Running head: HEALTH PROMOTION PROJECT

Health Promotion Project

Emma Shank and Brittany Brockner
Marywood University

HEALTH PROMOTION PROJECT

Health Promotion Project Part One

Hunger in Senior Citizens
According to the National Council on Aging, nearly 9.3 million seniors in America are at
risk for hunger, which represents 15.3% of all seniors in America (National Council on Aging,
2012). Senior hunger in America has also been directly correlated to the increasing prevalence of
food insecurity among seniors, and has been tracked from 2001 to 2013. During this time frame,
food insecurity among senior households raised from 5.5% to 8.6% which has caused more than
double of seniors to face the threat of hunger (National Council on Aging, 2012).
Food insecurity among senior citizens is an important area of concern since it can lead to
malnutrition and unintentional weight loss (Evans, 2005). If not enough food is available in their
homes, seniors are at greater risk to not consume the adequate amount of calories necessary for
optimal health. Data from The Health and Nutrition Examination Survey in 1999 concluded that
16% of home-bound Americans older than 65 years old consumed fewer than 1000 calories per
day, which places them at high risk for undernutrition (Evans, 2005). With such a prevalence in
undernutrition, seniors are constantly at risk for rapid decline in health both physically and
cognitively, increased risk for disease and possibly increased mortality (Evans, 2005).
The prevalence of malnutrition in seniors is often due to either inadequate food intake or
poor choices of available food that has little nutritional value. In fact, a study conducted at
Cornell University found that food insecure elderly people had significantly lower intakes of
energy, protein, carbohydrate, saturated fat, niacin, riboflavin, vitamins B-6, B-12, magnesium,
iron and zinc (Lee & Frongillo, 2001). One of the major gaps of knowledge in the senior
community facing this problem is their overall understanding for nutrition and how it may be

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possible to shop and cook on a low-budget while also consuming proper nutrition. Many seniors
facing food insecurity do not completely understand how to optimize their food choices for
correctional manners to improve their health. Since a large population of seniors are disabled,
they are not able to attend community seminars, talks, or lessons focused on nutritional education
and often this lack of interaction causes a gap in their overall understanding or motivation to stay
healthy.
Assessment Parameters
Due to this gap in nutritional guidance for many senior citizens today, we have decided to
implement a health promotion program for seniors in Pike County, PA who are part of the Pike
County Area Agency on Aging (AAA) home-delivered meal program. Individuals of the program
include both male and female aged 60 years and older of Non-Hispanic and Hispanic ethnicity.
In addition, all participants qualify under the eligibility requirements of the Pike County AAA for
the program with respect to income level or disability.
In order to adequately evaluate this group of seniors, a needs assessment was conducted.
The purpose of this needs assessment was to accurately identify the health status of Pike County
seniors and the effectiveness of Pike County AAAs home-delivered meals on their well-being.
The goal of the needs assessment was to examine possible areas of growth or change in the
home-delivered meal program to improve the participants overall health. The objective of the
needs assessment was to define the status of malnutrition, frailty, and weight change of
individuals in the program to accurately classify their needs for education.

HEALTH PROMOTION PROJECT

Data Collection
The Pike County Area Agency on Aging was originated in 1976. Governed by the Pike
County Commissioners with guidance from the AAA Advisory Council, the Pike County Area
Agency on Aging serves as a public, non-profit, senior service to provide resources and services
to members who are 60 years and over (Pike County AAA, 2015). The goal of their existing
program is to assist the individuals to remain in their homes safely and live a healthy life. The
Pike County AAA provides services, such as transportation, counseling sessions, health
education, legal assistance, home delivered meals, senior center meals, and senior activities.
Located in a rural surrounded area, Pike County AAA boarders New Jersey and New
York and consists of mostly wooded land and little available residential areas for the seniors to
live. Due to this scarcity in residential areas, taxes have raised in the state to meet the budget
demands of the living costs in Pike County (U.S. Census Bureau, 2010). As a result, the aging
population has become unable to keep up with the increases in taxes and living expenses, leading
many to poverty. According to the Census Bureau of 2010, 5.1% of family households lived in
poverty in Pike County since 2000 (U.S. Census Bureau, 2010).
In addition to the rise of poverty, the senior community has been increasing substantially.
From 2000 to 2010, there has been a 23.9% increase of 65+ year elderly individuals in the Pike
County area (U.S. Census Bureau, 2010). In addition, from 2000 to 2010, there was a 123.5%
increase of Hispanic consumers at the Pike County AAA, which has increased the need for
Spanish-speaking aides at the agency (U.S. Census Bureau, 2010). Due to the rise in elderly
individuals, a greater need for caregiving and assistance programs is required to meet their needs
(Pike County Health Profile, 2007). Even though many of the individuals involved in the Pike
County AAA receive either home-delivered meals or food assistance in the form of reduced-

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priced meals or food stamps, many seniors still remain food insecure. In fact, Pennsylvania alone
has a state-level estimate of 8.7% of seniors to be food insecure in 2011 (Zilak & Gunderson,
2013).
In result of this food insecurity, many of the seniors both nationally, state and locally in
Pike County are not adequately nourishing their body with enough nutrition on a daily basis.
Since the prevalence of malnutrition continues in America, programs, such as the Pike County
Area Agency on Aging strive to lower this health concern among seniors of Pike County.
Research also continues both locally, state and nationwide to gain a greater understanding of the
impact of malnutrition on the health of seniors. One study, in particular found that frailty among
elderly individuals was significantly more prevalent if less than 21 kcal/kg was consumed along
with low folate, vitamin D and protein (Bartali et al., 2006).
Malnutrition and frailty in seniors was further discussed with the Executive Director of
Pike County AAA, Robin LoDolce, RDN. She reviewed the process of how the home-delivered
meal system worked and the details that went into each process of preparation and delivery.
Individuals enrolled in the program are mostly, if not all, low-income individuals who qualify
under the state and county regulations to be eligible for the program. Many of the members live
either independently, with their spouse or with a caregiver who assist them in their daily
activities. Since many of the home-bound seniors are disabled, they are unable to partake in
community activities, such as senior center events. The Pike County AAA provides five meals a
week to their homes, which include four ounces of milk, an entre, fruit and vegetable and a
dessert. They are also given several emergency frozen meals during the year in case of weather
disaster or emergencies that prevent the access of meal delivery to their homes.

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One area that Robin discussed is a gap in their understanding is to save these emergency
meals for when they are needed. Many individuals eat them immediately after delivery and are
left with no food during an emergency. In addition, she stated that there is a substantial difference
between the food security and malnutrition levels among home-bound seniors and seniors that
are able to travel to the center, also known as congregate members. LoDolce suggests that more
education on incorporating higher amounts of fruits, vegetables, and dairy in their diet may lead
to improved health both physically and cognitively. She also emphasized the fact that these
individuals lack social interaction because many are unable to leave their homes, so if this
educational material were to be interactive, such as illustrations or games, they may be more
inclined to utilize the material or remember the content.
The target population was not directly observed since we were not presented with the
opportunity to distribute home-delivered meals to home-bound seniors yet, but we were able to
observe the group of seniors that came into the Pike County AAA, the Lackawaxen Fall Festival
and the Pike County Senior Expo. From what was observed, it seemed like many of the seniors
were either low-income or slightly above the poverty line. Several of the seniors were currently
experiencing diabetes mellitus type II, hypertension, and osteoporis. After discussing with some
of the seniors at all of these events, it appeared that they heavily relied on the meals from the
Pike County AAA. Many of the members had a general understanding of proper nutrition, but
others seems to have little concept of portion sizes and macronutrient content of several food
items. It did seem, however, to be very encouraging to see how eager many of the seniors
seemed to be toward learning about nutrition. In particular, several of the seniors were willing to
talk with me about their diet.

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Before entering the program, all members of the Pike County AAA must complete a
health screening survey known as the NAT-E. This survey ideally is revaluated every six months
after beginning the program and monitored to assess progress or decline in health parameter. In
order to assess our particular group of home-delivery meal recipients, we analyzed the NAT-E
survey of fifty home-bound seniors. It was found that 20% of that sample were consuming fewer
than two meals a day, 7% were eating fewer than two servings of dairy product a day, and 18%
of the individuals were consuming fewer than five servings of fruits and vegetables every day
(NAT-E 11-18-14 Survey, 2015). Additionally, 16% of the individuals showed symptoms of
being frail (NAT-E 11-18-14 Survey, 2015). One of the most targeted components of the survey
was the Nutritional Risk Score, which demonstrated warning signs of poor nutritional health.
Reporting a score of 0-2 signified good nutritional health, 3-5 demonstrated moderate nutritional
risk and 6 or more signified high nutritional risk. Among the 50 members analyzed, the mean
Nutritional Risk Score was 3.6, which demonstrated moderate nutritional risk (NAT-E 11-18-14
Survey, 2015).
Data Analyzation and Interpretation
The findings of our secondary data, interviews, observations and survey data determined
that the Pike County AAA home-delivered meal program members are at a moderate nutritional
risk and are experiencing malnutrition and frailty due to both food insecurity and poor food
choices. Increased living cost and taxes in the Pike County area have recently caused many
seniors to have less money available for purchasing enough food for their homes. Based on the
results of the most recent health screening survey, NAT-E, we were able to identify that some
members of the Pike County AAA were eating fewer than two meals a day, less than two
servings of dairy a day and fewer than five servings of fruits and vegetables a day. In addition to

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many of the health diagnoses mentioned in the survey, it was found that this poor nutrition has
led to frailty, tiredness, and disabilities.
Health Promotion Project Part Two
Goal Statement
After identifying current nutritional risk factors of seniors in the Pike County area, our aim is to
reduce the prevalence of malnutrition and risk for frailty in the seniors currently participating in
the Pike County AAA home-delivered meals program.
Objectives
To measure the success of our health promotion program, another NAT-E survey will be
administered to the same 50 sampled seniors of the Pike County AAA home-delivery program in
six approximately six months. Within the next 6 months after implementing our nutrition health
promotion program, we hope to:
1. Decrease the percentage of inadequate fruit and vegetable intake from 18% to <5%. In
order to facilitate this change, our program will distribute MyPlate diagrams in the form of an
illustrative magnet to demonstrate proper meal portions with fruits, vegetables, dairy and meat.
The magnets will encourage members to be reminded of healthy eating as they encounter their
refrigerator on a daily basis. This visual will also be delivered with a handout describing the
importance of fruits and vegetables and the impact it has on their health.
2. Decrease the percentage of elderly that consume fewer than 2 meals per day from 20%
to <5%. To enable this change, recipe cards will be sent along with home delivered meals to
educate the seniors on how low-budget meals can be prepared with minimal effort and difficulty.

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3. Decrease the percentage of elderly that consume less than 2 servings of dairy products
per day from 7% to <5%. This improvement will be facilitated through educational handouts
that provide information about dairy products, bone health and budget-conscious ways to
incorporate dairy into a low-income household.
4. Lower the average Nutritional Risk Score from a moderate nutritional risk score of 3.6
to a low nutritional risk score within the range of 0-2 and lower the percentage of individuals
showing symptoms of frailty from 16% to <5%. These objectives will be accomplished through
educational handouts of nutritional facts to live a health life and tips for shopping on a budget.
Through these educational materials, members of the program will be encouraged to improve
their nutritional health and risk for becoming frail.

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10
Resources

Bartali, B., Frongillo, E., Bandinelli, S., Lauretani, F., Semba, R., Fried, L., & Ferruci, L. (2006).
Low nutrient intake is an essential component of frailty in older persons. Journal of
Gerontology: Medical Sciences, 61(6): 589-593.
Evans, C. (2005). Malnutrition in the elderly: a multifactorial failure to thrive. The Permanente
Journal, 9(3): 38-41.
Lee, J. & Frongillo, E. (2001). Nutritional and health consequences are associated with food
insecurity among U.S. elderly persons. American Society for Nutritional Sciences, 15031508.
NAT-E 11-18-14 Survey (2015). Pike County Area Agency on Aging.
National Council on Aging. (2012). Senior hunger and SNAP facts. Retrieved from
https://www.ncoa.org/news/resources-for-reporters/get-the-facts/senior-hunger-facts/
Pike County AAA. (2015). Pike county area agency on aging. Retrieved from www.pikeaaa.org
Pike County Health Profile. (2007). Pennsylvania Department of Health Bureau of Health
Statistics and Research.
U.S. Census Bureau. (2010). American Community Survey.
Zilak, J. & Gunderson, C. (2013). Spotlight on food insecurity among senior americans 2011.
University of Kentucky and University of Illinois.