[Senate Hearing 115-467]
[From the U.S. Government Publishing Office]


                                                        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
         
         

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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina          KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee                RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina         JOE DONNELLY, Indiana
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska                CATHERINE CORTEZ MASTO, Nevada
                              
                              
                              ----------
                              
                              
                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director
                                
                                
                                
                               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

 
                    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.
    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.
    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 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 
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 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 
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 long-term 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 hospitalizations 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 low-
income 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 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 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 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 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. 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.
    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 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 underappreciated 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.
    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 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.
    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 comprehensive 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 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 affordable 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 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 important? 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 big-ticket 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?
    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.
    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 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.
    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.
    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 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 sites.
    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 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 low-income 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 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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                  Additional Statements for the Record

=======================================================================


                      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 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 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).

          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, diabetes, 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.
  

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