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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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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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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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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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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.
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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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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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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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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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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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(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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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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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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