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# Dairy Requirements in Senior Nutrition Programs

## Does the Senior Nutrition Program require milk? 

No. The Title III Senior Nutrition Program requires that meals meet the nutritional needs of older adults as outlined in the *Dietary Guidelines for Americans 2020-2025* and Dietary Reference Intakes.

Both sets of standards are designed to promote health and decrease the risk of disease. These standards indicate that older adults need the nutrients commonly found in dairy products, including protein, calcium, vitamin D, potassium, and magnesium.  These nutrients help to prevent sarcopenia, osteoporosis, strokes, and high blood pressure. 

One of the most common sources of calcium is milk, and many state nutrition policies require serving liquid milk (possibly including chocolate and strawberry milks, lactose-free milk, ultra-high temperature (UHT) milk, etc. However, other sources of calcium may be considered in place of liquid milk. 

## Does an older adult have to take the milk if they do not want it? 

No. The Senior Nutrition Program is an offer versus serve program. This means that a program is required to offer a food or beverage, such as milk, but participants can refuse them. A refusal does not determine whether a program can receive funding for the meal.

## Does fruit or salad count as a milk alternative? 

No. The program can use alternate food items for milk that have similar nutrients.  Salads, vegetables, and fruits generally do not have the same nutrients as milk. Toward the end of this document is a list of milk alternatives that can be used in place of milk in senior nutrition programs. The program nutrition expert should keep in mind that some milk alternatives may be high in cost. 

## Does milk have to be delivered as fresh and cold?

No. The Senior Nutrition Program allows milk served in congregate and home-delivered meals to be powdered and/or shelf-stable during situations that involve long meal routes, deliveries, supply chain issues, and emergency situations. Please see local state policies regarding milk substitutions.

## Does my program have to accommodate someone’s preference?

It depends. Programs should provide meals that, to the maximum extent practicable, are adjusted to meet special dietary needs of program participants, including meals adjusted for cultural considerations and medically-tailored meals (OAA, Title III Section 339). That said, any substitution request from a medical practitioner would require reasonable accommodations. Religious, ethnic, cultural, or regional dietary practices may be accommodated if foods and preparations are available, and they meet the nutritional needs of older adults as outlined in the DGA 2020-2025 and the DRIs.  Please see local state policies regarding accommodations.   

## Is lactose intolerance or difficulty in digesting milk and milk products common?

Yes, in some regions of the world, lactose intolerance or difficulty in digesting milk and milk products is common. It is estimated that about 36% of people in the U.S. have lactose malabsorption. 

While lactose malabsorption causes lactose intolerance, not all people with lactose malabsorption have lactose intolerance. Risk factors for lactose intolerance include age; ethnicity; diseases of the small intestine, such as celiac disease; and medical treatments, such as some cancer treatments. Some adults may have been able to tolerate milk earlier in life, but, as they age, their tolerance declines. Lactose intolerance is most common in people of African, Asian, American Indian, and Hispanic descent.

Some people who are lactose intolerant may be able to tolerate a small amount of milk over the course of a day, such as milk in coffee. Others may be able to tolerate lactose-free dairy products, yogurt, or cheese, particularly aged cheddar or Swiss cheeses, rather than younger cheeses, such as Colby. This varies by individual.

For individuals who are lactose intolerant, Lactaid, yogurt, and aged cheese, such as cheddar or Swiss, are common substitutes. However, some individuals may not tolerate any dairy products. For those individuals, there are other food substitutes, often fortified with calcium, listed in the milk alternatives table. For individuals who are vegan and consume no meat, fish, eggs, or dairy products, they may substitute fortified products.

## Menu Planning Tips

1. Try to incorporate milk alternatives for participants who do not prefer milk, are lactose intolerant, or are vegan. 

2. Try to incorporate milk several times a week and a milk alternative, such as cheese or yogurt, about once a week.  

3. Select dairy products are good sources of calcium (see list below). Some dairy products are **not** good sources of calcium. These include butter, cream, cream cheese, sour cream, ice cream, and frozen desserts. 

4. Fortified orange juice may have added sugar (20+ grams) or be too high in natural sugars for some populations. 

5. Flavored milks can be incorporated into menus without exceeding the Dietary Guidelines’ added sugar limits (17 grams per meal). 

6. Milk substitutes, like “milks” made from nuts or grains, may have little or no calcium or protein, another key nutrient found in milk. 

7. Policies requiring nutrient analysis rather than meal patterns can be considered and may allow for maximum flexibility since this approach may not require specific meal components, e.g., milk, etc. 

8. Consider participant population and ethnicity when choosing dairy and non-dairy products. Lactose intolerance is most common in people of African, Asian, Hispanic, and American Indian descent. 

## Milk Alternatives

The following table provides substitutions for 8 ounces (1 cup) of skim, 1%, 2%, or whole milk. It also includes a variety of cultural foods that can be incorporated into menus and meals to meet cultural and religious implications. Food items and the amounts are sourced from the Dietary Guidelines for Americans — Food Sources of Calcium.

*Adapted from:**DGA Food Sources of Calcium***

## Nutrition Education

Calcium is an important mineral that the body needs as it ages. Older adults often do not consume adequate amounts of calcium, and the amount that a person can absorb also decreases as they age. Encouraging older adults to increase their calcium consumption can help play a role in keeping bones and teeth healthy and help improve how muscles, nerves, and hormones work in their body. Visit the National Resource Center for Nutrition and Aging Program Basics webpage for more resources. 

## Resources

Calcium Resources (National Agricultural Library)

Dietary Guidelines for Americans, 2020-2025

Food Sources of Calcium (DGA)

Lactose Intolerance (NIH)

MyPlate: Dairy (USDA)

Nutrition Needs for Older Adults: Calcium (NRCNA)

Older Americans Act 

*Disclaimer: All resources provided are from government websites or have been gathered from the National Agricultural Library.*

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