U.S. GOVERNMENT PUBLISHING OFFICE

27–803 PDF WASHINGTON : 2019

S. HRG. 115–467 

NOURISHING OUR GOLDEN YEARS: HOW PROPER 

AND ADEQUATE NUTRITION PROMOTES 

HEALTHY AGING AND POSITIVE OUTCOMES 

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

WASHINGTON, DC 

JULY 12, 2017 

Serial No. 115–7 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.govinfo.gov 

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SPECIAL COMMITTEE ON AGING 

SUSAN M. COLLINS, Maine, Chairman 

ORRIN G. HATCH, Utah 

JEFF FLAKE, Arizona 

TIM SCOTT, South Carolina 

THOM TILLIS, North Carolina 

BOB CORKER, Tennessee 

RICHARD BURR, North Carolina 

MARCO RUBIO, Florida 

DEB FISCHER, Nebraska 

ROBERT P. CASEY, JR., Pennsylvania 

BILL NELSON, Florida 

SHELDON WHITEHOUSE, Rhode Island 

KIRSTEN E. GILLIBRAND, New York 

RICHARD BLUMENTHAL, Connecticut 

JOE DONNELLY, Indiana 

ELIZABETH WARREN, Massachusetts 

CATHERINE CORTEZ MASTO, Nevada 

KEVIN KELLEY, Majority Staff Director 

KATE MEVIS, Minority Staff Director 

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CONTENTS 

Page 

Opening Statement of Senator Susan M. Collins, Chairman .............................. 1 

Statement of Senator Robert P. Casey, Jr., Ranking Member ............................ 2 

PANEL OF WITNESSES 

Connie W. Bales, Ph.D., RD, Professor, Division of Geriatrics, Senior Fellow, 

Center for the Study of Aging, Duke University School of Medicine; Associate Director of Geriatrics Center, Durham VA Medical Center, Durham, 

North Carolina ..................................................................................................... 4 

Seth A. Berkowitz, M.D., MPH, General Internist, Massachusetts General 

Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, 

Massachusetts ...................................................................................................... 6 

Elizabeth Pratt, MPH, SNAP–Ed Program Manager, University of New England, Portland, Maine .......................................................................................... 8 

Patricia Ann Taylor, Retiree, Penn Hills, Pennsylvania ...................................... 10 

APPENDIX 

PREPARED WITNESS STATEMENTS

Connie W. Bales, Ph.D., RD, Professor, Division of Geriatrics, Senior Fellow, 

Center for the Study of Aging, Duke University School of Medicine; Associate Director of Geriatrics Center, Durham VA Medical Center, Durham, 

North Carolina ..................................................................................................... 32 

Seth A. Berkowitz, M.D., MPH, General Internist, Massachusetts General 

Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, 

Massachusetts ...................................................................................................... 35 

Elizabeth Pratt, MPH, SNAP–Ed Program Manager, University of New England, Portland, Maine .......................................................................................... 43 

Patricia Ann Taylor, Retiree, Penn Hills, Pennsylvania ...................................... 45 

ADDITIONAL STATEMENTS FOR THE RECORD

Meals on Wheels, Testimony .................................................................................. 48 

National Association of Nutrition and Aging Services Programs, Testimony .... 51 

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NOURISHING OUR GOLDEN YEARS: HOW 

PROPER AND ADEQUATE NUTRITION 

PROMOTES HEALTHY AGING AND 

POSITIVE OUTCOMES 

WEDNESDAY, JULY 12, 2017 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The Committee met, pursuant to notice, at 9:31 a.m., in Room 

SD–562, Dirksen Senate Office Building, Hon. Susan M. Collins 

(Chairman of the Committee) presiding. 

Present: Senators Collins, Fischer, Casey, Gillibrand, Donnelly, 

Warren, and Cortez Masto. 

OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, 

CHAIRMAN 

The CHAIRMAN. The Committee will come to order. 

Good morning. We all know the importance of nutritious food to 

our health and well-being. Yet as many as one out of every two 

older Americans is at risk for malnutrition. 

The number of older Americans who are food insecure, or uncertain of their ability to acquire nutritious foods, is troubling. In 

2014, more than 10 million Americans age 65 or older experienced 

food insecurity. This represents 16 percent of all older Americans. 

In Maine, one out of six seniors lives with the threat of hunger. 

With the arrival of America’s Baby Boomers into older age, the 

number of seniors who are food insecure will increase. 

Seniors in Maine and across the Nation are increasingly finding 

themselves choosing between buying nutritious food and paying essential bills. Donna, a 76-year-old woman from Steuben, Maine, reports having to make this trade-off. She has a farm, grows her own 

vegetables, and raises her own meat. Yet she still struggles to 

make ends meet. Donna said, ‘‘I never thought I would have to ask 

anyone for any help. At 76, you should be retired, or you should 

be able to take care of yourself.’’ Donna turns to her local food bank 

for staples such as lettuce, dried beans, and rice to help her get by 

during Maine’s long winters. 

Federal programs that help to keep such food banks stocked and 

meals delivered to seniors play a critical role. These programs 

work. They reduce food insecurity and improve health outcomes. 

They are also cost-effective. For the cost of a single day in a hospital, Meals on Wheels is able to feed a senior for an entire year. 

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We will hear today about how the University of New England is 

coordinating SNAP–Ed in my State. This is a Federal program that 

helps families and older Americans learn how to shop, cook, and 

eat healthy meals on a budget. 

Private partners are also playing an important role. Four years 

ago in Maine’s most northern county, a local family donated land 

and a company donated seeds to begin what would grow into a program called ‘‘Farm for Maine’’ to provide vegetables to those most 

in need. Farm for Maine partnered with Catholic Charities and has 

produced hundreds of thousands of pounds of nutritious food for 

those in need in Aroostook County—my home county, I would point 

out. 

With changing demographics, it will take all hands on deck to 

stay afloat. Today 15 percent of Americans are ages 65 and older. 

By 2060, this proportion will grow to one-quarter of our population. 

At the same time, markers of poor nutrition among seniors are on 

the rise. 

While the traditional image of a malnourished senior has been 

a frail and underweight older American, we will learn today that 

overweight, rather than just underweight, and obese seniors can 

also suffer from severe malnutrition. 

More than one-third of American adults are obese, and this trend 

is reflected in our seniors. If current trends continue, the obesity 

rate would raise to 44 percent by 2030. With the convergence of an 

aging population and poor nutrition, we are challenged to meet a 

public health threat of unknown proportions. 

We will learn today about the ways in which industry stakeholders, from grocery stores to health systems, are partnering with 

academia and community organizations to respond to food insecurity and to change the trajectory that worries us all. 

One solution puts into practice a piece of sage advice heeded by 

the father of medicine. Hippocrates said, ‘‘Let food be thy medicine 

and medicine thy food.’’ 

Hippocrates gave us that advice more than two millennia ago. 

Today we will learn from modern research how food can indeed 

serve as medicine, and vice versa. 

We are beginning to discover solutions that work. Research has 

found that appropriate nutrition in seniors promotes better health 

outcomes from reducing falls and diabetes to improving mobility 

and cardiovascular function. Translating this research can help to 

alter the forecasted tides of malnutrition for the one out two seniors at serious risk, while improving daily life for all older Americans. 

I would now like to call on our Ranking Member, Senator Casey, 

for his opening remarks. 

OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., 

RANKING MEMBER 

Senator CASEY. Thank you, Chairman Collins, for holding this 

hearing and for allowing us to discuss the issue of nutrition among 

older Americans and food insecurity as well. 

Today far too many older Americans do not know where their 

next meal is coming from, as Senator Collins just outlined. 

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These are the hardworking Americans who fought our wars, 

taught our children, and built the middle class. They should not 

have to struggle in their golden years for something as basic as the 

security of knowing they will have enough to eat. 

In 2014, 10.2 million seniors aged 60 and up faced this terrifying 

insecurity. More than 13 percent of seniors in Pennsylvania alone 

reported food insecurity. That means tens and tens of thousands of 

Pennsylvanians facing that insecurity. Those who are food insecure 

often suffer in silence, embarrassed to admit that they need help. 

And lack of adequate nutrition creates significant economic costs to 

society through increased doctor visits, emergency room visits, hospitalizations, and disability. 

Meals on Wheels reports that the disease-related cost of malnutrition is estimated to be approximately $51 billion. Their report 

finds that about 60 percent of older adults in emergency rooms are 

either malnourished or at risk of malnutrition. Up to 33 percent of 

older adults admitted to the hospital may be malnourished. 

The menu of nutrition programs supported by the Federal Government can actually help. 

We will hear from researchers today who will tell us that investing in nutritious meals for seniors contributes to better health outcomes and lower health care spending for the individual as well as 

the system itself. 

We know that healthy eating leads to healthier living. It is just 

common sense. And it is for this reason that I will continue to vocally oppose cuts to the Supplemental Nutrition Assistance Program (SNAP)—we used to call it ‘‘food stamps’’—cuts to Meals on 

Wheels, Congregate Meals; The Senior Farmers’ Market Nutrition 

Program; as well as the Commodity Supplemental Food Program, 

which serves the senior food box that our witness, Mrs. Taylor, receives in Allegheny County. 

These programs help seniors from having to decide between putting food on the table—specifically nutritious food—and refilling a 

prescription. 

Unfortunately, seniors right now are facing a threat to their nutrition and, I believe, their health care at the same time. The proposed budget cuts that I outline to those senior programs, senior 

nutrition programs, paired with the proposals to decimate Medicaid 

could devastate the health and financial security of entire families. 

We are better than that in America. And so we are grateful today 

to our witnesses for joining us here today to shed light on the important role that Federal Government programs play in promoting 

healthy aging. 

Thank you very much. 

The CHAIRMAN. Thank you, Senator. And I want to acknowledge 

that the idea for this hearing came from Senator Casey, and I 

thought it was an excellent one, and I was happy to pursue it. 

Our first witness today is Dr. Connie Bales, a professor at Duke 

University School of Medicine in the Division of Geriatrics. Dr. 

Bales also serves as the associate director of the Geriatric Center 

at the Durham VA Medical Center. She is the editor in chief of the 

Journal of Nutrition in Gerontology and Geriatrics. I am not sure 

I know what the difference between the two of those are. Dr. Bales 

will also discuss her most recent work concerning new trends in 

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senior malnutrition and the development of diet-based interventions. 

We will next hear from Dr. Seth Berkowitz, an assistant professor at Harvard Medical School. Dr. Berkowitz is a primary care 

physician at Massachusetts General Hospital. His research focuses 

on the impact of adverse social and economic circumstances on 

chronic disease management. Dr. Berkowitz will discuss food insecurity and interventions to prevent and treat chronic diseases 

through nutrition. And if the two doctors could cure my cold while 

you are here, I would appreciate that as well. 

Next I am delighted to introduce Elizabeth Pratt. She is the program manager of the Maine Supplemental Nutrition Assistance 

Education Program at the University of New England. SNAP–Ed 

is a U.S. Department of Agriculture program that teaches low-income individuals the knowledge and skills needed to make 

healthier lifestyle choices within a limited budget. UNE delivers 

SNAP–Ed through 23 community-based coalitions and reached 

more than 3,000 Maine seniors in 2016 alone. Ms. Pratt will discuss the innovative work she is leading in Maine to increase seniors’ access to healthy foods. 

And I would now like to turn to Ranking Member Casey to introduce our witness from Pennsylvania, but I welcome you also. 

Senator CASEY. Thanks, Chairman Collins. I am pleased to introduce Pat Taylor from Penn Hills, Pennsylvania. I mentioned Allegheny County in my opening. I was just making a reference to the 

home county of Pat and where Penn Hills is located. 

Pat is a wife, a mother, a grandmother, and as of today a community advocate and a witness on this critically important issue 

that we are here to discuss. Pat, along with her husband, James, 

has raised 10 children in total—5 biological children, 5 adopted 

boys with disabilities. My mother raised eight. I thought that 

was—my mother and my father, but mostly my mother, raised 

eight, and I thought that was a lot. 

Two of Pat’s daughters have joined us here today. Would you 

mind putting your hands up? Thank you very much for being here. 

Having worked her whole life, Pat never imagined to have to 

struggle to make ends meet after retirement. Pat will tell us about 

the monthly food box she receives from the Commodity Supplemental Food Program. 

So, Pat, we want to thank you for being here, for telling your 

story and that of your family, so that we can learn from you and 

also so that we can help other older Americans and their families 

facing similar challenges. Thanks, Pat. 

The CHAIRMAN. Thank you, Senator. 

We will start with Dr. Bales. 

STATEMENT OF CONNIE W. BALES, PH.D., RD, PROFESSOR, DIVISION OF GERIATRICS, SENIOR FELLOW, CENTER FOR THE 

STUDY OF AGING, DUKE UNIVERSITY SCHOOL OF MEDICINE; 

ASSOCIATE DIRECTOR OF GERIATRICS CENTER, DURHAM 

VA MEDICAL CENTER, DURHAM, NORTH CAROLINA 

Dr. BALES. Good morning, Chairman Collins, Ranking Member 

Casey, and members of the Aging Committee. Thank you for this 

opportunity to testify. My name is Dr. Connie Bales, and I am a 

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professor at the Duke University School of Medicine and an associate director of the Geriatrics Center at the VA Medical Center in 

Durham, North Carolina. I have been working in nutrition and 

aging research for the past 30 years, focusing on older adults as a 

population at high risk for malnourishment. Leading reasons for 

this malnutrition risk include physical changes that increase nutrient needs as well as social and economic limitations that reduce access to food. Older adults commonly also face multiple chronic 

health conditions; the medications they take and special diet restrictions they need to follow further increase their nutritional risk. 

I will bring to your attention two important trends that have 

dramatically altered the profile of malnutrition in older Americans. 

The first of these trends is the ongoing epidemic of obesity occurring in the United States. 

Rather than gaining weight slowly over time, now over one-third 

of Americans spend decades of their lives exposed to obesity. This 

is a situation that has never before been encountered in our society. 

As this Committee is well aware, the second dramatic trend is 

that of population aging. With the convergence of these two trends, 

geriatric obesity is now very common. Almost 40 percent of older 

Americans are obese, many with morbid levels of obesity. 

Contrary to what people may believe, being overweight or obese 

does not correspond with over-nutrition. In fact, obesity is a marker 

of malnutrition. Many obese older adults are not getting the nutrients they need. With low metabolic rates and little energy being 

spent on activity, their food intakes may actually be quite low 

while their nutrient requirements are the same or even higher. 

This state of chronic malnutrition creates major threats to 

health. We know that risk of chronic conditions like diabetes, heart 

disease, and arthritis increase with age. Aging muscles reduce in 

size and strength and fat accumulates around essential organs in 

the body core. Obesity leads to all of these same changes. So it 

brings a double threat, hastening chronic disease progression and 

hindering the ability to move around and be functionally independent. 

No longer is the typical picture of malnutrition in older adults 

one of a weak, thin elder subsisting on ‘‘tea and toast.’’ Soon the 

most common type of nutritional frailty will be the older adult who 

has excessive body fat that masks weak muscles and limits function. This condition, which is called ‘‘sarcopenic obesity,’’ enhances 

a host of health problems. It makes surgery and other medical 

treatments more risky, and it hastens the need for institutionalization. 

Obese older adults have a much greater likelihood of getting admitted to a nursing home than non-obese elders. Besides the increased cost to society of this early admission, nursing homes incur 

greater costs caring for the obese. Renovated facilities, larger 

equipment, and higher personnel costs are needed for their care. 

Some nursing homes are turning away those who are excessively 

obese. 

Obesity is highly correlated with food insecurity, the situation of 

having uncertain or limited access to nutritious food. We know that 

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both poor health and food insecurity interfere with the intake of 

adequate amounts of protein, vitamins, and minerals. 

Obesity treatment is challenging at any age, and it can be especially challenging in older adults. But we know that reducing obesity and improving diet quality is achievable for seniors and it 

lessens health problems like diabetes and hypertension and reduces the risk of falls while dramatically improving function. 

My research focuses on older adults with distinct mobility limitations due to their excessive body fat. These individuals often have 

multiple chronic diseases. They also have a very limited ability to 

burn calories and strengthen their muscles through exercise. My 

research team and I are testing a special 6-month diet intervention 

based on generous servings of high-quality protein from lean meats 

and low-fat dairy products at each meal. Our goal is to achieve the 

loss of body fat without the loss of muscle. We have shown that 

there are marked improvements in functional ability when frail, 

obese older adults reduce their obesity; but our higher protein diet 

does produce the best results for function so far. 

We have also discovered potential problems, however, with diet 

adherence and treatment responses that are linked with race and 

lower income level. Our future studies will explore enhanced interventions for these individuals who are also at higher risk for food 

insecurity 

In closing, l hope that I have raised your awareness regarding 

an important challenge facing many older Americans. Please realize that even though it is not shown outwardly, an overweight or 

obese elderly person may very well be undernourished in ways that 

threaten their health and ability to live a life of quality. Our research has shown that dedicated efforts to improve the nutritional 

status of these individuals can literally transform them in terms of 

their abilities to live more independent and healthy lives. 

I thank you for the opportunity to share my thoughts with you. 

The CHAIRMAN. Thank you very much, Doctor. 

Dr. Berkowitz. 

STATEMENT OF SETH A. BERKOWITZ, M.D., MPH, GENERAL INTERNIST, MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT 

PROFESSOR OF MEDICINE, HARVARD MEDICAL SCHOOL, 

BOSTON, MASSACHUSETTS 

Dr. BERKOWITZ. Thank you. Chairman Collins, Ranking Member 

Casey, members of the Aging Committee, thank you for this opportunity to testify and to shine a spotlight on the importance of food 

security and nutrition in America’s seniors. 

As we heard, food insecurity, defined as uncertain or limited access to nutritious food, affected over 40 million Americans in 2015. 

Though the American economy has been out of recession since 

2009, food insecurity rates have been slow to decline and remain 

higher than pre-recession levels. 

Three risk factors for food insecurity hit older adults particularly 

hard: disability, social isolation, and having a low income. Epidemiological studies have associated food insecurity with a large and 

growing number of health conditions, including obesity, diabetes, 

hypertension, coronary heart disease, congestive heart failure, 

chronic kidney disease, depression and serious mental illness, and 

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osteoporosis. Food insecurity also leads to increased use of expensive health care services such as hospitalizations and emergency 

department visits. Given all this, it is not surprising that food insecurity is estimated to result in $77 billion in excess health care expenditures annually. Even more importantly, food insecurity has 

been associated with a 30 percent increase in mortality over longterm follow-up. 

Current research has identified three key pathways by which 

food insecurity affects health. 

First, and perhaps the most obvious, is by worsening dietary 

quality. Less nutritious foods are often cheaper than healthier 

foods like fresh fruits and vegetables, lean proteins, and whole 

grains. 

Second, people experiencing food insecurity face competing demands for their scarce resources. Those with food insecurity frequently make trade-offs between food and other necessities, in particular, medications. What is sometimes called the ‘‘Treat or Eat’’ 

trade-off, where individuals face difficulties affording food, medication, or both, affects one out of three adults with chronic illness 

and is a significant contributor to poor health. 

Third, it is important to realize that food insecurity is not only 

about food. It is also about the insecurity. Food insecurity worsens 

stress, depressive symptoms, and anxiety, and can sap the ‘‘cognitive bandwidth’’ needed for chronic disease self-management. 

Addressing food insecurity is critical for our Nation’s health. Our 

largest food insecurity intervention is SNAP, the Supplemental Nutrition Assistance Program. SNAP is known to reduce the depth 

and breadth of food insecurity, and, moreover, recent evidence 

shows that even though it is not specifically designed to do so, 

SNAP has important effects on health. By helping improve chronic 

disease management, a recent study found that SNAP saved $1,400 

per person per year in health care expenditures. 

Beyond SNAP, however, we have exciting new interventions to 

help combat food insecurity and improve health. One type of intervention involves screening for food insecurity and nutrition issues 

in clinical care, followed by linking patients to community resources to help meet these needs such as referral to a local food 

pantry. These programs have been found to improve blood pressure 

and cholesterol in older adults with chronic illness. 

Another very promising type of intervention is medically tailored 

meal delivery. As its name suggests, medically tailored meal delivery provides home delivery of fully prepared meals specifically tailored to the medical needs of the patient. For our sickest older 

adults, medically tailored meals offer many benefits. The Food Is 

Medicine Coalition is a group of charitable organizations that provide these types of meals and study their health effects. 

In California, medically tailored meal delivery was found to decrease depressive symptoms and increase medication adherence 

and dietary quality in patients with HIV and diabetes. Where I 

work, in Boston, a medically tailored meal organization called 

‘‘Community Servings’’ is also doing groundbreaking work. 

In partnership with the health insurer Commonwealth Care Alliance, we found dually eligible Medicare-Medicaid beneficiaries who 

received medically tailored meals had major reductions in hosAGING-G33-GPO with DISTILLER

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pitalizations and emergency department visits. This translated into 

important cost savings. Participants in the medically tailored meal 

delivery programs saved $6,500 per year in health care expenditures. 

Public-private partnerships are at the heart of these nutrition 

interventions. Government partnering with health care delivery 

systems, social service providers, and nonprofit organizations enable resources to be efficiently targeted to those in need and maximize the health gains achieved. The interventions described above 

all make clear what public-private partnerships can accomplish. 

When everything is taken together, I think the evidence is compelling. Food insecurity along with malnutrition and hunger are 

major public health threats for older adults. Nutrition programs 

offer important improvements in health, health care use, and 

health spending. You as Senators and policymakers need to make 

decisions based on the best available evidence. And in this case, I 

can give you unequivocal advice: Do not just protect but expand our 

investment in food security and nutrition programs for our Nation’s 

seniors. This will promote healthy aging, and improve the public’s 

health. 

The CHAIRMAN. Thank you very much for your testimony. 

Ms. Pratt. 

STATEMENT OF ELIZABETH PRATT, MPH, SNAP–ED PROGRAM 

MANAGER, UNIVERSITY OF NEW ENGLAND, PORTLAND, MAINE 

Ms. PRATT. Good morning, Chairman Collins, Ranking Member 

Casey—— 

The CHAIRMAN. I think your mic may not be on. 

Ms. PRATT. Oh, sorry. 

The CHAIRMAN. There you go. 

Ms. PRATT. Good morning, Chairman Collins, Ranking Member 

Casey, and members of the U.S. Senate Special Committee on 

Aging. Thank you so much for inviting me to testify. My name is 

Elizabeth Pratt, and I am the program manager of Maine SNAP– 

Ed based at the University of New England in Portland. 

We administer the SNAP–Ed contract through the Maine DHHS 

Office for Family and Dependents. SNAP–Ed is the USDA’s nutrition education arm of SNAP, the Supplemental Nutrition Assistance Program. It offers education, social marketing, and environmental support in all 50 States. SNAP–Ed uses evidence-based, 

comprehensive public health approaches to improve the likelihood 

that low-income individuals will make healthier food and physical 

activity choices, consistent with the current USDA Dietary Guidelines for Americans. SNAP–Ed is designed to complement SNAP 

with nutrition education and obesity prevention. It is not focused 

on outreach or promotion of SNAP. 

The purpose of the Maine SNAP–Ed program is to provide lowincome Mainers with easy ways to shop, cook, and eat healthy on 

a limited budget, essentially stretching their limited food dollars. 

We have 44 highly qualified nutrition educators who work in 

every Maine district, and they are based in local community coalitions and hospitals. They work with partner organizations to reach 

low-income Mainers across the age spectrum. The program follows 

detailed guidance from the USDA Food and Nutrition Service. Our 

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educators provide series-based nutrition education and implement 

policy systems and environmental change strategies. 

As you may know, Maine is the oldest state in the country. We 

have the highest percentage of older adults, and many of them are 

low-income. Food insecurity is very prevalent in our rural State. 

Roughly 203,000 Mainers face hunger every day. 

Maine’s seniors have a reputation for being independent and 

proud. They are reluctant to ask for help despite their need. 

However, Maine seniors are open to learning, and this is part of 

why I think our program is successful in reaching low-income seniors. While many seniors know how to cook, they are facing new 

health issues and dietary restrictions and are very interested in 

learning about nutrition as a way to improve their health. 

Our educators are often from the same communities where they 

work. They know where the eligible sites are and how to engage 

with them effectively and respectfully. All of the sites must serve 

at least 50 percent low-income individuals. Examples include housing sites, food pantries, and federally qualified health centers. In 

Maine, it is not difficult to find eligible sites. 

In 2016, there were almost 3,000 seniors who participated in 

three curricula that we offer for this age group: 10 Tips for Adults, 

Eat Smart Live Strong, and Cooking Matters for Adults. Our Cooking Matters programming is implemented in partnership with Good 

Shepherd Food Bank and Hannaford Supermarkets. 

In order to give you a sense of our work, I just want to give you 

two different examples of nutrition educators doing great work 

with seniors in Maine. 

Sara McConnell works in the Down East District, a rural and 

coastal region of Maine with significant poverty. In Sara’s own 

words, she describes the class and the unexpected result: ‘‘I think 

one thing that stands out to me with the work that I have done 

with seniors is the connections they made in the community because of SNAP–Ed. This really rings true when I think of the group 

of seniors living with cancer that participated in a Cooking Matters 

series in Calais. People from many communities traveled to the 

class not only to learn about healthier eating but to support each 

other while they were living with cancer or taking care of a loved 

one with cancer.’’ 

‘‘After the 6-week course, participants were more like family than 

class members. About a month after teaching the class, I ran into 

a participant at the grocery store. She was so excited to tell me 

that many in the class had continued to meet on a regular basis 

to do crafts, cook, and socialize. With few social events and resources available in the communities, the SNAP–Ed classes are 

very beneficial, not just in improving people’s health. It is much 

bigger than that.’’ 

As Sara’s story illustrates, not only do seniors benefit from improved nutrition, SNAP–Ed helps address the social isolation of 

rural seniors. 

I also want to tell you a brief story about an educator in Aroostook County. Heather McGuire is the educator based out of 

Houlton. She grew up in ‘‘The County,’’ as Mainers call northern 

Maine, and was raised as many children are in this special part of 

our State—to hunt, grow food, forage for fiddleheads, and help out 

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during the potato harvest. Because of this upbringing, she understands the importance of growing food in the county. She did a couple projects to increase access to the farmers’ market in Houlton 

and also to build raised-bed gardens at a senior housing facility. 

As the oldest State in the country, Maine has a responsibility to 

care for its seniors and optimize their health as they age. SNAP– 

Ed plays a critical role in addressing one of our Nation’s greatest 

challenges. The number of food-insecure seniors is growing, and it 

is expected to increase by 50 percent by 2025. 

Thank you for this opportunity to share our experience with this 

100 percent federally funded program and its importance to low-income seniors in Maine. 

The CHAIRMAN. Thank you very much, Ms. Pratt. 

Mrs. Taylor, welcome. 

STATEMENT OF PATRICIA ANN TAYLOR, RETIREE, PENN 

HILLS, PENNSYLVANIA 

Mrs. TAYLOR. Chairman Collins, Ranking Member Casey, and 

members of the Committee, thank you for inviting me to testify 

today. It is an honor to be here. My name is Patricia Ann Taylor. 

I am 72 years old and a resident of Penn Hills, Pennsylvania. 

I am married to the love of my life, James, who is 79 years old, 

and this past April we celebrated 51 years together. We have five 

biological children. Two of my daughters, Dawn and Toni, have 

joined me here today, both who are employed and volunteer at our 

food pantry. James and I also adopted five boys with special needs. 

We have always had a full house. We are a close-knit family, and 

I love having my 10 children, 15 grandchildren, and 17 greatgrandchildren around us. 

My husband and I have always worked to support our large and 

boisterous family. James was self-employed, an owner of a beer distributor and laundromat. I have held various positions in the 

health care sector, at times having to work two jobs. It was not always easy to put food on the table and pay our bills, but we managed somehow. My husband has always had a strong work ethic 

and always believed that he should be the provider for his family. 

As we have gotten older, our health care costs have taken up a 

greater share of the bills, and we were forced to struggle because 

of our health care expenses. My husband has beaten prostate cancer, survived two heart attacks, is an insulin-dependent diabetic, 

has blood clots in both lungs, and has been fighting blindness due 

to diabetic neuropathy. I have beaten breast cancer, had back surgery, total right knee replacement; I have multiple sclerosis, which 

now is in remission, and heart disease. 

It was not easy to ask for help with our food expenses. When 

talking with other adults in our age bracket, we learned about a 

food pantry in our neighborhood, the Lincoln Park Community 

Center, which is run by Joyce Davis. This center serves over 600 

needy families monthly, and seniors such as ourselves receive a 

senior food box once a month. The help that Ms. Davis provides to 

my husband and I has truly been a blessing. 

Because of the senior food box that we receive through the Lincoln Park Community Center, we do not have to decide between 

paying for our medication and putting nutritious food on the table. 

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11 

Ms. Davis serves so many needy families that have come to the 

Lincoln Park Community Center. She also serves over 100 people 

at another local senior center and over 75 at another food pantry 

monthly. Her services, as you can see by the number of needy families that come to these centers, show the need in our community. 

She has definitely been an asset in our community by how efficient, 

organized, and successful her food pantry is. She tells me that the 

Federal support she receives for this work is essential. 

Neither my husband nor I ever dreamed that we would come to 

rely upon the senior food box. We were hardworking adults, and we 

saved for our retirement. Again, at times I even worked two jobs. 

Before the senior box, I noticed that I was not purchasing as 

much food that would help keep us healthy. It started a vicious 

cycle that I knew was not good for our health. 

Things changed when I started receiving the senior food box. 

Last month, I received canned fruit and vegetables, spaghetti 

sauce, cereal, dry milk, cheese, pasta, peanut butter, and canned 

chicken. 

I can supplement these items with groceries like, fish, meat, 

fruits, vegetables, Ensure, and Boost. With those items that I receive from the senior food box, I can make creative dishes. Last 

month, I was able to make chicken salad, spaghetti, grilled fish, 

and baked chicken. These are nutritious meals for me and my husband. The senior food box stretches our groceries and our budget. 

I am especially appreciative of the senior food box because it helps 

my family afford Ensure and Boost, which my husband needs to 

drink due to his loss of appetite caused by health issues and medications. 

When Senator Casey’s office called me to talk about my experience with the senior food box, I said that I would do anything to 

help support nutrition programs that benefit seniors, and that is 

how I wound up in this chair. 

The senior food box has been a godsend to me and James, and 

I strongly urge you to support the senior food box programs, food 

banks, and other programs that help people like me. I urge you to 

help spread the word that programs like the senior food boxes are 

available. And I hope that people will be able to continue to receive 

the senior box. 

Again, thank you for the invitation to testify before the Committee, and I look forward to answering any of your questions. 

The CHAIRMAN. Thank you very much, Mrs. Taylor, for being 

with us today. 

As I listened to each of you testify, I was struck by the fact that 

the programs that you mentioned all help to reduce social isolation 

as well as meeting nutritional needs. And we know from previous 

hearings that this Committee has held that seniors who are socially isolated and lonely have higher rates of disease and mortality. So it seems to me these programs have the function of not 

only helping ensure that people get better nutrition, but bringing 

people into contact with other people, whether through home-delivered meals or a senior center visit. And I think that is really important, and it struck me, as all of you talked about it, that that 

was a common element. 

AGING-G33-GPO with DISTILLER

12 

Dr. Berkowitz, I am going to start with you because I was so 

struck by the statistic that you gave us that food insecurity is estimated to result in $77 billion in excess health care expenditures 

annually. And this truly is an example of where we have to be 

careful not to be penny wise and pound foolish by reducing essential nutrition programs that help keep people healthier and would 

help lower that astonishing figure. 

You described the promise of using medically tailored foods based 

on pilot projects and demonstrations, and I had not heard of that 

concept, but it fits in with the advice from Hippocrates that I mentioned in the opening statement. 

Tell us a little bit more about that and how you would move from 

demonstration projects to scaling up this concept of medically tailored foods. 

Dr. BERKOWITZ. Thank you. That is a great question. Medically 

tailored meals are a program I am very excited about. We have 

known for a long time that home-delivered meals that are often 

non-tailored, like Meals on Wheels, have important benefits. But as 

people get sicker and their nutritional needs become more complicated, there becomes an opportunity to increase the value by 

specifically tailoring it in that way. 

A number of organizations across the country are able to provide 

these, but their overall numbers are small. And I think moving forward, the way to scale this is really through a public-private partnership. I think the organizations with the skills are out there, but 

we do not currently have a good mechanism to finance and grow 

these organizations, and so something that has been proposed that 

has worked well in demonstration projects is making this a covered 

benefit under certain circumstances. 

Now, you need to be selective about who these are for. This is 

not something where you would just rush out to do this if you have 

not tried other things, like the senior food box or SNAP enrollment 

or even non-tailored food. But for the most expensive people, if you 

can find the sort of appropriate situations to use it in, I think we 

have evidence to guide us in doing that. I think making this a covered benefit and then partnering with these private organizations 

that have experience in both the logistics of delivering the meals 

and the skills with registered dieticians on staff to really make 

sure the meals are meeting the needs of the people they serve has 

a lot of promise. 

And as you pointed out, these are often interventions that have 

a relatively small day-to-day cost but can avert a lot of the big-ticket items, like a very expensive hospitalization or emergency department visit or need for surgery or something like that. 

The CHAIRMAN. It seems to me that they also could be particularly helpful for people with cognitive impairments who may be 

having difficulty in swallowing certain foods. Is that another part 

of this? 

Dr. BERKOWITZ. That is absolutely right. So I think one of the 

real advantages of these are that you can sort of meet people where 

they are in terms of their needs. And so if their need is that they 

need a mechanical soft diet or, you know, they are on dialysis and 

need to avoid particular concentrations of potassium or something 

AGING-G33-GPO with DISTILLER

13 

like that, you can really finely dial in and get people exactly what 

they need. 

Other people may not need that. They may be able to shop themselves, prepare the food they need, and do that. But I think there 

are a lot of people in this situation where having that fine control 

over the healthy diet for them can really help meet their needs in 

the short term and prevent these long-term consequences. 

The CHAIRMAN. Thank you. 

Ms. Pratt, I love the metaphor that you told my staff, that SNAP 

provides a family with a fish and SNAP–Ed teaches a family to 

fish, and I would say teaches the family how to prepare that fresh 

fish, which is not necessarily a skill that all of us would have. 

You also told us that nearly three-quarters of Maine adults do 

not eat enough fruit and vegetables. After enrolling in the SNAP– 

Ed programs and training sessions, have you seen changes in the 

nutritional patterns of participants? In other words, is this program working to help solve that problem? 

Ms. PRATT. That is a great question, and we do have a lot of data 

nationally from all the SNAP–Ed programs across the country and 

our own data in Maine that shows that there is an increase in fruit 

and vegetable consumption with some of our curricula. 

We do have a small evaluation—we have one staff person who 

does internal evaluation on our team. She does a lot of quality improvement work and looks at key outcomes and tracks the classes 

and looks at two things, really, looks at their intent to change behavior and then also increases in fruit and vegetable consumption; 

and we have seen that this is working in Maine. And we also have 

an external evaluator. The State hires Altarum Institute to also 

evaluate our program, and a lot of the high-level data is in the annual report that I provided to each member on the Committee, and 

there are summaries of some of this data. And then we also have 

a full report with additional data that we can provide, if people are 

interested, or some of the Altarum data. 

But I do want to mention that all of the curricula that we choose 

is evidence-based, so we are using—and the USDA provides guidance to all SNAP–Ed programs and wants them to choose curricula 

that have been proven to work, that have been proven to increase 

fruit and vegetable consumption. And so my role as a manager is 

really to ensure that all of our educators are following and using 

that curricula with fidelity. And then I know that if they are doing 

that and if we really do a lot of work with them and training and 

technical assistance, then we know that we are following the guidance and most likely, you know, all of that work will pay off with 

increased benefits, and we will see behavior change across the 

State. 

The CHAIRMAN. Thank you. 

Senator Casey? 

Senator CASEY. Thanks very much, Chairman Collins. 

Pat, I wanted to start with you and highlight some of your testimony and focus in particular on the food box, the impact that has 

on your life and the life of your family. 

I was interested to read in your testimony that in addition to 

talking about what the food box means to you, you said something 

which was interesting in the sense that it is probably an underAGING-G33-GPO with DISTILLER

14 

appreciated part of this discussion. You said on page 2 of your testimony, ‘‘The senior food box stretches our groceries and our budget.’’ And I wanted to have you talk about that for a moment, because sometimes I guess we think of it as just a quantity of food 

as opposed to having a positive impact in other ways on your budget. Can you talk about that? 

Mrs. TAYLOR. I guess I am talking about my family, our nutritional needs, my husband’s especially, he needs the Boost and the 

Ensure along with the protein and vegetables and all those other 

things. Without the food box, I could not stretch my budget to meet 

those needs. 

Just to give you an example, his insulin test strips—and we have 

insurance. You know, we have Medicare and good supplemental insurance. Still, he is paying out of pocket $75 for the test strips several times a month because of how much testing he has to have 

done. 

I do not want to make the decision of his health care versus what 

I put on the table. I want protein, and I want the nutritional—you 

know, the food elements that we should be eating to keep him 

healthy, to keep us healthy. And that would go for all seniors. 

In talking with other people that are in our age group, you know, 

some of those people really cannot afford based on what their Social Security is monthly. I have worked all my life, so mine might 

be higher than somebody who has been just a mother—not ‘‘just a 

mother,’’ but, you know, a stay-at-home parent and does not have 

that X amount of dollars put into Social Security. 

So juggling is definitely a task that, you know, when you are 

faced with food, medicine, and other needs, it is difficult to do. 

Senator CASEY. So the food box, it is not just the quantity of the 

food; it is the healthy impact of it. 

Mrs. TAYLOR. Well, it is the nutrition that is in that box. It is 

the proteins and all those things that are needed on that table 

monthly to get us through, you know, that we should have for 

healthier living. You know, you hope that the cost of medical expenses is cut down because you are eating better. You know? 

Senator CASEY. Well, I was noting as well that I am not sure I 

have ever seen a list this long of health challenges for one individual. Your husband: cancer, two heart attacks, insulin-dependent 

diabetic, blood clots, fighting blindness. And you yourself had 

breast cancer, back surgery, lung replacement, and MS. That is 

quite a set of challenges. 

Mrs. TAYLOR. And I had to quit work because of heart disease. 

You know, again, we have worked all our lives, and, you know, to 

ask for somebody or go somewhere for additional help was a struggle. My husband is a very proud man and, as I said earlier in my 

testimony, always felt that he should be the one to put the food on 

the table and, you know, it is like—it was a lot of soul searching 

to be able to go to the food pantry and accept that food box. But, 

you know, I am glad we did, and I am hoping for other seniors 

that, again, I have talked to, it is a blessing. 

Senator CASEY. Thanks, Pat. 

The CHAIRMAN. Thank you. 

Senator Fischer? 

Senator FISCHER. Thank you, Madam Chairman. 

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15 

Dr. Bales, you mentioned in your testimony that the convergence 

of obesity and population aging are causing serious health problems for society, and one trend that we have seen in Nebraska is 

an increase in the number of community gardens, which, as you 

know, involve multiple people and they use a shared space to grow 

food. And these gardens often encourage a healthier lifestyle, more 

outdoor physical activity, healthier eating with fresh fruits. 

It seems to me that promoting further development of community 

gardens would be one way that we could combat both malnutrition 

and obesity at the same time. Would you agree with that? 

Dr. BALES. I definitely would agree with that. You know, the two 

pillars of the health that we are talking about are diet and exercise. The need to have a very high nutrient density in the amount 

of calories that you eat is difficult to meet as I said, because appetites are not that big for some of these older folks, but they still 

have to get all the vitamins and minerals. They almost need like 

the most nutritious diet they have ever had, and so the garden 

would do that. And then the moving around, move it or lose it, you 

know, is so important. 

So I think both of those things would be accomplished, along 

with the connection of reduced loneliness that Senator Collins mentioned. 

Senator FISCHER. And do you have any other suggestions on a 

way that we can promote combating obesity and what comes with 

aging, including physical activity and loneliness? 

Dr. BALES. I think that we need nutrition screening in primary 

care. Like when you go at least once a year for your check-up, there 

needs to be an assessment. And if an individual is malnourished 

or at risk of malnutrition, that would be picked up. And they 

should spend an hour with a registered dietician or a nutritionist 

and identify their plan: Do I have osteoporosis? Do I have heart 

disease? And I know that I am not addressing obesity specifically 

with this comment, but you cannot do all things. We get more and 

more different as we age, and so you cannot get your health priorities from the news or the back of the cereal box. You need to 

know: What do I need as an individual? And some guidance with 

that would really help. 

And then they are going to need guidance to reduce their weight. 

If you can lose just even 5 percent of your body weight or more, 

you will get benefits to your chemistries, to your metabolism. 

So I think the fact that older adults like to work together, they 

are actually quite open to new things, that they can actually do 

this. You know, they learn diabetic exchanges in our classes, and 

they can quote you the calories in different foods. So they can do 

it. The education really helps. But also putting things into their 

hands, like the gardens would do, like home-delivered meals do, 

that is the other piece that they lack. 

I want to say something about the independence. The group allows them to be independent of their children, to not ask for help 

and continue to be on their own, and that is the great thing about 

things that get food close to or actually into the home. 

Senator FISCHER. You had talked about the 6-month diet intervention, and your team is currently testing that. Could you tell us 

AGING-G33-GPO with DISTILLER

16 

a little more about that? And if you can, tell us some of the early 

findings that you have seen in that. 

Dr. BALES. Sure, sure. So let me just say that 6 months is not 

a magic time. That is just usually about how long funding allows 

you to do a research study, so you see a lot of them that way. So 

what we are doing is a very moderate weight loss intervention for 

obese older adults who are functionally limited, meaning that they 

are having trouble getting around, walking, getting up out of a 

chair, mostly because of the heaviness of their bodies. So we want 

them to lose their body fat but not their muscle, which we all have 

a tendency to do when we diet if we do not exercise. Well, it is a 

little hard to exercise if you walk with a cane or a walker. You can 

do some, but not a lot. 

So what we are testing is a higher protein intake at every meal 

during the day while the calories are low enough to lose weight. We 

are hoping that that can kind of substitute for exercise until they 

can get to the point that they are able to exercise more. 

So let me just say that in all of our frail, obese older adults, 

when they lose some weight, their function improves dramatically. 

It is wonderful to see. But we are getting preliminary findings that 

show that when we have the higher protein intake, we do get a significantly better improvement in function. This is preliminary, but 

it makes a lot of sense. Older adults probably have a higher protein 

requirement anyway. 

So that is what we are finding. We are continuing to test that. 

And if you want to ask more about that, feel free. 

Senator FISCHER. Thank you very much. 

Thank you, Madam Chair. 

The CHAIRMAN. Thank you. 

Senator Cortez Masto? 

Senator CORTEZ MASTO. Thank you. Thank you, Chairwoman 

Collins and Ranking Member. Thank you for this conversation, and 

all of you today, I so appreciate what you do on behalf of our communities. 

You know, my grandmother, Mrs. Taylor, was a sales clerk her 

entire life, worked hard, got up every day, was independent, nothing slowed her down, and was even known to be in my back yard 

landscaping. She just was a busy woman and retired on Social Security. There were days when I would go over and visit with her, 

and there were times when she had to make a decision to be able 

to afford her prescription drugs or pay the energy bills. And I 

would say, ‘‘Grandma, why aren’t you calling? Why aren’t you 

reaching out?’’ Because it is about dignity. It is about that independence that she had her entire life and not wanting to reach out. 

And I get it, and I worked most of my career on senior issues and 

understanding that it is hard sometimes to ask for that help when 

you have been so independent. 

But what these programs bring and what I see and I hear from 

you—and I thank you for being here—is that peace of mind and 

dignity that you can still have. Though you have a beautiful family, 

and your two daughters are sitting behind you, there is still that 

fight to have that independence and that dignity, and I appreciate 

it and am willing to fight for that for you, for many of our seniors, 

and that is why I thank you all for being here. 

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17 

One of the things I find, besides the fact that it is hard for many 

of our seniors to reach out, is also that many do not know about 

the programs, and particularly—I am from Nevada, and we have 

some rural communities. In two of them, in Laughlin and Searchlight, which are in southern Nevada, Meals on Wheels service is 

provided through a nonprofit called ‘‘Silver Rider,’’ and they do 

amazing work in that community. The executive director and her 

team, though, are very active in getting the word out about the 

program. They do public service announcements. They do print 

media. They are on radio stations. They do brochures. They are 

even appearing on a local morning show on a local TV station 

which is very popular. 

And so I guess I am going to open this up for the panel. Do you 

know of instances of seniors not accessing these programs like 

Meals on Wheels, the food box, the Senior Farmers’ Market Programs, et cetera, because they do not know that these programs 

exist? And how do we improve upon that? How do we make sure 

that they are aware of these programs? And I will open it up. Mrs. 

Taylor? 

Mrs. TAYLOR. I know in my situation, my husband and I were 

totally unaware, and it was through word of mouth. And I know 

where I live, you know, there is nothing. There are no morning TV 

programs or even on the radio that you hear about it. And my suggestion would be the senior high-rises have either somebody post 

notices, speak to the seniors in those areas, and what about public 

TV, you know, the local—because my understanding, it is not that 

expensive to do advertising through that kind of public television. 

A lot of your seniors are sickly and sitting at home and watching 

TV. So, you know, for them to be informed, because I know, again, 

if it had not been for someone telling me about it and directing me, 

I would be clueless. You know, I just would not know. That is very 

important. 

Senator CORTEZ MASTO. Thank you. Any other thoughts? Thank 

you very much. 

Dr. BERKOWITZ. So I can say in my own practice of seeing older 

adults, I would say it is more common than not that people do not 

know about the programs they may be eligible for or may not be 

using what they are eligible for. And I think a lot of it has to do 

with a lack of a systematic approach to doing this. I think one of 

the reasons in health care we have made such progress against 

breast cancer and colon cancer is because we screen for it, and 

when we find it, we do something about it. 

We have lots of great nutrition programs in the U.S. We have 

evidence that they work, but it is often a patchwork as to how you 

get into them, how you hear about them. And so I think really systematizing the approach of screening for food insecurity and malnutrition would be very helpful. 

One of the great advantages of an organization I work with, 

Health Leads, which I mentioned briefly, is that they do exactly 

that. So we have a systematic screening, and then they have a 

comprehensive database of all the resources someone may be eligible for, and they can go through and say, all right, this one will 

work for you, this one is a little too far, this one you do not meet 

the criteria. But there is a systematic assessment and then a comAGING-G33-GPO with DISTILLER

18 

prehensive listing of the resources, and I think that together is 

really how we put more people into the programs that are out there 

and will help them. 

Senator CORTEZ MASTO. Thank you. 

Ms. PRATT. I know in Maine we have amazing partners, organizations who do a lot of outreach and promotion of these programs 

to seniors. And one of them is Maine Hunger Initiative, but also 

the Maine Area Agencies on Aging do a lot of that work. And then 

our educators do encounter seniors who are very reluctant to access 

food pantries, and so they do some work with them to do more gardening, to go to farmers’ markets, and also to promote gleaning 

programs, because a lot of seniors are more willing to take a free 

box of gleaned produce that they see as it just might go to waste, 

and that is more appealing to them than going to a food pantry. 

So we do have some creative strategies to work with seniors. 

Senator CORTEZ MASTO. Thank you. That is very helpful. Thank 

you for the conversation. I have to leave to get to another committee hearing, but thank you so much. I appreciate the responses 

and the conversation this morning. 

The CHAIRMAN. Thank you so much, in a busy schedule, for taking the time to be here. 

Senator Gillibrand? 

Senator GILLIBRAND. Thank you, Madam Chairwoman and Mr. 

Ranking Member. I appreciate this hearing very much. It is a huge 

issue in my State. 

Dr. Berkowitz, in your testimony you mentioned that there are 

three ways food insecurity affects seniors: the quality of their diet, 

the cruel choices they have to make between food and medication, 

and the stress that makes caring for themselves more difficult. 

Would a reduction in SNAP benefits like those contained in the 

President’s budget affect low-income seniors more than other 

groups of SNAP recipients due to potential underlying health concerns? 

Dr. BERKOWITZ. I think it absolutely would. I think the effects on 

diet may be the same, but the other two issues are likely to be particularly worse in seniors. And I think the real thing they may see 

and may need to watch out for—and we have heard a lot about 

this—is the trade-offs between food and medications and other essential services. So I think if the resources provided by, say, SNAP 

or the senior nutrition boxes are taken away, that money has to 

be made up somewhere. And you will often see people scrimping on 

their medications, delaying filling their medications, taking less 

than they are prescribed, and we know that sets off a spiral of poor 

health, health consequences. And I think as Senator Collins alluded to, we could very well wind up causing more costs in excess 

health care than we save by reducing SNAP. 

Senator GILLIBRAND. So how can we get this message out? It is 

so frustrating to me as someone who fights for SNAP benefits every 

year that there seems to be a disconnect, a real disconnect, of who 

actually receives SNAP benefits. And there seems to be this general theory that the SNAP program is riddled with waste and fraud 

and abuse and that people are taking advantage of the system. But 

my understanding of SNAP beneficiaries is they are seniors, they 

are children, they are veterans, and families who are working, who 

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19 

are trying their best to make ends meet but do not. And without 

the benefit of SNAP, they do not have the nutrition quality they 

need. They are starving nutritionally by the end of every month, 

which causes childhood obesity and other terrible health outcomes. 

How do we change Congress’ understanding of what the benefit 

of SNAP is and why it saves money long term? 

Dr. BERKOWITZ. I think that is a great question, and certainly 

people smarter than me have tried to answer it. I agree completely 

with what you are saying. A large number of people on SNAP are 

working. A large number of people on SNAP are on it for a short 

period of time where they have a bump in the road and they get 

back on their feet. And the vast majority of people who are on 

SNAP and are not working, it is because they cannot; either they 

are a child or an older adult or someone with a disability. 

The evidence is there, but, honestly, I think—though I know she 

is not on SNAP specifically, I think testimony from people like Mrs. 

Taylor talking about the value of nutrition programs, showing that 

these are programs that are used by hardworking Americans, that 

they are really part of a safety net that helps people who are not 

trying to take advantage of the system but are just trying to do the 

best they can in the circumstances they find them in may hopefully 

be something that succeeds when simply looking at the data fails. 

Senator GILLIBRAND. Well, maybe something from the medical 

community, to the extent we could get a nationwide letter signed 

by doctors about the effects on seniors’ health, particularly your 

testimony, from all 50 States, I think that would be exceedingly 

meaningful, because it has become an ideologic issue, which is outrageous. There is nothing ideologic about it. It is just: Does it work 

or doesn’t it work? Does it protect people or doesn’t it? The facts 

are there, and I would like a fact-based analysis to be part of this 

discussion that, unfortunately, becomes a terrible political argument, which breaks my heart. 

Dr. Bales, in New York we have a program called N-Y-S-N-I-P, 

NYSNIP, that we automatically enroll seniors in SNAP if they live 

alone and receive Supplemental Security Income, SSI. I know there 

are a number of ongoing USDA pilot programs that can simplify 

the SNAP application process for seniors. Could programs that 

make it easier for seniors to enroll in SNAP and so be able to afford to buy lean meats and dairy products make a difference to 

your patients? 

Dr. BALES. Yes. We have talked a lot about fruits and vegetables, 

and they are key for getting the vitamins and minerals. But protein is a little bit of a neglected nutrient, especially with our highly 

processed kind of high-carb, low-fat trends that we have had. And 

as I mentioned before, we know that protein requirements are a little bit higher as we get older, and we also know that intakes go 

down. 

So these are expensive foods, relatively speaking. I did not mention this, but in my research we actually provide to them all of this 

generous serving, 30 grams of protein for two of the three meals 

a day, into their hands. When I first created this, my feeling was 

there was no way it would happen unless we provided it. 

So it is the same ideas as the food box, that the closer you can 

get the food to them, into their homes, the better, or making it afAGING-G33-GPO with DISTILLER

20 

fordable also does the same thing. And I do occasionally have, I 

must say, unfortunately, people who join my study just for the free 

food because that is very helpful to them. 

Senator GILLIBRAND. The reality. 

Dr. BALES. So, you know, protein has been around a long time, 

but it is a very important nutrient. And protein calorie malnutrition is actually what is going on when people do not eat, regardless 

of what they weigh. You know, if they are not eating enough protein and calories, they are slowly losing their muscle from their 

body and other important, detrimental things are going on. 

I think the idea of calling this malnutrition is good. That is what 

this Committee is doing, this meeting is doing. It sounds dramatic, 

but I think in order to get the attention of the Congress, we need 

to call it by its name and really talk about that idea that it is going 

on. 

Senator GILLIBRAND. Thank you. 

Thank you, Madam Chairwoman. 

The CHAIRMAN. Thank you. 

Ms. Pratt, we have talked a lot today about how to get the word 

out about programs that Mrs. Taylor and others are using that are 

so vital, and also how to reduce the reluctance, particularly of seniors, to come forth and use those programs. And I was impressed 

with your chart on SNAP–Ed in my State of Maine, and you have 

shown where the nutrition educators are located, in which district 

or county. But, to me, what is more significant is how integrated 

they are into places where people shop, learn, work, play, go to 

church. 

Could you talk a little bit about the partnerships you have with 

everything from public housing sites to grocery stores to farmers’ 

markets to churches? That is what really impressed me, because if 

we have that kind of integration, people are going to know about 

these programs because they are going to come across this integration in their everyday lives. 

Ms. PRATT. Thank you. That is a great point. And as you can see 

on the map, we have coalitions and we have organizations. Some 

of the coalitions are based in hospitals, but we have them in every 

district in Maine. And because the Directors of these agencies and 

the staff are so integrated in their communities and many of them 

live there and really know where eligible sites are, that is really 

the strength of our program in Maine. 

We at UNE in Portland cannot really understand all of the needs 

across the State, and every district, as you know, is very unique. 

And there are unique needs up in Washington County and Aroostook County. We have food deserts. And then in the urban areas 

we have a lot of new Americans from other countries with very different issues, and even across the ages, we have different needs. 

So it really is important, and we rely a lot on those local agencies 

and the fact that our educators are based in those agencies. And 

then they do needs assessments. They really do a lot of work in 

their communities and are able to take that USDA guidance and 

tailor the work to what the needs are in their districts. And they 

do go to all of these different settings to meet the needs. 

The easiest setting, of course, is the schools, and they all go to 

schools that are eligible. So any school that has 50 percent or more 

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21 

students on free and reduced lunch, they can go to those to do nutrition education. And then for adults, they use a similar criteria 

from the USDA to qualify adult sites, and they can work with senior housing facilities, other low-income facilities, and federally 

qualified health centers, as just some examples. 

So I am glad you raised that, and I think that really is the 

strength of our program in Maine. 

The CHAIRMAN. I think it is, too. I truly was struck by the number of different sites, adult education training sites, child care centers, public and community health centers, grocery stores, food 

pantries, farmers’ markets, churches, senior centers, public housing 

sites. It seems like you are everywhere, and I think that is a real 

strength in getting the program delivered, and I congratulate you 

for that. 

Ms. PRATT. Thank you. 

The CHAIRMAN. Dr. Bales, I want to follow up on a very interesting point that Senator Fischer was starting to approach with 

you. I am curious, in your 30 years of working in this field, if you 

have seen a change in the attitudes of the medical profession toward the importance of screening for nutrition. Dr. Berkowitz says 

that he does it routinely, but I think you are the exception to the 

rule in doing that. Maybe I am wrong. And, of course, Federal policies on whether or not that hour with a dietician or a nutritional 

expert is going to be reimbursed is also an issue. 

But have you seen a greater awareness among primary care physicians, nurse practitioners, those who are on the front lines in 

evaluating a patient’s nutrition? 

Dr. BALES. So I would like to say, ‘‘Oh, yes,’’ but nutrition in 

medical education is still variable. It has to do with the competing 

items in the curriculum for medical schools, and it does not always 

come out on top. So I think overall, yes, I think physicians certainly recognize more about the importance of nutrition than in the 

past. But it is variable whether they have enough training to actually know how to implement it in the very short time that they 

have now for examinations. 

For special programs, we do see dieticians and nutritionists at 

the table to discuss complex medical programs. At Duke we have 

a program where we rehab seniors prior to surgery, and nutrition 

is there. 

So I think overall, yes, but it is not at the level that we need. 

The reimbursement problem that you mentioned is a key issue, because, first of all, you have to screen, but also if you do not have 

somewhere to hand off for that individualized help that we were 

talking about to occur, then you have not been able to do very 

much with the identification of that risk. 

So progress has been made, but more is needed, and it would be 

great if nutrition was more of a part of medical training. And I 

would certainly appreciate my colleague’s comment on that as well. 

Dr. BERKOWITZ. Sure, so I completely agree with you that I think 

nutrition training is underemphasized in medical training overall. 

And I certainly did not mean to suggest that I think this is happening routinely anywhere. I think the opposite. 

I think you would be hard pressed to find people who do not 

think it is important. If you talk to doctors and say is nutrition imAGING-G33-GPO with DISTILLER

22 

portant? Absolutely. Does it happen routinely? No, it happens on 

an ad hoc basis; it happens in specific circumstances. But I think 

to take that next step of move beyond the promise of the interventions to actually really improving the public’s health, I think we 

need the systematization to be in place, and that includes screening, that includes having something to do with it, and that includes 

a financial mechanism to make it happen. 

The CHAIRMAN. Thank you. 

Dr. BALES. And if I could just add one more thing? 

The CHAIRMAN. Yes. 

Dr. BALES. If my physician—if I am an older person—tells me to 

do it, I am much more likely to do it. 

The CHAIRMAN. Very good point. 

Senator Warren? 

Senator WARREN. Thank you, Madam Chair, and thank you so 

much again for having this hearing. I think this is just a powerfully important point, and I commend you and Senator Casey for 

pulling this together and everyone for coming today. 

We all understand that nutrition is vitally important for health. 

So is access to health care. And if someone is not getting adequate 

nutrition or cannot afford to go to the doctor for preventive care, 

it is not just bad for the person. It is expensive for the system. 

In Massachusetts, we have been working hard to keep health 

care costs low by focusing on both sides of the equation: on nutrition and near-universal health care coverage. 

Tufts has a world-class research center where researchers study 

the links between nutrition and healthy aging. Our community 

health centers partner with local food banks and with grocery 

stores to improve access to nutritious foods. They have some really 

creative programs. I visited several of them. And our new State 

Medicaid waiver now incentivizes health care providers to keep 

people healthy by including providing nutrition services. 

So, Dr. Berkowitz, you have done a lot of research studying the 

links between food and health. Could I ask you, how do programs 

like SNAP or meal delivery impact health care costs for older 

adults? 

Dr. BERKOWITZ. Thanks for that question. I think what we are 

learning is that they have a very positive impact on health care 

costs, meaning that they reduce costs, and they do it in sort of the 

way we want to as well. Health care services cost money, whether 

that is a primary care visit or an emergency department visit or 

an inpatient admission. But I think we would all rather spend the 

money on prevention, spend the money on keeping people healthy, 

and not have it turn into a complication or a crisis. 

And what we see is that not only do programs like SNAP or meal 

delivery reduce health care costs, they do it by reducing these bigticket items, like inpatient hospitalizations or emergency department visits that usually signal something has gone wrong. 

Senator WARREN. Right. Now, I know that in one of your research studies, you looked specifically at how meal delivery lowered 

health costs for low-income seniors on Medicaid. So what would 

happen to seniors receiving food assistance if their Medicaid benefits were taken away? Would the meal delivery program be enough 

on its own to keep them healthy and out of the hospital? 

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23 

Dr. BERKOWITZ. So I would say it is not. First, the program really 

came as part of their Medicaid benefit, so it was part of a very innovative health insurer in Massachusetts, Commonwealth Care Alliance, who made it a covered benefit. So it is not even clear that 

the program itself would continue without Medicaid. But even if it 

were to for some reason, these are programs that work hand in 

hand with health care. Nutrition is an important part. Seeing your 

doctor is an important part. Seeing your nutritionist is an important part. Taking your medications is an important part. These all 

go together, and I do not think there is any one thing on its own 

that is going to keep people healthy. Just like just seeing your doctor will not keep you healthy without nutrition, just having the nutrition without being able to see your doctor or afford your medications is not likely to keep you healthy either. So I think this really 

all goes together. 

Senator WARREN. I really appreciate your emphasizing the importance of the integration and how many low-income seniors rely 

on Medicaid to be able to stay as healthy as possible. 

Ms. Taylor, you and your husband have raised ten children, five 

of them adopted. Congratulations. I know that food assistance has 

helped you make ends meet, but I want to ask you about another 

program that I think has helped a lot: Medicaid. I understand that 

several members of your family receive Medicaid benefits. Can I 

just ask, Ms. Taylor, if your children and grandchildren’s Medicaid 

benefits were taken away, what would that mean for your family? 

Mrs. TAYLOR. This is a very important part of my adopting five 

special-needs boys, because part of the adoption package was that 

they would receive Medicaid until they were 18. I could not by 

working, both my husband and I, again, all our lives, be able to afford health care, especially with special needs. You know, I have 

one child who, genetically, his teeth were falling out. It was a genetic problem. The dentist called it ‘‘ aesthetics,’’ so it had to come 

out of pocket. You know, it is those kinds of things that you pay 

for. But if I had to do the whole total caring or coverage for these 

children, I would not be able to take care of them. So not having 

Medicaid in my situation would impact them because I could not 

adopt and not be able to take care of five special-needs boys. It will 

impact the foster care system tremendously. They are crowded 

now. They are looking, begging for families. It is powerful. 

My one daughter that I brought with me today, she has taken— 

her godmother gave her a Down Syndrome child who is 96 percent 

blind. His life expectancy was supposed to be to 10 years of age. 

He is 22 now. It is necessary. She works. You know, she could not 

afford his needs to be met just by working alone. Where would he 

be? He would be a burden on the system in some facility. You 

know, it is important. You know, not in all cases. My husband and 

I, you know, we have worked, we have paid our dues. But in some 

cases, there are people who cannot. They just cannot. And it is important that those needs be met. 

Senator WARREN. Well, thank you very much. Thank you for all 

you have done. You have made a real difference in the lives of a 

lot of people. And I just appreciate all the work you are doing and 

the importance of health and nutrition here and how they go together. 

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24 

Thank you, Madam Chair. 

The CHAIRMAN. Thank you, Senator. 

Senator Casey? 

Senator CASEY. Thanks very much. Listening to Senator Warren’s question, it is apparent that a lot of these issues begin to 

compound or problems begin to compound, depending on what we 

do here. 

I wanted to focus, Dr. Berkowitz, on—I have not had a chance 

to ask you a question about the SNAP program itself. I was struck 

by the line in your testimony where you said that you would hope 

that we would expand and not just maintain funding for the SNAP 

program. Let me make sure I read it correctly, if I have it here. 

You said at the very end of your testimony—well, now I cannot find 

it, but I think that is the gist of it. 

What we are facing here in this budget debate and the only caveat or reminder that provides a little bit of a measure of comfort 

is that budgets proposed by Presidents usually are not adopted by 

either party, even the party of the President. So that is good. But 

what I worry about is the proposal in my judgment is so extreme 

that what is a program elimination may not be elimination but will 

end up being a drastic cut. 

The cuts to SNAP, for example, the 10-year number, is $190 billion of a cut over 10 years just in the SNAP program. To say that 

is devastating does not begin to describe it. 

Another program that is being proposed for cutting—not for cutting, it is for elimination, is LIHEAP, Low-Income Home Energy 

Assistance Program. And in your testimony, Doctor, you pointed 

out that the—you went through and itemized some of the other 

parts of the cuts. You said ‘‘people experiencing food insecurity face 

competing demands for their scarce resources, often leading to 

cruel choices. Those with food insecurity frequently make trade-offs 

between food and other necessities, such as, one, medications, two, 

housing, and, three, heating.’’ 

All three have implications for the budget debate. So if you could 

talk to us about those implications just in terms of what that could 

mean for one family. 

Dr. BERKOWITZ. Sure. So I think this situation of competing demands is really all too common. As you mentioned, you know, it 

takes a lot to stay healthy. There is the health care part. There is 

the healthy eating part, where you need to have a safe home, you 

need to have a warm home. Especially where I live in Massachusetts, probably where you are in Pennsylvania, winters can be long. 

Where I grew up in North Carolina, summers can be hot. And we 

see year after year seasonal variations in health conditions that are 

related to this. 

There have been studies that have shown families where they 

have to use the oven to heat their homes in the winter, and people 

have respiratory illness from this. People go to the emergency department with COPD, emphysema exacerbations. Their children go 

to the emergency department with asthma exacerbations from this. 

So, again, I wanted to emphasize one of Senator Warren’s questions. These programs all work together to help keep people 

healthy, and, you know, I think we now understand that health is 

not just, you know, what a doctor says or what comes from the 

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25 

medical community. It is really a state of being and that there are 

a number of things, basic needs that need to be met in order to do 

this. And I think cuts or eliminations to any of these programs will 

really have effects that impact other areas that may even be unintended or unforeseen, but will no doubt wind up hurting people’s 

health and costing more money. 

Senator CASEY. Senator Warren just gave me the right page 

here. You said, ‘‘Do not just protect but expand our investment in 

food security and nutrition programs for our Nation’s seniors.’’ The 

exact words. 

The last thing I would say is a lot of us I think sometimes forget 

in the numbers and the debate what this means. Look, believe me, 

I think that that kind of cut to the SNAP program, the opposition 

to it is bipartisan. The opposition to a lot of these cuts is bipartisan. That is the good news. The bad news is the impact on one 

senior could be devastating. 

I was looking at some numbers from the Center on Budget and 

Policy Priorities where they break down the characteristics of seniors receiving SNAP. This is as of 2015. Almost 4.8 million seniors 

are receiving SNAP. But here is among the most dramatic numbers. Seniors living alone and receiving SNAP, 73 percent of those 

who are seniors and receiving SNAP live alone. So we have to ask 

ourselves, what if that same senior not only is affected by the 

SNAP cut, but what if they are living alone in an apartment in 

those winters you mentioned and their low-income home energy assistance gets eliminated—not cut, eliminated? 

And I think sometimes we also forget some of the numbers here. 

This same report talks about what it means in monthly benefits. 

We are talking as of, I guess, 2015, in Pennsylvania 121 bucks. 

They are not getting hundreds of dollars or thousands of dollars. 

One hundred and twenty-one bucks. The national number is about 

128 bucks. 

So I think we have got to think long and hard about these budget 

issues as we approach the season. 

Madam Chair, sorry I am over my question time. 

The CHAIRMAN. Thank you very much. 

I want to thank all of our witnesses for being here today. You 

have advanced our understanding greatly of the importance of sustaining proper and adequate nutrition among our Nation’s seniors 

and the impact not only on their personal health but also on health 

care expenditures of our Nation. 

It may have come as a surprise to some of those who are watching on C–SPAN or listening in the audience today that malnutrition disproportionately affects our seniors, and many of you have 

talked about the convergence of an aging population—and as Ms. 

Pratt pointed out, this is particularly of concern to those of us who 

represent States with a disproportionately older population—and 

the malnutrition trend as well. 

And the stakes are very high. As I mentioned earlier, I think one 

of the most startling statistics of this hearing is from Dr. Berkowitz 

when he estimates that $77 billion in health care expenditures are 

attributable to poor nutrition. So armed with the knowledge that 

we have gained today, we can better prepare to reverse those forecasted tides for our aging population. 

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26 

I am encouraged by the number of effective programs and research interventions that we have learned about today. I am reminded of a practice, a medical practice in Maine, which, for its patients with diabetes, sets up a weekly phone call to see if they are 

in compliance with their nutritional regimen and their exercise regime, and they check on their blood sugar levels. And it has been 

extraordinarily effective, and it is because they do have them spend 

time with a dietician or other nutritional expert and work out a regime for them for both food and exercise. But I think it is that annual call—not annual, that weekly call checking on them that really helps to encourage compliance. 

But one of the problems is that they are not reimbursed for that 

call, and from my perspective, given the results that they can document, they should be. After all, if we can help someone with diabetes avoid amputations or blindness or other impacts on the entire 

body which diabetes causes, we are going to reduce health care 

costs, and we are going to improve the quality of life for that individual. And it is ironic to me that the reimbursement, which would 

be so small, for that essential phone call and that time with a nutritional expert is difficult to come by or impossible to come by, and 

yet if someone ends up having an amputation, of course, we will 

pay for that. And I am not suggesting we should not, but wouldn’t 

it be better if we avoided that kind of heartache, illness, and high 

cost? 

So we have learned a lot today about outstanding examples of 

how we can come together to help our older population age more 

successfully, and I thank each of you for bringing a different perspective and enhancing our knowledge. 

Senator Casey, any final words from you? 

Senator CASEY. Thank you, Madam Chair, and thanks for advocacy not only for seniors in Maine but across the country on this 

issue and so many others. 

I also want to thank our witnesses for your testimony, your expertise, and your life experience. And, Pat, I am speaking to you 

particularly on that because you are bringing your story here, and 

your daughters, Toni and Dawn, with you. We are grateful for the 

time you have spent with us. 

As we have heard today, senior nutrition programs like the Supplemental Nutrition Assistance Program, SNAP, the Senior Farmers’ Market Nutrition Program, and senior food boxes are a lifeline 

for many older Americans. Research supports the importance of 

these programs, and access to proper nutrition is critical to support 

healthy aging. 

We have also seen there are communities doing innovative work 

to connect seniors with these resources and to decrease the stigma 

of asking for help. Our seniors deserve to age with dignity, and it 

is clear that federally funded nutrition programs help provide that 

dignity. 

We must continue to support SNAP, the Senior Farmers’ Market, 

and senior food boxes, and I look forward to this Committee continuing support of seniors and their access to proper nutrition. 

And, again, Madam Chair, thank you for this hearing, a critically 

important hearing for this Committee. 

The CHAIRMAN. Thank you, Senator Casey. 

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I want to thank all of our witnesses one last time for your valuable contributions today, and all of the Committee members who 

felt that this was important enough that, even though this is an 

extraordinarily busy day here with a lot of committee conflicts and 

meetings on very important issues, they took the time to come by 

and express their concern. And, finally, I want to thank our staff 

who always work very hard in putting these hearings together. 

This concludes this hearing. This hearing is adjourned. 

[Whereupon, at 11:04 a.m., the Committee was adjourned.] 

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APPENDIX 

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Prepared Witness Statements 

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Prepared Testimony of Connie W. Bales, Ph.D., RD, Professor, Division of Geriatrics, Senior 

Fellow, Center for the Study of Aging, Duke University School of Medicine; Associate 

Director of Geriatrics Center, Durham VA Medical Center, Durham, North Carolina 

Good morning Chairman Collins, Ranking Member Casey, and members of the Aging 

Committee. Thank you for this opportunity to testify. My name is Dr. Connie Bales, and I am a 

Professor at the Duke University School of Medicine and an Associate Director of the Geriatrics 

Center at the Durham VA Medical Center. I have been working in nutrition and aging research 

for the past 30 years, focusing on older adults as a population at high risk for malnourishment. 

Leading reasons for this include physical changes that increase nutrient needs as well as social 

and economic limitations that reduce their access to food. Older adults commonly face 

multiple chronic health conditions; the medications they take and special diet restrictions 

further increase their nutritional risk (1). 

I will bring to your attention two important trends that have dramatically altered the profile of 

malnutrition in older Americans. The first of these trends is the on-going epidemic of obesity 

occurring in the United States. Rather than gaining weight slowly over time, now over one 

third of Americans spend decades of their lives exposed to obesity, a situation that has never 

before been encountered in our society. As this committee is well aware, the second 

dramatic trend is that of population aging. With the convergence of these trends, geriatric 

obesity is now very common. Almost 40% of older Americans are obese, many with morbid 

levels of obesity (2). 

Contrary to what people may believe, being overweight or obese does not correspond with 

over-nutrition. In fact, obesity is a marker of malnutrition. Many obese older adults are not 

getting the nutrients they need. With low metabolic rates and little energy being spent on 

activity, their food intakes may actually be quite low (3). 

This state of chronic malnutrition creates major threats to health. Aging increases the risk of 

chronic conditions like diabetes, heart disease and arthritis. Aging muscles reduce in size and 

strength and fat accumulates around essential organs in the body core. Obesity leads to all of 

these same changes! This brings a double threat, hastening chronic disease progression and 

hindering the ability to move around and be functionally independent (4). 

No longer is the typical picture of malnutrition in older adults one of a weak, thin elder 

subsisting on "tea and toast". Soon the most common type of nutritional frailty will be the 

older adult who has excessive body fat masking weak muscles and limited ability to move 

around (5). This condition, which is called "sarcopenic obesity", enhances a host of health 
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problems, makes surgery and other medical treatments more risky, and hastens the need for 

institutionalization due to loss of functional independence (6, 7). 

Obese older adults have a much greater likelihood of getting admitted to a nursing home than 

non-obese elders (8). Besides the increased cost to society of this early admission, nursing 

homes incur greater costs caring for the obese (9). Renovated facilities, larger equipment, and 

higher personnel costs are needed for their care. Some nursing homes are turning away those 

who are excessively obese. 

Obesity is highly correlated with food insecurity, having uncertain or limited access to 

nutritious food. We know that poor health and food insecurity interfere with the intake of 

adequate amounts of protein, vitamins, and minerals. 

Obesity treatment is challenging at any age, and, it can be especially challenging in older adults 

(9). But we know that reducing obesity and improving diet quality is achievable for seniors and 

that it lessens health problems like diabetes and hypertension, reduces risk of falls, and 

dramatically improves their function (4, 10, 11). My research focuses on older adults with 

distinct mobility limitations due to their excessive body fat. These individuals often have 

multiple chronic diseases. They also have a very limited ability to burn calories and strengthen 

their muscles through exercise. My research team developed and we are testing a special sixmonth diet intervention based on large servings of high quality protein from lean meats and 

low-fat dairy products at each meal (12). The goal is to achieve loss of body fat without the 

loss of muscle. We have shown that marked improvements in functional ability take place 

whenever these frail older adults reduce their obesity but our higher protein diet produces the 

best results for function (13). We have also discovered potential problems with diet 

adherence and treatment responses linked with race and lower education level (14). Our 

future studies will explore enhanced interventions for these especially vulnerable populations, 

which are also at higher risk for food insecurity. 

In closing, I hope that I have raised your awareness regarding an important challenge facing 

many older Americans. Please realize that even though it is not shown outwardly, an 

overweight or obese elderly person may very well be under-nourished in ways that threaten 

their health and ability to live a life of quality. Our research has shown that dedicated efforts 

to improve the nutritional status of these individuals can literally transform them in terms of 

their abilities to live more independent and healthy lives. 
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Supporting References: 

1. Porter Starr K, McDonald S, Bales C. Nutritional Vulnerability in Older Adults: A 

Continuum of Concerns. Current Nutrition Reports. 201S: 4(2): 176-184. 

2. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among 

Adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-91. 

3. Bernstein M, Munoz N. Position of the Academy of Nutrition and Dietetics: food and 

nutrition for older adults: promoting health and well ness. J Acad Nutr Diet. 

2012;112(8):1255-77. 

4. Porter Starr KN, McDonald 5R, Bales CW. Obesity and Physical Frailty in Older Adults: A 

Scoping Review of Lifestyle Intervention Trials. JAm Med Dir Assoc. 2014;1S(4):240-50. 

5. Alley DE, Ferrucci L, Barbagallo M, Studenski SA, Harris TB. A research agenda: the 

changing relationship between body weight and health in aging. J Gerontal A Bioi Sci 

Med Sci. 2008;63(11):1257-9. 

6. Chung JY, Kang HT, Lee DC, Lee HR, Lee YJ. Body composition and its association with 

cardiometabolic risk factors in the elderly: a focus on sarcopenic obesity. Arch Gerontal 

Geriatr. 2013;56(1):270-8. 

7. Lee J, Hong YP, Shin HJ, Lee W. Associations of Sarcopenia and Sarcopenic Obesity With 

Metabolic Syndrome Considering Both Muscle Mass and Muscle Strength. J Prev Med 

Public Health. 2016;49(1):35-44. 

8. Marihart Cl, Brunt AR, Geraci AA. The high price of obesity in nursing homes. Care 

Manag J. 2015;16(1):14-9. 

9. Porter Starr K, McDonald S, Weidner J, Bales C. Challenges in the Management of 

Geriatric Obesity in High Risk Populations. Nutrients. 2016;8(5):262. 

10. Villareal DT, Aguirre L, Gurney AB, Waters DL, Sinacore DR, Colombo E, et al. Aerobic or 

Resistance Exercise, or Both, in Dieting Obese Older Adults. N Eng I J Med. 

2017;376(20):1943-55. 

11. Porter Starr KN, Bales CW. Excessive Body Weight in Older Adults. Clinics in Geriatric 

Medicine. 2015;31(3):311-26. 

12. McDonald SR, Porter Starr KN, Mauceri L, Oren duff M, Granville E, Ocampo C, Payne 

ME, Pieper CF, Bales CW. Meal-based enhancement of protein quality and quantity 

during weight loss in obese older adults with mobility limitations: Rationale and design 

for the MEASUR-UP trial. Contemp Clin Trials. 2015;40:112-23. 

13. Porter Starr KN, Pierper CR, Orenduff M, McDonald SR, McClure LB, Zhou R, Payne ME, 

Bales CW. Improved function with enhanced protein intake per meal: A pilot study of 

weight reduction in frail, obese older adults. J Gerontal A Bioi Sci Med Sci. 

2016;71(10):1369-75. 

14. Bales C, Porter Starr K, Orenduff M, McDonald 5, Molnar K, Jarman A, et al. Influence of 

protein intake, race, and age on responses to a weight reduction intervention in obese 

women. Curr Dev Nutr. 2017;1(5):1-10. 
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Food Insecurity, Malnutrition, and the Health of Older Adults: 

Testimony for the United States Senate Special Committee on Aging 

july 12, 2017 

Prepared Statement of Seth A. Berkowitz, M.D., MPH 

General Internist, Massachusetts General Hospital 

Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts 

The opinions herein are solely my own, and do not reflect the official position of any 

organization 
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Chairman Collins, Ranking Member Casey and Members of the Aging Committee, thank you 

for this opportunity to testify, and help shine a spotlight on the importance of food security 

and nutrition in America's seniors. 

Food insecurity, defined as uncertain or limited access to nutritious food1, affected 

12.7% of American households in 2015, or over 40 million Americans.2 Though the 

American economy has been out of recession since 2009, food insecurity rates have been 

slow to decline, and remain higher than pre-recession levels.z Food insecurity is a 

particular problem for older Americans, as many live on a fixed income, and often have 

worse health than younger adults. These health conditions are often caused or exacerbated 

by an inadequate diet. Two related concepts also important for understanding the public 

health implications of food insecurity: hunger and malnutrition. Food insecurity may cause 

hunger, which is a physiological experience "that, because of prolonged, involuntary lack of 

food, results in discomfort, illness, weakness, or pain ... "1 Malnutrition "refers to 

deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients."3 

The picture of food insecurity and malnutrition in older adults is changing. 

Historically, an older, frail person consuming a restricted 'tea and toast' diet with scant 

calories exemplified food insecurity and malnutrition. However, the advent of cheap but 

non-nutritious foods has given rise to the coexistence of food insecurity and obesity, along 

with complications of obesity, such as diabetes and heart disease. Less healthy foods are 

often much cheaper, on a per-calorie basis, than healthier foods such as fresh fruits and 

vegetables, lean protein, and whole grains. Because adhering to a healthy diet is vital both 

for maintaining health and managing many illnesses once they occur, food insecurity can 

significantly affect health even for older adults who are not frail or underweight. It is 

critical to realize that, far from being paradoxical, food insecurity and obesity go hand-inhand. 

Key risk factors for food insecurity include being a racial/ethnic minority, 

disability4, social isolation, and having a low income.2 The latter three are particularly 

important for older adults. Epidemiological studies have associated food insecurity with a 

large and growing number of health conditions, including obesitys, 6, diabetes?, 

hypertension8·10, coronary heart diseases, congestive heart failures, chronic kidney 

disease 11• 12, depression and serious mental illness13, 14, and osteoporosis.JS Furthermore, 
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food insecurity may exacerbate these illnesses once they occur. For example, food 

insecurity is associated with worse blood sugar control among diabetes patients16· 17, and 

increased use of expensive healthcare services such as inpatient admissions and 

emergency department visits.1s. 19 Given all this, it is not surprising that food insecurity is 

estimated to result in $77 billion dollars in excess healthcare expenditures annually.18 Even 

more importantly, food insecurity has been associated with a 30% increased risk of 

mortality over long-term follow-up.2o 

Food insecurity is also important in the management of illnesses that are not caused 

by food insecurity. For example, while there is no evidence that food insecurity causes 

breast cancer, adequate nutrition is vital when undergoing breast cancer treatments such 

as chemotherapy. The body simply cannot respond appropriately to chemotherapy when 

nutrition is compromised. Similarly, adequate nutrition is needed for healing after surgery, 

or to recover from a broken bone sustained in a fall. Even infectious diseases, such as 

tuberculosis or pneumonia, are much more deadly in the presence of malnutrition. Studies 

have estimated that achieving nutrition goals would reduce the global burden of 

tuberculosis by 20%.21 

As scientific knowledge has grown, experts have developed a conceptual model of 

the relationship between food insecurity and chronic illness,22 While there are likely many 

ways that food insecurity affects health, three key pathways have strong scientific support. 

The first, and perhaps the most obvious, is through dietary quality. As described above, 

food insecurity can lead to worsened dietary quality, malnutrition, and hunger, with 

attendant consequences on health. Second, people experiencing food insecurity face 

competing demands for their scarce resources, often leading to cruel choices. Those with 

food insecurity frequently make trade-offs between food and other necessities, such as 

medications, housing, or heating. This is particularly relevant to health in the context of 

medications. What is sometimes called the "Treat or Eat" trade-off, where individuals face 

difficulties affording food, medication, or both, is all too common. Almost one third of 

American adults with chronic illness report this trade-off.23 Patients unable to adhere to 

their medical therapy for this reason face needless suffering, solely because they cannot 

otherwise afford enough to eat. Third, food insecurity's effects are psychological: food 
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insecurity worsens stress, depressive symptoms, and anxiety, and can sap the "cognitive 

bandwidth" needed for self-management of complex illnesses. 

The problems associated with food insecurity have led to interventions meant to 

improve health and healthcare use by addressing nutrition. Programs have generally taken 

one of two forms. The first, sometimes called "linkage" interventions, involves assessing for 

food insecurity and/or nutrition issues in clinical care, followed by "linking" patients to 

community resources to help meet these needs, such as enrolling in the Supplemental 

Nutrition Assistance Program (SNAP), or referral to a local food pantry. The other type of 

intervention, sometimes called "direct provision", involves providing food directly to those 

in need. Both of these are emerging areas of scientific investigation, where knowledge of 

how best to intervene is increasing rapidly. From this new evidence, we are seeing that 

these types of programs can lead to important improvements across a wide variety of 

health outcome types, including clinical, health service use, and expenditures. 

Examining clinical outcomes, a recent study of a "linkage" program run by 

Massachusetts General Hospital and the non-profit organization Health Leads, found that 

the intervention Jed to important improvements in blood pressure and cholesterol 

control.24 A study from Feeding America, America's largest network of food banks, found 

that education and providing foods tailored to the needs of diabetes patients at local food 

pantries improved blood sugar controJ.ZS A particularly promising type of "direct 

provision" intervention is medically-tailored meal delivery, where fully prepared meals, 

specially tailored to the medical needs of participants, are delivered to their homes. In 

California, a medically-tailored meal delivery organization, Project Open Hand, found that 

medically tailored meal delivery decreased depressive symptoms, and increased 

medication adherence and dietary quality in patients with HIV and diabetes.26 A study of a 

similar medically-tailored meal organization in Boston, Community Servings, also found 

improvements in dietary quality in diabetes patients with meal deliveryP 

Studies of SNAP deserve special attention. As our nation's largest food security 

intervention, SNAP is known to reduce the depth and breadth of food insecurity. However, 

recent evidence shows that, even though it is not designed specifically to do so, SNAP may 

have important effects on health. Studies of SNAP have found that participation led to 

improved dietary quality28, emergency low blood sugar events went down during a period 
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of increased SNAP benefit levels29, the SNAP-education program helps improve fruit and 

vegetable consumption and lower consumption of sugar-sweetened beverages3o, and that 

making additional resources available for purchasing fruits and vegetables helped achieve 

the healthy diets they need.31. 32 

Regarding health service utilization and expenditure, the evidence is also clearly in 

favor of nutritional interventions. A recent study found that SNAP participation was 

associated with approximately $1400 less in annual healthcare expenditures.33 A study of 

Meals on Wheels-type meal delivery programs for older adults found that these programs 

helps keep older adults out of nursing homes.34 Most recently, a study of Commonwealth 

Care Alliance's dually eligible Medicare-Medicaid beneficiaries found that both a Meals on 

Wheels-type non-tailored food intervention and a medically tailored meals intervention 

from Community Servings had important benefits, showing reductions in emergency 

department visits and ambulance transportation.35 This translated into cost savings: 

participants in the non-tailored food program had $1900 lower annual healthcare 

expenditures, and participants in the medically tailored meal program had $6500 lower 

annual healthcare expenditures.35 

It is important to note that public-private partnerships are at the heart of these 

nutrition interventions. The charitable food system is a critical stop-gap for those facing 

hunger, but the federal government provides the bulk of nutrition program spending in the 

U.S., and the charitable system could not make up for a funding reduction. By no means, 

however, is the federal government is working alone. Partnerships with state and local 

agencies, healthcare delivery systems, social service providers, and non-profit 

organizations enable federal resources to be efficiently targeted to those in need, and 

maximize the health gains achieved. The interventions described above make clear what 

public-private partnerships can accomplish. In addition to spending on nutrition programs 

in, for example, the Farm Bill, waivers and pilot programs within Medicare and Medicaid 

have been vital to developing and testing new interventions, as has specific legislation like 

the Ryan White CARE Act, and research funding from the NIH, CDC, AHRQ, and PCORI. 

While there is always more to learn, and no single study is ever definitive, the 

evidence is compelling when taken together. Food insecurity, along with malnutrition and 

hunger, are major public health threats for older adults. Nutrition programs offer 
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important improvements in health, healthcare use, and health spending. As a scientist, I 

always want to learn more, study more, and improve on what we already have. I can spend 

years trying to get a study just right. But you, as senators and policy makers, need to make 

decisions now, based on the best available evidence. Therefore, my unequivocal advice is 

this: Don't just protect but expand our investment in food security and nutrition programs 

for our nation's seniors. This will promote healthy aging, and improve the public's health. 

References 

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2. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United 

States in 2015. In: United States Department of Agriculture Economic Research Service, ed2016. 

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14. Mangurian C, Sreshta N, Seligman H. Food insecurity among adults with severe mental illness. 

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and use of health care resources: results of the Measuring Economic Insecurity in Diabetes 

study. JAMA internal medicine. Feb 2015;175(2):257-265. 

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among U.S. adults with diabetes. Diabetes care. Oct 2013;36(10):3093-3099. 

18. Berkowitz SA, Basu S, Meigs JB, Seligman HK. Food Insecurity and Health Care Expenditures in 

the United States, 2011-2013. Health services research. Jun 13 2017. 

19. Kushel MB, Gupta R, Gee l, Haas JS. Housing instability and food insecurity as barriers to health 

care among low-income Americans. Journal of general internal medicine. Jan 2006;21(1):71-77. 

20. Zhu J, Parikh A, Lipsitz SR, Natarajan S. ASSOCIATION BETWEEN FOOD INSUFFICIENCY AND 

MORTALITY: JOINT EFFECT WITH INCOME ON ALL-CAUSE AND CAUSE-SPECIFIC MORTALITY 

JGIM: Abstracts from the 35th Annual Meeting of the Society of Genera/Internal Medicine. 

2012;27(Suppi2):S126-127. 

21. Odone A, Houben RM, White RG, Lonnroth K. The effect of diabetes and undernutrition trends 

on reaching 2035 global tuberculosis targets. The lancet. Diabetes & endocrinology. Sep 

2014;2(9):754-764. 

22. Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. The New 

England journal of medicine. Jul 01 2010;363(1):6-9. 

23. Berkowitz SA, Seligman HK, Chaudhry NK. Treat or eat: food insecurity, cost-related medication 

underuse, and unmet needs. The American journal of medicine. Apr 2014;127(4):303-310 e303. 

24. Berkowitz SA, Hulberg AC, Standish S, Reznor G, Atlas SJ. Addressing Unmet Basic Resource 

Needs as Part of Chronic Cardiometabolic Disease Management. JAMA internal medicine. Feb 01 

2017;177(2):244-252. 

25. Seligman HK, Lyles C, Marshall MB, et al. A Pilot Food Bank Intervention Featuring DiabetesAppropriate Food Improved Glycemic Control Among Clients In Three States. Health affairs 

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26. Palar K, Napoles T, Hufstedler LL, et al. Comprehensive and Medically Appropriate Food Support 

Is Associated with Improved HIV and Diabetes Health. Journal of urban health: bulletin of the 

New York Academy of Medicine. Feb 2017;94(1):87-99. 

27. Berkowitz SA, Delahanty LM, Terranova J, Pyke A, Wexler OJ. Medically Tailored Meal Delivery 

for Diabetes Patients with Food Insecurity: A Randomized Clinical Trial. Society of General 

Internal Medicine 40th Annual Meeting. 2017. 

28. Gregory C, Ploeg MV, Andrews M, Coleman-Jensen A. Supplemental Nutrition Assistance 

Program (SNAP) Participation Leads to Modest Changes in Diet Quality. Economic Research 

Service: Economic Research Report Number 147 2013; 

https:f /www.ers.usda.gov/webdocs/publications/err147/36939 err147 .pdf. Accessed 06 Jan 

17. 

29. Basu S, Berkowitz SA, Seligman H. The Monthly Cycle of Hypoglycemia: An Observational Claimsbased Study of Emergency Room Visits, Hospital Admissions, and Costs in a Commercially 

Insured Population. Medical core. Jul2017;55(7):639-645. 

30. Molitor F, Sugerman SB, Sciortino S. Fruit and Vegetable, Fat, and Sugar-Sweetened Beverage 

Intake Among Low-Income Mothers Living in Neighborhoods With Supplemental Nutrition 
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Assistance Program-Education. Journal of nutrition education and behavior. Nov- Dec 

2016;48(10):683-690 e681. 

31. Choi SE, Seligman H, Basu S. Cost Effectiveness of Subsidizing Fruit and Vegetable Purchases 

Through the Supplemental Nutrition Assistance Program. American journal of preventive 

medicine. May 2017;52(5):e147-e155. 

32. Olsho LE, Klerman JA, Wilde PE, Bartlett S. Financial incentives increase fruit and vegetable 

intake among Supplemental Nutrition Assistance Program participants: a randomized controlled 

trial of the USDA Healthy Incentives Pilot. The American journal of clinical nutrition. Aug 

2016;104(2):423-435. 

33. Berkowitz SA, Seligman HK, Rigdon J, Meigs JB, Basu S. Supplemental Nutrition Assistance 

Program (SNAP) Participation and Healthcare Expenditures among Low-income Adults. 

AcademyHealth Annual Research Meeting. 2017. 

34. Thomas KS, Mor V. Providing more home-delivered meals is one way to keep older adults with 

low care needs out of nursing homes. Health affairs (Project Hope). Oct 2013;32(10):1796-1802. 

35. Berkowitz SA, Terranova J, Hill C, Unksey T, Tishler L, DeWalt D. Meal Delivery Programs and 

Healthcare Use: A Coarsened Exact Matching Evaluation. {In Preparation]. 2017. 
43 

Prepared Statement of Elizabeth Pratt, MPH, SNAP–Ed Program Manager, 

University of New England, Portland, Maine 

Dear Chairman Collins, Ranking Member Casey and members of the U.S. Senate 

Special Committee on Aging, thank you so much for inviting me to talk about older 

adults in Maine, their nutrition needs, and an overview of the program I manage, 

Maine SNAP-Ed. My name is Elizabeth Pratt and I am the Program Manager of 

the Maine SNAP-Ed program. 

SNAP-Ed is the USDA’s nutrition education arm of the Supplemental Nutrition 

Assistance Program. It offers education, social marketing campaigns, and environmental support in all 50 States, the District of Columbia, and three territories. 

SNAP-Ed uses evidence-based, comprehensive public health approaches to improve 

the likelihood that low-income families will make healthier food and physical activity choices, consistent with the current Dietary Guidelines for Americans and 

MyPlate.gov. SNAP-Ed is designed to complement SNAP. SNAP gives a family a 

fish, while SNAP-Ed teaches a family to fish. In FY 2016, 350,000 low-income seniors across the country received direct nutrition education through SNAP-Ed. 

The purpose of the Maine SNAP-Ed program is to use evidence-based approaches 

to provide low-income Mainers with easy ways to shop, cook, and eat healthy food 

on a limited budget—stretching their limited food dollars. 

We have 44 highly qualified Nutrition Educators who teach low-income Mainers 

across the age spectrum how to make healthy food choices. They work in every 

Maine District and are based in local community coalitions and hospitals. They 

work in eligible community settings and with multiple organizations to reach children in schools, Veterans, adults with disabilities, seniors and working adults. The 

program follows detailed guidance by the USDA Food and Nutrition Service (FNS). 

This means that our educators follow the Federal guidance related to qualifying settings and providing series-based nutrition education as well as implementing policy 

change work. 

As you may know, Maine is the ‘‘oldest State in the country.’’ We have the highest 

percentage of older adults and many of them are low-income. Food insecurity is very 

prevalent in our rural State and Mainers struggle with hunger, regardless of age. 

Roughly 203,000 Mainers face hunger every day. The rate of hunger, or food insecurity, in the United States as a whole dropped to 12.7% in 2015. In Maine, it remained elevated at 15.8%. 

Four out of 10 SNAP participants in Maine (43%) are in families with members 

who are elderly or have disabilities (source: Maine Equal Justice Partners Fact 

Sheet). Thirty-five percent (35%) of Maine seniors 65 and older had incomes less 

than $25,000 per year. Twenty percent (20%) of Maine seniors 65 and older were 

diagnosed with diabetes (Source: BRFSS). 

Seventy-two percent (72%) of adults in Maine do not eat enough fruits and vegetables. Many Maine seniors have to make hard decisions related to their food choices. 

Anecdotally, we have heard about seniors who have to choose between their prescriptions, feeding the children who live in their households, fuel for heating in the 

winter, and their own nutrition needs. Often, taking care of themselves is not the 

priority as they struggle to care for their children and grandchildren. At a critical 

time in their lives when balanced diets are important, they are frequently compromising their dietary needs for the benefit of others or other needs. 

Maine seniors have a reputation for being independent and proud. Maine is a very 

rural State and many seniors grew up on small farms or had gardens to help them 

meet their needs. They are reluctant to go to food pantries and are hesitant to ask 

for help despite their need. 

However, Maine seniors are open to learning and this is part of why I think our 

program is successful in reaching low-income seniors. Our Nutrition Educators 

share concrete tips and strategies to compare unit price tags, read nutrition facts 

labels, buy in bulk, purchase low-cost fruits and vegetables, and cook simple, nutritious meals. 

Our 44 educators are based in local coalitions so they are often from the same 

communities where they work. They are familiar with the community and they 

know where the eligible sites are and how to engage with them effectively and respectfully. All of our educators follow the USDA FNS Guidance to qualify sites and, 

to put it simply, that means that all of the sites must serve at least 50% low-income 

individuals. Essentially, they can only teach classes in schools that have at least 

50% of the students on free and reduced meals. And they can only work in adult 

settings that serve low-income adults such as housing sites, worksites, food pantries, 

and federally Qualified Health Centers. In Maine, it’s not difficult to find eligible 

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In 2016, there were almost 3,000 adults 60 years or older who participated in the 

Maine SNAP-Ed nutrition education classes. There are three evidence-based curricula we offer for this age group: 10 Tips for Adults, Cooking Matters for Adults, 

and Eat Smart Live Strong. In addition, many seniors participate in our Cooking 

Matters at the Store tours at Hannaford grocery stores—a large supermarket chain 

based in Maine. Our Nutrition Educators focus on teaching them how to shop, cook 

and eat healthy on a budget. In Maine, Cooking Matters is implemented through 

a partnership between the Good Shepherd Food Bank and Maine SNAP-Ed. Share 

Our Strength’s Cooking Matters at the Store is a guided grocery store tour providing opportunities for adults to learn easy ways to shop for healthy foods. In FY 

2016, 3,109 Mainers participated in these Cooking Matters store tours and were 

taught skills such as how to use unit price tags, how to read the Nutrition Facts 

label, and how to identify whole grains. Hannaford Supermarkets donates a $10 gift 

card to all class participants. 

In order to give you an example of the great work happening in Maine with seniors, I want to tell you about our Nutrition Educator in Aroostook County. Aroostook 

County is in northern Maine and it borders Canada. Heather McGuire is the educator based out of Houlton. She grew up in ‘‘The County’’, as Mainers call northern 

Maine, and was raised as many children are in this special part of our State—to 

hunt, grow food, forage for fiddleheads, and help out during the potato harvest. Because of this upbringing, she understands the importance of growing nutritious food. 

Heather teaches nutrition education to children and adults in this rural part of 

southern Aroostook County. 

In her own words, I will share her story about her project to help low-income seniors access fruits and vegetables at a low-income senior housing site. 

‘‘As a SNAP-Ed Nutrition Educator I have had the privilege of helping put a garden in at Market Square Commons. It was around the first of April when I asked 

them about setting up a garden and they were all on board. Soil was donated by 

the groundskeeper and a local carpenter built some raised beds. The cedar planks 

were donated by a local volunteer and Scott Farms gave a great discount on the 

cedar wood. The local tenants bought the seeds and seedlings with their own money 

or with their returnable bottle fund. Additional volunteers in the community also 

donated large pots for the seniors in wheelchairs or walkers who wanted to garden 

on the patio. Some of these donations came in because we shared our story on 

Facebook. To see the tenants wish for, plan, and plant a small vegetable garden in 

front of their downtown apartment building is something I am, and many others 

are, very proud of. To see tenants out of their apartments tending to the garden 

or making casual conversations is what our area needs. Many tenants, who grew 

up and tended to large gardens for most of their lives, now find themselves living 

in apartments with no access to garden plots. Planted raised beds and containers 

help bring the mini gardens to them!’’ 

In addition to the garden project, Heather learned quickly how to respectfully help 

low-income seniors in her community access nutritious food. She learned from other 

Nutrition Educators in rural Maine communities about gleaning. Gleaning projects 

(the collection of leftover crops from farmers) have been successful in Maine because 

many proud seniors will readily take extra produce from farms to avoid waste rather than go to a food pantry. When Heather tried this strategy, she found that the 

seniors in her community would happily accept this free produce from the farmers. 

Then they would cook community meals for themselves and their friends. 

SNAP-Ed is the one USDA program that brings the powerful combination of education, marketing, and policy, systems, and environmental support to low-income 

communities. It can be delivered in diverse settings such as schools, worksites, retail food stores and faith communities. SNAP-Ed interventions are customized for 

different rural, urban, age, ethnic, cultural and regional settings. Efforts expand beyond the classroom to engage residents of all ages in community changes that strive 

to make the healthy choice the easy choice. SNAP-Ed is invaluable to supporting 

healthy aging for low-income families in Maine and across the country. 

Since SNAP-Ed promotes the health benefits of SNAP and focuses on making 

healthy choices within a limited budget, it builds on the short-term economic and 

nutritional value of SNAP food dollars while helping SNAP-Ed eligible Americans 

make better food and lifestyle choices. Empowering SNAP participants to make 

healthy food choices through SNAP-Ed is a win for everyone. American diets fall 

far short of recommendations for good health and contribute to excess rates of preventable chronic diseases. Our Nutrition Educators are not only teaching seniors the 

importance of balanced and nutritious diets but they are giving them concrete strategies to accomplish this on a limited food budget. 

As the oldest State in the country, Maine has a responsibility to care for its seniors. According to ‘‘Feeding America’’, there are an estimated 24,000 seniors in 

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Maine who are considered food insecure, or don’t have enough food to sustain a 

healthy diet. Food insecurity among seniors is significantly underreported. Many 

seniors in Maine are reluctant to admit they struggle with hunger so they often do 

not reach out for help. In fact, our Nutrition Educators often find that seniors downplay their struggles and firmly believe that others are more deserving of food assistance. The SNAP-Ed program is extremely important in Maine as we are able to empower low-income seniors by teaching them how to stretch their limited food dollars. 

In addition to the direct nutrition education, our experienced and highly qualified 

educators work hard to find creative solutions to address the dietary challenges lowincome Mainers face. They are committed to finding strategies to help them access 

fruits and vegetables through their local expertise and partnerships with organizations throughout Maine who have a similar focus on food access. 

Prepared Statement of Patricia Ann Taylor, Retiree, Penn Hills, 

Pennsylvania 

Chairman Collins, Ranking Member Casey, and Members of the Committee, 

thank you for inviting me to testify today. It is an honor to be here. 

My name is Patricia Ann Taylor. I am 72 years old and a resident of Penn Hills, 

Pennsylvania. 

I am married to the love of my life, James, who is 79 years old. This past April 

we celebrated 51 wonderful years together. We have 5 biological children, 2 of my 

daughters, Dawn and Toni, have joined me here today, both who are employed and 

volunteer at our Food Pantry. James and I also adopted 5 boys with special needs. 

We have always had a full house. We are a close-knit family, I love having my 

10 children, 15 grandchildren and 17 great-grandchildren around us. 

My husband and I have always worked to support our large and boisterous family. 

James was self-employed, an owner of a beer distributor and laundromat. I have 

held various positions in the healthcare sector at times having to work 2 jobs. It 

was not always easy to put food on the table and pay our bills, but we managed 

somehow. My husband has always had a strong work ethic and always believed that 

he should be the provider for his family. 

As we have gotten older, our health care costs have taken up a greater share of 

the bills, and we were forced to struggle because of our healthcare expenses. My 

husband has beaten prostate cancer, survived two heart attacks, is an insulin dependent diabetic, has blood clots in both lungs and has been fighting blindness due 

to diabetic neuropathy. I have beaten breast cancer, had back surgery, and total 

right knee replacement. I also have multiple sclerosis, which is now in remission 

and heart disease. 

It was not easy to ask for help with our food expenses. When talking with other 

adults in our age bracket, we learned about a food pantry in our neighborhood, the 

Lincoln Park Community Center, which is run by Joyce Davis. This center serves 

over 600 needy families monthly, and seniors such as ourselves, receive a Senior 

Food Box once a month. The help that Ms. Davis provides to my husband and I has 

truly been a blessing. 

Because of the Senior Food Box that we receive through the Lincoln Park Community Center we do not have to decide between paying for our medication and putting 

nutritious food on the table. Ms. Davis serves so many needy families that have 

come to the Lincoln Park Community Center. 

She also serves over 100 people at a local Senior Center and over 75 at another 

food pantry. Her services, as you can see by the number of needy families that come 

to these centers, shows the need in just our community. She has definitely been an 

asset to our community by how efficient, organized and successful her food pantry 

is. And, she tells me that the Federal support she receives for this work is essential. 

Neither my husband nor I ever dreamed that we would come to rely upon the senior food box. We were hard-working adults and we saved for our retirement. At 

times I even worked two jobs. Before the senior box, I noticed that I was not purchasing as much food that would help keep us healthy. It started a vicious cycle 

that I knew was not good for our health. 

Things changed when I started receiving the senior food box. Last month, I received canned fruit and vegetables, spaghetti sauce, cereal, dry milk, cheese, pasta, 

peanut butter, and canned chicken. 

I can supplement these items with groceries like, fish, meat, fruits, vegetables, 

Ensure, and Boost. With those items that I receive from the senior food box, I can 

make many creative dishes. Last month I was able to make chicken salad, spaghetti, grilled fish, and baked chicken. These are nutritious meals for me and my 

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46 

husband. The senior food box stretches our groceries and our budget. I am especially 

appreciative of the senior food box because it helps my family afford Ensure and 

Boost, which my husband needs to drink due to his loss of appetite caused by health 

issues and medications. 

When Senator Casey’s office called me to talk about my experience with the senior 

food box, I said that I would do anything to help support nutrition programs that 

benefit seniors, and that is how I wound up in this chair. 

The senior food box has been a god-send to me and James. I strongly urge you 

to support senior food box programs, food banks, and other programs that help people like me. I urge you to help spread the word that programs like the senior food 

boxes are available. And, I hope that people will be able to continue to receive the 

senior box. 

Again, thank you for the invitation to testify before the Committee. I look forward 

to answering your questions. 

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(47) 

Additional Statements for the Record 

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Testimony of Meals on Wheels 

Chairman Collins, Ranking Member Casey and Members of the Committee: 

On behalf of Meals on Wheels America, the network of more than 5,000 community-based nutrition programs and the millions of seniors they serve nationwide, we 

thank you for the opportunity to submit this statement for the record. We commend 

you for your leadership and attention to the needs of our nation’s older adults and 

appreciate your holding this important hearing to assess the growing problem of 

senior hunger, and the role proper nutrition plays in improving health and overall 

quality of life. We offer our perspective on the risks and consequences of poor nutritional status among seniors, as well as present for your consideration policy recommendations to address these challenges. We look forward to working with you to 

seek solutions for a future where no senior in America is left hungry or isolated. 

The Current State 

Programs like Meals on Wheels are a frontline defense against senior hunger, isolation and malnutrition. For nearly five decades, in communities large and small, 

rural, suburban and urban, Meals on Wheels programs—with the Federal support 

and structure largely from the Older Americans Act (OAA)—have been effectively 

serving seniors in the greatest economic and social need. The nourishing meals, 

friendly visits and safety checks delivered each day supply an efficient and vital 

service for our most vulnerable seniors, our communities and our taxpayers. Both 

congregate and home-delivered nutrition services provided by local Meals on Wheels 

programs enable seniors to live healthier, safer and more independent lives longer 

in their own homes—where they want to be—reducing unnecessary visits to the 

emergency room, admissions and readmissions to hospitals and premature nursing 

home placement. Data from the Administration for Community Living’s (ACL) State 

Program Reports and National Survey of OAA Participants demonstrates that the 

seniors receiving meals at home and in congregate settings, such as senior centers, 

need these services to remain in their own homes. They are primarily women, age 

76 or older, who live alone. Additionally, they have multiple chronic conditions, take 

six or more daily medications and are functionally impaired. Further, the single 

meal provided through the OAA Nutrition Program represents half or more of their 

total daily food intake. Significant numbers of seniors receiving meals are impoverished, live in rural areas and belong to a minority group. In short, the individuals 

requesting and being provided services through the OAA nutrition network are 

largely high-risk and high-need—and potentially high-cost to our healthcare system, 

if their unique needs are not met. 

Yet, while the Federal infrastructure exists to address these needs of our nation’s 

most vulnerable seniors—through successful programs administered by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services— 

the number of individuals struggling far outpaces the resources available to serve 

them. Today, 10.2 million seniors, or one in six, struggle with hunger, representing 

a 65 percent increase since the start of the recession in 2007 and a 119 percent increase since 2001. In 2014, funding provided through the OAA supported the provision of meals to 2.4 million seniors nationwide, while the President’s Fiscal Year 

2018 budget request would reduce that number to 2.3 million seniors. Underscoring 

this growing gap, a 2015 Government Accountability Office report found that about 

83 percent of food insecure seniors and 83 percent of physically impaired seniors did 

not receive meals [through the OAA], but likely needed them. 

To further illustrate these troubling trends, the Meals on Wheels network overall 

is serving 23 million fewer meals to seniors in need than it was in 2005, due in 

large part to Federal funding not keeping pace with inflation or demand. And, one 

in four Meals on Wheels programs reports having a waiting list for services, with 

an average of 200 seniors and growing. Quite simply, too few seniors who need 

meals are getting them today, and each year, the chasm widens between those 

struggling with hunger and those being served. This harsh reality is not only felt 

on a personal level by those suffering from hunger and isolation, but it is also felt 

on a fiscal level by taxpayers, in terms of increased Medicare and Medicaid expenditures. 

The Costs of Hunger and Malnutrition 

The consequences of hunger and malnutrition in older adults are profoundly more 

significant than with other populations. Older adults are among the most vulnerable 

to malnutrition, with 50 percent of all older adults at risk for malnutrition, and minority groups at a disproportionately higher risk. The Causes, Consequences, and 

Future of Senior Hunger in America—the first ever assessment of the State of senior 

hunger in America—found that a senior facing the threat of hunger has the same 

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chance of much more severe activities of daily living (ADL) limitations as someone 

14 years older. This means there is a large disparity between a senior’s actual 

chronological age and his or her ‘‘physical’’ age, such that a 67 year old senior struggling with hunger is likely to have the ADL limitations of an 81 year old. In addition, declines in cognitive and physical function as a result of the aging process, coupled with the onset and management of chronic disease, make older adults more 

physically susceptible and at-risk to hunger and malnutrition. These complications 

are further exacerbated for individuals living on fixed incomes and/or in poverty, 

with limited food access and mobility challenges. 

Malnutrition has been found to further diminish an individual’s ability to manage 

and overcome sickness and increase the likelihood of further illness, disability or injury. As a result, malnourished seniors have higher utilization rates of expensive 

healthcare services, higher rates of hospitalization admissions and readmissions and 

a greater need for long-term care services and facilities. For seniors who would 

other wise be healthy with appropriate dietary intakes, this puts an added burden 

on the individual, as well as on our healthcare system. Annual healthcare costs attributable to malnutrition in older adults are estimated to be $51.3 billion. 

Malnourished seniors, both underweight and overweight, do not have the intake 

of essential nutrients needed to maintain a favorable health status. They also experience higher rates of morbidity and are at an increased risk for a myriad of health 

complications, including injury from falls, delayed wound healing, infection and decreased cardiac and lung function. With a diminished health status made worse by 

lack of adequate nutritional intake, seniors lose the ability to maintain healthy, active and independent lives. The need for interventions that prevent hunger and malnutrition from occurring, as well as large-scale implementation of cost-effective 

methods known to treat these problems, is paramount. 

The Solution Exists 

Proper nutrition is essential to one’s health and well-being. As cited above, this 

is particularly true for seniors, whose health status may be compromised as even 

a slight reduction in nutritional intake can exacerbate existing health conditions, accelerate physical impairment and impede recovery from illness, injury or surgery. 

Seniors with chronic disease who receive adequate nutrition have improved health 

outcomes and are better able to support a healthy and active lifestyle. Senior nutrition programs like Meals on Wheels are already minimizing the negative impact of 

malnutrition in communities across the country. These public-private partnerships 

have been, and continue to be, exemplary as they are able to harness diverse resources from the local, State and Federal Government along with private donations, 

while enlisting the help of two million volunteers nationwide, to carry out much of 

the services the programs offer. For every Federal dollar appropriated through the 

OAA, states and communities are able to leverage an additional $3 from other funding sources. Meals on Wheels is able to feed a senior nutritionally balanced, and 

in some cases, medically tailored, meals for one year at the same cost as one day 

in the hospital or 10 days in a nursing home. By improving the nutritional status 

and maintaining the independence of seniors who are homebound and/or have limited mobility, we are able to keep potentially expensive patients out of hospitals and 

long-term care facilities. As a result, Meals on Wheels generates considerable 

health-related savings for seniors, their families and our healthcare system, as a 

whole. 

In addition to the cost-effectiveness made possible by the ability to prolong the 

physical health and self-sufficiency of seniors, Meals on Wheels programs offer more 

than just nutrition; the model improves the mental and emotional health of participating seniors, too. Frequent and consistent visits by a volunteer or staff member 

offer companionship, to which seniors can look forward, reducing social isolation and 

feelings of loneliness. Seniors who rely on home-delivered meals self-reported that 

they found a reduction in the likelihood of injuries from falls, a dangerous and expensive safety risk that affects many independent seniors and amounts to $31 billion in annual Medicare costs. Regular check-ins by volunteers can help identify potential hazards both inside and outside the home, sudden declines in health or other 

troubling changes early, before they become more serious problems. For example, 

findings from a 2015 study entitled More Than a Meal—commissioned by Meals on 

Wheels America, underwritten by AARP Foundation and conducted by Brown University—showed that those seniors who received daily home-delivered meals (the 

traditional Meals on Wheels model of a daily, in-home-delivered meal, friendly visit 

and safety check), experienced the greatest improvements in health and quality of 

life. Specifically, between baseline and follow-up, seniors receiving daily home-delivered meals were more likely to exhibit improvements in physical and mental health 

(including reduced levels of anxiety, feelings of isolation and loneliness and worry 

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about being able to remain at home) and reductions in hospitalizations, falls and 

the fear of falling. In addition to being a preventative measure for emergency department visits and hospital admissions, investing in Meals on Wheels is also a 

proven way to reduce hospital readmissions and post-discharge costs. A 2012 Brown 

University study showed that investments in Meals on Wheels of $25 more per senior per year could reduce the low-care nursing home population by one percent, 

which translates annually to millions of dollars in Medicaid savings alone. Not only 

are these programs providing more than just a meal to those who are fortunate 

enough to receive services, but they are also an essential part of the solution to our 

nation’s fiscal and demographic challenges, helping to bend the cost curve on the 

mandatory side of the budget. 

Policy Recommendations 

In light of the immense vulnerability and array of health and mobility challenges 

our nation’s seniors face, coupled with the high-cost, high-risk factors they pose to 

our healthcare system, it is imperative that proven and effective programs designed 

to meet their unique nutritional and social needs are further strengthened. At the 

same time, it is important to recognize that there is not a one-size-fits-all solution 

to the problem of senior hunger. Rather, there is a wide continuum of need and a 

variety of federally supported nutrition programs, and each program is targeted to 

meet the specific needs of vulnerable populations along that spectrum while promoting health and wellbeing. For those seniors who are most mobile and may struggle with hunger primarily as a result of limited income and access to affordable 

foods, the Supplemental Nutrition Assistance Program (SNAP) may serve as the 

best intervention. For those seniors who are hungry as a result of mobility and 

health challenges and are physically unable to cook or prepare meals, Meals on 

Wheels may serve as the best intervention, instead. In other cases, it may be a combination of Federal and local programs working together to address hunger in the 

community. 

Given the magnitude of the senior hunger problem, coupled with continued demographic shifts resulting in a rapidly aging population, we urge you to consider the 

following policy recommendations to improve the nutritional status of at-risk and/ 

or malnourished older adults. 

1. Modify Medicare and Medicaid to meet the nutritional needs of our most vulnerable seniors. 

• Expand Medicare managed care plans to include coverage for home-delivered 

meals prepared and delivered by a private nonprofit for seniors, with physician recommendation. 

• Expand Medicaid managed care plans to include coverage, with a physician 

recommendation, for home-delivered meals prepared and delivered by a private nonprofit for individuals who are too young for Medicare, but who are 

at serious medical risk or have a disability. 

• Allow doctors to write billable Medicare and Medicaid ‘‘prescriptions’’ for nutritious and medically appropriate meals prepared and delivered by a private 

nonprofit for individuals prior to being discharged from a hospital. Seniors receiving short-term nutrition interventions post-hospital discharge, ranging 

from a daily hot meal to a combination of different meal types (i.e., lunch, 

dinner, snack, hot or frozen meals) has resulted in readmission rates of 6%– 

7% as compared to national 30-day readmission rates of 15%–34%. 

2. Protect and bolster funding for Older Americans Act (OAA) Nutrition Programs. 

• Increase funding for OAA Nutrition Programs (Congregate, Home-Delivered 

and Nutrition Services Incentive Program) to a minimum of $874,638,011 in 

FY 2018; the same level authorized and unanimously passed by Congress and 

signed into law last year. 

• End sequestration for FY 2018 and beyond by replacing it with a bipartisan 

budget plan that recognizes the significant cuts already made. 

3. Standardize nutritional assessment and screening process for seniors in 

healthcare settings. 

• Implement validated malnutrition and food insecurity screening tools, including a patient’s ability to access nutritious food, in hospital admission and discharge processes. 

• Include nutrition screening questions in the Centers for Medicare & Medicaid 

Services annual wellness and Welcome to Medicare physical exams. 

4. Defend and support nutritional access for seniors via the Supplemental Nutrition 

Assistance Program (SNAP) and the Commodity Supplemental Food Program 

(CFSP). 

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• Strengthen policies that improve senior SNAP participation by expanding the 

use of simplified applications, lengthening recertification periods and utilizing 

a standard medical deduction. 

• Protect SNAP from structural changes (e.g.,block grants) that would undermine their effectiveness. 

• Provide enough funding for CSFP to maintain current caseloads and expand 

to a completely nationwide program. 

An Urgent Responsibility 

The disproportionately high risk for malnutrition among older Americans, in addition to demographic shifts toward an older population, means we have an urgent 

responsibility to establish policies that support healthy aging. The causes and consequences of senior hunger and malnutrition are complex, so a uniform approach 

for all seniors will not be successful. However, there is already an existing network 

and Federal nutrition program infrastructure in place to address the needs of today 

and tomorrow’s seniors, and strong evidence that demonstrates their effectiveness. 

Now is the time for Congress to act and support legislation that will promote the 

adoption of methods known to successfully prevent and treat these challenges. Ensuring that no senior in need struggles with hunger, malnutrition or isolation is not 

only doing right by our nation’s seniors—our veterans, teachers, police officers, firemen and others who have done so much for us—but is also a solution for saving 

taxpayers and bending the cost curve on the mandatory side of the budget. 

We ask that you please consider the recommendations outlined in this Statement 

and call on your colleagues to do so, as well. These are issues within our reach to 

solve and are among our greatest moral, social and economic imperatives. We thank 

you again for your continued leadership and support for senior nutrition programs 

and look forward to working together in the weeks and months ahead. 

Submitted by Meals on Wheels America 

1550 Crystal Drive, Suite 1004 

Arlington, VA 22202 

1–888–998–6325 

www.mealsonwheelsamerica.org 

Testimony of the National Association of Nutrition and Aging Services 

Programs 

The National Association of Nutrition and Aging Services Programs (NANASP) 

commends the Senate Special Committee on Aging for today’s hearing entitled 

‘‘Nourishing our Golden Years: How Proper and Adequate Nutrition Promotes 

Healthy Aging and Positive Outcomes.’’ NANASP is an 1,100-member nonpartisan, 

nonprofit, membership organization for senior nutrition and aging services providers. 

We support the Committee’s interest in working to strengthen and support the 

array of existing federally funded nutrition assistance programs for older adults. We 

see this as a three-pronged issue. 

First, it is an issue of funding. The inability of key programs, including and especially the Older Americans Act (OAA) Nutrition Programs, to have Federal funding 

keep pace with demand leads to programs serving far fewer participants than intended. For example, a Government Accountability Office report released in 2015 

found that about 83 percent of food insecure older adults and 83 percent of physically impaired older adults did not receive OAA meals but likely need them. OAA 

meals programs overall are serving 21 million fewer meals annually to seniors than 

we were in 2005 due to declining Federal and State grants, stagnant private funding, and rising food and transportation costs. 

Further, we note in the President’s budget that his call for the elimination of 

funding for the Social Services Block Grant, the Community Development Block 

Grant and the Community Services Block Grant, as well as a $193 billion cut in 

the Supplemental Nutrition Assistance Program (SNAP) over the next 10 years, will 

also severely weaken our commitment to providing nutrition assistance to older 

adults. 

Second, it is an issue of recognizing the essential link between nutrition and better health outcomes—which in turn leads to cost savings for health programs. Investing in these programs is cost-effective because many common chronic conditions 

such as hypertension, heart disease, diabetes, and osteoporosis can be effectively 

prevented and treated with proper nutrition. The Academy of Nutrition and Dietetics estimates that 87 percent of older adults have hypertension, high cholesterol, diAGING-G33-GPO with DISTILLER

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abetes, or some combination of all of these. These seniors need healthy meals, access 

to lifestyle programs, and nutrition education and counseling to avoid serious medical care. We further see the potential cost savings related to nutrition when we examine disease-associated malnutrition. As Ranking Member Casey notes, disease-associated malnutrition costs our nation $51.3 billion annually. 

Finally, it is an issue of proper nutrition education throughout the lifespan. It is 

important that we support in every way possible those programs which provide 

needed education to help people achieve better nutrition. This includes SNAP-Ed as 

well as the nutrition education provisions in the OAA. 

We look forward to continuing our work with the Committee on this important 

subject. 

Æ 

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