# National Resource Center on Nutrition and Aging

# Understanding Nutrition Requirements During COVID-19

## FOR SENIOR NUTRITION PROGRAMS

*Updated: November 2022*

Older adults need access to nutritious food to enhance their health and prevent unnecessary negative health consequences. Senior nutrition programs (SNPs) should make every attempt to deliver the most nutritious meals possible, even during an emergency such as the COVID-19 pandemic.

This resource will provide an overview of nutrition requirements, including Dietary Reference Intakes (DRIs) and Dietary Guidelines for Americans (DGAs), and how they have been affected by COVID-19. It will also provide recommendations for how to provide meals and meet minimum calorie requirements during the COVID-19 crisis when Congressional authorization has allowed for nutrition requirements flexibility, addresses the provision of groceries, responds to FAQs, and shares sample menus and meal patterns.

*Abbreviation Guide*

DGA = Dietary Guidelines for Americans DRI = Dietary Reference Intake

MDD = Major Disaster Declaration

NSIP = Nutrition Services Incentive Program OAA = Older Americans Act

PHE = Public Health Emergency SNP = Senior Nutrition Program

# Background and Older Americans Act Intent

SNP meals are funded through the OAA Titles III C-1, C-2, and the Nutrition Services Incentive Program (NSIP), Title III-A. The intent of the OAA is to reduce hunger, food insecurity, and malnutrition; promote socialization; and enhance health and well-being.

To support these intents, OAA Section 339 indicates that SNP meals must comply with the most recent DGAs and provide:

· A minimum of 33 1⁄3% of the DRIs for one meal per day.

· A minimum of 66 2⁄3% of the DRIs for two meals per day.

· A minimum of 100% of the DRIs for three meals per day.

# Providing Meals During an Emergency

Red Cross guidance recommends having a two-week food supply at home in case of emergencies. Senior nutrition programs can help older adults to meet this goal by providing a combination of fresh, hot, frozen, and shelf stable meals when seniors must stay in place due to an emergency, such as during the COVID-19 pandemic.

Meals served during emergencies can be produced by state and local nutrition providers or sourced through local food service companies. Examples of food service companies include restaurants, grocery

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stores, hospitals, senior living facilities (e.g., assisted living or independent living facilities), and other contractors.

If sourcing meals through a third-party, be sure to request the nutritional information as part of your agreement. Refer to Options for Contracting Meals During COVID-19 for insights on purchasing and contracting and the Guide to Working with Restaurants and Grocery Stores for Meals for tips on working with food retailers.

# Groceries

Offering groceries (e.g., via delivery of food boxes) to seniors is another strategy to ensure they have an adequate supply of food on hand during an emergency. Providers may include a sample meal pattern along with grocery or supply deliveries that seniors can use as they make their own meals.

Groceries are foods that may be used by seniors to prepare meals. Groceries may not be counted as meals for reporting purposes; instead, these items are reported as Other Nutrition Services. Groceries cannot be structured in a way to count as a meal. In addition, groceries cannot be counted towards the Nutrition Services Incentive Program (NSIP) meals and funding allocations. Use of Title III-C funding to purchase groceries may reduce NSIP meal counts and thus the amount of the NSIP allocation that a SUA receives.

If groceries are provided caution should be used – remember the senior nutrition program is a *meals*program, there are other Federal programs which give seniors ways to purchase groceries or receive food boxes; we do not want to be duplicative of such programs. Please refer to ACL’s COVID-19 webpage guidance regarding how to report groceries and Using Groceries and Other Nutritional Services to Meet the Needs of Senior Nutrition Program Participants for more information on considerations for using groceries.

# Nutritional Requirements During the PHE

On January 31, 2020, due to confirmed cases of COVID-19, the Secretary of U.S. Department of Health and Human Services (HHS) declared a nationwide PHE. This led to new fiscal and programmatic flexibilities, including those affecting nutrition requirements for SNPs.

*DRI and DGAs Waiver*

Under normal circumstances, ACL cannot waive Title IIIC meal nutritional requirements. However, with the passing of the Coronavirus Aid Relief and Economic Security (CARES) Act, additional funding and authorities were granted, including waiving the requirement for Titles IIIC-1 and C-2 meals to meet the DRIs/DGAs during the entire PHE. States which have a Major Disaster Declaration (MDD) in place are permitted to bucket OAA funds (e.g., from Titles III B, III C, III D and III E).

*Once the PHE incident period ends, the flexibilities available for DRIs/DGAs also end. However, obligations made during the PHE incident period where these flexibilities were obligated may continue until the obligation is liquidated or the obligation period ends.*

*NSIP Meals*

At all times, even during PHE and Major Disaster Declarations (MDD), NSIP meals must meet the DRI/DGA requirements. ACL does not have the legal authority to waive NSIP requirements, and therefore, the DRI/DGA waiver does not apply to NSIP meals. Similarly, NSIP funds may not be bucketed or transferred.

Because it was understood that finding meals meeting the DRIs/DGAs may have been difficult during the pandemic, to ensure that future funding allocations would not be impacted ACL held harmless NSIP meal counts from FY2019 and applied them to FY2020-2023 NSIP allocations. However, beginning in FY2023

(starting October 1, 2022) ACL will resume using each state and/or territory meal count to establish NSIP allocations for FY2024.

For more information, Nutrition Services Incentive Program (NSIP) of the Older Americans Act Guidance addresses many questions around allocations, spending, and requirements of NSIP.

# Importance of Meeting DRI/DGA Standards

SNPs are encouraged to use DRI/DGA standards to help older adults maintain health and manage their chronic conditions. Nutritionally balanced meals ensure older adults are receiving the nutrients they need, particularly as the meals they receive through the SNP may be their only nutritious meal.

The flexibility in nutrition standards provided by ACL during the pandemic has helped SNPs to continue to provide meals even when food supplies and selection have been limited. However, serving meals that maintain nutrition requirements is essential to helping seniors remain healthy, especially during a public health emergency.

OAA nutrition program participants have high rates of chronic disease, including heart disease, hypertension, diabetes, and obesity. These chronic health conditions place older adults at greater risk for poor health, including making them more susceptible to COVID-19 and its short-term and long-term effects.

Adequate nutrition is essential for managing chronic health conditions and maintaining immune function. Older adults need to ensure they are eating nutritious foods that are low in sodium, saturated fats, and added sugars, and high in fiber, which is found in whole grains, fruits, and vegetables. Nutrients such as protein, the B vitamins, vitamins C, D, and E, and zinc, all boost the immune system. These nutrients are found in enriched grain and whole grain products, fruit, vegetables, dairy, dairy alternates, and protein products, such as meat.

See Appendix A for sample menus that meet DRI/DGA nutrition requirements.

# Calorie Requirements During COVID-19

As outlined earlier, SNPs should make every attempt to deliver the most nutritious meals possible, meeting the DRIs/DGAs. If unable to meet the DRI/DGA requirements, meals should provide a minimum of 1⁄3 of the recommended daily caloric intake for an older individual.

As seen in the chart below, calorie requirements are determined by a number of factors including the age, gender, and activity level of an individual. Remember that the demographics of participants served by a respective SNP may have changed during the pandemic, so a review of clients by program may be warranted to ensure the appropriate caloric levels are being met. A good rule of thumb would be to serve all participants meals that deliver approximately 600 calories for ease of production and delivery process.

*Under no circumstances should any OAA meal be lower than 534 calories.*The 534 minimum is based on pre-COVID-19 demographics (combining both home delivered and congregate data), which indicates the average participant is 80 years old, and 68% are female. An assumption was made that more participants are sedentary in their behavior based on recent national surveys and given changes in physical activity resulting from the pandemic.

### Males

[a] Sedentary means a lifestyle that includes only the physical activity of independent living; [b] Moderately Active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the activities of independent living; [c] Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the activities of independent living.

## Calculating calories

Understanding the portion sizes and calorie levels of specific foods is a critical step in determining total calories of a meal. There are many tools in the marketplace to help you calculate calories, including a number of websites and apps that are simple and easy to use. A few examples are:

· FoodData Central

· MyPlate

· Calorie King

· MyFitnessPal

Calories can also be calculated manually. Below are two examples of restaurant meals that were developed to deliver approximately 600 calories. Meeting the exact number of 600 is difficult, so it is recommended to exceed the 600-calorie target. See Appendix A for calorie guidance for specific food items.

Sample Meal Planner

# Appendix A

# Guide to Calculating Calories in Meals

Use the below charts to help you calculate the calories of a meal. Serving sizes are provided for commonly consumed food from the fruit, vegetable, grain, dairy, and protein groups.

## Fruits

· One fruit choice has 15 grams of carbohydrate and 60 calories.

## Vegetables

### Non-starchy vegetables

· One non-starchy vegetable choice (1⁄2 cup cooked or 1 cup raw) has 5 grams of carbohydrate, 2 grams of protein, 0 grams of fat and 25 calories.

### Starchy vegetables

· One starchy vegetable choice (cooked) has 15 grams of carbohydrate, 3 grams of protein, and 80 calories.

· Beans, peas, and lentils count as 1 starch choice + 1 lean protein choice.

## Grains

· One starch choice has 15 grams of carbohydrate, 3 grams of protein, 1 gram of fat and 80 calories.

· Unless otherwise indicated, serving sizes listed are for cooked grains.

### Bread

### Cereal

### Crackers

## Dairy

· One milk choice has 12 grams of carbohydrate and 8 grams of protein.

· One fat-free (skim) or low-fat (1%) milk choice has 0-3 grams of fat and 100 calories per serving.

· One reduced-fat (2%) milk choice has 5 grams of fat and 120 calories per serving.

· One whole milk choice has 8 grams of fat and 160 calories per serving.

### Fat-free (skim) or low-fat (1%)

### Reduced fat (2%)

### Whole

## Proteins

· One ounce is usually the serving size for meat, fish, poultry, or hard cheese.

### Lean Protein

· One lean protein choice has 0 grams of carbohydrate, 7 grams of protein, 2 grams of fat, and 45 calories.

### Medium-fat protein

· One medium-fat protein choice has 0 grams of carbohydrate, 7 grams of protein, 5 grams of fat and 75 calories.

### High-fat protein

· One high-fat protein choice has 0 grams of carbohydrate, 7 grams of protein, 8 grams of fat and 100 calories.

· *Notes: These foods are high in saturated fat, cholesterol, and calories and may raise blood cholesterol levels if eaten on a regular basis. Limit consumption to 3 or fewer choices from this group each week.*

### Plant-based protein

# Appendix B

# Frequently Asked Questions

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## What are the recommendations for providing food and meal services during the COVID-19 pandemic, and looking forward, to reopening meal sites?

State Units on Aging (SUAs), Area Agencies on Aging (AAAs), and local nutrition services providers are working under stressful conditions to provide services to vulnerable older adults during the COVID-19 pandemic. During this time, SUAs and AAAs may want to provide additional guidance and technical assistance to program sites. Local nutrition service providers may need to rethink their usual way of providing services, and balance trying to meet both short- and long-term needs, including during reopening.

Some state and local nutrition providers are collaborating with **local restaurants, food banks, grocery stores**, and other food vendors to design meals that meet DRIs/DGAs. This public health emergency can be an opportunity to expand services with a new partner, help keep local restaurants open, and take advantage of local food service expertise and food supply chains. Programs have used restaurant partnership and restaurant vouchers for over 40 years. Guide to Working with Restaurants and Grocery Stores for Meals may be a helpful resource.

The additional funding available through the COVID-19 recovery funds will not last forever. The COVID-19 emergency is not a sprint, but a marathon. Local nutrition service providers may need to continue to adjust service provision methods and operations to deal with increasing demands, social distancing constraints, fewer employees and volunteers, confusion over requirements, and exhausting work schedules.

For more strategies and a consideration of the complexities of **reopening**and related policies and procedures, be sure to reference:

· Reopening Considerations for Senior Nutrition Programs

· Reopening Signage & Communication Resources for Senior Nutrition Programs

· Reopening Resources List for Senior Nutrition Programs

These resources are designed to address many of the questions and issues senior nutrition programs are encountering with reopening decisions. Nutrition programs are encouraged to be prepared to move forward, but also for the potential need to move back to more limited in-person programming. Additional federal recovery funds should be used to address these hybrid models, and future policies should examine their effectiveness in reaching targeted populations and achieving equitable service provision.

## Do frozen meals, shelf stable meals, or Federal Emergency Management Agency (FEMA) meals meet the DRIs/DGAs?

Many vendors of frozen meals and shelf stable meals advertise that their meals meet OAA nutrition requirements. If an SUA, AAA, or local provider requests nutrition information from them, these vendors should be willing to provide it. It is the responsibility of the entity buying meals to determine whether the purchased meals are in line with the policies, procedures, and guidance from the SUA about meeting the DRIs/DGAs. Two resources to assist with purchasing meals can be found here:

· Options for Contracting Meals During COVID-19

· Contracting Toolkit: Tips for Purchasing Meals During COVID-19

Meals available through FEMA may be designed to meet the nutritional needs of a widely varying population and generally contain more calories than would be recommended for older adults. Additionally, these meals may need to be supplemented with a dairy or dairy alternative, such as a packet of non-fat dry milk or container of ultra-high temperature milk, as FEMA meals do not always include a dairy or dairy alternative.

Frozen meals may also need supplementation, such as with a dairy or dairy alternate source, and possibly a fruit or grain product.

Shelf-stable meals may be high in sodium and may not contain adequate potassium or protein. They may also provide too many carbohydrates and too much added sugar. All of these are nutrients of concern for those with hypertension, heart disease, and diabetes.

As previously stated, although meals funded during this the PHE do not require adherence to the DRIs/DGAs, SUAs, AAAs, and local nutrition service providers are encouraged to continue to provide quality, healthy, nutritious, palatable meals to older adults in order to keep them healthy. If nutrition providers must serve meals that do not meet DRIs/DGAs, they are encouraged to provide older adults with written nutrition education materials to help their decision process. Tele or Virtual Nutrition  Education for Older Adults and Senior Nutrition Program COVID-19: Response and Recovery Promising Practices Collection may be helpful resources to review.

## Can shelf stable meals meet the nutritional requirements for NSIP?

If the shelf stable meals meet the DRIs/DGAs, and part of the meal is domestically produced, the meals would meet the nutritional requirements of NSIP. Programs should be aware that some shelf stable meals may be higher in sodium than recommended by the DRIs/DGAs. Meals which do not meet nutritional standards can be supplemented to meet NSIP requirements, for example, by adding milk, which is domestically produced.

To learn more about NSIP meals, including participant eligibility and donation requirements, see Nutrition Services Incentive Program FAQ.

## Can SUAs allow local nutrition service providers to send boxes of groceries to older adults rather than meals?

COVID-19 recovery funding (e.g., FFCRA, CARES Act, Supplemental 5-HDC5, and the American Recovery Plan Act) provides maximum flexibility to the aging services network. SUAs, AAAs, and local providers are encouraged to provide meals and food that meet the DGAs and the DRIs. When purchasing any food or meals for older adults, consider both the nutritional needs of the individuals and the availability of healthy foods.

The USDA website, MyPlate, provides suggestions for food and meal planning during the COVID-19 pandemic. The suggestions include shopping lists, grocery store tips, and recipes. Local nutrition service providers may want to use these suggestions to assemble bags or boxes of groceries that require limited preparation. Additional resources that may be helpful:

· FAQs: Groceries and OAA Programs

· Using Groceries and Other Nutrition Services to Meet Senior Needs

· Partnerships with Foodbanks and Other USDA Programs

## What is a common eating pattern that provides adequate nutrition and meets the requirements of the DRIs/DGAs?

Below is a common eating pattern for lunch or dinner funded by the OAA and used by many SUAs, AAAs, and local providers with a sample menu.

## How can SUAs provide additional help during this emergency?

During the COVID-19 pandemic, SUAs provide a conduit for essential, accurate, and supportive information. They are a lifeline to AAAs and local nutrition service providers looking for guidance, assistance, and up-to-date information about what is happening in the state.

SUAs can assist in providing information for older adults on topics such as healthy eating during an emergency, food for two weeks,food safety during COVID-19 for consumers and food service, and suggestions for keeping safe. They can also share tips and guidance on food service, catering contract procurement, and food assistance programs.

SUAs may visit the National Resource Center on Nutrition & Aging to find current resources and information for the nutrition and aging network, including webinars, white papers, and samples of state policies to help program staff develop trainings and policies.

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