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Providing Healthy and Safe Foods as We Age: Workshop Summary 7 Future Challenges and Solutions to Providing Healthy and Safe Foods to Aging Populations The final session of the workshop began with a panel discussion aimed at highlighting the most important issues and future challenges to providing healthy and safe foods to aging populations. Moderators Susan Crockett of General Mills, Minneapolis, Minnesota, and Steven Gendel of the Food and Drug Administration’s (FDA’s) Center for Food Safety and Applied Nutrition (CFSAN), College Park, Maryland, introduced the four panelists: Pamela Starke-Reed, Deputy Director of the Division of Nutrition Research Coordination at the National Institutes of Health (NIH), Bethesda, Maryland; Johanna Dwyer, Senior Nutrition Scientist in the Office of Dietary Supplements (ODS) at NIH, Bethesda, Maryland, and Director of the Frances Stern Nutrition Center at Tufts University, Boston, Massachusetts; Jean Lloyd, National Nutritionist, Administration on Aging, U.S. Department of Health and Human Services (HHS), Washington, D.C.; and Dennis Sullivan, Director of Little Rock Geriatric Research, Education, and Clinical Center and Executive Vice Chairman of the Donald W. Reynolds Department of Geriatrics at the University of Arkansas for Medical Sciences, Little Rock, Arkansas. Panelists considered a range of issues, from what one participant referred to as the “demographic imperative” (i.e., the large and fast-growing 65-and-over and 85-and-over populations) to the need for industry/government/academic collaborative efforts to improve nutrition communication to older consumers.
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Providing Healthy and Safe Foods as We Age: Workshop Summary Issues included heterogeneity in the older population (with respect to age, race, income, functionality, family support, etc.) and the need to define what is meant when discussing “the older population”; the need for more research on different subsets of the older population (e.g., on exposure levels and the risk of infection or illness from eating pathogen-contaminated foods) and the lack of sufficient population-level data for conducting that research; the likelihood that the scope of some food safety and nutrition-related problems in aging populations may be underestimated as a result of insufficient data; the need to more carefully consider the food safety and nutrition needs of the 85-and-over population, such as the diet quality of assisted living facility residents; the need for a stronger infrastructure and better nutrition services for older adults relying on home- or community-based care systems, particularly given that the “baby boom bubble” is moving across time and the 65 to 90 age group soon will represent a large proportion of the U.S. population; the need to reconsider the definition of an optimal diet for older adults, given changes in both physiology and eating habits; the need for more research on genetic variability and the potential importance of individualized nutrition (i.e., making dietary decisions based on genetic make-up); the need for more research on the value of probiotics in older adults’ diets; the need for NIH and other government agencies to improve the way they communicate science to the public; the need to collaborate and involve the food industry in devising solutions to certain problems, such as communicating with older consumers and managing sodium intake in older adults’ diets; and the need to consider how other countries are managing food safety and nutrition for older adults and whether the problems they encounter are similar. An open dialogue with the audience followed the panel discussion, with the goal of discussing some of these and other challenges in detail and identifying possible solutions. In particular, workshop participants focused on the need to include nutrition education and communication in home-and community-based services for older adults;
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Providing Healthy and Safe Foods as We Age: Workshop Summary the importance of reducing sodium intake and the challenge of doing so with older adults; the need for more funding and stronger cross-sector collaborations (e.g., public-private) that have as one of their main goals addressing key unanswered questions about nutrition and food safety in aging populations; the need to balance apparently contradictory messages about food safety and nutrition (i.e., recommending that older adults eat or avoid certain foods as a way of maintaining long-term cardiovascular health while simultaneously warning about the risks of pathogen contamination in those same foods); and the challenge of communicating about food safety and nutrition in general with older adults. Importantly, the goal of the panel discussion and open dialogue was not to reach consensus on any issue, including which issue(s) was considered most urgent. With some issues, there was a sense of general agreement among those voicing their opinions. With other issues, participants expressed varying opinions. PANEL DISCUSSION The Most Important and Urgent Issues Gendel initiated the panel discussion with a deliberately unfocused question. He asked each panelist to elaborate on two or three issues that they considered the most important for follow up. Starke-Reed mentioned several: She was struck by the heterogeneity of the aging population even with respect to age. For example, she observed that some presenters included all adults age 50 and over when discussing aging populations, whereas others considered only those age 65 and over. She stressed the importance of defining “aging population” in discussions because of this heterogeneity. She commented on some of the interesting research being conducted on probiotics and prebiotics and mentioned that NIH has a Roadmap Initiative focused on microorganisms. Her division at NIH has a working group devoted to researching the nutritive role of probiotics and prebiotics. She explained that there are 10,000 times as many bacterial cells as human cells in the human body and that
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Providing Healthy and Safe Foods as We Age: Workshop Summary this is clearly an area of science that deserves the growing interest it is receiving. She commented on the lack of discussion around genetics and the importance of understanding whether individual genetic variation makes a difference in terms of optimizing nutrition for older adults. As with probiotics and prebiotics, research on nutrigenomics is also expanding not just at NIH but also at institutions worldwide. Finally, she stated that NIH is a research institution and does not do a very good job with “messaging.” She said that NIH needs “a lot of help in that area.” They need to know where they can send messages so that those messages can be translated and communicated to the appropriate population(s). Dwyer commented on several points: She agreed with Starke-Reed that NIH must do a better job of communicating not just to the public but also to health care providers. For example, based on her work at the ODS, it is very important that information on the quality, safety, and efficacy of dietary supplements be effectively communicated to health care providers. While some supplements may be important or necessary for some older adults, others could be harmful. She encouraged workshop participants to visit the ODS website, remarking that it “is a very good piece of communication,” but she said there is room for improvement. Like Starke-Reed, she was struck by some of the information on the demographics of aging populations. She said that she was particularly concerned with the 85-and-over population. She has been examining assisted living facilities for the past several years, and her research results have not been reassuring with respect to food safety. Food safety regulations vary from state to state, and nutrition regulations are practically nonexistent. The situation is very similar to what child daycare was like before it was regulated. She emphasized that this very important issue will need to be addressed soon, especially as the 85-and-over population becomes an increasingly large component of the aging population. Many people develop functional impairments when they reach the 85-and-over age group and are unable to live independently. Finally, she wondered when the United States is “going to wake up to the fact that we need a better system and a better infrastructure than we now have” for providing support to older community-dwelling adults who need assistance. She made this observation based on
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Providing Healthy and Safe Foods as We Age: Workshop Summary her own personal situation with a 62-year old cousin who lives by herself and is suffering from multiple disabilities. She remarked that the issue is much broader than providing healthy and safe foods to aging populations. Lloyd commented on a couple of issues: She agreed with the previous two panelists’ comments about the heterogeneity of the aging population. Not only are there different age cohorts within “the aging population” but also different groups with varying needs (e.g., different incomes, varying amounts of family support). She expressed pleasure with the number of times that caregivers had been mentioned throughout the course of the workshop, given that the majority of elder care in the United States is provided by family caregivers. She noted that only 17 percent of the 85-and-older population is living in any kind of assisted care or other facility and that most of the “oldest old” remain community dwellers. Yet, while caregivers were mentioned at various times throughout the workshop, there was no discussion about how they should be providing the care. For example, most home- and community-based care systems do not have nutrition education components as Dwyer also mentioned. Like regulation of assisted living facilities, regulation of home- and community-based care is very fragmented, with different states imposing different sets of regulations. While some of the state-funded programs do have nutrition components, others do not. A major challenge is making all of this complex information about nutrition available to these caregivers in a way that enables the caretakers to make the best decisions. Meeting this challenge will be difficult given the lack of funding for home- and community-based care services and the long list of things that need to be done with that funding. Also, most home- and community-based care service programs are social service systems with limited awareness or understanding of nutrition and food safety. Sullivan offered what he described as a “clinician perspective” on several key issues. He observed that not only are most older adults probably unaware of many food safety risks, but many health professionals do not fully comprehend the risks. There are many unanswered questions about individual variability, with respect to genetics as well as other factors. For example, many older patients have comorbid condi-
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Providing Healthy and Safe Foods as We Age: Workshop Summary tions or are taking medications that have profound physiological effects and can increase the risk of foodborne illness (e.g., people with age-related or drug-induced acid suppression are much more likely to have lower bowel infections; people on antibiotics are more susceptible to Salmonella and various other infections). He argued that in certain situations, there may be no cause for alarm and no reason to initiate a food recall on a national level, “we may be dramatically underestimating the significance of the problem on an individual basis, particularly when we are dealing with some of these very old patients.” In other words, older patients may be at an even greater risk than the evidence suggests for the population at large. Complicating the problem is the fact that many older adults are unlikely to present with classic foodborne illness symptoms; in fact, they are more likely to present with confusion or other atypical symptoms. Also, older adults tend not to complain and do not like to discuss incontinence, diarrhea, and other similar problems with their physicians. Sullivan said that he personally would be paying more attention to food habits when dealing with older patients in the future. He commented on the fact that many older adults tend to be grazers and do not eat regular meals. This is particularly true of older women who live alone. Also, older adults tend to have fewer energy needs and therefore eat less. He said that for these and other reasons, as several previous speakers had alluded, “We have to rethink our ideas of what represents an optimal diet.” For example, there are many unanswered questions about the role of supplements, such as how supplements should be manufactured (e.g., how they should be formulated), under what circumstances they are needed, and when they could be harmful. He stated that considerable evidence suggests that polymeric formulas may not be helpful in certain situations. He said that he was fascinated but also frightened by some of the demographic numbers presented during the workshop and the way the “baby boom bubble” is moving across time. Soon, the 65 to 90-year-old age group will represent a very large proportion of the U.S. population. That raises the question, “Who is going to be supporting them, particularly if they live to be 100, as a lot of people say they will?” The current U.S. infrastructure is predicated on the assumption that there will always be more workers than there are retired people, but what will happen when all the baby boomers retire? He also wondered about the social implications of the growing gap in life expectancy between females and males.
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Providing Healthy and Safe Foods as We Age: Workshop Summary After the panelists reflected on what they thought were some of the important or interesting issues, the moderators voiced their opinions. Gendel observed that several speakers, as well as all four panelists, commented on the need to realize the tremendous heterogeneity of the “aging population” and the importance of differentiating among different subsets of older adults in order to better understand food safety risks. However, in reality this is difficult because of the lack of relevant data. He said, “We do in this country, by and large, a really bad job of monitoring health conditions and generating the kind of [population-level] information that would allow us to do that kind of impact analysis.” It is very difficult to gather enough information on pathogen susceptibility such that it can be broken down and the relative susceptibilities of different subsets of older adults identified (e.g., susceptibilities of people 60 to 65 years old vs. people 85 and older). His point was that there is just not enough statistical information generated to allow for that kind of differentiation. Crockett observed that the working model of the Food Forum is to bring academic, food industry, regulatory, and consumer representatives together to discuss common problems and identify potential solutions. This same model needs to be continued. She said, “I see enormous opportunity for the food industry to be part of the solution, but it won’t happen unless we work very closely together.” As just one example of how the food industry could contribute, she described a new community, Mill City Commons, forming in Minneapolis, Minnesota, where 50 to 55 year old empty nesters are moving into apartments downtown, close to the river, and are making provisions/plans to support themselves when they grow older and are in need of assistance. General Mills sees itself as a potential provider of foods for this type of “creative solution.” Lloyd remarked that Mill City Commons is an example of a naturally occurring retirement community (NORC). She stated that there is a large body of literature and many websites with information on NORCs, and in fact the Administration on Aging funds grants to support this type of livable community (not just for older adults but for other populations as well). She noted similar communities forming in Washington, DC and Boston. Crockett said that she was pleased to hear that Mill City Commons was part of a broader movement. Questions Needing Answers Crockett then asked the panelists if they had any remaining questions that they wish could be answered or would like to see answered through future research. Starke-Reed stated that her main question is, “What is the optimal nutrition and diet for the older population?” Although there is some in-
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Providing Healthy and Safe Foods as We Age: Workshop Summary formation available, she said, “We are really far from being able to define that right now.” Dwyer expressed concern in asking, “Where is the home and community-based older adult care system we keep hearing about?” She said that she did not want to downgrade current efforts, but the system at large is at the same place the United States was in the early years of the Roosevelt Administration with respect to children’s services. She emphasized the need to develop the home- and community-based older adult care system so that it becomes more “coherent.” She said that while the program in Boston’s Beacon Hill is wonderful, there is no easily accessible comparable program in the Boston neighborhood where she lives. Lack of a coherent infrastructure poses a tremendous challenge for family members and others who are suddenly faced with the need to care for a parent or other older adult. Without that infrastructure, how are food safety and nutrition messages going to reach the large proportion of older adults still living in their homes? Lloyd agreed that there is no infrastructure in place at the federal level and that the fragmented, multi-funded, state-by-state system that does exist creates terrific geographic as well as economic challenges. What can be done to improve the situation? For example, she administers an Alaskan program that delivers home meals by dogsled, which is difficult when the service provider is in one location and the client is 90 miles away. That is a “very real challenge,” she said. It is an example of what she referred to as a “whole system problem.” As an example of a more specific problem, Lloyd raised the issue of sodium level in foods. She questioned what would happen if the sodium level in foods was reduced and older adults with a reduced sense of saltiness ended up adding way too much salt. She asked, “How do we help people who may salt their food and never know, like a younger person knows, that it is too salty?” Sullivan said that he agreed with Gendel’s earlier point about the need for more data on aging populations, particularly among adults age 80 and over, so that appropriate risk management can be conducted. Most disabilities and some of the least manageable health problems occur in people age 80 and over, and therefore it would be very helpful to have a better understanding of this population. He said, “We need more data and more systems for obtaining that data.” Both moderators voiced their opinions. Gendel observed that everything discussed during this workshop was focused on the situation in the United States, even though all of the various components and ingredients of foods come from all over the world and foods are moved in and out of countries in a much more integrated fashion than in the past. He emphasized the need to consider how foods are produced in other countries and what the safety issues are elsewhere, because those factors can impact domestic
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Providing Healthy and Safe Foods as We Age: Workshop Summary food safety and nutrition. He also questioned how other countries would define “the aging population” and whether they would segment their aging population into multiple susceptible subpopulations (e.g., 50-and-over vs. 65-and-over vs. 85-and-over) in the same way that U.S. experts would. He asked, “Are the assumptions that we are making here going to hold true in other countries?” Finally, Crockett responded to Lloyd’s observations about sodium. She said that General Mills and other companies are working hard to reduce sodium levels in foods and that sodium reduction efforts represent an area where industry, scientists, and regulators need to work together. Efforts at General Mills are predicated on the assumption that the best way to reduce sodium is in relatively slow, small steps done in a “stealth way.” Announcing that sodium is being reduced sets up consumers for expectations that may not be true. She emphasized the importance of teaching consumers to “like and accept a lower sodium food” by making slow changes over time. Crockett also commented on the “us against them” type of attitude that is so pervasive throughout the food industry, although she observed that it was not evident during this workshop. As an example, she pointed to the way that some scientists and communicators make statements such as, “Avoid processed foods.” General statements like that, with undefined terms, create confusion not just among consumers but also health professionals. Messages need to be more precise since the term processed foods has different meanings to different people. The need for more precise communication around nutrition is another example of where cooperative efforts among industry, scientists, and others could be constructive. Dwyer agreed that nobody has really defined “processed food” very well and that there are different types of processing with different nutritional and safety implications. OPEN DISCUSSION1 Nutrition Services in Home- and Community-Based Services for Older Adults Wellman said that she was delighted to hear the panelists comment on the emergence, albeit slow, of home- and community-based services for older adults. However, as she emphasized in her presentation, nutrition services (e.g., meals, counseling, and education) are often overlooked, taken for granted, or underfunded. She echoed other suggestions that the 1 In this section, workshop speakers and panelists are identified by name. Other workshop participants (i.e., members of the audience) are not identified by name.
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Providing Healthy and Safe Foods as We Age: Workshop Summary Institute of Medicine (IOM) Food and Nutrition Board establish a committee to examine the role of nutrition in home- and community-based elder services. Good nutrition services should be universally accessible to older adults, particularly if efforts are going to be directed toward keeping older adults in the community and out of nursing homes. An audience member commented on the opportunity to incorporate nutrition services into NORCs now, while they are still emerging, rather than waiting until all of these naturally occurring retirement communities have been built and then trying to work nutrition services into them later. This remark prompted Lloyd to suggest that state dietetic associations learn more about how decisions are made regarding the nutrition aspects of state-provided home- and community-based older adult care services and become more involved in that process. The Challenge of Reducing Sodium Intake Pelchat remarked that she appreciated the panelists’ comments about sodium and stated that familiarity plays a large role in how much salt people like in their food. People that become familiar with low sodium will start preferring low sodium. However, it is very easy to “slip” and revert to a preference for a high level of sodium. While it may take a month to become accustomed to low sodium, it takes only a few days of eating a high sodium diet to start preferring that high level again. Pelchat also commented on the gate-keeping function she had mentioned in her presentation. While it becomes reduced in the oldest old, with people who have lost some of their gate-keeping function less able to detect spoilage or excessive salt, there is also an upside: the “oldest old” typically do not notice disagreeable characteristics of salt substitutes and therefore tend to find them okay. For example, potassium chloride, a popular salt substitute, has several negative sensory properties detectable by younger adults (e.g., a metallic or bitter taste). People who have lost some gate-keeping function do not notice those properties. The same is true of dietary supplements, with many younger adults complaining that dietary supplements taste like chemicals or vitamins but many older adults thinking that they are “just delicious.” An audience member remarked on the important technological challenges of reducing sodium in many foods. He said, “Very often it is easy for us to say, ‘take the salt out,’ without recognizing the technological and scientific challenges.” He agreed with Crockett that a “true partnership” between industry and NIH with the goal of developing innovative ways to remove salt would serve the older population well. This last comment prompted Dwyer to suggest that perhaps it is time for the IOM Food and Nutrition Board to consider an updated report on
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Providing Healthy and Safe Foods as We Age: Workshop Summary designing foods for the aging population, with a focus on safety as well as nutrition. She mentioned a 1989 IOM report that focused on designing foods for meeting the dietary guidelines. An audience member agreed, commenting on the need to include in any updated report all of the new technologies being applied to food design (e.g., nanotechnology). More Data, Funding, and Cross-Sector Collaborations Meydani stated that there are many unanswered questions about what constitutes optimal nutrition for older adults, how to communicate about nutrition with older adults, and how food products for older adults should be designed. However, research in any of these areas cannot be conducted without funding. She asked the panelists what efforts were being made to increase funding for this type of research and whether public-private partnerships would be helpful in providing some answers. Starke-Reed replied that this is definitely an area of focus for the National Institute of Aging (NIA), although she did not know any details about the actual level of funding or whether plans were in place to increase funding. She said, “But it certainly is in their mission … and they do a fair amount of funding in that.” Nutrition is a component of many of the other Institutes, besides NIA. However, she doubted that anyone at the Institutes would agree that funding for nutrition research is at the level it should be. Starke-Reed also mentioned that while there are opportunities and avenues for NIH to collaborate with industry, it would be “really helpful for government” if industry would make the necessary information (which is otherwise proprietary) available so that it can be used to guide policy decision-making. She pointed to Wellman’s use of proprietary data in her presentation as an example of how helpful those data can be. Crockett remarked that at a previous Food Forum workshop on sodium reduction, several suggestions were made about possible ways that consumer behavior data could be shared with the U.S. Department of Agriculture (USDA) for nutrition monitoring. That discussion is ongoing and serves as just one example of an effort to initiate industry-government collaboration. She agreed that Wellman’s use of General Mills’ data is another. While on the topic of data-sharing, Gendel remarked that the food industry generates a lot of data in areas such as quality assurance/quality control and sanitation that would be very useful for risk assessment and for understanding what exposure is occurring and the consequences of that exposure. However, it is very difficult to obtain those data. He mentioned several efforts being directed toward developing a way to share those data, but the problem has yet to be solved. He also mentioned the importance
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Providing Healthy and Safe Foods as We Age: Workshop Summary of negative test results. He says that he often hears industry representatives say that they have conducted thousands of tests a year and that “they all come up negative.” From a risk assessment perspective, knowing that zero tests have come up negative is just as important as knowing that one test has come up positive. He said, “I wish there was a better way of getting some of those data.” In response to Crockett’s earlier comments about the potentially very beneficial role that industry could play in addressing some challenges, Dwyer remarked that the food and perhaps equipment industries could help with communication around microwave wattage as earlier mentioned by Hallman (see Chapter 6). Given the increasing variety of microwaveable foods and the convenience and ease of using a microwave oven to heat food, the potential arises for inadequately cooked food, which has possible food safety implications. Many microwaveable food packages feature cooking instructions that vary depending on the wattage of the microwave used to heat the product. However, most people, not just older adults, do not know where wattage is indicated on their microwaves. “Yet,” she said, “it is a simple food safety thing that could really perhaps make a difference with a lot of people.” An audience member mentioned that the food industry, microwave manufacturers, and retailers are currently working on this issue and that wattage will be placed on the front of microwaves in the future. Another audience member remarked on the “little rules” that exist around collaborating with industry. She said, “The minute you do that, then everybody starts saying you have lost your credibility.” Another audience member commented on how industry is “very willing and open” to public-private partnerships but that a major challenge is the notion that industry has no credibility. He said that much of this attitude is historic and that it is time to move forward and create a new “framework” for partnership. The Challenge of Communicating About Food Safety and Nutrition with Older Adults An audience member expressed concern that most regulatory communication is directed to the general public and does not target specific subpopulations, like older adults. He asked how nutrition information that is of particular relevance to older adults should be communicated. Starke-Reed mentioned a past collaborative effort between NIA and the Grocery Manufacturers Association (GMA) that was aimed at older adult consumers, whereby NIA provided the science and GMA communicated the information in a consumer-friendly way. The program provided older consumers with information about foods that they should consider; changed the way products were located on shelves so that somebody did not have to reach up
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Providing Healthy and Safe Foods as We Age: Workshop Summary and grab a five-pound bag of sugar, worried that it might fall; etc. She cited it as an example of how nutrition science can be communicated directly to a specific population without going through any regulatory avenues. Balancing Conflicting Messages About Food Safety vs. Nutrition An audience member commented on how nutrition experts usually advise consumers to eat more fruits and vegetables, as a way to reduce their risk of chronic disease, while food safety experts express concern about foodborne disease originating from consumption of those very same foods (e.g., E. coli O157:H7 in spinach, Salmonella in tomatoes). She asked the panelists how the nutrition and food safety communities, which traditionally have not worked together, can work together to craft a message about the need to eat nutritiously while also keeping safety in mind. Starke-Reed commented on the combined efforts of HHS and USDA in issuing the Dietary Guidelines for Americans and that those guidelines contain both food safety and nutrition information. Dwyer added that while considerable work was done in order to include the food safety guidelines in the 2000 Dietary Guidelines for Americans, the issue has “sort of gone underground” since then and that “it is time for that to come out again.” Starke-Reed mentioned that the forthcoming Dietary Guidelines’ subcommittee on food safety is “deliberating right now” and “would be very welcome” to comments. Lloyd mentioned that when the 2005 Dietary Guidelines for Americans were issued, a brochure designed specifically for older adults was also issued, with larger font sizes, artwork, and an emphasis on safety. The new guidelines should do the same. An audience member remarked on need to “re-energize” the food safety program of the American Dietetic Association (ADA) and to do so with a focus on the older population. Another audience member agreed that balancing messages about food safety and nutrition is very important. He said he is very concerned when he hears messages about the risks of eating fruits and vegetables given that the majority of older adults are going to die from chronic diseases, not foodborne illnesses. Today, not a single state “meets the basic guidelines for fruits and vegetables.”
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