6

Research Gaps

The final session consisted of a panel discussion addressing research gaps in knowledge about nutrition interventions and services for older adults in the community setting. The discussion was moderated by Nancy S. Wellman, from Tufts University, and included presentations by panel members Mary Ann Johnson from the University of Georgia, Rebecca Costello from the National Institutes of Health (NIH) Office of Dietary Supplements (ODS), Robert M. Russell from the NIH ODS and Tufts University, and Judy Hannah from the NIH National Institute on Aging (NIA). Each panel member had been asked to identify what they perceived to be the top three areas in which research is needed on nutrition issues and aging. Their presentations were followed by an open discussion period. The research gaps identified during this session are summarized below.

EDUCATION OF DIETITIANS

Mary Ann Johnson opened the panel discussion by addressing the need for educating future dietitians on issues related to aging. While the registered dietitian is the expert in food and nutrition services and interventions, nutrition is only one of the many issues that a client or patient will experience. She called for broad training and exposure to the many problems older people face. She also stressed that dietitians need an appreciation of related social and health professions so they can function effectively within health care teams and systems that serve older adults. Wellman agreed that more should be done to educate future dietitians about aging, noting that other health professions have multiple undergraduate and graduate courses on aging.



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6 Research Gaps The final session consisted of a panel discussion addressing research gaps in knowledge about nutrition interventions and services for older adults in the community setting. The discussion was moderated by Nancy S. Wellman, from Tufts University, and included presentations by panel mem- bers Mary Ann Johnson from the University of Georgia, Rebecca Costello from the National Institutes of Health (NIH) Office of Dietary Supplements (ODS), Robert M. Russell from the NIH ODS and Tufts University, and Judy Hannah from the NIH National Institute on Aging (NIA). Each panel member had been asked to identify what they perceived to be the top three areas in which research is needed on nutrition issues and aging. Their pre- sentations were followed by an open discussion period. The research gaps identified during this session are summarized below. EDUCATION OF DIETITIANS Mary Ann Johnson opened the panel discussion by addressing the need for educating future dietitians on issues related to aging. While the registered dietitian is the expert in food and nutrition services and interventions, nutri- tion is only one of the many issues that a client or patient will experience. She called for broad training and exposure to the many problems older people face. She also stressed that dietitians need an appreciation of related social and health professions so they can function effectively within health care teams and systems that serve older adults. Wellman agreed that more should be done to educate future dietitians about aging, noting that other health professions have multiple undergraduate and graduate courses on aging. 105

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106 NUTRITION AND HEALTHY AGING NUTRITION SERVICES FOR OLDER ADULTS Johnson also called for the integration of food and nutrition care and services among all settings, including community, outpatient, rehabilitation, assisted living, and nursing homes. Older adults who need nutrition services should be targeted through well-designed screening programs. Interventions need to be developed and implemented that are tailored to diverse cultures, geographic locations, and characteristics of older adults in those settings. Johnson believes patient-directed services, with a dietitian or health care provider functioning as a coach, will likely be embraced by older adults. Elizabeth Walker suggested research on how to educate people to make competent health-related decisions, such as selecting nutrition services as a patient-directed benefit. Judy Simon raised the issue of the disconnect between the requirement that meals provided by the Older Americans Act (OAA) Nutrition Program meet current dietary guidelines and the food preferences of older adults. She suggested research examine how to bridge that gap and determine if differ- ent meal standards and more palatable meals would attract more people into the declining congregate meal programs. She added that it is essential to determine the effect of changing dietary guidelines on program costs. Very few caterers bid on providing foods for these programs because it is not cost-effective to prepare these meals since the nutrition programs are small and have restrictions related to nutrient requirements. REFINING OUTCOME MEASURES Another research gap identified by Johnson is the refinement of out- come measures for interventions to demonstrate cost effectiveness and im- proved quality of life. Robert Russell concurred and, as noted earlier in the workshop, pointed out that one of the major goals of the Administration on Aging (AoA) is to have people remain in their homes as long as possible instead of going into a nursing home. However, the evaluations of AoA pro- grams have been small in scale and have not addressed the main interest of Congress—do the interventions prevent people from being institutionalized and reduce health care expenses? Furthermore, if current evaluations tying these programs to Medicare and Medicaid outcomes show ineffectiveness and do not result in reduced health care spending, it must be determined why they are unsuccessful so improvements can be made. Wellman also emphasized the need for more outcome data on the cost effectiveness of the OAA Nutrition Program. About 40 percent of older adults who participate in the home-delivered meal program are in and out of the hospital during the year. She proposed that many of these homebound people should be identified through nutrition assessment at the

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107 RESEARCH GAPS hospital and provided more than just five lunches a week. It is necessary to document Medicare and Medicaid cost savings for those whose food and other service needs are met through the program. The importance of documenting outcomes should be made clear to the local staff who carry out the OAA Nutrition Program. Wellman compared the OAA program to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Both federal programs started in the 1970s. Federal funding for WIC has increased 332-fold, Wellman reported, while funding for OAA has increased only sixfold. She attributed this difference partially to the fact that evaluations of the WIC program demonstrated cost savings from the beginning. Early data revealed that for every dollar spent in WIC, $3 were saved in inten- sive care unit dollars. Nadine Sahyoun noted that the WIC program is an established national program and the participants are not sick, making it somewhat easier to follow and have an end point. Alternatively, the OAA Nutrition Program is a grassroots program and many participants have chronic conditions and may be frail. The aging network is complicated because programs vary by state and locales; therefore, innovations may be required to determine what outcomes to measure. Judy Hannah noted that government recognizes that most of a person’s health care expenditures occur in the last 2 years of his or her lifespan. Therefore, she stressed that the focus of programs and research must be to ensure health-related quality of life, to keep people in their homes instead of institutions, and to reduce health care costs. USE OF FORTIFIED FOODS AND DIETARY SUPPLEMENTS Johnson pointed to the need to conduct basic and translational research on the development, evaluation, and appropriate use of fortified foods and dietary supplements to maintain and enhance health and well-being. She said there is a need to establish an evidence base for specific nutrients and supplements with an evidence base of effectiveness and to help health care professionals and consumers make appropriate choices. Rebecca Costello suggested the creation of informational databases on dietary supplements for this same reason. She also acknowledged the continued need for devel- opment of relational databases that address structural-activity relationships and are populated with biochemical, toxicological, and dietary supplement information. Costello reported that data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES) cycle revealed that 54 percent of adults consume dietary supplements, with 70 percent of adults over 71 years of age using them. She presented on the progress made related to the research gaps identified at a 2003 NIH conference on dietary supplements

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108 NUTRITION AND HEALTHY AGING in older adults. The first was further characterization of dietary supplement usage behaviors, including the need to describe the effect of caregivers’ advice. While some newer data have been reported, the need still exists to collect data on caregivers. There is also a need to characterize the diversity of beliefs (e.g., alternative medicine) and behavioral, cultural, and social factors that can affect and confound dietary supplement data. Costello identified various entities (or groups) that have collected this type of data, including the Centers for Disease Control and Prevention’s 2002 National Health Interview Survey and NHANES, the Jackson Heart Study, the Women’s Health Initiative, and the Gingko Evaluation of Memory Study. Nevertheless, there is an ongoing need to evaluate dietary supplement use as well as the methods for the collection of dietary supplement data. Another research gap that remains, according to Costello, includes preclinical and clinical studies to • better distinguish which population groups of older adults may need dietary supplements, • evaluate supplement safety and efficacy, • capture usual dietary intakes and total daily intakes of nutrients, • evaluate drug-nutrient interactions, and • determine micronutrient needs of an aging population. NUTRIENT REQUIREMENTS Costello identified another research gap as the need for improved meth- odologies, including biomarkers, analytical methods, diet assessment tools, and systematic reviews. While progress has been made on the validation of biologic markers used in national surveys, such as the NHANES col- lection of data on biochemistry for folic acid and vitamin D assessments, similar work must be done for other nutrients that may be of public health importance for older adults. Costello reported significant developments in the area of analytic methods. The ODS Analytical Methods and Refer- ence Materials Program has supported the development and validation of reference standards for a host of dietary supplements and supplement constituents. In particular, the program collaborated on the development and use of a National Institute of Standards and Technology Vitamin D standard. Costello noted that it is still necessary to determine the best way to incorporate formal methods of weighing the evidence for interpretation into policy and clinical practice. Multiple groups, such as the Agency for Healthcare Quality and Research, NIH, the U.S. Department of Agriculture (USDA), the American Dietetic Association, and most recently the Institute of Medicine (IOM), have explored the methodology for evaluating, tabulat- ing, and interpreting the evidence base for dietary supplements.

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109 RESEARCH GAPS Russell identified research on nutrient requirements as a priority re- search gap, explaining that some current Dietary Reference Intakes (DRIs) are “clearly wrong.” For example, the Estimated Average Requirements (EARs) for vitamin E (and probably vitamin A) are too high; continued research and improved biomarkers are needed to obtain more realistic and accurate EARs. Additionally, evidence suggests that the Recommended Dietary Allowance (RDA) for vitamin B12 might be too low; European trials indicate that older adults may need as much as 6 µg per day. As mentioned earlier in the workshop, vitamin D has been linked to diseases other than bone disease. However, after an exhaustive review of the evidence the IOM Committee to Review DRIs for Vitamin D and Calcium found that the evi- dence supported a role for these nutrients in bone health but not in other conditions. Macronutrient requirements must also be studied further, as highlighted by the discussion of protein requirements during the workshop (see Chapter 5). Russell pointed out that safe upper levels of nutrients must also be evaluated in light of the elevated usage of dietary supplements by older adults; for example, as mentioned by Katherine Tucker, folate intake is a concern (see Chapter 2). Furthermore, as more products are developed with nanotechnology, the bioavailability of certain nutrients will be enhanced and adjustments in RDAs or EARs may be needed to compensate for in- creased bioavailability. NUTRITION AND COGNITION Russell identified nutrition and cognition as a research priority that should continue to be addressed. Current research focuses mainly on the B vitamins, particularly vitamin B12 and folate; however, increasing the thiamine requirement should be considered because many older people use diuretics, which increase the loss of thiamine in the urine. Furthermore, he explained that there are recent data showing some B vitamins can slow the progression of early dementia and brain atrophy in individuals with high homocysteine levels. Russell stated that further research should be con- ducted on the relationship between cognition and the B vitamins, omega-3 fatty acids, and vitamin D, and that good biomarkers need to be developed. COMMUNICATION AND EDUCATION According to a workshop participant, another area for development is communication with caregivers and educational materials that are ame- nable to older adults’ needs as nutrition science evolves. For example, information on how USDA’s “MyPlate” (http://www.choosemyplate.gov) translates to the older American diet would be helpful. Additionally, there

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110 NUTRITION AND HEALTHY AGING is a need to effectively communicate best practice approaches to implemen- tation of these recommendations for the patient and the patient’s family. Messages can be very confusing as patients move through the health care system continuum from community to hospital(s), therefore, the use of common language would be helpful. Sahyoun said that more outreach to the most vulnerable people in the aging population is necessary. Referring to James Hester’s discussion on the three silos in the transition of care (see Chapter 4), she commented that in times of recession it would be beneficial to use available linkages and resources to increase awareness of existing programs and services. However, since funding is limited, a method of prioritization to serve the people most in need of assistance would have to be established. OBESITY AND RELATED DISORDERS Prevention and treatment of obesity and obesity-related disorders (in- cluding sarcopenic obesity) across the spectrum of health and functional status was another area of research identified by Johnson and Russell. Johnson noted that the increase in the aging population is colliding with the epidemic of obesity and suggested that failure to address the problem of obesity in older adults may even erode some of the gains made in life expectancy in the past century. FOOD INSECURITY AND HEALTHY AGING Referring to James Ziliak’s presentation on Food Insecurity Among Older Americans, Johnson emphasized that the basic food needs of older adults must be met, noting that nutrition interventions cannot work if people cannot access, afford, or prepare the foods they need. Connie Bales, questioning the current recession’s impact on food insecurity in older adults, worried that they may be overlooked in light of concerns for children and suggested the examination of ways to prioritize the needs of many. Nancy Cohen stated that the study of food deserts is important, with focus on policy changes that communities can make to enhance food availability and food access. Karen Jackson Holzhauer identified the role of commu- nity gardens, local produce, and food banks in increasing food availability in food deserts. Sustainability of such programs and their impact on the quality of life and food would need to be measured. A related issue to be examined, according to Elizabeth Walker, is “food swamps,” urban areas with a large concentration of fast food outlets.

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111 RESEARCH GAPS FUNDING OPPORTUNITY Judy Hannah concluded the presentations by providing information on an NIA/AoA funding announcement for R01 applications. The topic of research for this funding is Translational Research to Help Older Adults Maintain Their Health and Independence in the Community. Hannah noted that the goal of this funding is to move the evaluation of well-documented, evidence-based interventions from a strict research setting into community settings, thus forming a true partnership. Two of the requirements listed in the announcement are (1) a link between the university and organizations working with older adults in the community and (2) cost effectiveness as one of the criteria. Nutrition is one of a variety of criteria that can be evaluated. OTHER RESEARCH GAPS Marketing research is another significant gap identified by workshop participants. Mary Pat Raimondi believes that more focus groups with older adults should be conducted to determine what foods appeal to them and to identify other issues of concern. She also suggested addressing marketing claims since there is a lack of trust by older consumers. Holzhauer proposed studying how the sensory appreciation of foods by older adults and plate appeal could change the way older adults eat. Russell mentioned the effect of microbiomes on human metabolism and disease is a relatively new area of research to explore. Douglas Paddon-Jones provided a different viewpoint on research gaps; quite often knowledge of the interface between practitioners and patients is lacking from a researcher’s perspective. Forums such as this workshop pro- vide an opportunity to inform researchers on how to adapt their research to best meet the needs of practitioners and, ultimately, their patients.

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