Analysis of interventions addressing the nutrition status of seniors in Ontario

Analysis of interventions addressing the nutrition status of seniors in Ontario

Lauren McKay MPH, Assistant Coordinator COVID-19 Food Program, The Gathering Food Centre
Julia Ianiro MPH RD, Public Health Dietitian, North Bay Parry Sound District Health Unit
Cameron Sharpe MPH, Health Promotion and Research Analyst, Region of Waterloo
Shannon L. Sibbald PhD, Associate Professor, Western University

ABSTRACT: Introduction: Malnutrition, specifically undernutrition, can result from a lack of energy intake. It leads to altered body composition and body cell mass, and ultimately diminished function and impaired clinical outcome from disease. Seniors, defined as age 65 years and older, are particularly vulnerable to malnutrition for many reasons. The global senior population is increasing rapidly and by 2050 it is projected that one in six people will be in this age group. Globally, the prevalence of undernutrition in seniors living in communities is as high as 47.8%. In Canada, approximately 34% of seniors are at nutritional risk. Objectives: To explore programs and services available to seniors living in Ontario, Canada that address malnutrition, identify their strengths and weaknesses, and provide recommendations for improving the effectiveness of these nutrition programs and services for seniors. Methods: We conducted a two-stage literature review. The first stage included a search to identify programs that address malnutrition in seniors in Ontario, Canada’s most populated province, and to identify best practices. The results were analyzed by three internal reviewers to identify the most common programs. The second stage was a more detailed search of the four most common programs. Keywords including malnutrition, seniors, nutrition, and meal delivery programs were used in Google, Google Scholar, and PubMed. Results: The four most common programs identified in Ontario were Unlock Food, Meals on Wheels, community kitchens, and community gardens. These programs appear to mitigate factors associated with malnutrition in seniors by increasing the availability of nutritious foods. The degree to which these programs affect change may not be significant enough to reduce the overall prevalence of malnutrition, specifically undernutrition, among seniors in Ontario. Conclusion: While the programs that are currently available support the nutrition of a portion of seniors, they are not sufficient for Ontario’s aging population. These programs should be scaled up to expand their reach, standardized across the province, consistent, and tailored to the needs of seniors.

SUBMITTED: December 10, 2021 | PUBLISHED: February 23, 2022

DISCLOSURE: None of the above authors have any conflicts of interest. No funding was received for the purpose of this paper.

DISCLAIMER: Research conclusions and policy recommendations are those of the authors and should not be interpreted as a reflection of the opinions or policy positions of their employers and affiliated organizations.

CITATION: McKay, Lauren et al (2022). Analysis of interventions addressing the nutrition status of seniors in Ontario. Canadian Health Policy, FEB 2022. ISSN 2562-9492 https://doi.org/10.54194/VISB6120 www.canadianhealthpolicy.com.

Background

The global population is aging, with seniors representing a continually growing demographic (1,2). The United Nations predicts that by 2050, one in six people in the world will be over the age of 65: a stark increase from one in 11 people over the age of 65 in 2019 (2). In Canada, 17.6% of the population was aged 65 and older in 2019, and this number is expected to increase to 22.8% or 9.3 million by 2030 (1).

In Ontario, the largest and most populous province in Canada, the provincial government recently partitioned the Ministry of Health and Long-Term Care (MOHLTC) into two separate ministries: The Ministry of Health (MOH) and the Ministry of Long-Term Care (MOLTC) (3,4). The MOH works to deliver high-quality, coordinated care and protect the sustainability of the healthcare system (5). The purpose of the MOLTC is to provide the best quality of care in the community and long-term care homes and to bring healthcare closer to home (6). This change in structure demonstrates the government’s prioritization of the aging population, and a commitment to improving both seniors’ health and the sustainability of the healthcare system. Notably, the number of seniors in Ontario is projected to nearly double from 2.4 million in 2018 to more than 4.6 million by 2046, which represents 16.9% and 23.4% of the population, respectively (7).

Data from the 2008/2009 Canadian Community Health Survey-Healthy Aging found that 34% of Canadian seniors are at nutritional risk (8). Nutritional risk is defined as the risk of poor nutrition status and lies on a continuum between nutritional health and malnutrition (8). Nutritional risk is closely related to malnutrition and undernutrition. Sobotka (9) defines malnutrition as “a state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat-free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease.” According to the World Health Organization (10), undernutrition is a type of malnutrition that includes underweight and micronutrient deficiencies. Total energy intake, along with omega-3 fatty acids, dietary fibre, Vitamins B6, B12 and D, calcium, and iron are essential nutrients that are most commonly a concern for seniors (11,12). Undernutrition in seniors is a more complex issue than simply not having access to food. Undernutrition can result from metabolic changes, decreased appetite, dental concerns, mobility issues, financial hardship, lack of social contact, and other reasons (12). The number of seniors at nutritional risk, combined with Canada’s aging population, signifies a growing issue that demands attention.

Globally, the prevalence of undernutrition in seniors living in the community ranges from 1.3% to 47.8%, with low- to middle-income countries observing a higher prevalence compared to high-income countries (13). Undernutrition is strongly associated with premature mortality, poor quality of life, and reduced functional ability (13). Similarly, malnutrition has several implications including frailty, disability, loss of independence, and social isolation (14). This paper will focus on the undernutrition component of malnutrition, as well as nutritional risk which is closely tied to malnutrition, and these terms will be used interchangeably (10).

The ramifications of undernutrition can be seen at the individual level, impacting seniors’ activities of daily living and quality of life, in addition to larger-scale impacts on communities and the healthcare system. Given these micro and macro-level implications, it is critical to discuss approaches to reduce the prevalence of malnutrition in seniors both provincially and nationally. There is an opportunity to enhance current interventions, drive policy development, and fill gaps in nutrition programming. This commentary presents the strengths and challenges of four programs that address malnutrition in seniors in Ontario and recommendations for improving these programs, informed by best practice.

Methods

A literature search composed of two stages was completed. In stage one, keywords including “nutrition programs” AND “seniors” were used to identify programs that address malnutrition globally. The terms “nutrition programs”, “seniors”, AND “Ontario” were used to identify the programs or program types that are most common in Ontario. Google, Google Scholar, and PubMed were used for the search. The results of stage one helped identify the key terms used in stage two, including “community garden” and “meal delivery program”. The purpose of stage two was to research the most common programs identified from stage one in more detail. PubMed was the primary database used in stage two. Researchers independently completed the search using keywords developed from each stage to determine inclusion criteria. The inclusion criteria for our literature search included journal articles, reports, and websites. Search results were included if they related to Unlock Food, EatRight Ontario, community gardens, community kitchens, food delivery programs, or seniors’ nutrition. Search results that did not include these topics were excluded.

Results

Stage one yielded 71 results that were classified according to the type of nutrition program or service it addressed. The results focused on 11 different programs and services that address malnutrition in seniors in Ontario. Search results included primary and secondary research and grey literature. Of the 11 different programs, Unlock Food, Meals on Wheels (MOW), community kitchens (CK), and community gardens (CG) were identified as the four most common nutrition programs because these programs are either officially recognized and funded by the Ontario government or are well established and documented through literature as existing in many regions of Ontario.

The results showed that while Unlock Food is a provincial online nutrition service for Ontarians that includes resources for seniors, the three other programs identified are implemented at the municipal level and vary regionally (15). Since Unlock Food is a relatively new service, literature on its predecessor, EatRight Ontario, was considered in the analysis. MOW emerged as another well-established program that operates at the municipal level (16). Several other small community-based programs arose in the literature search and were categorized into either the CK or CG program design.

A farmers’ market-based nutrition program does not exist at a provincial level in Ontario (17). However, this commentary includes this type of program as an example of best practice due to its success in other provinces and other countries (17). The resulting papers on the four most common program types in Ontario, and the market programs, were each read thoroughly and critically appraised to identify the strengths and weaknesses of each program, and the quality of the research.

Unlock Food 

From 2007-2018, the MOHLTC funded EatRight Ontario, which included a phone-based service operated by Dietitians of Canada (15). The MOHLTC oversaw the program that enabled Ontarians of all ages to talk to a dietitian directly (15). Over its ten years of operation, the program expanded to include an e-mail contact and a website with articles on nutrition, including meal planning advice, healthy eating tips, and recipes, many of which focused on senior nutrition (15,18). In March 2018, EatRight Ontario was discontinued and rebranded as Unlock Food. The MOHLTC modified the service by consolidating all telephone counselling and support services (19). Ontarians can no longer call EatRight Ontario. Instead, they must call Telehealth Ontario, a toll-free number for Ontarians seeking health advice, and request to speak with a registered dietitian (15). Unlock Food now operates under Dietitians of Canada and houses all the resources previously found on EatRight Ontario (20).

Evaluative studies of Unlock Food are lacking in the literature, likely because of the recent rebranding. A report on EatRight Ontario provides a glance into the possible success of Unlock Food (18). Before the rebranding occurred, EatRight Ontario released their legacy report with data from 2007-2017, outlining the program’s major successes (18). Over its ten years, 32,864 older adults completed the Nutri-eSCREEN questionnaire to determine their nutritional risk, 9,413 nutrition education resources for seniors were distributed, and 53% of all calls and 29% of all emails received were from individuals over age 50 (18). EatRight Ontario was proven to be a useful program with 90% of clients stating that they made a change to their diet that they felt would improve their health and/or reduce their risk of disease (18). These markers of success are important to recognize, but given the recent changes to the program, are likely to diminish. Since Unlock Food is a provincial service to improve nutrition for all age groups in Ontario, the program needs to be expanded to reach its full potential (18).

Unlock Food does not address the physical barriers that older adults face to access nutritious foods. Huang et al. (21) discussed several physical barriers, such as transportation to the grocery store and food access. These barriers also impact community members who help older adults access food, significantly impacting the public. The study’s findings suggest that disabilities and chronic diseases also impact individuals’ healthy eating decisions (21).

Meals on Wheels

MOW is a meal delivery program that exists in 181 communities across Ontario (16). This not-for-profit service is designed to provide nutritious and affordable ready-to-eat meals to eligible individuals, including seniors (16). MOW operates at the municipal level, with 141 organizations receiving some funding from the MOHLTC to facilitate the program (16). Since the MOHLTC recently split, it is unknown which ministry will fund MOW moving forward. Government funds cover a portion of the costs and donations and/or client fees make up the remainder. This funding model works to keep client fees as low as possible (16).

Research suggests that meal delivery services like MOW are a feasible way to improve seniors’ nutritional status and indicators of malnutrition. Young & Argáez (22) demonstrate meal delivery programs to be a cost-effective intervention to reduce hospital readmissions and the length of hospital stay. Denissen et al. (23) showed that during the 3-month intervention, body weight, BMI, upper leg circumference, and fat-free mass increased significantly more when participants received meal deliveries. Wright et al. (24) observed improvements for nutritional status, dietary intake, food security, loneliness, and well-being in participants who received MOW deliveries. Other studies have also shown positive outcomes (25,26). The cost-effectiveness of meal-delivery programs provides an opportunity for government officials to invest in these preventative interventions (27).

Despite the paucity of research describing the challenges faced by MOW programs in Canada, one report suggests that recruiting and relying on volunteers is perhaps the greatest challenge (28). A Volunteer Toronto report illustrates the critical volunteer shortage specific to MOW programs in Toronto (28). A specific factor that makes volunteer recruiting a challenge is that volunteers are required to be available during mealtimes, which often coincides with typical work hours (28). Another deterrent is that volunteers do not see MOW as an opportunity for skill development (28). Additionally, MOW seeks to recruit volunteers who can commit on a weekly basis, whereas volunteers are often looking for short-term commitments (28). Acquiring volunteers who can deliver the meals is another notable challenge with additional barriers. Specifically, driving positions mean the volunteer must have their driver’s license and, in most cases, their own car (28).

Community Kitchens

CK programs involve a group of people who meet to prepare healthy and affordable meals in a shared space (29). CKs are designed to enhance participants’ food security by promoting food knowledge and food skills while addressing social isolation (29). The number, design, and target population of CKs varies across Ontario. For example, the Victorian Order of Nurses, a national non-profit organization, runs CKs for older adults in Middlesex-Elgin County that include educational sessions on meal planning, nutrition, and budgeting (30). The City of Hamilton offers CKs tailored to different population groups, including seniors, women, and people living with diabetes (31). In Toronto, FoodShare aims to inspire long-term solutions for an affordable and nutritious food system, including a CK program, but it is not tailored to seniors (32).

While researchers agree that CKs have social and educational benefits, the impact on nutritional status and food security has been debated because CKs only provide a few meals and do not increase participants’ income, which is the primary driver of food insecurity (33). In a Canadian study, participants reported that joining a CK increased the variety of their diets, especially for single-dwelling individuals trying to avoid food waste (31). Participants also reported increased vegetable consumption and consuming better quality food (33). In a systematic review, Iacovou et al. (34) found that CKs may effectively increase cooking skills, social interactions, and nutritional intake, as well as budgeting skills. Increased intake of nutritious foods, greater variety of foods, increased variety of fruits and vegetables, and eating less fast-food have been reported as outcomes of CKs (32,33).

Most studies assess the impact of CKs on food security, rather than nutritional status, and do not focus on seniors, who may or may not experience food insecurity. While the systematic review by Iacovou et al. (34) found CKs likely improve social interactions and nutritional intake, the authors report that CKs are not a long-term solution due to the low frequency of meals and issues with program sustainability. Engler-Stringer and Berenbaum (33) reported dependency on CKs and participants expressed worry when CK programs took time off. Furthermore, CK programs tend to be small and operate at the community level with limited funding and reliance on volunteers (35). A main issue surrounding CKs is accessibility: a Toronto study by Loopstra & Tarasuk (35) found that 65.6% of participants reported not participating in CKs because they were not accessible for reasons such as not knowing how to participate, not having a program in their neighbourhood, not knowing what the program was, and not being eligible (35). 41.1% of the Toronto participants reported not participating in CKs because they did not fit their needs, interests, schedules, or health status (35). In the senior population, accessibility concerns are likely exacerbated by mobility and other health issues (35).

Community Gardens

A CG involves cultivating a piece of land to grow and harvest vegetables and fruits for a collective group of people (34,35). CGs are a city-based initiative, so the number and design of CGs varies across Ontario. These gardens may be useful in addressing food insecurity, social isolation, promoting social connections, and increasing consumption of fruits and vegetables amongst community members, including seniors (36,37). CGs have been associated with environmental, economic, and health benefits (36,37).

CGs have shown some efficacy in improving community nutrition, physical activity, and connection among community members (36,37). CGs can be cost-effective for low-income individuals and families. It is estimated that each dollar invested in CGs results in six dollars’ worth of vegetables being produced (36). Carney et al. (37) found that self-reported vegetable intake of ‘several times a day’ increased from 24% to 64% after joining a CG (36). Studies have found that CG participants have a higher intake of fruits and vegetables than non-participants (36). Social benefits result from CG members sharing recipes, gardening tips, and healthy foods (36). In the study by Carney et al. (37), 94.9% of the participants reported the garden improved their family’s health. Joining a CG resulted in a four-fold increase in vegetable intake, reduced food insecurity, and mental health improvements (37). The researchers concluded that CGs can improve vegetable intake, reduce food insecurity, and strengthen relationships (37).

Challenges associated with CGs include start-up costs, lack of gardening skills and knowledge amongst community members, securing suitable land in a desirable location, and the seasonality aspect (36,37). Generally, CG programs have struggled to secure high enough participation to influence a community’s nutrition status (36). CGs show promise, but so far, participation has been low across Canada (36). Loopstra and Tarasuk (35) found CGs to be inaccessible, as 66.3% of participants reported that CGs were not accessible and 38.7% reported they did not fit their needs. Most participants reported they lacked knowledge of how to participate and that the programs were not in their neighbourhood (35). CGs were also not compatible with some study participants due to health issues, like arthritis, that affect mobility (35). Loopstra and Tarasuk (35) concluded that CGs are likely not an efficient way for people experiencing food insecurity to meet their food needs.

Discussion

Each of the four programs discussed plays an important role in communities. However, the programs face similar challenges that limit their potential to improve the nutrition status of seniors and reduce the prevalence of malnutrition. Issues with capacity, funding, and accessibility became clear from the literature and our own critical analysis.

CGs only produce fruits and vegetables, which are important for seniors’ nutrition status but do not provide all the essential nutrients. Canada’s climate does not allow CG programs to operate and produce food year-round. This is especially apparent in Northern regions of Ontario where the growing season is short. The capacity of MOW, CK, and CG programs can be limited by their reliance on volunteers. The program structure means some programs operate at a greater capacity than others based on factors such as their volunteer pool. Also, most clients cannot access all their meals through these programs, leaving seniors to manage some meals independently, which can be challenged by mobility and health issues. This service gap means that seniors, especially those without close family or friends, may not have access to enough food, resulting in undernutrition.

As community-based programs, CKs and CGs largely rely on donors, fundraising, and grant support which can fluctuate over time and threaten sustainability. Funding impacts the capacity of CK and CG programs by determining the number of people they serve, the amount of food they provide, and the nutritional quality of the food provided. Funding can vary between communities, exacerbating inconsistencies in programs across the province. Similarly, MOW receives minimal funding from the government with the rest of the funds coming from local donors or clients themselves. The literature suggests that programs like MOW, CGs, and CKs can improve markers of malnutrition by improving food access, increasing social supports, and providing nutrition education. These programs need increased financial support from the government to ensure they provide the maximum benefit to the community they serve. Investing in these up-stream approaches can prevent senior malnutrition.

As an internet-based resource, Unlock Food faces unique challenges. We identified that EatRight Ontario lost its provincial funding and was rebranded under Dietitians of Canada as Unlock Food. With Dietitians of Canada now being the primary funder, the program’s funding is likely less than what was previously budgeted by the provincial government. Unlock Food’s main services have merged with Telehealth Ontario (ehealth Ontario) meaning that the remaining budget of the program consolidates to the Telehealth budget (15). Funding cuts are noticeable when visiting the website, as many of the resources are outdated or seemingly incomplete. Despite Canada releasing a new food guide in 2019, Unlock Food contains many resources that pertain to the food guide developed in 2007. While EatRight Ontario’s 10-year legacy report from 2007-2017 demonstrates it had a significant reach, it is unclear if it directly impacted senior malnutrition rates both before and after receiving provincial funding (18).

While there is evidence that each program can improve the nutrition status of seniors, the literature also highlights issues of inaccessibility. Seniors can face challenges in accessing CGs and CKs due to their location, lack of personal transportation, lack of city transit, or inability to walk long distances. CGs and CKs can also be physically demanding by requiring participants to actively participate, which benefits physical and social wellbeing but may exclude seniors with limited physical mobility. The differing needs and abilities of the senior population is a vital consideration in the design of these programs. MOW does overcome most barriers to accessibility by delivering food but is limited by costs and dependence on volunteers (28). The accessibility of Unlock Food is affected by seniors’ access to the internet and internet literacy.

Recommendations

Through our analysis, we identified four key attributes to focus on when planning programs that aim to meaningfully change the prevalence of malnutrition among seniors. The strengths and challenges of the four programs form the basis of our recommended attributes. The four attributes are: accessible, standardized, consistent and sufficient, and tailored.

Accessible

When comparing the programs, accessibility emerged as an important element for success. Many factors can hinder or facilitate the accessibility of food programs for seniors. MOW is accessible for most seniors as it provides home delivery with few physical barriers, which lends to its popularity. Studies have shown that CKs can be difficult for seniors to access due to mobility issues, lack of awareness about the programs, and lack of eligibility for the programs (35). Comparisons of these two programs demonstrate that accessibility is an important consideration to ensure seniors can access the respective services. Current and future nutrition programs in Ontario should prioritize the impact of seniors’ mobility and transportation on program accessibility.

Standardized

Apart from Unlock Food, the programs in this analysis operate at the community level. While this structure allows programs to be tailored to community needs, it also means the programs can differ between communities, creating inequities. The analysis revealed that MOW programs vary across communities in terms of the cost to the client and the frequency and quality of the meals provided. The online platform of Unlock Food can be considered a strength since it allows people across the province to access the same resources. It would be advantageous for the provincial government to regulate programs that address malnutrition in seniors to ensure equitable services. If Ontario sets statutory recommendations for food programs, including MOW, CKs, and CGs, it can standardize the services provided across different regions in Ontario and beyond.

Consistent and Sufficient

A limitation of Unlock Food is the lack of consistency with posting on the website. Inconsistency can result in a lack of engagement with the target audience and reduced website traffic. Programs and services that target community members through the use of technology, such as Unlock Food, should ensure they maintain an online presence by consistently providing users with up-to-date quality content. With more support, MOW can achieve greater capacity, reach more seniors, provide them with enough food, and increase the quality of services for current clients. When a program is consistent and sufficient, it can build trust with the population it supports. The province could set minimum standards for meal programs, describing how many meals per week MOW needs to deliver, along with funding to support increased capacity, ensuring the programs equitably meet seniors’ needs.

Tailored

Successful nutrition programs are tailored to the population or community they serve. For example, MOW best serves seniors who face mobility barriers and benefit from having prepared meals delivered to their homes to avoid travel. Conversely, CKs are best suited to mobile seniors who may also be socially isolated or lacking in food skills. CKs can be further tailored by providing programming for seniors with specific nutrition needs, such as diabetes or heart disease. By considering the needs of the target population, food programs can work towards meaningful change. Guidance on how to best design programs for seniors living with diabetes, mobility challenges, cognitive decline, and other health issues would be helpful.

Example from Best Practice

The initial literature search revealed a program design that has been successful in other jurisdictions. Farmers’ market-based nutrition programs have been implemented in Australia and British Columbia (BC) at the provincial level and in the United States at the federal level. Preliminary research shows these programs to be effective in improving the nutrition status of seniors. Farmers’ market-based nutrition programs do not currently exist in Ontario, but the province should consider adoption (17). A farmers’ market-based nutrition program can be regarded as a best practice as it has the potential to fulfill the recommendations of accessible, standardized, consistent and sufficient, and tailored as discussed in this commentary.

The province of BC’s Farmers’ Market Nutrition Coupon Program is a healthy eating initiative that aims to strengthen food security and support farmers’ markets (38). The Province of BC and the Provincial Health Services Authority supports the program. In partnership with community organizations, the program provides coupons to lower-income families, pregnant women, and seniors. Each household is eligible for a minimum of $21 per week in coupons (38). The Ministry of Health funds this program which serves over 12,000 individuals in BC (38). An evaluation of the market program found that 84% of participants reported eating more fruit and vegetables, and 84% reported it was easier to make healthy choices (39). Similarly, the United States’ national Senior Farmers’ Market Nutrition Program is designed to provide low-income seniors with access to local fruits and vegetables and is administered by state agencies. An evaluation in South Carolina found the program effectively increased the consumption of products purchased from farmers’ markets (40).

Farmers’ market programs can be made more accessible to seniors by offering a mobile service. The Braystone Project in Melbourne, Australia, consisted of a mobile fruit and vegetable stall that visited retirement housing communities with limited access to fruit and vegetable shops. They also partnered with community teas or luncheons to address social isolation (41). This project improved access to fruits and vegetables and the long-term nutritional status of senior community members (42). These programs provide evidence that a market program is feasible and effective at a federal, provincial, and municipal level. Ontario should consider a similar program to protect its older residents’ health and well-being while investing in the local economy.

Limitations

This commentary discussed the four most common programs or program types for addressing malnutrition in Ontario and is not exhaustive. Many small, successful, grassroots programs exist but were excluded from the analysis. Some of the strengths and limitations of the programs discussed in this paper may differ across regions in Ontario as MOW, CGs, and CKs operate at the municipal level.

Conclusion

As Ontario’s senior population continues to grow, greater effort is needed to address the prevalence of malnutrition in this demographic. While programs that support seniors’ nutritional status exist, most operate at the community level and face challenges with capacity, funding, and accessibility. Ultimately, funding directly impacts program accessibility and capacity by dictating the frequency and quality of the meals the program can serve. Examining these challenges restates the need to improve the quality of nutrition programs in Ontario to reduce malnutrition in the senior population and the strain on our healthcare system. Nutrition programs are best designed for success when they are accessible, standardized, consistent and sufficient, and tailored. The Government of Ontario needs to invest in programs that support the nutrition status of seniors before the opportunity for positive change passes.

References

1. United Nations, Department of Economic and Social Affairs, Population Division. (2019). World Population Ageing 2019 Highlights (ST/ESA/SER.A/430). https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf
2. United Nations, Department of Economic and Social Affairs. (2019). World Population Prospects 2019 Highlights (ST/ESA/SER.A/423). United Nations, Department of Economic and Social Affairs, Population Division (2019b). World Population Prospects 2019: Highlights (ST/ESA/SER.A/423).
3. (2017). Aging with Confidence: Ontario’s Action Plan for Seniors. https://files.ontario.ca/ontarios_seniors_strategy_2017.pdf
4. CHCH-TV. (2019, June 20). Ontario Premier Doug Ford Makes major changes in cabinet shuffle. Ontario News. https://www.chch.com/ontario-premier-doug-ford-to-shuffle-cabinet/.
5. (2020a, October 8). Ministry of Health. Ministries. https://www.ontario.ca/page/ministry-health
6. (2020b, July 10). Ministry of Long-Term Care. Ministries. https://www.ontario.ca/page/ministry-long-term-care
7. Ministry of Finance. (2019). Ontario Population Projections Update, 2019–2046. https://www.fin.gov.on.ca/en/economy/demographics/projections/#s3
8. Ramage-Morin, P.L & Garriguet, D. (n.d.). Nutrition risk among older Canadians. Statistics Canada. https://www150.statcan.gc.ca/n1/pub/82-003-x/2013003/article/11773-eng.htm
9. Sabotka L, editor. (2012). Basics in Clinical Nutrition 4th ed. Galen.
10. World Health Organization. (2020, April 15). What is Malnutrition? https://www.who.int/news-room/q-a-detail/malnutrition
11. Institute of (US) Food Forum. (2010). Providing Healthy and Safe Foods As We Age: Workshop Summary. https://www.ncbi.nlm.nih.gov/books/NBK51837/
12. Unlock Food. (2020, October 13). Older Adults Eating Well. https://www.unlockfood.ca/en/Articles/Seniors-nutrition/Older-adults-eating-well
13. World Health Organization. (2017). Integrated Care for Older People (ICOPE: Guidelines on community-level interventions. https://www.who.int/ageing/health-systems/icope/evidence-centre/ICOPE-evidence-profile-malnutrition.pdf?ua=1
14. Porter Starr, K. N, McDonald, S. R., & Bales, C. W. (2015). Nutritional Vulnerability in Older Adults: A Continuum of Concerns. Current nutrition reports. 4(2), 176–184. https://doi.org/10.1007/s13668-015-0118-6
15. (2018). Archived—EatRight Ontario. https://www.ontario.ca/page/eatright-ontario
16. Meals on Wheels Ontario. (n.d.). About Meals on Wheels. https://www.mealsonwheels.ca/about
17. Community Food Centres Canada. (2020). Fruit and vegetable voucher program backgrounder. https://cfccanada.ca/CMSPages/GetFile.aspx?guid=79117e9d-65b9-406b-9c68-ad6ed4ae1498
18. Dietitians of Canada & EatRight Ontario. (2018, April 9). EatRight Ontario Dietitian Advisory Service 10 Year Legacy Report 2007—2017. https://www.unlockfood.ca/EatRightOntario/media/PDFs-new-website/ERO-10-Year-Legacy-Infographics-Report.pdf
19. CBC News. (2018, March 9). EatRight Ontario phone line will no longer connect Northerners with dietitians. https://www.cbc.ca/news/canada/sudbury/nutritional-counselling-eatrightontario-northern-ontario-phone-1.4568815
20. Unlock Food. (2018, March 31). 10 years of excellence from EatRight Ontario.
21. Huang, D. L., Rosenberg, D. E., Simonovich, S. D., & Belza, B. (2012). Food Access Patterns and Barriers among Midlife and Older Adults with Mobility Disabilities. https://doi.org/10.1155/2012/231489.
22. Thompson, J., Tod, A., Bissell, P., & Bond, M. (2017). Understanding food vulnerability and health literacy in older bereaved men: A qualitative study. Health expectations: An international journal of public participation in health care and health policy. 20(6), 1342–1349. https://doi.org/10.1111/hex.12574.
23. Calvin Young & Charlene Argáez. (2019). Interventions for malnutrition in older adults: A review of clinical effectiveness. https://www.ncbi.nlm.nih.gov/books/NBK541429/pdf/Bookshelf_NBK541429.pdf
24. Denissen, K. F. M., Janssen, L. M. J., Eussen, S. J. P. M., van Dongen, M. C. J. M., Wijckmans, N. E. G., van Deurse, N. D. M., & Dagnelie, P. C. (2017). Delivery of nutritious meals to elderly receiving home care: Feasibility and effectiveness. The Journal of Nutrition, Health & Aging, 21(4), 370–380. https://doi.org/10.1007/s12603-016-0790-2
25. Wright, L., Vance, L., Sudduth, C., & Epps, J. B. (2015). The Impact of a Home-Delivered Meal Program on Nutritional Risk, Dietary Intake, Food Security, Loneliness, and Social Well-Being. Journal of Nutrition in Gerontology and Geriatrics, 34(2), 218–227. https://doi.org/10.1080/21551197.2015.1022681
26. Sattler, E. L. P., Lee, J. S., & Young, H. N. (2015). Factors Associated with Inpatient Hospital (Re)admissions in Medicare Beneficiaries in Need of Food Assistance. Journal of Nutrition in Gerontology and Geriatrics, 34(2), 228–244. https://doi.org/10.1080/21551197.2015.1031601
27. Campbell, A. D., Godfryd, A., Buys, D. R., & Locher, J. L. (2015). Does Participation in Home-Delivered Meals Programs Improve Outcomes for Older Adults? Results of a Systematic Review. Journal of Nutrition in Gerontology and Geriatrics, 34(2), 124–167. https://doi.org/10.1080/21551197.2015.1038463
28. Gualtieri, M. C., Donley, A. M., Wright, J. D., & Vega, S. S. (2018). Home Delivered Meals to Older Adults: A Critical Review of the Literature. Home Healthcare Now, 36(3), 159–168. https://doi.org/10.1097/NHH.0000000000000665
29. Volunteer Toronto. (2018). Research Report: Why Toronto’s Meals on Wheels Programs Are Facing a Critical Volunteer Shortage. https://cdn.ymaws.com/www.volunteertoronto.ca/resource/resmgr/Meals_on_Wheels_Report.pdf
30. Gunnion, T. (2008). Frankston Community Kitchens Pilot Project: Final Report. Peninsula Health. https://communitykitchens.org.au/wp-content/uploads/2015/06/Frankston-pilot-project-report-2008.pdf
31. Victorian Order of Nurses. (n.d.). Collective Kitchens. https://www.von.ca/en/middlesex-elgin/service/collective-kitchens
32. The Food Access Guide, Eating Well in the City of Hamilton. (n.d.). Red Book Community Information. http://foodaccessguide.ca/community-kitchens/.
33. FoodShare. (n.d.). Community Kitchens. https://foodshare.net/program/community-kitchens/
34. Engler-Stringer, R., & Berenbaum, S. (2007). Exploring Food Security With Collective Kitchens Participants in Three Canadian Cities. Qualitative Health Research, 17(1), 75–84. https://doi.org/10.1177/1049732306296451
35. Iacovou, M., Pattieson, D. C., Truby, H., & Palermo, C. (2013). Social health and nutrition impacts of community kitchens: A systematic review. Public Health Nutrition, 16(3), 535–543. https://doi.org/10.1017/S1368980012002753
36. Loopstra, R., & Tarasuk, V. (2013). Perspectives on Community Gardens, Community Kitchens and the Good Food Box Program in a Community-based Sample of Low-income Families. Canadian Journal of Public Health, 104(1), e55–e59. https://doi.org/10.1007/BF03405655
37. Awjja, S. (n.d.). Efficacy of Community Gardens as a Tool to Enhance Food Security. http://www.ohpe.ca/node/13198
38. Carney, P. A., Hamada, J. L., Rdesinski, R., Sprager, L., Nichols, K. R., Liu, B. Y., Pelayo, J., Sanchez, M. A., & Shannon, J. (2012). Impact of a Community Gardening Project on Vegetable Intake, Food Security and Family Relationships: A Community-based Participatory Research Study. Journal of Community Health, 37(4), 874–881. https://doi.org/10.1007/s10900-011-9522-z
39. C. Farmers’ Markets. (n.d.). How It Works—Nutrition Coupon Program. https://bcfarmersmarket.org/coupon-program/how-it-works/
40. (2014). Farmers’ Market Nutrition and Coupon Program Report on 2013 Evaluation. https://bcafm.files.wordpress.com/2014/02/fmncp-evaluation-report-2013-jan-6-2014.pdf
41. Kunkey, M., Luccia, B., & Moore, A. (2003). Evaluation of the South Carolina Seniors Farmers’ Market Nutrition Education Program. 103(7), 880–883. https://doi.org/10.1053/jada.2003.50164
42. Victorian Order of Nurses. (2006). Food for All: Lessons from two community demonstration projects. https://www.vichealth.vic.gov.au/-/media/ResourceCentre/PublicationsandResources/healthy-eating/Food-for-all/VHP-food-for-all-8pp.pdf?la=en&hash=FDDA13AF30A6D7CC934A25949FA4A29E25F72EA2.
43. Elsworth, G., & Astbury, B. (2005). Sustainability in Health Promotion: Case Studies of Two Food Insecurity Demonstration Projects. https://scarp.ubc.ca/sites/scarp.ubc.ca/files/Sustainability%20in%20Health%20Promotion%20%20Case%20Studies%20of%20Two%20Food%20Insecurity%20Demonstration%20projects.pdf