5

Successful Intervention Models in the Community Setting

This session focused on the successes and challenges of developing practical interventions that address the nutrition needs of older adults in the community. Douglas Paddon-Jones, associate professor at the University of Texas Medical Branch and the session moderator, noted that the strength of this session was the practitioner-based approaches presented by speakers with expertise in nursing, physical therapy, and gerontology. The interventions that were discussed include the following:

•   Community telephonic interventions

—  Vision is Precious Program

—  Improving Diabetes Outcome Study

•   The Diabetes Prevention Program

•   Medical nutrition therapy

—  Dietary Approaches to Stop Hypertension (DASH) Diet

•   Nutrition interventions for frailty and sarcopenia

•   Eat Better, Move More program

DIABETES SELF-MANAGEMENT SUPPORT IN THE COMMUNITY:
HEALTHY EATING CONSIDERATIONS

Presenter: Elizabeth A. Walker

Elizabeth Walker, professor of medicine, and epidemiology and population health at Albert Einstein College of Medicine, described two theoretical



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5 Successful Intervention Models in the Community Setting This session focused on the successes and challenges of developing practical interventions that address the nutrition needs of older adults in the community. Douglas Paddon-Jones, associate professor at the University of Texas Medical Branch and the session moderator, noted that the strength of this session was the practitioner-based approaches presented by speakers with expertise in nursing, physical therapy, and gerontology. The interven- tions that were discussed include the following: • Community telephonic interventions — Vision is Precious Program — Improving Diabetes Outcome Study • The Diabetes Prevention Program • Medical nutrition therapy — Dietary Approaches to Stop Hypertension (DASH) Diet • Nutrition interventions for frailty and sarcopenia • Eat Better, Move More program DIABETES SELF-MANAGEMENT SUPPORT IN THE COMMUNITY: HEALTHY EATING CONSIDERATIONS Presenter: Elizabeth A. Walker Elizabeth Walker, professor of medicine, and epidemiology and popula- tion health at Albert Einstein College of Medicine, described two theoretical 83

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84 NUTRITION AND HEALTHY AGING approaches used in diabetes self-management interventions. The first, com- munity telephonic interventions, falls under the community category of Ed Wagner’s Chronic Care Model (see Chapter 3, Figure 3-1). The goal of these interventions is to produce informed and active patients who interact productively with their health care teams to improve outcomes (Wagner, 1998; Wagner et al., 2001). The second approach she discussed, the social- ecological model, is used to inform the development of interventions that address individual behavior and influences within their environment of family, community, culture, and policy issues (Fisher et al., 2002; Stokels, 1996). Walker suggested that diabetes self-management interventions include methods for addressing the American Association of Diabetes Educators’ seven self-care behaviors: 1. healthy eating 2. being active 3. monitoring 4. taking medication 5. problem solving 6. healthy coping 7. reducing risks Since types 1 and 2 diabetes are chronic conditions, Walker suggested that psychosocial interventions should focus on treatment adherence through motivating behavior change and emotional support. These interventions include goal setting, problem solving, maintenance strategies, continuing support, and treatment of distress and psychiatric disorders such as depres- sion. In addition, the interventions should include some form of activation, such as coaching or empowerment, and be tailored to meet the individual’s needs (Peyrot and Rubin, 2007). Telephonic Interventions A telephonic intervention can be used as a stand-alone intervention, or as part of a multicomponent intervention such as one that includes face-to-face interviews. Depending on available funding, the intervention can consist of an automated voice message, text message (personalized or not), or person-to-person conversation. Walker noted that the interventions she developed involve person-to-person conversations because she and her researchers have not determined appropriate wording for an automated voice or text message that would effectively improve motivation or self-care behaviors. Telephonic interventions can be used multiple ways within an intervention, such as focusing on improving participants’ glycemic control

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85 SUCCESSFUL INTERVENTION MODELS and medication adherence or as a supplement to a diabetes education program during the maintenance phase. Regardless of how they are used, interventions should be tailored to meet the needs of the target population, to take into account costs and benefits, and, if necessary, to be scalable and translatable (Schechter et al., 2008; Walker et al., 2008). The Vision is Precious Program was a telephonic intervention used to promote diabetic retinopathy screening within 6 months among low- income minority adults who had not had a dilated eye exam in over a year. It resulted in a 74 percent increase in the rate of screening in the interven- tion group as compared to the control group that received a printed booklet in the mail (Walker et al., 2008). Walker pointed out that this intervention was for a single behavior, and it is more difficult for interventions to pro- duce the multiple behavior changes needed to improve diabetes control. Improving Diabetes Outcome Study The Improving Diabetes Outcome Study was a randomized controlled trial focused on adults 30 years and older who were prescribed oral diabetes medication, had HbA1c levels at or below 7.5 percent, were members or spouses of the health care workers labor union, and had less than optimal medication adherence. The aims of the study are listed in Box 5-1. The social cognitive theory was used to emphasize self-efficacy and tailor the intervention to the participants’ readiness to change stage (Bandura, 1986). Participants in the intervention group could receive up to 10 phone calls from a health educator over 12 months and discussed a diabetes-related behavior of the participant’s choosing during those calls. BOX 5-1 Specific Aims of the Improving Diabetes Outcome Study • im 1: A tailored telephone intervention compared to a standard print (active A control) intervention will significantly improve glycemic control measured by HbA1c. • im 2: A tailored telephone intervention . . . will significantly improve medication A adherence and lifestyle behaviors. • im 3: To describe characteristics of those who benefit most from the tel- A ephonic intervention. • im 4: To evaluate costs of the intervention. A

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86 NUTRITION AND HEALTHY AGING The active control group received printed self-management materials. The majority of participants in both groups were female (67 percent), non- Hispanic black (61.6 percent), and foreign-born (76.8 percent), and the average body mass index was 31.2 (obese) (Walker et al., 2011). Participants in the intervention group had significant improvements in their HbA1c levels, a reduction of 0.36 percent difference from the active control group (see Figure 5-1). Adjusted multivariate analysis of the HbA1c levels showed that older age, lower income, and higher baseline HbA1c were independently associated with improved HbA1c. While the third finding was not surprising because higher levels are somewhat easier to improve, Walker did note that the first two results suggest that the intervention was well tailored to this group. Participants received, on average, eight calls totaling about 109 minutes over 12 months. Calls ranged in length from 2 to 35 minutes, with a mean length of less than 15 minutes. Results indicated that there was an improve- ment in HbA1c among those people who received 6 phone calls or more; however, there was not a linear relationship between number of phone calls and amount of HbA1c improvement (Walker et al., 2011). 0.15 0.10 0.05 Percent Change in HbA1C 0.00 –0.05 –0.10 –0.15 –0.20 –0.25 Telephone Group Print Group FIGURE 5-1 Change in HbA1c baseline to end of study. SOURCE: Walker et al., 2011. R02158 Figure 5-1

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87 SUCCESSFUL INTERVENTION MODELS Associations between participation in self-care activities (from the Summary of Diabetes Self-Care Activities [Toobert and Glasgow, 1994]) and participation in the intervention were analyzed. While there were associations between several activities and the intervention (e.g., thinking about healthy eating), only two activities were significantly associated with the telephone intervention: (1) the number of days per week following a healthy eating plan and (2) exercising for 30 minutes or more. However, none of the activities was significantly associated with improved HbA1c levels (Walker et al., 2011). Walker concluded that “small improvements in self-care activities may add up to a meaningful HbA1c improvement.” The Diabetes Prevention Program The Diabetes Prevention Program (DPP) was a randomized clinical trial aimed at preventing type 2 diabetes in high-risk people. Study participants were randomized into one of three groups: (1) intensive lifestyle (Wylie- Rosett and Delahanty, 2002), (2) metformin, or (3) placebo. On average, the lifestyle changes and metformin groups resulted in 58 and 31 percent reductions of risk, respectively (Knowler et al., 2002). In the 60 years and older group, which comprised about 20 percent of the total study popula- tion, lifestyle changes produced a 70 percent reduction of risk. As compared to the other age groups, this age group experienced the most weight loss, the greatest reduction in waist circumference, the most recreational activ- ity per week, and the most people who met their weight loss and exercise goals (Crandall et al., 2006; Diabetes Prevention Program Research Group, 2009; Wing, 2004). As summarized by Walker, “lifestyle modifications can prevent diabetes or delay diabetes in high-risk older people” and reduce cardiovascular risk and urinary incontinence (Brown et al., 2006). Further- more, people preferred the lifestyle modifications to taking the medication (Crandall et al., 2006; Diabetes Prevention Program Research Group, 2009; Wing, 2004). Closing Comments Lower cost interventions can be effective at addressing health behaviors provided they are tailored to the needs of the target population. Diabetes self-management or prevention interventions, including those conducted over the telephone, can result in improved medication adherence, behavior change, weight loss, reduced glucose intolerance, and lowered diabetes risk if the intervention focuses on behaviors selected by the participants. Since self- management interventions may address various diabetes self-care behaviors, including healthy eating and medication, experts in diverse fields should be involved as participants decide what behavior they would like to change.

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88 NUTRITION AND HEALTHY AGING NUTRITION INTERVENTION FOR CARDIOVASCULAR DISEASE: HOME-DELIVERED MEDICAL NUTRITION THERAPY AND DASH MEALS Presenter: Jennifer L. Troyer Jennifer L. Troyer, associate professor and chair of the Department of Economics at the University of North Carolina at Charlotte, discussed nutrition interventions she conducted with older adults. She described the results of providing medical nutrition therapy (MNT) and therapeutic meals to older adults with cardiovascular disease in their homes, including data on adherence to a modified diet, changes in dietary knowledge, health outcomes, and cost effectiveness. Medical Nutrition Therapy The Institute of Medicine recommended MNT to promote the health of older adults with chronic illnesses (IOM, 2000). MNT is a multisession intervention though which a registered dietitian (RD) determines the type and frequency of nutrition care appropriate for the individual’s medical condition. The RD conducts a lifestyle assessment and helps the indi- vidual develop goals that are revisited in future sessions (Gehling, 2011; Michael, 2001; Rezabek, 2001). It is “more intensive, diagnosis-specific, and behavior-oriented than traditional nutrition counseling,” said Troyer. The American Dietetic Association recommends MNT for people with cardiovascular disease as the initial intervention for people with hyperten- sion and hyperlipidemia (McCaffree, 2003) based on evidence that it is the best option for treatment of hyperlipidemia (Baron, 2005) and has been found to lower serum cholesterol and LDL levels among people with hyper- tension (Delahanty et al., 2001, 2002; Lim et al., 2008; Sikand et al., 2000). In 2000, Congress authorized RDs as eligible providers of MNT under Medicare, but only for renal disease and diabetes because of the strong ef- fectiveness data available for those conditions (Franz et al., 2008). There is some evidence that MNT is a cost-effective way to reduce serum cholesterol levels, but not elevated blood pressure. However, these randomized clinical trials were not restricted to older adults and did not include data on general medical costs that may be affected by MNT; rather they only considered costs of conducting the interventions (Pavlovich et al., 2004). Therapeutic Meals: The DASH Diet Therapeutic meals are “designed in accordance with dietary guidance in an effort to assist in disease management through dietary modification,”

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89 SUCCESSFUL INTERVENTION MODELS said Troyer. The therapeutic meals provided to participants in this interven- tion were designed based on the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH diet repeatedly has been found as an effective way to reduce blood pressure through lifestyle and diet changes. It is designed to reduce intake of saturated fat, total fat, sodium, and cholesterol; increase intakes of fruits and vegetables; and increase consumption of potassium, calcium, magnesium, fiber, and protein (Appel et al., 1997; Blumenthal et al., 2010; Dickinson et al., 2006; Elmer et al., 2006; Lin et al., 2007; Sacks et al., 2001). Clinical Trial This intervention considered the effects of MNT and therapeutic meals on changes in adherence to the DASH diet and changes in dietary knowl- edge among community-dwelling adults ages 60 years and older diagnosed with high cholesterol, high blood pressure, or both. Since Medicare funds MNT for individuals with diabetes or renal disease, those individuals along with those that had recent surgery or adverse health conditions were excluded from the study. Participants were randomized into one of four groups, as shown in Figure 5-2. The “literature” group received brochures containing information on how to handle their high blood pressure or high cholesterol. The “meals” and “MNT and meals” groups received frozen meals that conformed to Administration on Aging (AoA) requirements that meals provide one-third of participants’ Dietary Reference Intakes and adhere to the Dietary Guide- lines for Americans. In addition they received milk, calcium-fortified orange Participant Cardiovascular Study Literature Meals MNT MNT and Meals Medical brochures 7 frozen therapeutic 3 personalized MNT 7 frozen meals and regarding participant’s meals delivered weekly sessions 3 MNT visits diagnoses 12 months 12 months 12 months 12 months FIGURE 5-2 Clinical trial design. SOURCE: Troyer, 2011. R02158

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90 NUTRITION AND HEALTHY AGING juice, and some shelf-stable products. The two groups receiving MNT were provided therapy in their homes by an RD who also assessed participants’ food and cooking situation and provided MNT to caregivers, if applicable. Data were collected at baseline, 6 months, and 12 months on 298 participants. Study participants were primarily white (61 percent), women (83 percent), and had incomes above the poverty line (52 percent had in- comes greater than 165 percent of the poverty level). Twenty-eight percent had hypertension, 20 percent had hyperlipidemia, 54 percent had both hypertension and hyperlipidemia, and 80 percent were taking medication to manage their hypertension or hyperlipidemia. The data were analyzed to answer three questions: 1. Do home-delivered DASH meals change adherence to a DASH diet? The DASH diet includes nine dietary recommendations for intake of protein, total fat, saturated fat, cholesterol, fiber, magne- sium, calcium, potassium, and sodium. Participants were scored as “DASH accordant” and “intermediate DASH accordant” based on the number of nutrient targets they reached or partially reached. Between baseline and 6 months, there was a significant increase in the percentage of participants who adhered to a DASH diet; recipients of DASH meals had a 20-percentage-point-higher prob- ability of being intermediate DASH accordant at 6 months than those who did not receive the meals, with higher gains among whites and higher-income individuals. Nonwhite meal recipients had significant reductions in cholesterol intake and significant gains in intermediate DASH scores and fiber intake as compared to nonwhites who did not receive the meals (Troyer et al., 2010a). From baseline to 12 months there was less change, which Troyer described as participants “losing a little bit of speed at the end of the study.” 2. Does home-delivered MNT affect dietary knowledge and dietary change? Participants in the literature-only or MNT-only groups were administered a 20-question survey on dietary knowledge. While there was no significant change in dietary knowledge from baseline to 6 months, MNT recipients had a 1.88 point (out of 20) increase from baseline to 12 months. The effects of MNT on knowledge gain were higher for whites, those not living alone, those with less than a high school diploma, and those with income below the poverty level. Increases in dietary knowledge produced few significant results and no positive change in adherence to a DASH diet. Troyer posited reasons for the results may have been poor delivery, reluctance of people to change, or inability to trans- late knowledge into behavior change (Racine et al., 2011).

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91 SUCCESSFUL INTERVENTION MODELS 3. Are home-delivered MNT and DASH meals cost-effective? Cost data were collected on MNT administration; therapeutic meal production and delivery; and participant-level medical costs, pharmaceuticals, and personal assistance costs. In addition, quan- tity and quality of life gained were measured in quality-adjusted life years (QALYs). Troyer stated that the question to be answered is “what does it cost [society] in terms of this intervention to generate a year of life at full health?” If society is willing to pay $109,000 for one QALY (Braithwaite et al., 2008), then the probability that the therapeutic meals program is cost-effective is 95 percent, that MNT is cost-effective is 90 percent, and that therapeutic meals plus MNT is cost-effective is less than 50 per- cent (Troyer et al., 2010b). Closing Remarks Providing home-delivered DASH meals to older adults with cardio- vascular disease is likely to change adherence to a DASH diet. Therefore, Troyer suggests further research to explore the differential effects of meals by recipient’s income level and to determine if meal customization for those with multiple conditions is feasible and cost-effective. Further research is needed to review the relationship between dietary knowledge and dietary change, to determine the role that food insecurity plays in dietary change, and to conduct a cost-benefit analysis of home-delivered MNT. Troyer noted that cost-effectiveness results suggest that Medicare should consider paying for MNT for cardiovascular disease because costs would be less than suggested in the study if MNT were provided in a “real-world” setting; over 80 percent of study participants were taking medication; the study included a small dose of MNT; and data were collected on partici- pants that dropped out of the study yet, despite these factors that would bias the findings toward no positive results, still obtained positive results. NUTRITION INTERVENTIONS FOR FRAILTY AND SARCOPENIA Presenter: Elena Volpi The cycle of frailty, to which chronic undernutrition and sarcopenia contribute, can lead to reductions in strength and power and increased risk of falls and injuries which may lead to physical dependence. Elena Volpi, professor of internal medicine–geriatrics at the University of Texas Medi- cal Branch, presented research illustrating the importance of protein intake and intake patterns in determining the rates of muscle protein synthesis

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92 NUTRITION AND HEALTHY AGING and anabolism and their potential role in the prevention of muscle loss in older adults. Muscle Protein Synthesis Sarcopenia is the “universal, progressive and involuntary decline in lean body mass and function associated with aging, primarily due to loss of skel- etal muscle” (Roubenoff and Castaneda, 2001), leading to loss of strength and power. Maintaining muscle mass and strength is important for older adults because strength is associated with mortality; in the Health Aging and Body Composition (ABC) study, older adults with initially greater strength were more likely to be alive after an average 5-year follow-up than those with initially lower strength (Newman et al., 2006). Another paper from the Health ABC group shows that habitual protein intake also predicted muscle loss; older persons with the highest protein intake lost the least amount of muscle mass (Houston et al., 2008). The process by which insulin stimulates muscle protein synthesis dur- ing a meal is impaired in older adults (Volpi et al., 2000). This can be considered a true insulin resistance, as larger doses of insulin can stimulate protein synthesis in healthy older adults (Fujita et al., 2009; Rasmussen et al., 2006). Since there is no other inactive, immediately accessible reservoir for protein, the protein that is not synthesized into muscle in older adults is converted to fat or oxidized, further contributing to sarcopenia, obesity, and loss of function. This reduced protein synthesis response in older adults can be nor- malized if a vasodilator is administered along with the increased insulin (Timmerman et al., 2010a). Vasodilation seems to be a fundamental regula- tor of the response of muscle protein synthesis to insulin in younger persons (Timmerman et al., 2010b). “The good news is that you don’t need a drug to get [vasodilation in older adults],” said Volpi, “aerobic exercise can do that as well.” Preliminary data from Timmerman and colleagues also sug- gest that aerobic exercise can improve the response of muscle protein syn- thesis to a meal in older adults. “So,” Volpi summarized, “physical activity is fundamental, it looks like, for maintenance of the anabolic stimulation of muscle protein synthesis by a meal.” Protein Intake to Maximize Muscle Protein Synthesis How much protein should older adults consume to maximize muscle protein synthesis? Katsanos and colleagues (2006) studied the relationship between various amounts of leucine, the amino acid that stimulates pro- tein synthesis in muscle, and changes in protein synthesis. An amount of 1.7 g of leucine increased protein synthesis by 30 percent in young adults

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93 SUCCESSFUL INTERVENTION MODELS but produced no change in that of older adults. Both the young and older adults showed about a 50 percent increase in synthesis when given 2.8 and 3.2 g of leucine, leading researchers to conclude that a dose of about 2.8 g of leucine maximally stimulates muscle protein synthesis during a meal. Paddon-Jones and colleagues (2004) studied the effect of whole pro- tein on muscle protein synthesis. Participants were given a 4-oz beef patty (equivalent to 30 g of protein) and a 12-oz beef patty (about 90 g of pro- tein). In both cases, muscle protein synthesis increased by about 50 per- cent, suggesting that 30 g of whole protein is an amount at which protein synthesis is already maximized. Protein Intake Distribution Data from the 2007–2008 National Health and Nutrition Examination Survey (NHANES) report that adults 70 years and older are consuming an average of 1 g of protein per kilogram of weight per day (ARS, 2010). This amount is broken down to about 20 percent at breakfast, 23 percent at lunch, and 50 percent at dinner. For an average 70-kg person, this equals 14 g of protein at breakfast, 16 g at lunch, and 32 g at dinner. Based on results from the above-mentioned controlled studies, this means that on average community-dwelling older adults eat enough protein to stimu- late muscle protein synthesis only at dinner. Paddon-Jones and Rasmussen (2009) introduced the theory of an ideal distribution of protein across meals that would maximize protein synthesis and improve muscle protein retention in older adults. Based on findings from previous studies, they proposed that 30 g of protein should be consumed at each of the three major meals. This translates into 1.3 g/kg of protein for a 70-kg person; an amount higher than the Recommended Dietary Allowance (RDA) (0.8 g/kg [IOM, 2002/2005]) and current NHANES data (1.04 g/kg [ARS, 2010]). Special Considerations for Hospitalized Adults While healthy older adults tend to lose functionality fairly slowly over time, catastrophic events like falls and illnesses can result in significant losses in muscle mass and physical function. After a catastrophic event, some older adults are unable to return to their initial state of functionality and instead decline toward a state of physical dependence. Hospitalization, as a result of a catastrophic event, causes previously independent older adults to become sedentary, experiencing reductions in number of steps per day and minutes of daily activity. Adults who leave the hospital and increase their steps per day by tenfold are still categorized as sedentary (Fisher et al., 2011). Longer hospital stays for older adults result in fewer steps per day and more muscle lost. Studies in healthy older adults have shown that 10 days

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94 NUTRITION AND HEALTHY AGING of bed rest induce more muscle loss than 28 days of bed rest in younger adults (9 percent compared to 2 percent) (Kortebein et al., 2007). This muscle mass loss occurred even when the subjects were consuming the RDA for protein of 0.8 g/kg/day. However, older adults in the hospital are not likely to eat an adequate amount of protein to stimulate protein synthesis. Preliminary data (unpublished) from Paddon-Jones’ group suggests that older adults in a geriatric hospital that were given a meal containing 40 g of protein only ate about 10 g. On the other hand, a study has shown that protein synthesis can be maintained in older adults through a 10-day bed- rest period when diet is supplemented with 15 g of essential amino acids in addition to the protein RDA (Ferrando et al., 2010). Closing Remarks Inadequate protein intake is a predictor of sarcopenia, frailty, and dis- ability. Research shows that muscle protein synthesis in older adults can be stimulated by exercise or intake of about 30 g of protein at each major meal. Additional protein intake above the current RDA may help prevent muscle loss and loss of function in hospitalized older adults. However, fur- ther research is needed to determine if the current protein recommendations are adequate to maintain functionality in active, inactive, and hospitalized older adults. EAT BETTER, MOVE MORE: A COMMUNITY-BASED PROGRAM TO IMPROVE HEALTH BEHAVIORS AMONG OLDER AMERICANS Presenter: Neva Kirk-Sanchez The Eat Better, Move More program was a community-based physi- cal activity and nutrition program that was part of the AoA You Can! Steps to Healthier Aging national campaign. The purpose of this program was to encourage older adults participating in community-based programs through the Older Americans Act (OAA) nutrition programs to “take simple steps for better health.” National data were collected in order to monitor outcomes among the diverse program population. Neva Kirk- Sanchez, associate professor of clinical physical therapy at the University of Miami Miller School of Medicine, described the development, format, and results of the program as it was implemented by Florida International University in 2005–2006.

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95 SUCCESSFUL INTERVENTION MODELS Program Format and Development The program consisted of 12 weekly sessions composed of mini lessons, participatory activities, goal setting, take-home assignments, and incentives. The sessions were designed to encourage people visiting congregate meal sites to participate in a nutrition and physical activity program and improve their health behaviors, such as • increasing intake of fruits and vegetables, • increasing calcium and fiber intake, • eating sensible portion sizes, • following the food guide pyramid recommendations, • using pedometers, and • setting weekly goals to increase the number of daily steps by 10 per- cent each week in attempts to reach the overall goal of 10,000 steps per week. Before the national campaign was implemented, two pilot programs tested some aspects of the program. The first pilot program found that older adults would wear pedometers; 80 percent of adults ages 61–90 years with multiple impairments wore them. The second pilot compared the change in daily step count of two groups, one that received pedometers and another that received a preliminary guidebook and educational activities in addition to the pedometers. While both groups increased their number of steps, the latter group showed a larger increase. Recruitment was targeted to OAA nutrition program sites and elicited through announcements posted on aging websites, distributed through Aging Network listservs, and disseminated through state and local agencies on aging. Of the 106 programs that applied, 10 were chosen to receive the $10,000 grants. Grantees were selected based on size, lack of existing physi- cal activity programs, geographic location, and capacity to collect and report data. A facilitator from each site was trained on protocol implementation and outcome measurement, with a focus on physical activity outcomes since most facilitators were nutritionists. Facilitators discussed successes, chal- lenges, and solutions during biweekly conference calls and through a listserv. Data Collection and Results Data were collected on demographics, health conditions, nutrition and physical activity, and activities of daily living (ADLs). In addition, partici- pants completed a Timed Up and Go test (Podsiadlo and Richardson, 1991) and a Health Behavior stages of change questionnaire related to nutrition and physical activity. Of the 999 participants who started the project, 620

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96 NUTRITION AND HEALTHY AGING (62 percent) completed either the nutrition or the physical activity com- ponent (completion rates varied by site from 35 to 85 percent). All of the participants were 60 years or older, except for the Native American par- ticipants who were 50 years and older. Fifty-seven percent were Caucasian, 81 percent were women, and the average age was about 74 years (Wellman et al., 2007). The prevalence of chronic conditions was similar to that found in the NHANES except that participants exhibited higher rates of diabetes (19 percent) and arthritis (39 percent), and 53 percent had high or moder- ate nutrition risk scores. Select data on physical activity participation and limitations in function and activity are as follows: • 58 percent reported participating in regular activity at least once a week. • 56 percent agreed they should be more active. • 63 percent had access to physical activity programs (45 percent participated in those programs). • 81 percent had access to places to walk (70 percent walked). • 91 percent had no difficulty with basic ADLs. • 83 percent had no difficulty with instrumental ADLs. • 12 percent had some activity limitations due to having fallen in the last month. • 12 percent used canes. • 4 percent used walkers (Wellman et al., 2007). Results from Program Completers Versus Noncompleters The demographics of the participants who completed the program were nearly identical to those who began the program: 59 percent Caucasian, 25 percent African American, 82 percent women, and an average age of about 75 years. Kirk-Sanchez said people may have dropped out of the pro- gram due to the culture of their particular group or the performance of their facilitator. Participants were more likely to adhere to the nutrition compo- nent of the program than the physical activity (walking) component. There were only modest differences in the presence of chronic conditions between those who did and did not complete the program. The presence of a chronic condition did not seem to be related to completion of the program, with the exception of much higher rates of reported dizziness among those who dropped out of the physical activity component. She noted that dizziness may be a factor that prevents people from grocery shopping and scanning the shelves. People who dropped out of the program were more likely to • have difficulty with one or more basic or instrumental ADL, • be a minority,

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97 SUCCESSFUL INTERVENTION MODELS • live at or near the poverty level, • be at nutritional risk, • have a fear of falling, and • have lower activity levels, including baseline steps and blocks walked per week. As compared to those who dropped out of the program, the completers were more likely to be independent in their basic and instrumental ADLs, to have a safe place to walk, and to have incomes above the poverty level. They also had lower nutrition risk scores, reported less fear of falls, and walked more blocks per week and more steps per day at baseline (Wellman et al., 2007). In order to prevent the more frail people from dropping out, Kirk-Sanchez asked, “what kinds of things can we complement the program with? Can they benefit if [they are given] a little extra guidance in either nutrition or physical therapy [or] physical activity?” Nutrition and Physical Activity Outcomes Participants who completed the nutrition component of the program increased their intake of fruits, vegetables, calcium-rich foods, fiber-rich foods, and water (see Figure 5-3). Participants who completed the physical activity component of the program reported increasing the number of blocks walked daily from 10 to 15, the number of stairs climbed daily, their amount of vigorous activity, and their amount of moderate weekend activity. On average, their number of daily steps increased from 3,110 to 4,190—a total of about half a mile per day and a 35 percent increase from week 2 to week 11. Self-reported information was consistent with information obtained from participants’ pedometers. On average, participants reported an 8 percent increase in the number of days walked per week from 5.7 at week 2 to 6.2 at week 11. Kirk-Sanchez pointed out that the changes in daily steps were generally made within the first week and sustained throughout the duration of the program. The Timed Up and Go test consists of a person standing up from sitting in a chair, walking 10 feet, turning around, coming back to the chair, and sitting down. Results from this test are associated with fall risk; if completed in more than 14 seconds, the individual is at a high fall risk (Podsiadlo and Richardson, 1991). The average improvement was significant at 1.38 sec- onds, which included people who were fairly high functioning at baseline. Among the 113 participants who were in the high fall risk category at base- line, about 39 percent improved to the normal fall risk category with a mean improvement of 3.65 seconds.

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98 NUTRITION AND HEALTHY AGING 60 50 40 Percent 30 plus 1 serving plus 2 serving 20 10 0 Fruits Vegetables Calcium-rich Fiber-rich Water/fluids foods foods FIGURE 5-3 Percentage of participants that increased their intake of foods and water. SOURCE: Wellman et al., 2007. Stages of Change Outcomes R02158 Figure 5-4 Participants who completed the nutrition component were asked ques- editable vectors tions related to their readiness to change their intake of calcium-rich foods. More than half (56 percent) increased one or more stages, including 61 per- cent who moved from the Preparation to the Action or Maintenance stage. There was a threefold increase in the number of people in the Action stage and a 6 percent increase in the Maintenance stage. Similar changes were seen among those who completed the physical activity component; 67 percent increased by one more stage and 35 per- cent increased by more than two stages. Three-quarters of participants moved from the Preparation stage to the Action or Maintenance stage, and the number of people in the Pre-Contemplation and Contemplation stages decreased by 21 percent. “This is great news. We really changed people’s attitudes. We seemed to change people’s behavior. Changes were modest in some cases, but I think it’s important to note that,” said Kirk-Sanchez.

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99 SUCCESSFUL INTERVENTION MODELS Follow-Up to Eat Better, Move More In response to requests for more weekly modules, a second part of Eat Better, Move More was published online and translated into Spanish. It includes updated nutrition information on the 2005 Dietary Guidelines for Americans (HHS and USDA, 2005), the DASH diet (NHLBI, 2006), and nutrients of concern, including vitamins D and B12 and potassium. Addi- tional physical activity recommendations were added related to stretch- ing, balance, strengthening, use of an exercise band, and continued use of pedometers (Kamp et al., 2007). Kirk-Sanchez and the group at Florida International University also con- ducted a small pilot study with 30 older subjects (average age of 82 years), 14 of which completed the 12-week intervention. Results included an aver- age improvement of 2.3 seconds in the Timed Up and Go test, an increase of 83 meters in the timed 6-minute walk, and an increase of 4 repetitions in the timed bicep curls. Due to the small sample size, changes in nutrition behaviors could not be assessed. Kirk-Sanchez closed by suggesting that future steps include conducting a larger and more controlled pilot study of Eat Better, Move More Part 2 with a focus on special populations, such as Latinos and people with specific chronic conditions, and additional outcomes including depression and cognition. DISCUSSION Moderator: Douglas Paddon-Jones During the discussion, points raised by participants included protein intake and recommendations, and aspects of MNT. Chronic Versus Acute Feeding of Protein Robert Russell revisited the idea of changing the Dietary Reference Intakes (DRIs) for protein and asked, since changes in Estimated Aver- age Requirements are based on chronic feeding experiments, if there were data on chronic feeding of protein over the 33 percent distribution that was presented. Volpi responded that those data do not currently exist and agreed that more studies in that area need to be conducted. Paddon-Jones agreed and added that he has nearly completed a study comparing 24-hour protein synthesis among people on an evenly distributed diet to those on a skewed “carbohydrate breakfast diet.” He said they hope to tie those results to nitrogen balance in order to reevaluate the protein DRIs. Volpi noted that the distribution of protein intake in nitrogen balance studies is highly

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100 NUTRITION AND HEALTHY AGING controlled and evenly distributed, unlike the pattern of protein intake in peoples’ diets. Studies, such as NHANES, should not focus on total daily intake since it obscures variability throughout the day; rather they should look at distribution of intake, she suggested. Volpi noted that animal proteins are higher quality than plant proteins because they contain a proportion of amino acids, particularly essential amino acids, that is similar to that of our bodies. There have been small acute studies and short-term clinical trials that compared proteins and how protein quality is measured. For example, dairy protein is slightly better at stimulating protein synthesis than soy protein, and lower-quality proteins, such as wheat and chickpea, are less digestible. She suggested that the type of protein be considered when measuring intake and making recommendations. Revisions to the Dietary Guidelines for Americans’ Recommendations for Protein Intake by Older Adults Adele Hite observed that several presenters suggested that the DRI recommendation for protein intake for older adults may not be appropri- ate. She expressed concern since the DRIs are the basis for federal nutrition policy, programs, and research. Volpi said that more studies need to be conducted that vigorously test different protein intake distribution patterns among older adults. Therapeutic Meals Robert Miller asked Troyer to elaborate on a description of the therapeu- tic meals and whether people without hypertension received low-sodium or low-fat meals. Troyer said that all participants received low-sodium DASH diet meals designed for people with hypertension. Miller commented that palatability may be an issue for people who did not require low-sodium meals. Troyer said that they conducted some follow-up with regard to what the participants were eating; however, they do not know if recipients added anything to the meals, such as butter or salt. Cost Effectiveness of MNT Mary Pat Raimondi commented that, based on her work on the re- authorization of the OAA, cost data related to return on investment are needed by legislators. She was directed to data presented in two articles in the Journal of the American Dietetic Association, by Troyer (Troyer et al., 2010b) and Nancy Cohen (Delahanty et al., 2001). Cost-effectiveness val- ues are based on quantity and quality of life gained and include dimensions of health such as mobility, depression, and social functioning.

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