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Hidden Hunger: Solutions for America’s Aging Population

Hidden Hunger

Presented By

The Sackler Institute for Nutrition Science

The New York Academy of Sciences


Micronutrient deficiency in older adults is caused by a number of biological factors, such as reduced absorption and environmental factors, including food access. These factors may not be immediately obvious to health care providers and are often referred to as “hidden hunger.” As a result, the condition is not well diagnosed or documented. On March 23, 2018, the Sackler Institute for Nutrition Science at the New York Academy of Sciences presented Hidden Hunger: Solutions for America’s Aging Population. This one-day event, designed for public health officials, healthcare practitioners, and scientists interested in elder nutrition, focused on our current understanding of hidden hunger in the U.S. and highlighted the role of policies to encourage quality health care practices that promote adequate nutrition among the elderly.


Hidden Hunger
Simin Nikbin Meydani, DVM, PhD, JMUSDA Human Nutrition Research Center on Aging at Tufts University
Hidden Hunger
Katherine L. Tucker, PhD, University of Massachusetts Lowell
Hidden Hunger
Regan Bailey, PhD, MPH, RD, Purdue University
Hidden Hunger
Mary Ann Johnson, PhD, University of Georgia
Hidden Hunger
Jeffrey B. Blumberg, PhD, Tufts University
Hidden Hunger
Ucheoma Akobundu, PhD, RD, Meals on Wheels America
Hidden Hunger
Caitlin R. Hodgkins, Office of Congressman James P. McGovern
Hidden Hunger
Bob Blancato, MPA, Blancato and Associates
Hidden Hunger
Emily Allen, AARP Foundation



Session 1: Unique Dietary Needs and Challenges Meeting These Needs for the 65+ Population


Hidden Hunger in Older Adults: Size and Scope of the Challenge and Its Role in Healthy Aging

Simin Nikbin Meydani, DVM, PhD
JMUSDA Human Nutrition Research Center on Aging at Tufts University

Hidden hunger is defined as lack of vitamins and minerals and is the main cause of malnutrition world wide. It does not produce hunger as known by its classic definition, but it strikes health and vitality at its core. Until recently, the focus of malnutrition problem world-wide has been on those related to protein and energy under or over nutrition. However, 1 in 3 of the world’s population is suffering from hidden hunger and its related conditions because of insufficient micronutrient status. Up to 80% 0f heart disease, stroke and diabetes and 30% of cancer death are preventable. Malnutrition is a key modifiable risk factor for chronic and infectious diseases. Hidden hunger leads to serious chronic diseases, impacts mental health, traps societies in poverty and ultimately slows economic growth. In recent years, health problems associated with micronutrient deficiency in children has been highlighted and received well-deserved attention. Hidden hunger, however, impacts individuals across all age groups, and socio-economic status globally. By 2050 the number of people over 60 will increase to 2 billion and exceed all children under 14, yet the problem has not been acknowledged/addressed in older adults.

The United Nations recently linked food insecurity and health to aging populations for the first time in setting its new Sustainable Development Goals. A significant portion of older adults in US are at risk for micronutrient insufficiency as well as obesity and often the two conditions co-exist. In the US alone, the costs associated with disease related malnutrition in older adults is estimated at $157 billion. However, assessment of micronutrient status is not part of health evaluation of older adults. The level and type of micronutrient deficiencies varies among older adults and contributes to inconsistency in efficacy of micronutrient supplementation. The problem is compounded because a true assessment of micronutrient status cannot be achieved using dietary intake data and/or anthropometric measurements. A concerted effort by scientists, health care providers, and policy makers is needed to include micronutrient assessment as an integral part of older adult’s health evaluation. This information will help document the prevalence of “hidden hunger” in older adults at population as well as individual level and sharpen strategies to address it, which will ultimately improve health span of elderly. Ending all forms of malnutrition by 2030 as outlined by United Nations will only be achievable if we shine light on the problem of hidden hunger across all age groups and commit to strategies that reverse the current trends.

Foods, Nutrients, and Dietary Patterns for Healthy Aging

Katherine L. Tucker, PhD
University of Massachusetts Lowell

Many aging individuals have chronic health concerns, including type 2 diabetes, heart disease, osteoporosis, physical frailty and cognitive decline. As a modifiable risk factor, healthy diet offers tremendous promise for improving health and wellbeing with age. Unfortunately, intakes of several nutrients are inadequate for a large segment of the older population. These “shortfall nutrients” include macronutrients: protein, n-3 fatty acids, dietary fiber; vitamins: vitamins B6, B12, D, E, and carotenoids (vitamin A precursors); and minerals: calcium, magnesium, and potassium. Other nutrients tend to be consumed in excess, increasing risk of obesity, hypertension and related chronic conditions. These include: saturated fats (i.e. fatty meats, processed meat, full fat dairy products), trans fat (i.e. hydrogenated oils, margarine, shortening, many processed baked products, crackers), refined carbohydrate foods (i.e. soft drinks, fruit drinks, white bread and products with white flour, white rice) — and sodium (salt and sodium compounds in canned and other processed foods, table salt).

Relative to food group intake recommendations, older adults tend to report inadequate intakes of fruit, vegetables, legumes, whole grains, nuts or seeds, fish, lean meat, poultry, and low fat fluid dairy products. Because of lower energy needs, but higher needs for some nutrients, the importance of these nutrient dense food groups is of central importance. Supplements may be needed in the case of nutrient deficiencies, and when health conditions or medications interfere with absorption or effective nutrient utilization of specific nutrients, making it difficult or impossible to obtain adequate intakes from diet alone. Examples of these include vitamin B-12 with atrophic gastritis, use of acid blocking medication, metformin or other interfering medications, and vitamin D for individuals who get inadequate sun exposure, and during the winter months in northern latitudes. For most nutrients, however, increasing intakes of nutrient dense whole foods, while reducing energy dense refined and processed foods, is the best way to optimize metabolism, protect cellular and organ function and maintain health with aging.

Defining Hidden Hunger in the Context of Aging in the US

Regan Bailey, PhD, MPH, RD
Purdue University

Many older adults may have compromised intakes of foods and nutrients that place them at nutrition risk without evidence of clinical malnutrition. Two distinct nutritional “phenotypes” of risk exist: the under-nourished, under-fed and the under-nourished-over-fed. The well-established malnutrition due to inadequate energy intakes often manifests with overt physical wasting. However, our nation’s older adults can also present with nutrition risk due to adequate or even excessive energy intakes, but suboptimal intakes of nutrients, particularly among the overweight and obese. Screening for nutrition risk is a proactive strategy to identify individuals at both types of risk. The Dietary Screening Tool is one population-specific dietary screener has been validated to measure nutrition risk in the under-nourished-overfed phenotype. Furthermore, national data on this phenotype will be described using the National Health and Nutrition Examination Survey, 2011–2014.

Panel Discussion

Session 2: Strategies and Interventions to Diagnose and Address Hidden Hunger in the 65+ Population


Innovative Programs to Diagnose and Address Hidden Hunger, with Measureable Outcomes

Mary Ann Johnson, PhD
University of Georgia

This presentation focuses primarily on hidden hunger among the more than 95% of the older adult population in the US that resides in communities (rather than in nursing homes). While hidden hunger usually refers to deficiencies of vitamins and minerals, many older adults also experience food insecurity. Subgroups of the older adult population that are particularly at risk for hidden hunger and food insecurity include those accessing food and nutrition assistance programs. These assistance programs include USDA’s Supplemental Nutrition Assistance Program (formerly known as food stamps) and the Administration on Community Living’s Home Delivered Meals “Meals on Wheels” and Congregate Meals programs. Older adults enrolled in these programs often have low-incomes along with a high prevalence of obesity (40%), food insecurity (19%) (Brewer et al., 2010), and poor vitamin and mineral status, such as vitamin D insufficiency (37%) or deficiency (8%) (Johnson et al., 2008) and vitamin B12 deficiency (23%) (Johnson et al., 2003). Innovations in addressing hidden hunger and food insecurity from the “Georgia State Plan to Address Senior Hunger” will be discussed and include understanding today’s seniors, impact of senior hunger on health, food access, food waste and reclamations, and meeting the needs of the community.

A Role for Food Fortification and Dietary Supplementation in Combating Hidden Hunger Among Older Adults

Jeffrey B. Blumberg, PhD
Tufts University

The Dietary Guidelines for Americans 2015–2020 (DGA) identify vitamins A, C, D, E, and choline and the essential minerals calcium, magnesium, and potassium as “underconsumed nutrients”. Inadequate intakes (i.e., less than the Estimated Average Requirement) of these and other micronutrients in older adults can lead to increases in morbidity and mortality as well as healthcare costs. Compared to conventional food alone, the use of fortified foods is associated with a lower prevalence of micronutrient inadequacies. However, an even lower prevalence of nutrient inadequacies is found among those using dietary supplements. Recent data from the National Health and Nutrition Examination Survey (2009–2012) reveal that supplement use is associated with higher intakes of 15 to 16 of 19 micronutrients and successively greater reductions with advancing age from 19–50 to 51–70 to ≥71 years. Among all supplement users, compared to young adults, those ≥71 years had lower rates of inadequacy for iron and vitamins A, C, D and E. In addition to the same problem facing younger Americans consuming diets rich in energy but poor in micronutrients, older adults are particularly vulnerable to hidden hunger due to age- and disease-associated increases in nutrient requirements or needs plus the impact of ubiquitous but often over-looked drug-induced nutrient inadequacies, particularly with the challenge of widespread polypharmacy regimens. Nonetheless, the DGA and most medical and nutrition organizations recommend educational efforts and behavioral changes that promote healthier dietary patterns but not routine dietary supplementation to prevent micronutrient shortfalls and their adverse impact on health and risk for chronic disease.

Addressing Food Insecurity in Homebound Older Adults: Challenges and Opportunities

Ucheoma Akobundu, PhD, RD
Meals on Wheels America

Nutrition assistance programs targeted at older adults play an essential role in supporting the health and independence of this population. However, the aging process can result in a myriad of functional, physical and biological changes that can adversely impact the nutritional status. These changes, coupled with key socioeconomic and demographic challenges unique to older adults, can also increase their risk of poor health outcomes. In 2014, 10.2 million older adult households faced the threat of hunger in the United States. Food insecurity, hunger and malnutrition in the older adult population remains a persistent challenge to be addressed. While a myriad of solutions are possible, the needs of homebound older adults are less often taken into account. Research has demonstrated that participating in nutrition assistance programs, i.e., Meals on Wheels, can assist at-risk homebound older adults to successfully age-in-place, mitigate the impact of malnutrition and food insecurity, and attenuate healthcare utilization. These community-based programs provide client-centered services that address the social determinants of health needs of the vulnerable populations they serve. This presentation will present a research-supported review the risk factors that place older Americans at risk of food insecurity, the challenges surrounding their participation in community-based nutrition programs, and the traditional and non-traditional opportunities that such programs can and currently leverage to optimally address the nutrition and health needs of community-residing older adults.

Panel Discussion

Session 3: Bringing Attention to Policy Makers and Public Health Experts


Protecting and Strengthening our Federal Safety Net to Improve Nutrition and End Hunger

Caitlin R. Hodgkins
Office of Congressman James P. McGovern, Committee on Agriculture

Hidden hunger among our senior population is a problem Congress and the Trump Administration should be working to address. Instead, too much effort and focus has gone into proposals to cut, weaken, and create additional barriers to access safety-net programs that help ensure seniors remain healthy and with proper nutrition. Past budgets in the House of Representatives and from the Administration have called for drastic cuts to the Supplemental Nutrition Assistance Program (SNAP), our nation’s first line of defense against hunger and malnutrition. We already know SNAP is underutilized by seniors for a number of reasons, and efforts to cut the program further would exacerbate this problem.

In addition to SNAP, there are a number of federal programs seniors rely on for nutrition assistance such as the Commodity Supplemental Food Program, Meals on Wheels, and other Older Americans Act Nutrition Programs.

As part of the conversation about alleviating hunger and improving nutrition among older adults, we must consider ways to bolster these programs and expand their reach so these seniors are able to age well and remain healthy. This is especially important as baby boomers age into these programs.

We must also look at new ways to address these issues. For example, access to nutritious food for seniors continues to be a problem in both urban and rural areas. How can policy makers work to better address that issue?

In addition, there is an effort underway by some Members of the House of Representatives to advance the “Food is Medicine” conversation. How can we better understand the impacts hunger and malnutrition have on our nation’s health and health care system? Can we alleviate human suffering, promote independent living, and address rising health care costs by investing in interventions like medically tailored meals? And what role can science play in impacting and informing the discussion about nutrition policy in our country?

Hidden Hunger and Malnutrition: The Need to Address Both (More) in Policy

Bob Blancato, MPA
Blancato and Associates

In the United States, up to 1 out of 2 older adults is at risk for malnutrition. Whether this is caused by the hidden hunger of micronutrient or macronutrient deficiencies or results from acute or chronic disease, the outcomes for older adults are the same: poorer health and functionality and higher costs of care. Yet, the contributing factors to this may not be immediately recognized by health care providers. This presentation will focus on how we are working to gain the recognition of malnutrition as a key indicator and vital sign of older adult health risk by describing the goals and strategies outlined in the National Blueprint: Achieving Quality Malnutrition Care for Older Adults. In addition, the presentation will discuss opportunities in which stakeholders, policymakers, and aging services providers can work together. More specifically, the focus will be on how we can implement a policy agenda for achieving a greater focus on malnutrition screening and intervention through regulatory and/or legislative change across the nation’s health care system.

Incentivizing Healthy Eating: Does Purchase Lead to Consumption?

Emily Allen
AARP Foundation

A sizable body of research shows that hunger wields as much influence over health as any disease — and it is an especially pernicious problem among older adults.

One in five U.S. adults over 50 struggles with food insecurity. Seniors who are food insecure are 50 percent more likely to have diabetes, 60 percent more likely to have congestive heart failure or a heart attack, and three times more likely to suffer from depression. Beyond the individual toll, there is a societal one, as hunger costs the U.S. health care system $130.5 billion annually.

AARP Foundation, which works to end senior poverty by helping vulnerable older adults build economic opportunity and social connectedness, will discuss food security as a social determinant of health, the efficacy of incentivizing low-income older adults to purchase nutritious food, and the broader implications for public health policy.

Underscoring its evidence-based approach, the Foundation will outline its efforts to help low-income seniors purchase fresh produce and develop healthy eating habits on a budget. This includes developing MyPlate for Older Adults, ich corresponds with the federal government’s 2015–2020 Dietary Guidelines for Americans, and launching Fresh Savings RxSM, a new initiative through which health care providers can “prescribe” fruits and vegetables to patients who have a diet-related chronic disease and participate in SNAP.

The presentation will also highlight preliminary results from a study of AARP Foundation’s Fresh Savings (of which Fresh Savings Rx is a component) that examined whether providing incentives to purchase fresh produce leads to greater consumption.

Panel Discussion