate meals or food stamps than private charities' food pantries. Hispanic households were more than twice as likely as non-Hispanic households to say they feel uncomfortable using food stamps (Martin et al., 2003). Whether they choose public or private assistance, elders largely choose one or the other rather than both (Nord, 2002).

Private assistance programs include food banks or pantries, soup kitchens, and congregate meal programs. Food banks are “nonprofit, community-based warehouses that receive donations of edible but usually unsalable food from producers, retail food sources, the Federal Commodity Distribution program, and the food industry, both locally and nationally” (Daponte, 2000). These banks distribute food to pantries, which in turn distribute food directly to the community. Second Harvest, a private national food-relief program, reports that 11 percent of those who use its services are elders (America's Second Harvest, 2004).

Many elders do not use the Food Stamp Program for a number of reasons. First, many people, not just elders, do not understand the rules of the program and do not think they are eligible (Martin et al., 2003). Or, they are sometimes eligible for only a small amount of money in food stamps and do not wish to go to the trouble of obtaining it. On the other hand, some elders do indeed have assets that render them ineligible for food stamps.

Some elders choose private assistance over public because of a negative stigma attached to food stamps, which many view as welfare. Many elders do not want to use taxpayer money or receive what they think of as government handouts. Because of the informality of much private assistance, elders do not always perceive the aid as coming from the government, even though much of it does.

There are other benefits to the informality of food pantries and soup kitchens, where volunteers often know clients on a first-name basis. Many pantries or soup kitchens are affiliated with religious organizations and thus have an effective way of reaching food-insecure elders easily (Daponte, 2000).

Implications for Practitioners

Practitioners should first try to prevent food insecurity among their older clients, an ethical and much more cost-effective approach than dealing with the consequences. Practitioners should keep in mind that because of their beliefs, attitudes, and values, some elders who would benefit from food-assistance programs may be reluctant to participate or are even unaware of their need to do so. It is helpful for practitioners to use assessment tools to determine whether clients are experiencing food insecurity to better identify elders who may need assistance. The best tool for assessing food insecurity is the U.S. Household Food Security Survey Module (Bickel et al., 2000). In addition, Wolfe and colleagues (2003) suggest some questions specific to elders that may help assess food insecurity.

Edward A. Frongillo, Ph.D., is associate professor, Division of Nutritional Sciences, and Claire M. Horan is an undergraduate scholar, both at Cornell University, Ithaca, N.Y.

References

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Clark, R. L., et al. 2004. The Economics of an Aging Society . Malden, Mass.: Blackwell Publishing.

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From Generations Fall 2004 issue, 28(3): 62-63. © 2004 American Society on Aging

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