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2
Nutrition Issues of Concern
in the Community
Presenters during the first session provided background on nutrition
issues that characterize the needs of older adults who would benefit from
community-based nutrition services, said moderator Connie W. Bales, pro-
fessor of medicine at the Duke University School of Medicine and associate
director for education/evaluation at the Durham Veterans Adminstration’s
Geriatric Research, Education, and Clinical Center. Attention to the is-
sues of nutrition screening, food insecurity, sarcopenic obesity, and dietary
patterns, along with supportive community resources, can contribute to
improved functionality, independence, and quality of life for older adults.
NUTRITION SCREENING AT DISCHARGE
AND IN THE COMMUNITY
Presenter: Joseph R. Sharkey
Joseph Sharkey, professor of social and behavioral health at the Texas
A&M Health Sciences Center, drew on his research with home-delivered
meal participants and providers in North Carolina and Texas to discuss
nutrition screening and its role in community-based programs within the
Aging Network and potential partners. Screening can be a vital part of
reaching the national goal of eliminating nutritional health disparities, pre-
venting and delaying chronic disease and disease-related consequences, and
improving postdischarge recovery, daily functioning, and quality of life. He
15
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16 NUTRITION AND HEALTHY AGING
discussed nutrition screening versus assessment, challenges associated with
screening, determinants of nutritional risk, and uses for nutrition screens.
Nutrition Screening Versus Assessment
Sharkey began by clarifying the difference between nutrition screening
and assessment. Screening is used to identify characteristics associated with
dietary or nutrition problems, and to differentiate those at high risk for nu-
trition problems who should be referred for further assessment or counsel-
ing. Assessment is a measurement of dietary or nutrition-related indicators,
such as body mass index or nutrient intake, used to identify the presence,
nature, and extent of impaired nutritional status. This information is used
to develop an intervention for providing nutritional care.
Sharkey presented the pathway from the presence of a health condi-
tion, to impairment, functional limitations, disability, and adverse outcomes
(Nagi, 1976; Verbrugge and Jette, 1994) and noted the role that nutrition
and screening could play throughout that progression in preventing ad-
vancement to the next stage. Additional reasons for conducting nutrition
screening are listed in Box 2-1.
Who Should Be Screened?
In the past, the only people screened were nutrition program partici-
pants and those seeking nutrition services. “Is that enough,” asked Sharkey,
“or should screening be used more broadly to identify and pre-empt some
individuals’ needs?” While screening people in the community may iden-
BOX 2-1
Reasons for Conducting Nutrition Screening
• Determine potential need/demand for community programs
• Prioritize services
• Define short- and long-term outcomes
• Identify or develop interventions
• Prepare nutrition care plans
• Make referrals
• Build basis for additional funding
• Engage community partners
SOURCE: Sharkey, 2011.
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
tify more high-risk individuals, doing so is made difficult by the following
contextual challenges:
• Geography. Screening and follow-up may be conducted differently
in rural versus urban areas.
• Population shifts. The population of older adults in rural areas is
increasing due to older adults choosing those locations to retire and
younger adults leaving to find jobs.
• Culture and context. Immigration may result in the development
of new communities that require screening to be conducted within
the context of that population’s culture.
• Language. Nutrition providers should employ people who speak
the languages of the populations being screened and can translate
materials into those languages. For example, there are nuances to
the Spanish language that should be considered when the popula-
tion includes people from different Spanish-speaking countries.
• Literacy. Both educational and health literacy should be consid-
ered, especially in the context of various immigrant populations.
He also discussed community challenges for the use of screening:
• Spectrum of vulnerability. Screening can be used to identify those
individuals at the frail end of the spectrum as well as to prevent
people from moving along the continuum to that point. Screeners
should be trained to provide people at all points with the appropri-
ate nutrition information, counseling, or referrals.
• Rapid hospital discharge. Hospital discharge plans may not take
into account challenges associated with high-risk individuals’ home
and community environments or provide linkages to community-
based services.
• Limited/reduced funding. Community programs have limited re-
sources so it may be challenging for individuals to locate programs
that provide the services they need, such as access to healthy food
and transportation.
• Engagement of nontraditional partners. How can nontraditional
partners, such as the Special Supplemental Nutrition Program for
Women, Infants, and Children and Federally Qualified Health Cen-
ters be engaged to assist with screening?
Determinants of Nutritional Risk
As previously mentioned, the main purpose of nutrition screening is
to identify those at high risk for nutritional problems. Screening for nutri-
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18 NUTRITION AND HEALTHY AGING
tional risk includes gathering information on topics that may be thought
of as only partially related or unrelated to food and nutrition, such as
social support and transportation. Table 2-1 identifies what are or should
be components of nutrition screening and determinants of nutritional risk.
In closing, Sharkey encouraged people to consider the use of screening as
a component of prevention as well as the associated ethics of screening,
“How can one determine someone to be at risk for poor nutritional health
and do nothing?”
TABLE 2-1 Components of Nutrition Screening
Component Determinants of Risk
Material resources • Adequacy of income and competing demands (other household
members and financial demands)
• Household environment (e.g., adequate refrigeration and storage)
• Food security
• Money, resources, and access
• Frequency and duration
• Individual components
• Energy security (e.g., heating oil, air conditioning)
Individual resources • Individual capacity and complexity of tasks
• Social support: familial and extrafamilial
• Partnership status
• Food preparation and consumption tasks (e.g., opening a jar,
lifting a glass)
• Depressive symptoms
• Life stresses
• Meal patterns (e.g., eating breakfast)
Health • Disease burden
• Medications
— Multiple prescribed and over the counter (number and
therapeutic categories)
— Practices to reduce or restrict cost
— Adherence
• Oral and chemosensory health (e.g., problems with chewing and
swallowing)
• Depressive symptoms
• Life stresses
Other • Acculturation
• Transportation
• Access to affordable, healthy foods
• Access to food programs
SOURCE: Sharkey, 2011.
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19
NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
FOOD INSECURITY AMONG OLDER ADULTS
Presenter: James P. Ziliak
James Ziliak, chair of microeconomics at the University of Kentucky,
presented data from research that he and Craig Gundersen, from the Uni-
versity of Illinois, conducted on food security and food assistance among
older Americans. Their research examined the extent, distribution, and
determinants of food insecurity among older adults, including differences
by age, poverty status, race, and presence of grandchildren, and the health
and nutritional consequences of food insecurity.
Households are assigned to food security categories based on responses
to 18 questions in the Core Food Security Module (CFSM) developed by
the U.S. Department of Agriculture (USDA) and administered as part of a
supplement to the Current Population Survey. The CFSM includes ques-
tions related to conditions and behaviors experienced by households hav-
ing trouble meeting basic food needs, such as, “Did you or other adults in
your household ever cut the size of your meals or skip meals because there
wasn’t enough money for food?” (FNS, 2000). The number of affirmative
responses dictates the household’s food security category (see Table 2-2).
Trends in Food Insecurity Among Older Adults, 2001–2009
Ziliak presented analyses of nationally representative data from the
December 2001–2009 Supplements to the Current Population Survey (CPS)
TABLE 2-2 Categories of Food Security
Number of Affirmative
Category Description of Household Condition Responses to CFSM
Fully food secure No reported indications of food access 0
problems or limitations
Marginal food One or two reported indications—typically 1 or more
insecurity of anxiety over food sufficiency or shortage
of food in the house
Food insecurity Reports of reduced quality, variety, or 3 or more
desirability of diet
Very low food Reports of multiple indications of 8 or more in households
security disrupted eating patterns and reduced food with children
intake 5 or more in households
without children
NOTE: CFSM, Core Food Security Module.
SOURCE: Ziliak and Gundersen, 2011.
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20 NUTRITION AND HEALTHY AGING
(U.S. Census Bureau, 2011a) to provide an overview of food insecurity
rates among adults ages 40 years and older. CPS data represent the full set
of questions from the CFSM and are used to establish official estimates of
food insecurity in the United States.
Background on Adult Food Insecurity in the United States
Between 2001 and 2007, food insecurity rates for adults over age 50
years remained relatively constant. There were spikes in the rates after
2007, which Ziliak suggested is a result of the recession (see Figure 2-1).
However, while the rates remained relatively constant in the early 2000s,
the actual number of people affected by food insecurity increased at a
greater rate; the numbers of people who are food insecure and very low
food secure increased 40 and 52 percent, respectively. This is probably a
reflection of the “aging society” and the growing number of people 50 years
and older, said Ziliak.
Food insecurity among older adults is associated with age, poverty
level, race, presence of grandchildren in the household, and geography.
Among adults over age 40 years, food insecurity is inversely related to
age; the highest rates are among persons 40–49 years (15.2 percent) and
the lowest rates are among those 60 years and older (7.3 percent). Among
adults ages 50 years and older whose incomes are below 200 percent of the
poverty line,1 about 40 percent are marginally food insecure, 23 percent are
food insecure, and 10 percent are very low food secure. There was a linear
long-term increase in these rates between 2001 and 2009 and no spike in
rates after 2007. There was, however, a spike in rates among people whose
incomes were greater than 200 percent of the poverty line, suggesting that
income is not the only factor affecting an individual’s food security status.
Food insecurity rates among those living below the poverty line are two to
three times higher than the rates among those living above it.
In 2009, food insecurity rates were highest among Hispanics and
African Americans age 50 years and older (about 18 percent) and lowest
among whites (7 percent). The spike in rates after 2007 was seen among
Hispanics, whites, and Asian and Pacific Islanders, while the rates among
African Americans exhibited linear increases. There remains a large gap
in food insecurity rates between racial groups even after accounting for
income differences (Ziliak and Gundersen, 2011).
Discussing the results from his research on multigenerational hunger,
1 In 2009, the Poverty Thresholds were $11,161 for one person under 65 years of age,
$10,289 for one person 65 years of age and over, $14,787 for two people, including a
householder under 65 years of age, and $14,731 for two people, including a householder 65
years of age and over (U.S. Census Bureau, 2010).
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21
NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
18
16
14
28% increase
12
P erc ent
10
8
32% increase
6
4
2 44% increase
0
2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Marginal Food Insecurity Food Insecurity Very Low Food Secure
FIGURE 2-1 Food insecurity rates for people ages 50 years and older by level of
food insecurity.
SOURCE: Adapted from Ziliak and Gundersen, 2011.
Ziliak showed that the presence of grandchildren in the households of
adults 60 years and older is associated with higher rates of food insecurity.
In 2009, about 20 percent of adults 60 years and older who had grandchil-
dren in their households were food insecure compared to 7 percent without
grandchildren in their households. While these data are more volatile due
to the small sample size, rates of food insecurity are on average about three
R02158
times higher in older adult households with a vectors present than in
Figure 2-1, editable grandchild
those without grandchildren. Ziliak also illustrated the potential destabi-
lizing effect that the presence of a grandchild can have on a food-secure
household (see Table 2-3). Regardless of income level, the added presence
of a grandchild greatly increases the predicted risk of food insecurity among
food secure and insecure households.
“Geographically . . . [food insecurity] is a southern problem,” said
Ziliak. Rates of food insecurity among adults 50 years and older are highest
in the South (7.78 to 12.99 percent) and lowest in the northern Midwest
(2.53 to 5.50 percent) (Ziliak and Gundersen, 2011), following the same
trend as poverty levels.
After reviewing the data and controlling for other factors, Ziliak and
Gundersen found that food insecurity is more likely to affect older adults
who
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22 NUTRITION AND HEALTHY AGING
TABLE 2-3 Destabilizing Effect of a Grandchild on Food-Secure and
Food-Insecure Households
Food-Secure Household Food-Insecure Household
Adult 60–64 years old,
Adult over 80 years old, African American, retired,
white, retired, married, with divorced/separated, did not
a college degree, living in a finish high school, living in a
metro area metro area
Predicted risk of food insecurity with and without a
grandchild present
Income No Yes No Yes
< 50% Poverty line 5.8 36.9 53.8 69.6
50–100% Poverty line 5.2 25.8 51.6 57.9
100–200% Poverty line 2.8 21.0 40.5 51.7
> 200% Poverty line 0.6 5.7 19.9 23.2
SOURCE: Analysis of December 2001–2009 Supplements to the Current Population Survey
(CPS) data (U.S. Census Bureau, 2011a).
• are living at or below the poverty level,
• do not have a high school degree,
• are African American or Hispanic,
• are divorced or separated,
• have a grandchild living in the household, and
• are younger.
Health Consequences of Food Insecurity
Ziliak and Gundersen reviewed nutrient intake data from the National
Health and Nutrition Examination Survey (NHANES) to identify nutrients
of concern among adults over 40 years of age. The differences in nutri-
ent intake between food-secure and food-insecure adults in different age
groups varies. There are no statistically significant differences in nutrient
intake between 40–49-year-old food-secure and food-insecure individuals.
Statistically significant differences in nutrient intake in the 50–59-year-old
age group were identified for vitamin A, thiamin, vitamin B6, calcium,
phosphorus, magnesium, and iron. However, the differences are not large
in magnitude and were no longer present when the sample was restricted
to adults below 200 percent of the poverty line. Food-insecure adults over
age 60 years have substantially lower intakes of food and all nutrients as
compared to food-secure adults in the same age group.
Food-insecure adults ages 50–59 years are more likely than food-secure
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
adults to have limitations in their activities of daily living (ADLs); to be
depressed; or to have diabetes; and are less likely to describe their health
status as good, very good, or excellent. The gap in health outcomes between
food-secure and food-insecure individuals in this age group narrows when
the sample is restricted to individuals whose income is below 200 percent of
the poverty level. This is due to the increased number of individuals, both
food secure and insecure, who have relatively poor health outcomes in this
age group and income level.
When controlling for all other factors, Ziliak and Gundersen’s multi-
variate regression models indicate that food-insecure individuals
• ages 50–59 years do not have lower nutrient intakes;
• ages 60 years and older have statistically significant lower nutrient
intakes; and
• ages 50 years and older are
— less likely to be in excellent or very good health,
— more likely to be depressed, and
— more likely to have ADL limitations (roughly equivalent to being
14 years older) (Ziliak and Gundersen, 2011).
Concluding Remarks
Ziliak concluded by reiterating the effects that various factors have on
food-insecurity rates among older adults in the community and suggesting
that they need to be taken into account when developing policy. Rates are
highest among 40–49-year-olds, something that should be considered when
developing policies for the Supplemental Nutrition Assistance Program
(SNAP) since SNAP participation declines with age. Food-insecure indi-
viduals over the age of 50 years face serious health consequences; therefore,
constructing policies that meet the needs of this population may reduce
their risk of negative health outcomes and result in lower health care costs.
SARCOPENIC OBESITY AND AGING
Presenter: Gordon L. Jensen
When the first research on obesity and aging was published over
15 years ago, researchers needed to overcome resistance from geriatricians,
said Gordon Jensen, head of the Department of Nutritional Sciences at the
Pennsylvania State University. Geriatricians were trained to treat frail older
adults in skilled nursing facilities who were underweight, undernourished,
and suffering from functional limitations and disability; the idea of obese
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24 NUTRITION AND HEALTHY AGING
older adults was new. A great deal has changed in the past 15 years and
now many older adults in acute care, transitional care, chronic care, and the
community are obese, representing a new population with different health
care and nutrition needs.
Obesity and Function Among Older Adults
As with other age groups, obesity is a growing concern among older
adults. Data from NHANES 1999–2004 show that the prevalence of obe-
sity among men and women ages 40–79 years is over 30 percent, with
rates higher than 40 and 50 percent among Mexican American and black
women, respectively (Ogden et al., 2007). The rates may be higher among
women because, as Jensen noted, “obese [middle-aged] men tend not to
live to be obese older men.” Particularly concerning is the relationship
between obesity and functional limitations. Elevated current or past body
mass index (BMI) has been linked with increased self-reported functional
limitations, physical performance testing has confirmed a strong relation-
ship between elevated BMI and functional impairment, and elevated BMI
has been associated with increased self-reported homebound status (Jensen,
2005). Predictors of reporting homebound status include
• 75 years of age and older,
• BMI of 35 or greater,
• poor appetite,
• income less than $6,000 a year, and
• limitations in activities of daily living and instrumental activities of
daily living (Jensen, 2005).
“These days many older persons in need of services are not tiny and frail;
they are large and frail,” said Jensen.
Whereas body composition studies have found positive associations
between total body fat mass and functional limitations, links between
muscle mass and functional limitations have been inconsistent. However,
with appropriate adjustment for body size, an association may be detected
between relative loss of muscle mass and increased functional limitations
(Villareal et al., 2004; Zoico et al., 2004). Obesity is a proxy for sedentary
living among older adults because it negatively impacts function. Contribut-
ing factors are likely to include obesity’s associated medical comorbidities
such as diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome,
heart disease, and osteoarthritis of the knee. Recent findings further im-
plicate inflammation, sarcopenia, and impairment of muscle function and
strength as possibly contributing to functional limitations (Jensen, 2005).
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
Sarcopenic Obesity
Sarcopenia, the loss of muscle mass with aging, can affect both under-
and overweight adults. It can be a major concern for obese older adults
since they require more muscle mass to move and function. Loss of α-motor
neuron input, changes in anabolic hormones, and malnutrition may lead to
loss of muscle mass. However, inflammation-driven erosion of muscle mass
and a vicious cycle of physical inactivity, increased body fat, and disease
burden are likely to culminate in sarcopenic obesity (Jensen and Hsiao,
2010; Stenholm et al., 2008, Zamboni et al., 2008).
Weight Loss Among Obese Older Adults
Although a growing body of research supports consideration of weight
loss for some obese older adults, the practice remains controversial. Jensen
identified the following reasons (Jensen and Hsaio, 2010):
• Involuntary weight loss usually reflects a serious underlying dis-
ease or injury associated with adverse outcomes (Huffman, 2002;
McMinn et al., 2011).
• Overweight and mild obesity may be associated with reduced mor-
tality risk (Bouillanne et al., 2009; Curtis et al., 2005).
• Some extra weight may provide a metabolic reserve needed to sur-
vive illness or injury (Davenport et al., 2009; Flegal et al., 2007).
• There are concerns for potential losses of muscle and bone mineral
density during weight reduction (Chao et al., 2000; Miller and
Wolf, 2008; Shapses and Riedt, 2006).
However, findings from weight loss studies suggest that weight loss
through exercise and dietary interventions can result in improvements in
physical performance testing and functional assessments (Villareal et al.,
2006a); reductions in coronary heart disease risk factors such as waist
circumference, blood pressure, and glucose, triglyceride, C-reactive pro-
tein, and interleukin-6 levels (Villareal et al., 2006b); reductions in the
diagnosis of metabolic syndrome (Villareal et al., 2006b); and improve-
ments in systemic and adipose tissue inflammatory states, including reduced
levels of C-reactive protein, interleukin-6, and other inflammatory cyto-
kines (Dalmas et al., 2011). A study conducted by Villareal and colleagues
(2011) found that a combination of diet and exercise resulted in the greatest
improvements in physical function (see Figure 2-2) and diet or a combina-
tion of diet and exercise resulted in the most weight loss (see Figure 2-3).
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38 NUTRITION AND HEALTHY AGING
tively transferred $67 million out of the congregate meal program and into
other OAA programs, such as home-delivered meals and support services
(GAO, 2011b). Despite the growing need for nutrition services, funding
decreased for all programs in 2010, resulting in many programs reducing
operational and administrative costs and services.
Closing Comments
Over $90 billion a year is currently spent on nutrition assistance pro-
grams, including multiple programs providing services to older adults. Re-
search shows that some of these programs are effectively addressing older
adults’ nutritional and social needs, yet more updated research is needed
to provide additional effectiveness data and to identify services to meet
older adults’ changing needs. Unfortunately, while need for these programs
continues to increase, funding will only continue to decrease in the current
budgetary environment. Therefore, it is important that further research
identifies and reduces overlap, duplication, and fragmentation of services
so funds can be used efficiently.
DISCUSSION
Moderator: Connie W. Bales
During the discussion, points raised by participants included the im-
portance of breakfast, vitamin B12 intake, food insecurity, the role of SNAP,
and socioeconomic status and food patterns.
The Importance of Breakfast
In response to a request from Robert Miller, Sharkey expanded on the
importance of breakfast by stating that consumption of a regular break-
fast “jump-started the metabolism for the day” and resulted in increased
intake of calcium, vitamin D, magnesium, and phosphorus. Older adults
who received breakfast and lunch delivered to their homes consumed more
calories, protein, carbohydrates, fiber, and minerals than those who only
received lunch, said Larin. Nancy Wellman said that breakfast is one of the
easier meals for older adults to assemble; therefore, they should be encour-
aged to eat that meal at some point during the day.
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
Crystalline Vitamin B12 Intake
Melanie Polk raised the issue of vitamin B12 absorption among individ-
uals who are on chronic use of proton pump inhibitors for gastroesophageal
reflux disease. Tucker noted that one of the reasons so many older adults
are diagnosed as vitamin B12 deficient is due to the use of these proton
pump inhibitors. However, studies show that some crystalline vitamin B12
will be absorbed even in those taking proton pump inhibitors if given in
large enough doses.
Food Insecurity Among Older Adult Households
with Grandchildren Present
Elizabeth Walker asked why the presence of a grandchild in an older
adult’s household is associated with higher food insecurity. She wondered
whether it was related to the grandparents acting as the primary care-
givers or simply due to children being given first choice of the available
foods before the adults? Ziliak explained that he and Gundersen are cur-
rently examining the health consequences associated with multigenerational
food insecurity and will have more results in the near future. The results
he presented during the workshop are based solely on the presence of a
grandchild, and findings suggest that food insecurity is associated with “the
additional anxiety of trying to provide for multiple other individuals [on] a
very fixed income.” After controlling for income, “on average the presence
of a grandchild increases that risk [of food insecurity] by about 50 percent,
whether the parent is there or not.”
Wellman said that the percent of grandparents caring for a grandchild
is fairly low, and Ziliak confirmed that it is probably around 3 to 5 per-
cent; however, there are substantial differences between races and the rate
is probably closer to 15 percent in African American households. Sharkey
suggested further research to determine food distribution in households
where grandparents are present but are not the primary caregivers for the
children.
Role of SNAP Among Older Adults
In response to a request from Julie Locher for more information on the
role of SNAP in addressing food security among older adults, Larin noted
that SNAP is underutilized by older adults. They have the lowest participa-
tion rates in SNAP, possibly since they are only eligible for the minimum
benefit ($14–$16 per month). Ziliak said, although he cannot prove cau-
sality, SNAP participants are at a greater risk of food insecurity and more
research needs to be done on that relationship.
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40 NUTRITION AND HEALTHY AGING
Socioeconomic Status and Food Patterns
Charlene Compher inquired about the association between socio-
economic status and dietary patterns. Tucker confirmed this association;
she noted that people with limited resources are more likely to choose
high-calorie, highly refined, high-sugar foods because they are generally less
expensive. Diets comprising fruits and vegetables, low-fat dairy foods, and
lean meats are more expensive, less widely available, and heavier to carry,
all of which may prevent low-income older adults from purchasing them.
NUTRITION ISSUES RELATED TO AGING IN THE COMMUNITY:
PERSPECTIVES AND DISCUSSION
Moderator: Gordon Jensen
In the final session of the morning, several speakers representing the
workshop sponsoring agencies provided perspectives on nutrition issues
of concern related to aging in the community. The moderator, Gordon
Jensen, encouraged presenters to discuss important nutritional needs
for older adults that differ from those of the community, gaps in services for
older adults choosing to stay in their homes, and promising actions for ad-
dressing the unique needs to this population.
A Perspective from Abbott Nutrition
Robert Miller, Divisional Vice President of Global Research and Devel-
opment and Scientific Affairs at Abbott Nutrition, asked “how does [the
industry] get nutrition to those people that most need it?” He pointed to
the lack of data from intervention studies needed to demonstrate nutrition’s
impact and stressed the importance of more research to track the effects of
nutrition education and supplementation.
In 2010, about 15 percent of hospital patients received nutrition sup-
plementation, the same percent as in 2000. Initial reviews of data suggest
that people receiving nutritional supplementation have shorter hospital
stays and lower rates of readmission, resulting in lower health care costs.
Clinical trials should be used to translate research into something that can
be implemented by industry, Miller said. For example, Abbott conducted
a pilot study to determine the effect of a nutrition screening and education
initiative on hospital readmission rates. The 30-day readmission rate of the
1,000 people followed over 6 months was 8.7 percent, compared to about
24 percent for the area average and 26 percent for the national average.
“One of the most simple things in a doctor’s bag is education and nutrition
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
. . . and how do we bring everything from payer, industry, manufacturer,
academics, [and] government together to tackle this,” Miller concluded.
A Perspective from the Administration on Aging
Jean Lloyd, national nutritionist for the Administration on Aging (AoA),
expanded on previous presentations’ discussion of the OAA Nutrition Pro-
grams. “Although we’ve talked primarily about the fact that meals are our
primary service, it’s not just a meals program; it is a nutrition program . . .
not a malnutrition program.” In efforts to meet the program’s three goals
(see earlier discussion in this chapter), each year about 50 million meals
are home delivered (about 170 meals per participant) and 92.5 million con-
gregate meals are served (about 55 meals per participant). Due to limited
government funding, the number of meals served each year has declined;
federal funds account for only about 28 percent of the expenditure for
home-delivered meals and 41 percent for congregate meals.
In addition to providing meals that meet the current dietary guidelines,
the OAA Nutrition Program also includes nutrition education and coun-
seling. The OAA, Lloyd said, provides the opportunity for collaboration
among various assistance programs in parallel systems, such as Medicaid
waiver programs and the Veterans Administration, in order to develop
“comprehensive and coordinated service systems” to meet the nutrition
needs of older adults. Despite the success of the program in meeting the
needs of this complex and vulnerable population, AoA still faces funding
and service cuts and limited nutrition expertise in sites across the country.
However, AoA is committed to continuing to improve the way it provides
services by conducting research to better understand the needs of its service
population. Future plans include conducting outcomes research in the field,
administration of process improvement surveys, and research of short-term
methods for reducing food insecurity. As a long-term goal, AoA will be
conducting impact studies that include reviews of Medicare records for
data on emergency room visits and hospitalizations among participants
and nonparticipants.
A Perspective from Meals On Wheels Association of America and
Meals On Wheels Association of America Research Foundation:
The Hidden Hungry
“Over the past 21 years, which is as long as I have been with [Meals On
Wheels Association of America], I have become something of an authority
on what we at Meals On Wheels Association of America call the ‘hidden
hungry,’” said Enid Borden, president and Chief Executive Officer. She
travels across the country, speaks with people who are “living behind
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42 NUTRITION AND HEALTHY AGING
closed doors,” gives them meals, and, most important, listens to their sto-
ries. These older adults may live in the community, but they often stand
apart from it and are overlooked. She hoped her presentation would help
the audience get to know the population being served by giving these older
adults a “human face and voice.”
Older adults needing nutrition services are often overlooked by the
community in which they live. She described a trip to a town in Arkansas
with a population of 117 that had become a food desert.3 She met an
86-year-old woman that had lived there all her life in the house where she
was born. This woman was all alone except for the Meals On Wheels vol-
unteer who delivered her meals. Borden said, “She told me that if it weren’t
for Meals On Wheels, she would be dead. She was right.”
DISCUSSION
Moderator: Gordon Jensen
During the discussion, points raised by participants included informa-
tion for case managers, research steps, and aging in place.
Information for Case Managers
Heather Keller inquired about information that case managers should
have to help them determine if they are missing people at nutrition risk.
Lloyd responded that many tools used by case managers do not include
a nutrition component, with the exception of obtaining information on
special diets or nutrition needs based on ADLs. She suggested that case
managers find out more about a person’s weight history, appetite, income,
oral conditions, and instrumental ADLs (e.g., shopping for and preparing
meals) and correlate them with responses to food insecurity and func-
tionality questions.
Research Gaps
Robert Russell noted that a real research gap is the lack of analysis
of Medicare and Medicaid records to track the effectiveness of interven-
tions on preventing hospital admissions and readmissions. He asked how
3 TheFood, Conservation, and Energy Act of 2008 (also known as the Farm Bill) (HR 6124,
Sec. 7527) defines a food desert as “an area in the United States with limited access to afford-
able and nutritious food, particularly such an area composed of predominantly lower-income
neighborhoods and communities.”
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NUTRITION ISSUES OF CONCERN IN THE COMMUNITY
this would be done by AoA considering differences between programs in
various regions of the country; would it be a nationwide evaluation or a
review of a selection of similar programs? Lloyd responded that it will
be a nationwide evaluation that includes process surveys conducted in all
state units on aging, about half of the area agencies on aging, and local
providers. The statistical method is still being finalized, but the evaluation
will include meal cost at the local level to compare the cost of preparing
meals different ways in various parts of the country and a comparison of
Medicare data from participants and nonparticipants with different racial
and ethnic backgrounds in the same community.
Aging in Place
Katherine Tallmadge pointed out that many communities are organiz-
ing groups focusing on aging in place, but wondered if there were any
regulations ensuring that people in those groups receive appropriate nutri-
tional care, such as having them track their weight and food intake for
consultation with a dietitian. Since those organizations are locally funded
and organized and receive no federal funds, the community decides on the
requirements, said Lloyd.
Lloyd also addressed the larger issue of programs designed to help keep
older adults in their homes. Medicaid funds home- and community-based
waivers that are used to keep people out of nursing homes. It is a person-
centered program and there are no nutrition or food requirements; however,
the states have the option of including them. Over half the states offer a
meal service under the waiver program and some states include nutritional
supplements and other nutrition services.
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