Abstract

To test the efficacy, acceptability, and appropriateness of a nutrition education and support program, 4 community-based group homes for adults with intellectual or developmental disabilities participated in a pilot intervention with extended baseline period and pre–post-test design. Adults (N = 32) with intellectual or developmental disabilities, 20 direct service staff, 4 managers of group homes, and 2 health specialists at private service providers participated in the intervention, consisting of a system of nutrition supports in nutrition education and guidelines, menu and meal planning, grocery shopping, and cooking designed for the special needs of this population. Positive impacts were found using the program, including fidelity measures, food systems changes and acceptability to users, planned and served foods, and cost changes associated with implementation.

An estimated 2–4 million Americans experience an intellectual or developmental disability. Most adults with intellectual or developmental disabilities now live in the community (Prouty & Lakin, 2006), and it is an explicit national objective to move individuals with intellectual or developmental disabilities from more restrictive environments to less restrictive, more independent arrangements (Olmstead v L. C., 1999).

Research documents nutritional deficits, inadequate diets, and poor nutritional status among adults with intellectual or developmental disabilities living in the community (Bertoli et al., 2006; Bryan, Allan, & Russell, 2000; Humphries et al., 2004; Robertson et al., 2000; Springer, 1987). Nutrition-related secondary conditions, including weight problems, gastrointestinal dysfunction, cardiovascular disease and risk factors, diabetes, osteoporosis, and allergies, significantly limit community-dwelling adults with intellectual or developmental disabilities (Traci, Seekins, Szalda-Petree, & Ravesloot, 2002). In 2002, the U.S. Surgeon General declared that improved nutrition for adults with intellectual or developmental disabilities was to be a national priority (U.S. Surgeon General, 2002).

The trend toward less restrictive living environments means that vital nutrition education and supports are delivered in a community-, home-based system rather than being controlled by trained nutrition professionals within a structured, institutional food system. A food system includes menu planning and all its elements, how foods are served, characteristics of meal times and eating occasions, time and effort spent on food-related tasks, individuals involved in food activities, and the perceptions of those taking part in food activities and meals.

Compared with those in institutions, consumers in community settings are more involved in food planning and purchasing and determining when and how their foods are prepared. Still, direct care paraprofessionals in group homes are the final gatekeepers of which foods are acquired, prepared, and served to residents. Food choices in group homes are primarily limited to those available in the home and on the menu (Humphries et al., 2004). Consumers tend to have limited control over menu contents and food purchases.

Group home food systems are complicated by high staff turnover (Felce, Lowe, & Beswick, 1993; Larson & Lakin, 1992; Seninger, Bainbridge, Traci, & Seekins, 2004), staff's lack of food preparation skills and nutrition knowledge (Rimmer, Braddock, & Marks, 1995), and inadequate direct care staff training in foods and nutrition (Humphries, Traci, & Seekins, 2004; Humphries, Traci, Seekins, & Brusin, 2002).

Our early assessment (Humphries et al., 2004) of group homes in Montana showed that group home managers and staff received little or no training in menu planning, nutrition, or creating health-promoting food environments. In part, very high turnover rates among group home staff made such training impractical for provider agencies (Seninger & Bainbridge, 2004; Traci, Szalda-Petree, & Seninger, 1999). In addition, there are no current acceptable nutrition support and education programs that show a positive effect on food systems, dietary adequacy, dietary intake, or the most important secondary health conditions experienced by adults with intellectual or developmental disabilities.

Recent health-promotion activities have begun to target the environment as a critical component to changing health behavior. For example, the U.S. Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (2001) combined recommendations for individual responsibility and health behavior education for children and youth with “ensure daily, quality physical education in all school grades” (p. 34) to develop “the knowledge, attitudes, skills, behaviors, and confidence” (p. 34) that they need to manage their weight.

Similarly, nutrition education targeting consumers in group homes will only be successful if the environment supports their informed choices. An examination of group home menus and pantries revealed that less than 45% of the recommended daily amount of vegetables (U.S. Department of Agriculture [USDA], 1996) were available for consumption (Humphries et al., 2004). In other words, teaching individuals to eat more vegetables only works if vegetables are available.

We hypothesized that improving group home food systems would improve menus and provide residents with healthy food choices. Subsequently, dietary intake would improve and secondary conditions would be prevented or better managed. In this article, we describe a new nutrition supports program for adults with intellectual or developmental disabilities living in community group homes, the program's acceptability, related food systems changes, and changes in foods available to consumers.

We conducted previous participatory action research (Whyte, 1991) in 15 community-based living arrangements for adults with intellectual or developmental disabilities. Consumers, staff, and administrators suggested that nutrition intervention be a priority for community-based group homes (Humphries et al., 2004). The needs assessment established the following goals for support materials:

  1. Materials must be conceptually and practically coordinated to cover menu and meal planning, shopping, and cooking. Focus should be on effective environmental supports, processes, and procedures rather than staff training.

  2. Supports should encourage increased consumer engagement and participation in food systems, including decision making and operations.

  3. Supports must be acceptable to residents, administrators, and direct service staff; must improve health and nutritional status; must adhere to budgets; and training–implementation must not substantially increase direct service staff's workload.

  4. Menus must not be rigid (standardized menus failed in the past). Weekly menus should be flexible and reflect consumers' preferences, individual needs, food availability (fresh produce in rural Montana may be scarce and expensive), and grocery sales.

We hypothesized that a relevant, useful, appropriate, and acceptable intervention would modify the food environment and its policies and procedures. This intervention would improve group home food systems and dietary adequacy of foods offered in group homes.

Method

Materials–Supports Development

We created the MENU-AIDDs program (materials supporting education and nutrition of adults with intellectual or developmental disabilities) after a series of meetings with group home residents in Montana, direct service staff, group home managers, and community service provider administrators and health specialists. Montana's Department of Public Health and Human Services staff, the Montana Disability and Health Program Advisory Board, Montana People First self-advocates, and Montana Dietetic Association members also reviewed and contributed to the materials.

We designed MENU-AIDDS materials and supports to work in concert or as individual components. They adhered to the USDA's Dietary Guidelines for Americans (1995) and the Food Guide Pyramid (1996) and emphasized dietary adequacy and healthier food choices (whole grains; low-fat dairy; fruits and vegetables; soy and fish protein; less high-fat, processed protein [meat]; and beneficial oils [e.g., olive, canola]). (Note: The USDA released its new Dietary Guidelines [2005] and MyPyramid Food Guidance System [2005] after the MENU-AIDDs pilot materials were developed and produced. Minor modifications to MENU-AIDDs now reflect the new recommendations.) MENU-AIDDs has five components:

1. Basic, flexible menu

The basic menu was an 8.5 × 14 in., laminated sheet listing three meals and snack options for each day of the week. Aside from specifying quantities and food groups, the menu allowed flexible meal planning. The meals and snacks provided approximately 1,800 kilocalories per day, with additional calories selected from a snack guide to meet individual needs. The menu provided spaces for developing specific weekly meal plans.

To address the desire for flexibility, we developed a procedure for planning house menus to comply with the basic menu. For example, 1 day's basic dinner menu specified a 3-oz. serving of beef as an ingredient. The staff, with consumer input and within the service provider's budget constraints, decides how to prepare that ingredient. We also provided “food group options charts,” a recipe book (see below), and some training on how to make nutritionally appropriate substitutions if the basic menu ingredient was unacceptable or inconvenient in a particular group home.

2. Food group options charts

We provided a chart for each of the USDA's five Food Guide Pyramid (1996) food groups (grains, vegetables, fruits, dairy, protein) and the extras category. Each chart listed equivalents for one serving of the food group and could be used to create each week's specific meal plans.

3. Shopping organizer

The shopping list and shopping organizer were designed to streamline group home grocery shopping. The laminated shopping list was printed on double-sided, letter-size paper and listed common items from the basic food groups, arranged according to their location in a grocery store. Spaces allowed staff to list other items as needed. The shopping organizer was a plastic carrying case with an attached three-ring binder containing folders for organizing coupons, USDA food stamps, and sale circulars.

4. Recipe book

The recipe book was a three-ring binder providing 35 examples of delicious, inexpensive, and healthful recipes, primarily for entrees made from foods specified by the basic, flexible menu.

5. Coordinating poster

The poster was a large, sturdy board with pockets and places to attach the basic, flexible menu; food group options charts; and grocery lists from the shopping organizer. The poster also provided general information about nutrition standards, the Food Guide Pyramid (USDA, 1996), and instructions on how to use the MENU-AIDDs components.

Participants and Study Settings

In Montana, nonprofit community service providers contract with the state to provide residential, supported living; work; and transportation services to adults with intellectual or developmental disabilities. The current study involved four community-based group homes, operated by two service providers in small Montana cities.

Table 1 shows characteristics of the study group. Each service provider randomly selected two group homes from those available to participate. Each home (identified as A, B, C, and D) recruited for this study was a large house in a residential or mixed business–residential neighborhood. Each housed eight adults, with men and women evenly represented. The ethnic makeup reflected that of the state of Montana. Consumers represented a variety of diagnoses related to intellectual or developmental disabilities, including intellectual disability, Down syndrome, cerebral palsy, and epilepsy– seizure disorder. Most had moderate cognitive impairments or mild intellectual or developmental disabilities combined with other medical, emotional, or behavioral limitations requiring group home supports. Older adults with intellectual or developmental disabilities (M age = 71 years) lived in Group Home C. Each residence was staffed 24 hr a day. The service providers also operated other living arrangements with less intense support services that did not include menu planning, meal preparation, and shopping assistance.

Table 1

Characteristics of Group Homes and Residents

Characteristics of Group Homes and Residents
Characteristics of Group Homes and Residents

Group home managers and direct service staff were responsible for menu planning, grocery shopping, meal preparation, serving, clean up, and food storage and safety. Consumers provided varying degrees of input and assistance. Breakfast and dinner were either plated in the kitchen and brought to the dining table, or served family-style at the table. Monday through Friday, most residents had regularly scheduled work, sheltered workshop, or other day activities and took sack lunches or ate lunch in day-program cafeterias. State licensing regulations and providers' policies require that group home support staff make, follow, and post weekly menus. Menus must be retained for 3 months. Previous research has showed a high degree of correspondence between menus planned and meals served (Humphries et al., 2004). In accordance with provider policy and state regulations, meal substitutions must be documented and justified. The study indicated that it is easier for direct care staff to follow a menu than to alter it. Group home managers or senior staff compiled a shopping list from the planned menus and made one weekly grocery shopping trip for the household. Depending on each home's policy, on-duty staff might share group home meals.

The University of Montana Institutional Review Board approved study activities prior to participant recruitment. All interviewees or their legal guardians signed informed consent forms.

Procedures

Each of the two community service providers had qualified health specialists on staff who provided oversight to group home staff on medications, diet, and medical issues and made health referrals when necessary. Each health specialist attended a sponsored MENU-AIDDs training at The University of Montana. The 6-hr training discussed how to use MENU-AIDDs components effectively and described the research study's testing procedures. The health specialists delivered the materials to the group homes, introduced the study to the group home residents, taught the home managers and staff to use the materials, and supported their use for the duration of the study. The pilot-study group homes were instructed to use all the program components and to evaluate them as a coordinated package. However, to reduce socially desirable interview responses, they were assured they need not use all components at all times for the study to be successful.

The study design extended the baseline to 8 weeks for two of the participating group homes (Cohort B), whereas the other two (Cohort A) began implementing the MENU-AIDDs program (Figure 1). The extended baseline design controlled for normal changes in group home food systems unrelated to MENU-AIDDs. For example, the study began in early summer when food patterns might change (e.g., summer schedules, availability of seasonal fruits and vegetables).

Figure 1.

Study protocol

Figure 1.

Study protocol

The entire pilot study lasted 16 weeks. Time 1 assessments consisted of food systems interviews and completion of food account questionnaires for each of the four group homes. After 8 weeks (Time 2), the assessments were completed again with all four group homes; then, Cohort B began using MENU-AIDDs and Cohort A continued using it. After 8 more weeks (Time 3), the assessments were repeated for all homes.

Outcomes Measurements

The field researcher conducted individual, tape-recorded, semistructured interviews with group home managers and senior staff who were responsible for food systems and who observed consumers during meal times. The interview topics included the degree to which they used the MENU-AIDDs program components, changes to the home's food system routines and procedures, the reactions of consumers and direct service staff to implementing MENU-AIDDs, foods planned and available to eat, and the group home's food expenditures before and during the study period. Food intake of residents was not tested because of the lack of a validated testing instrument or procedures (Braunschweig et al., 2004; van Staveren, de Groot, Blauw, & van der Wielen,1994).

Use of MENU-AIDDs

Public health research uses process evaluation to identify the effective key components of an intervention or program and identify for whom and under what conditions the intervention is effective (Steckler & Linnan, 2002). We measured the variable fidelity in this pilot test of MENU-AIDDs and defined it as the extent to which our planned treatment or intervention was delivered to the group homes. According to Steckler and Linnan (2002, p. 12), fidelity represents “the quality and integrity of the intervention as conceived by the developers.”

Managers were encouraged to use the all components and were told that researchers would want assessments and feedback for each component, if possible. Fidelity to the program was measured by interviews with the managers or senior staff, in which they indicated the extent to which each particular component of the MENU-AIDDs was used during the study period. Questions included, “Did you and/or your staff use the basic, flexible menu? If so, how much?” These questions were repeated for the food groups options cards, recipe book, shopping organizer, and coordinating poster. Responses were coded as 1 = did not use the component, 2 = sporadically used component, or 3 = consistently used component. Each participating group home's scores on each of the five MENU-AIDDs components were averaged to yield an overall fidelity score for that home.

Food system changes

Interviews assessed changes to the food system routines and procedures through a series of general questions for all homes and individual follow-up questions specific to Time 1 responses of interviewees. Interviews were structured but were free response, and the interviewer often asked the respondents probing follow-up questions. Interviewees described any changes in the way the food system operated, including meal and menu planning, shopping, cooking, meal service, and food storage. They were asked how well the program fit the needs of their homes, residents, and staff and how acceptable it was to the users. Each interview also determined consumers' reactions to the food systems changes, including any adverse reactions requiring immediate response. This was an important outcome.

At the Time 2 interviews, managers and senior staff were instructed as follows: “Tell me about any changes that have occurred related to food and eating at this house since you started with the MENU-AIDDs.” If a topic mentioned in a previous interview was not updated in a subsequent interview, the researcher asked specifically if there was any new information about it.

Interviews were audiotaped and transcribed. Researchers followed Creswell's (1998) procedures to identify and categorize themes and answers to direct questions about the food system. Follow-up telephone interviews allowed informants to clarify or confirm responses. Interview responses that supported the data and other interpretations are quoted below.

Foods planned and available to eat in household

The household food account is a valid, accepted method for measuring food available, mean food consumption, and selection patterns of a population at the household or group level (Gibson, 2005). Group home managers or staff responsible for the food systems completed food account questionnaires as evidence of change in foods available to eat in the homes. The food account questionnaire included the following foods and food groups: whole grains, dairy foods, fruits, vegetables, tofu (soybean curd) and dried beans, fish, healthful oils (olive oil and canola oil), and higher fat meats (e.g., luncheon meat, bacon, sausage, hot dogs). The basic, flexible menu targeted these foods and food groups for modification to bring the planned diets into alignment with standard nutrition recommendations.

At Times 1, 2, and 3, managers quantified the number of times per week each of the above foods were served. After 8 weeks of MENU-AIDDs program implementation, the interviewer also asked the managers to rate how frequently the foods were served compared with baseline. The interviewer did not reveal the baseline amounts to the interviewee. The forced-choice responses were, “We serve (the food item): a lot less than before”; “somewhat less than before”; “about the same amount as before”; “somewhat more than before”; and “lot more than before.”

Food expenditures

Community service providers establish group home budgets and the managers are responsible for their homes' food budgets. Researchers evaluated cost changes associated with using MENU-AIDDs in baseline and postintervention interviews of the managers. Food budgets are complex, which became apparent when researchers had originally tried to collect food expenditure and usage information from group home grocery receipts (Humphries et al., 2004). As in that study, the current study's grocery receipts did not contain clear or comprehensive data for proper analysis. Foods were purchased or otherwise acquired from a variety of sources, including grocery stores, USDA Commodities programs, donations (e.g., a bakery donated day-old bread to a group home), residents' hunting and fishing trips, and kitchen gardens. Groceries and dining out were funded from different budget line items (dining out is “entertainment”). Some group home residents received government food stamps and Farmer's Market coupons to offset household food expenditures.

Managers collected all food receipts and records from all sources for the month before Time 1 and throughout the 16 weeks of the study. At the Time 3 interview, managers referred to expenditure records and their impressions of the significance of the changes to answer the question, “Did you spend more, less, or about the same amount of money on food using the MENU-AIDDs program than you did before?” Managers determined the significance and acceptability of cost changes.

Results

One of the Cohort A homes (Group Home A) delayed using the materials because of unanticipated events (e.g., vacations, staffing changes) and were instructed to begin using the materials at Week 9 when Cohort B began. Therefore, Cohort A had one group home member and Cohort B had three.

The extended baseline showed no changes in the three Cohort B homes from Time 1 to Time 2 in food systems changes, foods planned and served, or food expenditures. Therefore, the Time 1 baseline measurements for all four groups were used for comparison. The data presented here are all baseline versus the first 8-week postintervention-period measures, regardless of whether the group home began using the program at Time 1 or Time 2.

Use of MENU-AIDDs

Table 2 shows the fidelity variable results of direct service staff and group home managers' responses regarding the extent to which they used the MENU-AIDDs materials during the intervention period. Three of the four group homes scored 2.4 on a scale of 1–3 (1 = did not use components, 3 = used components consistently). The fourth home, Group Home A scored 1.6, indicating less usage of the program than the others.

Table 2

Fidelity Scores: Reported Use of MENU-AIDDs Components

Fidelity Scores: Reported Use of MENU-AIDDs Components
Fidelity Scores: Reported Use of MENU-AIDDs Components

Managers encouraging their staff to use the program sometimes encountered reticence and reluctance to change. One manager reported, “I had a lot of questions from staff:

‘Do we have to have this many vegetables?’

‘Yes, that is what it says and we are going to do this.’ I was determined that we were going to follow this as close as possible.”

At Group Home C, the senior staffer in charge of menu planning and cooking was intimidated, saying, “At first I was stressing out looking at it (the MENU-AIDDs). Do I have to have everything exactly the same? [My manager] was like, ‘We are supposed to try it.’”

Ultimately, most group homes' staff adopted MENU-AIDDs with the encouragement of the managers, one of whom said, “The staff were very rigid about it; they did a really good job. They tried really, really hard to do it.”

Group homes found the menu planning system (the basic, flexible menu plus the food group charts and recipe book) was the most broadly useful (see Table 2). Respectively, Group Homes A–D showed average composite fidelity scores of 2.0, 2.7, 3.0, and 3.0 for those three components.

Three of the four homes did not use the shopping organizer. All managers reported previous unsuccessful attempts to delegate grocery shopping to staff. Managers are responsible for group home budgets, and the risk of not having adequate food for the month or going over budget is too great to delegate. Managers do the shopping themselves and had already developed shopping procedures that MENU-AIDDs did not replace or augment.

Two of the four homes did not use the large poster that consolidated the MENU-AIDDs components and provided nutrition standards information. The managers reported that its size (30″ × 40″) was a barrier—their kitchens and food service areas did not have adequate wall space to accommodate it.

Food System Changes

The study participants noted changes in the food system routines. Staff of three group homes became increasingly aware of and attentive to proper portion sizes. One reported,

At first, the first few weeks, we would put half a cup of this and a cup of this (on each menu) so that everyone would get used to the serving portions and set things out for them to measure. That was a big deal. That is a key in this to keep those portion sizes appropriate. And that is something that we weren't paying very much attention to before. You don't realize that you are over-serving until you start to measure.

Staff responsible for implementing the program reported that implementation required an increased time commitment. One manager said of her staff, “There was a lot of grumbling the first week or two, because it was extra work because it was something new.” However, interview responses from all four group homes indicated that staff dissatisfaction decreased to baseline after a few weeks or was compensated by renewed interest or competence in food-related tasks. For example, one veteran manager said, “This [program] made [menu planning] interesting to me again, because it was a challenge to try and make sure that we got everything incorporated into each meal.” By the 8-week interviews, the time commitment was also reportedly back to baseline in all four homes.

According to managers and staff, participating consumers were almost uniformly accepting of the program, the menu changes, and the ways in which staff interpreted the basic menu and made the meal plans. One manager at a group home offered this comment, “The [residents] didn't complain about [the food changes] and if they were hungry they would let you know!” Low appetite is typical among the general elderly population and was identified at Time 1 as a problem in the senior group home. At 8 weeks, the manager reported improved appetites and food consumption: “[The residents] sure like it [the MENU-AIDDs meals]. And eat it. They seem to eat a lot more than they were.”

Ironically, staff who were accustomed to eating at work reportedly “grumbled” the most about the dietary changes. One manager, who negotiated a trial period with her staff and consumers, said in the 8-week interview, “The first week was a lot of complaining. But I said, ‘Give me two more weeks. Because I know your body system, two weeks from now let's see if you're satisfied.’ And it ended up that the complaining quit.” Another group home senior staffer commented, “We realized that the group [of consumers] did not miss the breakfast meat. The staff missed the breakfast meat! But the [residents] did not.”

At the Time 3 interview, the Cohort A group home interviewee reported continued improvements during the pilot intervention's second 8 weeks. Staff found it easier to judge portion sizes without having to measure, consumers were more engaged in menu planning and meal preparation, and consumers were satisfied with and accepting of the new meals and ingredients.

Foods Planned and Available to Eat in the Household

According to the food account questionnaires, using the MENU-AIDDs materials resulted in healthful changes in the menus planned and meals served. Table 3 summarizes information from each group home's questionnaire on dietary modifications of foods and food groups. Responses were scored on a scale of −2 to 2. Planning and serving a food or food group “a lot less than before” (i.e., baseline) was scored −2; “somewhat less than before” scored −1; “about the same amount as before” scored 0; “somewhat more than before” scored 1; and “a lot more than before” scored 2. Scores for the four group homes were averaged to create an average change score for each food group.

Table 3

Food Account Questionnaire Results of Group Homes A, B, C, D: Planning and Serving MENU-AIDDs–Emphasized Foods

Food Account Questionnaire Results of Group Homes A, B, C, D: Planning and Serving MENU-AIDDs–Emphasized Foods
Food Account Questionnaire Results of Group Homes A, B, C, D: Planning and Serving MENU-AIDDs–Emphasized Foods

Reported consumption of all food groups changed in the desired direction. As a result, we were able to calculate average change scores across food groups for each group home to show how much dietary change an individual home made. In all cases except “higher fat meats,” where the goal was to reduce consumption, a dietary improvement was reflected by serving more of the food group. We used absolute values in calculating a home's average change score to account for the positive and negative values of the food group scores.

All four homes reported eating “a lot more” whole grains and whole grain products than before the MENU-AIDDs intervention. They all reported planning and serving “somewhat more” or a lot more dairy products, vegetables, and tofu and dried beans. Consumers and staff of two of the four group homes accepted tofu well. At the Week 8 interview, a senior staff person said, “We have been using the tofu every week. It is very inexpensive and the recipes are very good. Our consumers love it. I love it. We made the BBQ tofu and love that recipe.” Staff in one of the remaining homes did not offer tofu, and staff at the other home offered it once. At the former house, the manager said, “We did a lot of the MENU-AIDDs … but the tofu? That was too weird. I knew they would hate it. We just didn't even go there.” Three homes reported serving more fruit, and two served more fish. One home used more healthful cooking oils, but the other homes did not change from their baseline use of minimal amounts of healthful oils. All four homes reduced the amount of higher fat and processed meats they planned and served by “a lot” or “somewhat.” One interviewee explained, “They still get a good breakfast, but instead of having the hash browns and the eggs and bacon every day, we just do it two or three times a week. So, they are not losing that stuff but we are just not having it as often.”

Food Expenditures

Three of the group home managers reported that overall food expenditures did not change during the intervention period. The cost of adding higher priced items to menus, such as whole grain pastas and more dairy products, was offset by purchasing fewer processed foods, such as higher fat meats. The fourth group home manager explained her higher expenditures: “Yeah, it cost us more. But that was the [single serving] yogurts. I probably could've done better if I bought larger containers of yogurt. … [As you use the program more] you would find more things that would bring the budget down instead of increase it, I believe.”

Discussion

This pilot study supported the hypothesis that the MENU-AIDDs program can prompt group home staff to plan, prepare, and serve more healthful diets to residents. The program was implemented easily and economically in four group homes with little discomfort to the management, staff, and consumers (who accepted the new foods and procedures well). Food systems improved, as evidenced by increased awareness of portion sizes, reasonable time allocations for food-related tasks, and acceptance of the program by consumers, staff, and management. Food account data indicated that healthful foods were more available to consumers in their homes.

Each service provider agency has policies to ensure choice and self-determination, the cornerstones of the independent living philosophy. The role of support staff is to support consumers' choices, including the choice to live in a health-promoting environment. A healthful environment meets individual needs by offering appropriate, health-promoting food choices in adequate amounts. MENU-AIDDs helps group home staff provide these choices.

The MENU-AIDDs education component is an experiential immersion model for direct care staff and consumers. The structured system involves consumers in menu planning, shopping and making informed food choices, and meal preparation and serving.

On completion of the pilot, group home staff asked to keep the MENU-AIDDs materials so they could continue to use the system. Researchers accommodated that request and will provide ongoing support as needed. We met with consumers, managers, staff, and administrators to report the results of the research study and discuss future areas for collaboration. Their formal and informal feedback was used to modify the MENU-AIDDs materials.

Based on evaluation and feedback, the revised MENU-AIDDs program includes more nutrition education materials for both staff and consumers, including a module on using soy products. Teaching basic nutrition concepts to higher functioning individuals in particular could further improve group home food systems and increase positive health outcomes. Nutrition education would enable direct service staff to engage consumers in the food system; knowledgeable consumers will contribute more.

The revised MENU-AIDDs has more recipes, including, at the users' request, additional recipes using tofu. The modified shopping aids for group home managers serve to support their established systems. The new MENU-AIDDS discontinued the large wall poster. Although group home managers in early focus groups had recommended it, the pilot test showed that group home kitchens were too small to conveniently display the poster and MENU-AIDDs components. Pilot study participants preferred to have all components in a binder for storage on a kitchen counter or bookshelf.

Before this study was completed, the USDA released MyPyramid (2005), the latest version of its Food Guide Pyramid. This web-based, interactive, nutrition education tool can be tailored for an individual based on gender, body weight, and level of physical activity. It was not developed with input from, or tested with, individuals with intellectual or developmental disabilities before or after its public release (J. Webster, USDA, personal communication, February 20, 2007). The revised MENU-AIDDs continues to use the old Food Guide Pyramid icon concept because the new pyramid is conceptually complex and difficult for adults with intellectual disabilities to use. In addition, none of the participating group home staff have Internet access to the MyPyramid website. However, MENU-AIDDs has adopted MyPyramid's substantive nutrition recommendations, as well as the revised Dietary Guidelines for Americans (2005).

Managers and senior staff monitored and reported consumer reaction to the intervention, which is a limitation of the study design. For future MENU-AIDDs testing, researchers have developed direct consumer-feedback mechanisms, including peer interviews. However, we will continue to use managers' proxy reports on consumers' reactions to food systems changes, because consumers may find it difficult to attribute systemic procedural changes to an intervention.

Other limitations are worth noting. This pilot studied only four group homes, so the statistical power was low and only nonstatistical significance can be ascribed, such as self-reports of usage, acceptability, and menu changes. Individual dietary intake could not be extrapolated from household food account data, and dietary change must be viewed with appropriate caution. Researchers could account for most of the food available to and consumed by the group home residents, but did not observe foods eaten at work, on outings with staff, or on family visits.

Group Home A manager cited “being too busy” to fully implement the program as the reason for that home's low fidelity score. We concluded that this home's staff were neither ready to recognize that changes were necessary, though the provider's administrative management were, nor ready to implement a health-promotion program. This group home was originally in Cohort A, but did not begin the program at Time 1 due to “unanticipated events.” That staff of randomly assigned homes differed in readiness confirms that stages of change are important to positive outcomes in a health-promotion program (Prochaska, Norcross, & DiClemente, 1994). Had we recruited volunteers, the participating group home staff may have been more ready to change and more amenable to the intervention.

The cost of a new system or program may be a significant barrier to group home managers. Studying and disseminating the strategies used by managers to contain MENU-AIDDs start-up costs would reassure others that they too can control their food budgets. A publication addressing this is being drafted.

Adults with intellectual or developmental disabilities also live in less restrictive community settings, such as semisupported or independent-living arrangements. Less restrictive settings pose very different nutritional challenges because these individuals are arranging and implementing their own food systems. According to needs assessments, community-living experts, and self-advocates, these individuals need improved nutrition too. The MENU-AIDDs program is not appropriate for independent-living environments because it supports staff changes to food systems. Consumers who live more independently need individual training in nutrition and food education, cooking skills, food safety, shopping, and accessing appropriate resources.

During the second half of 2006, we modified the MENU-AIDDs materials, disseminated them, and provided training to approximately 60 other Montana group homes. An advisory board with full representation and participation by group home residents and other stakeholders is planning national dissemination. The results of this study informed our MENU-AIDDs program training. Future training will ensure that implementation is successful and relevant by focusing more on meeting the specific needs and preferences of consumers and staff.

This study's participants had no or little previous nutrition education or guidance in creating a healthy, practical food system in a community-based group home. It appears the MENU-AIDDs filled that gap in a way acceptable to consumers, staff, and service providers.

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Cooperative Agreement U59/CCU821224 from the U.S. Centers for Disease Control and Prevention (CDC) supported the information in this manuscript. The contents are solely the authors' responsibility and do not necessarily represent CDC's official views. The Research and Training Center on Disability in Rural Communities provided additional support. We thank the pilot study participants and the community members who participated in the program design and preliminary needs determinations for these materials.

Author notes

Authors:

Kathleen Humphries, PhD (khumphries@ruralinstitute.umt.edu), Nutrition Project Director; Meg Ann Traci, PhD, Montana Disability and Health Program Director; and Tom Seekins, PhD, Research Director, Research and Training Center on Disability in Rural Communities, University of Montana Rural Institute, 52 Corbin Hall, University of Montana, Missoula, MT 59812