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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, professor 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 issues 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, preventing and delaying chronic disease and disease-related consequences, and improving postdischarge recovery, daily functioning, and quality of life. He



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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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17 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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23 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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25 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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39 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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41 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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43 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. REFERENCES AoA (Administration on Aging). 2011. Home & Community Based Long-Term Care: Nutrition Services (OAA Title IIIC). http://www.aoa.gov/aoaroot/aoa_programs/hcltc/ nutrition_services/index.aspx (accessed November 14, 2011). Bouillanne, O., C. Dupont-Belmont, P. Hay, B. Hamon-Vilcot, L. Cynober, and C. Aussel. 2009. Fat mass protects hospitalized elderly persons against morbidity and mortality. American Journal of Clinical Nutrition 90(3):505–510. Britten, P., K. Marcoe, S. Yamini, and C. Davis. 2006. Development of food intake patterns for the MyPyramid Food Guidance System. Journal of Nutrition Education and Behavior 38(6 Suppl):S78–S92. Buell, J. S., T. M. Scott, B. Dawson-Hughes, G. E. Dallal, I. H. Rosenberg, M. F. Folstein, and K. L. Tucker. 2009. Vitamin D is associated with cognitive function in elders receiving home health services. Journal of Gerontology—Series A Biological Sciences and Medical Sciences 64(8):888–895.

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