1

IssueBRIEF

Marisa Shenk, James Mabli, Arkadipta Ghosh, and Bob Schmitz, Mathematica

Older Americans Act Title III-C Nutrition 

Services Program: Examining the 

Prevalence of Chronic Conditions 

among Congregate Meal Participants

BACKGROUND

Many older adults live with chronic health conditions, which are illnesses that usually last a year or 

more, are generally incurable, and require ongoing medical help (AARP Chronic Care 2009; U.S. 

Department of Health and Human Services 2010). These conditions can severely limit activities of 

daily living and substantially increase the costs older adults incur for disease management and support 

services (AARP Chronic Care 2009; Lehnert et al. 2011). Most chronic conditions, including diabetes 

and hypertension—which were prevalent among 28 and 59 percent of Medicare beneficiaries in 2016, 

respectively—can lead to complications or hospitalizations if not properly managed (CMS Chronic 

Conditions Data Warehouse 2016). Additionally, the prevalence of many conditions among older 

adults has increased over recent years (Hung et al. 2011; Ward and Shiller 2013). Given that adults 

ages 65 and older are projected to account for more than 20 percent of the population by 2030, the 

share who experience chronic conditions is cause for concern (U.S. Census Bureau 2018). 

The Older Americans Act Title III-C Nutrition Services Program (NSP) is the largest program in the 

United States that provides prepared meals to older adults in need. Overseen by the Administration 

on Aging (AoA) within the Administration for Community Living of the U.S. Department of Health 

and Human Services, the NSP strives to promote the health and well-being of, and reduce hunger and 

food insecurity among, older adults by providing congregate and home-delivered meals and a range 

of services—including nutrition education and counseling, opportunities for social engagement, and 

health promotion and disease prevention services.

Research on the NSP has focused on the program’s effects on outcomes such as food security, diet 

quality, socialization, and health events, but little is known about the prevalence of chronic health 

conditions among older adults who receive congregate or home-delivered meals (Frongillo and Wolfe 

2010; Mabli et al. 2017, 2018; Racine et al. 2012; Thomas et al. 2015, 2018; Wright et al. 2015). Some 

research has shown that chronic conditions are highly prevalent among NSP participants (Huffman 

et al. 2017; Kleinman and Foster 2011; Mabli et al. 2018). However, there is less information on the 

prevalence of specific and multiple chronic conditions among participants, how the prevalence changes 

over time, and whether the prevalence differs by participant characteristics or by the availability of 

health promotion services by NSP agencies. 

Using a combination of survey data describing participants’ personal characteristics and circumstances, 

agency-level data indicating health services offered, and longitudinal Medicare administrative records 

indicating chronic conditions based on submitted healthcare claims, this issue brief assesses prevalence 

of chronic conditions observed over approximately a 2.5-year period for a sample of nationally 

representative congregate meal participants. It assesses the prevalence of multiple conditions, identifies 

10 common conditions, and assesses the incidence of these conditions over a one-year period. It also 

examines how these rates differ by participants’ income, living arrangements, and geography, and 

whether they receive meals from agencies that offer health promotion activities. This brief is the first 

June 2020

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1

 Because Medicare claims, which 

identify specific events such as 

a hospital stay or emergency 

department visit, are not available 

for beneficiaries enrolled in managed care plans such as Medicare 

Advantage, the research team 

limited the evaluation to those who 

were enrolled in fee-for-service 

(FFS) Medicare (known as Original 

Medicare). Among the individuals 

with a valid Medicare beneficiary 

identification number, 64 percent 

of participants were FFS beneficiaries for either all or part of the 

2015–2017 analysis period and were 

included in the analysis.

2 If a condition was observed in a 

claim in the baseline period, that 

participant was coded as having that 

condition in the following follow-up 

period as well. Each of the chronic 

conditions was included because 

they have long-term effects; even if 

it did not show up on a subsequent 

medical record, it is still an important part of recent medical history. 

3 All analyses were weighted to 

account for the sample design and 

to adjust for differences in nonresponse propensities across respondent groups. The weights make the 

estimates in this article nationally 

representative of the population of 

congregate meal participants at the 

time of the survey.

of two issue briefs about the chronic conditions 

experienced by NSP participants. A second 

brief focuses on the same set of conditions for 

home-delivered meal participants. Together, these 

issue briefs can help the AoA, local program 

administrators, and policymakers better understand 

the types of conditions experienced by participants 

in order to improve the ways in which health 

promotion and disease prevention activities are 

tailored to older adults in need.

METHODS

The data used in the analysis were collected as 

part of the Title III-C NSP Evaluation (Mabli 

et al. 2017, 2018). The evaluation examined the 

effectiveness of the NSP in reducing older adult 

food insecurity and improving health and health 

care use. The original evaluation sample consisted 

of 596 congregate meal participants. Limiting the 

sample to participants with valid Medicare claims 

information resulted in 316 participants in the 

analysis sample.1

 Some analyses also compared 

the prevalence of chronic conditions among older 

adults who received meals from agencies that 

reported offering health promotion activities 

and, therefore, limited the sample further to 260 

participants with non-missing agency-level data. 

The outcomes analyzed include whether the 

individual had a chronic condition in the 

nine months preceding the 2015–2016 survey 

interview (referred to as the baseline period), or 

in the 12 months after the interview (referred 

to as the follow-up period). These observation 

periods were selected based on Medicare data 

availability. Chronic conditions were identified 

using individual hierarchical condition categories 

(HCCs), which are Medicare claims-based 

conditions that are routinely defined as part of 

the algorithm for creating a risk score (HCC 

score) for Medicare beneficiaries. 

To examine changes in common chronic 

conditions over time, the research team mapped 

individual HCCs into 10 conditions, which were 

selected based on the role of individual behavior 

in affecting both the risk of their occurrence, 

and—to some degree—in exacerbating or 

reducing their severity. The 10 conditions are: 

hypertension; hyperlipidemia; diabetes with or 

without complication (diabetes); vascular disease 

with or without complications (vascular disease); 

congestive heart failure (CHF); acute myocardial 

infarction, unstable angina and other acute 

ischemic heart disease, or angina pectoris (IHD); 

chronic obstructive pulmonary disease (COPD); 

morbid obesity; other significant endocrine and 

metabolic disorders (endocrine disorder); and 

cerebral hemorrhage, or ischemic or unspecified 

stroke (stroke). Participants were coded as 

having a chronic condition if claims submitted 

during the observation period indicated the 

presence of a corresponding HCC.2, 3

Subgroups were based on participants’ personal 

characteristics as well as agency characteristics 

and consisted of household income, living 

arrangement, geography, and whether the 

agency provided health promotion activities. 

Individuals are referred to as living in lowerincome households if their monthly income 

(calculated from the NSP outcomes survey 

as a percentage relative to the federal poverty 

threshold) was less than the median value in 

the sample (128 percent for congregate meal 

participants). Individuals living in higher-income 

households had income-to-poverty ratios that 

were greater than or equal to the median value. 

Living arrangement was determined using the 

NSP outcomes survey, and was defined as living 

alone versus living with others. Geography was 

determined by linking the participants’ geocoded 

address data to the Economic Research Service 

food environment atlas (Economic Research 

Service, 2016). These data contain the urban/

rural status of the population-weighted center of 

each census tract based on the 2010 census. An 

indicator of whether the individual attended an 

agency that provided health promotion activities 

was determined by matching participants to the 

Local Service Provider survey.

FINDINGS

Chronic conditions among congregate 

meal participants

More than 85 percent of congregate meal 

participants had at least one chronic condition 

in the baseline period, and 73 percent had 

multiple chronic conditions (Table 1). On 

average, participants had about 3 conditions. 

Over the following year, there was a sizable 

increase in the prevalence and number of 

chronic conditions among participants, with 

nearly 92 percent of participants having at least 

one condition and more than half (52 percent) 

having four or more conditions in the follow-up 

period. The average number of conditions 

increased to about 4 conditions.
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TABLE 1: Number of chronic conditions experienced by congregate meal participants

Chronic conditions Select chronic conditions*

Number of chronic conditions Baseline Follow-up Baseline Follow-up

0 13.9% 8.3% 19.0% 9.7%

1 13.2% 8.9% 11.9% 11.9%

2 12.8% 11.1% 23.8% 16.1%

3 24.1% 19.6% 25.6% 31.2%

4 or more 36.1% 52.0% 19.7% 31.0%

Average number of chronic conditions 2.9 3.7 2.2 2.9

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data. 

Note: All units are percentages of the total sample, unless otherwise noted. 

 Tabulations are based on unweighted sample sizes of 316 congregate meal participants.

*The set of select chronic conditions includes the following 10 conditions: hypertension, hyperlipidemia, diabetes, vascular disease, CHF, IHD, COPD, morbid 

obesity, endocrine disorder, and stroke.

The prevalence of the set of 10 chronic 

conditions was also high. More than 80 percent 

of congregate meal participants had at least 

one of these chronic conditions and 69 percent 

had multiple chronic conditions in the baseline 

period. On average, participants had about 2 of 

these chronic conditions. As with the larger set 

of conditions, there was a large increase in the 

prevalence and number of conditions over the 

following year. About 90 percent of participants 

had at least one condition in the follow-up 

period and the average number of these chronic 

conditions increased to about 3 conditions.

The 10 chronic conditions of interest had a wide 

range of prevalence among congregate meal 

participants (Table 2). Hypertension, the most 

common condition, was experienced by nearly 

75 percent of participants. Hyperlipidemia and 

diabetes were also common, experienced by 

58 and 36 percent of participants, respectively. 

About one in six participants had vascular disease 

(17 percent) or CHF (15 percent), while IHD, 

COPD, morbid obesity, endocrine disorder, and 

stroke were each experienced by fewer than 7 

percent of participants.

The prevalence of each chronic condition 

increased in the follow-up period. The 

percentages of participants with vascular 

diseases and CHF each rose by more than 

10 percentage points (17 to 28 percent and 

15 to 26 percent, respectively). Hyperlipidemia 

increased in prevalence by 9 percentage points to 

more than two thirds of participants (68 percent). 

The share of participants with hypertension, 

the most common condition, rose to more 

than 82 percent of participants, while the share 

with diabetes increased from 36 to 42 percent. 

Some of the less common conditions also had 

large increases. COPD more than doubled in 

prevalence, increasing from 6 percent to more 

than 14 percent. IHD, morbid obesity, endocrine 

disorder, and stroke also had proportionally large 

increases in prevalence. Another way to look 

at changes in the extent of chronic conditions 

is to examine their incidence, defined as the 

percentage of participants without a chronic 

condition in the baseline period who experienced 

the condition in the follow-up period. Based 

on Table 2, about 49 percent of participants 

without a chronic condition in the baseline 

period had a new chronic condition during 

the follow-up period. About a third of 

participants (32 percent) were newly diagnosed 

with hypertension and 22 percent with 

hyperlipidemia. Vascular disease and CHF 

were each newly diagnosed for 13 percent 

of participants. An additional 9 percent of 

participants were diagnosed with diabetes.
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TABLE 2: Number of chronic conditions experienced by congregate meal participants

Chronic condition Baseline Follow-up Increase

Any condition 81.0% 90.3% 9.3

Hypertension 73.9% 82.2% 8.4

Hyperlipidemia 58.4% 67.5% 9.1

Diabetes 36.0% 41.8% 5.8

Vascular disease 17.3% 28.2% 10.9

CHF 15.1% 25.6% 10.6

IHD 6.5% 10.1% 3.6

COPD 6.2% 14.2% 8.0

Morbid obesity 4.9% 8.5% 3.6

Endocrine disorder 2.8% 4.9% 2.1

Stroke 2.2% 4.9% 2.7

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data. 

Note: All units are percentages of the total sample, unless otherwise noted. 

 Tabulations are based on unweighted sample sizes of 316 congregate meal participants.

*Estimates equal the percentage point increase between percentage of participants with the condition during the baseline period and the follow-up period.

Chronic conditions by participants’ 

income, living arrangements, and 

geography

The prevalence of chronic conditions differed 

according to participants’ household income, but 

generally did not differ by living arrangements 

or geography. Having a chronic condition was 

less likely for participants in households with 

lower income than for those in households with 

higher income (79 versus 83 percent; Table 3). 

In particular, hypertension and hyperlipidemia 

were more prevalent among those with higher 

income than those with lower income. Although 

the likelihood of having a chronic condition was 

similar for participants who lived alone and for 

those who lived with others (about 81 percent), 

vascular disease was much more prevalent among 

individuals who lived with others (23 versus 

14 percent). Finally, the likelihood of having a 

chronic condition was similar for participants 

who lived in an urban area (81 percent) and 

those who lived in a rural area (82 percent), 

although diabetes and vascular disease were more 

prevalent in urban areas.

The incidence of chronic conditions differed 

according to participants’ household income, 

living arrangements, and geography. Nearly 

40 percent of participants in households with 

lower income acquired hypertension, compared 

to 24 percent of those in households with higher 

income (Table 4). Those in higher-income 

households were twice as likely to experience 

onset of diabetes (12 versus 6 percent) and 

about three times as likely to be diagnosed with 

IHD (6 versus 2 percent). Participants who 

lived alone were more likely to experience a new 

chronic condition than participants who lived 

with others. The largest differences for these 

groups were for vascular disease (8 versus 

23 percent), hyperlipidemia (25 versus 

17 percent), and hypertension (30 versus 

36 percent). Finally, participants who lived in 

rural areas were much more likely to acquire 

hypertension (44 versus 27 percent), but less 

likely to have new incidences of less common 

conditions, including IHD (3 versus 4 percent), 

COPD (7 versus 9 percent), and morbid obesity 

(2 versus 4 percent).
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TABLE 3: Prevalence of select chronic conditions experienced by congregate meal 

participants, by household income, living arrangement, and geography

Chronic condition

Total 

(N=316)

Individuals 

in lowerincome 

households 

(N=138)

Individuals 

in higherincome 

households 

(N=178)

Individuals 

who live 

alone 

(N=184)

Individuals 

who live 

with other 

family 

members 

(N=132)

Individuals 

who live 

in an 

urban area 

(N=165)

Individuals 

who live in 

a rural area 

(N=151)

Any condition 81.0% 78.7% 83.2% 80.8% 81.3% 80.6% 81.9%

Hypertension 73.9% 71.5% 76.3% 75.0% 72.3% 73.7% 74.4%

Hyperlipidemia 58.4% 56.6% 60.2% 57.4% 60.0% 58.8% 57.4%

Diabetes 36.0% 36.2% 35.9% 35.5% 36.9% 38.0% 31.0%

Vascular disease 17.3% 16.7% 17.9% 13.5% 23.1% 19.1% 12.5%

CHF 15.1% 17.9% 12.2% 13.5% 17.5% 15.9% 13.0%

IHD 6.5% 6.0% 7.0% 5.4% 8.2% 5.7% 8.7%

COPD 6.2% 5.8% 6.7% 6.1% 6.4% 5.5% 8.1%

Morbid obesity 4.9% 9.0% 0.8% 5.9% 3.3% 5.5% 3.2%

Endocrine disorder 2.8% 1.9% 3.8% 2.4% 3.5% 3.2% 1.9%

Stroke 2.2% 2.1% 2.4% 2.6% 1.6% 2.1% 2.6%

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data. 

Note: All units are percentages. Estimates represent the percentage of participants that experienced the chronic condition during the baseline period, 

among the individuals in each group.

 Tabulations are based on unweighted sample sizes of 316 congregate meal participants. 

Chronic conditions by agencies’ 

provision of health promotion activities

Local service providers in the national aging 

network offer a variety of services to improve 

the health and nutrition of the older adults 

they serve. These include nutrition screening, 

assessment, and education services, as well 

as health promotion and disease prevention 

services. In 2015, 63 percent of local service 

providers offered health promotion services 

(Mabli et al. 2015). This section describes the 

prevalence and incidence of chronic conditions 

for older adults who received meals from a local 

service provider that offered health promotion 

activities, and for older adults who received meals 

from a provider that did not offer these activities.

Slightly less than 80 percent of congregate 

meal participants who received meals from 

agencies that provided health promotion 

activities experienced one or more select chronic 

conditions (Table 5). The most common 

conditions, each experienced by more than 

10 percent of participants, were hypertension, 

hyperlipidemia, diabetes, vascular disease, and 

CHF. Compared to participants who received 

meals from agencies that provided health 

promotion activities, participants who received 

meals from agencies that did not provide these 

activities were slightly more likely to have 

a chronic condition at baseline (81 versus 

78 percent). For several of the most common 

chronic conditions, such as vascular disease 

and CHF, participants had similar prevalence 

of specific conditions regardless of the type 

of agency from which they received meals. 

However, participants who received meals 

from agencies that provided health promotion 

activities were less likely to have hypertension 

and diabetes than those who received meals from 

agencies that did not provide these activities.

The percentage of participants who acquired 

chronic conditions was generally similar 

regardless of whether participants received meals 
6

TABLE 4: Incidence of new select chronic conditions experienced by congregate meal 

participants, by household income, living arrangement, and geography

Chronic condition

Total 

(N=316)

Individuals 

in lowerincome 

households 

(N=138)

Individuals 

in higherincome 

households 

(N=178)

Individuals 

who live 

alone 

(N=184)

Individuals 

who live 

with other 

family 

members 

(N=132)

Individuals 

who live 

in an 

urban area 

(N=165)

Individuals 

who live in 

a rural area 

(N=151)

Any condition 48.9% — — — — — —

Hypertension 32.0% 39.1% 23.5% 29.5% 35.5% 27.4% 44.3%

Hyperlipidemia 21.8% 22.3% 21.3% 24.6% 17.2% 20.8% 24.2%

Diabetes 9.0% 5.7% 12.4% 7.8% 10.9% 9.2% 8.6%

Vascular disease 13.2% 12.9% 13.4% 7.5% 22.9% 13.2% 13.0%

CHF 12.5% 12.9% 12.1% 14.1% 9.8% 12.7% 11.8%

IHD 3.9% 2.0% 5.7% 4.2% 3.4% 4.3% 2.6%

COPD 8.5% 9.3% 7.7% 9.2% 7.4% 9.2% 6.7%

Morbid obesity 3.8% 5.0% 2.8% 5.8% 0.9% 4.4% 2.4%

Endocrine disorder 2.1% 1.7% 2.6% 2.5% 1.5% 2.1% 2.2%

Stroke 2.7% 2.8% 2.7% 1.5% 4.7% 2.9% 2.4%

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data. 

Note: All units are percentages. Estimates represent the percentage of participants that experienced the chronic condition during the follow-up period, 

among the individuals in each group that did not experience the chronic condition during the baseline period.

 Tabulations are based on unweighted sample sizes of 316 congregate meal participants. Sample sizes by cell vary based on the prevalence of the 

condition during baseline.

“—“ Incidence in the “any condition” row not presented due to small sample sizes among subgroups.

from agencies that provided health promotion 

activities. An exception was that the incidence of 

hypertension was almost three times larger for 

participants who received meals from agencies 

that provided health promotion activities, 

compared to those who received meals from 

agencies that did not (45 versus 17 percent).

DISCUSSION

The findings in this issue brief indicate that 

the prevalence of chronic conditions is high 

among congregate meal participants. Most (85 

percent) participants had at least one condition 

in the baseline period, and about three quarters 

(73 percent) had multiple chronic conditions. 

The three most common conditions in this 

analysis were about 10 to 15 percentage points 

more prevalent among NSP participants 

than among all Medicare beneficiaries, 

including hypertension (74 versus 59 percent), 

hyperlipidemia (58 versus 46 percent), and 

diabetes (36 versus 28 percent) (CMS Chronic 

Conditions Data Warehouse 2016). 

Many participants experienced onset of new 

chronic conditions over a one-year period, 

indicating that changes over time in the 

prevalence of chronic conditions are common. 

The congregate meal participants showed large 

(more than 10 percentage point) increases in the 

prevalence of vascular disease and CHF. 

Among participants without a specific chronic 

condition at baseline, the percentage that 

acquired a condition was high. Hypertension, 

hyperlipidemia, and vascular disease had the 

highest incidence rates among participants. 

Even though hypertension was already the most 

common condition before baseline, about a third 

of congregate meal participants who did not 

have it experienced it the following year. 
7

TABLE 5: Prevalence and incidence of select chronic conditions experienced by 

congregate meal participants, by whether agency provided health promotion activities

Agency provided health 

promotion activities (N=185)

Agency did not provide health 

promotion activities (N=75)

Chronic condition Prevalence at 

baseline Incidence Prevalence at 

baseline Incidence

Any condition 78.3% — 81.0% —

Hypertension 70.7% 45.4% 77.9% 16.6%

Hyperlipidemia 53.4% 13.8% 57.8% 17.6%

Diabetes 28.9% 9.3% 36.1% 9.5%

Vascular disease 17.6% 14.6% 17.6% 11.7%

CHF 14.6% 11.4% 16.0% 11.8%

IHD 6.0% 4.7% 4.9% 4.3%

COPD 7.2% 8.8% 5.7% 7.4%

Morbid obesity 5.0% 3.7% 1.9% 6.5%

Endocrine disorder 4.2% 0.4% 0.6% 2.6%

Stroke 2.0% 2.5% 0.0% 1.1%

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, and Local Service Provider survey, 2014, weighted data. 

Note: All units are percentages. Prevalence at baseline measures the percentage of participants that experienced the chronic condition during the baseline 

period, among the sample specified. Incidence measures the percentage of participants that experienced the chronic condition during the followup period, among the individuals in each group that did not experience the condition during the baseline period.

 Tabulations are based on unweighted sample sizes of 185 congregate meal participants who received meals from agencies that provided health 

promotion activities and 75 congregate meal participants who received meals from agencies that did not provide health promotion activities. Sample 

sizes by cell vary based on the prevalence of the condition during baseline.

“—“ Incidence in the “any condition” row not presented due to small sample sizes among subgroups.

The prevalence of chronic conditions differed 

according to participants’ household income 

(having a chronic condition was less likely 

for participants in households with lower 

income than for those in households with 

higher income), but generally did not differ by 

living arrangements or geography. There were 

notable differences in incidence rates according 

to congregate meal participants’ personal 

characteristics and circumstances, however. 

Participants who lived in households with lower 

income were more likely to acquire hypertension 

and less likely to acquire diabetes and to be 

diagnosed with IHD than those in households 

with higher income. Hypertension was also 

more likely to develop among individuals who 

lived with other family members or in rural 

areas. Local service providers serving meals to 

these populations should consider targeting 

non-meal services toward them to help at-risk 

participants manage these conditions. 

The percentage of participants who had a chronic 

condition was similar among participants who 

received meals from agencies that did not provide 

health promotion activities and participants who 

received meals from agencies that did. However, 

a high percentage of participants who received 

meals from agencies that provided health 

promotion activities had chronic conditions. The 

incidence of hypertension was almost three times 

larger for participants who received meals from 

these agencies compared to those that received 

meals from agencies that did not provide these 

services. Agencies that provide these services 

might be more likely to serve populations with 

higher rates of illness; these findings underscore 

the need to identify best practices of how to 

manage these illnesses. 

Nutrition screening and health promotion 

activities could be especially important 

to help participants manage conditions 
8

such as hypertension, hyperlipidemia, and 

diabetes. These three conditions can all lead 

to cardiovascular complications or mortality, 

yet many older adults are unaware of their 

conditions, do not receive treatment, or do not 

properly control these conditions (McDonald 

et al. 2009). Program administrators might find 

it helpful to tailor services and education to 

particular conditions that increase the most over 

time, including hypertension, hyperlipidemia, 

vascular disease, and CHF. Differences between 

groups could reflect underlying differences in 

overall health or access to care. Services should 

be designed to target groups at high risk of 

developing certain conditions; for example, 

information about hypertension might be 

especially effective in sites serving more rural 

areas. More work is needed to identify the 

need for targeted health promotion and disease 

prevention activities.

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