Position of the American Dietetic Association: nutrition, aging, and the continuum of care

Psoas Muscle Index and Density as Prognostic Predictors in Patients Hospitalized with Acute Pancreatitis

Background: Early prognostication of acute pancreatitis (AP) patients for those at high risk of complications during hospitalization can facilitate clinical decision-making. Sarcopenia has been proven to be a risk factor for poor prognosis in patients with AP. We aimed to evaluate the association between the muscle parameters measured in computed tomography (CT) and the clinical outcomes of hospitalized patients with AP. Methods: A total of 132 consecutive patients hospitalized between 1 January 2015 and 31 December 2021 for AP with a valid CT scan were analyzed. The first CT conducted during hospitalization was analyzed for psoas muscle area (PMA), index (PMI), and density (PMD) at the L3 vertebral level. The main adverse outcomes indicating a worse prognosis were the development of extrapancreatic complications, infections, ICU transfer, in-hospital mortality, and hospitalization length. Results: The lowest tertile of PMI, as a surrogate for sarcopenia, was significantly correlated with increased rates of extrapancreatic complications, infections, and longer hospitalizations. It was additionally correlated with a worse CT severity index. The results for PMA and PMD also showed worse outcomes, largely mirroring the results for PMI. Although in-hospital mortality was relatively low, none of the patients died in the highest tertile of PMI. A clear cutoff with sufficient predictive capability could not be found. Conclusions: A low psoas muscle index can serve as an additional potential predictive marker for more severe disease and worse outcomes in hospitalized acute pancreatitis patients. More studies are needed to determine its combination with existing prediction tools.

Associations between social isolation and diet quality among US adults with disability participating in the National Health and Nutrition Examination Survey, 2013-2018

Social isolation and disability are established risk factors for poor nutrition. We aimed to assess whether social isolation is associated with diet quality specifically among adults with disabilities. This cross-sectional analysis used data from the National Health and Nutrition Examination Survey, 2013-2018. Adults with a disability, who were not pregnant, breastfeeding, or missing dietary intake data were included (n = 5,167). Disability was defined as a physical functioning limitation based on difficulty with any activities of daily living, instrumental activities of daily living, lower extremity mobility activities, or general physical activities. The Healthy Eating Index (HEI)-2015 measured diet quality; higher scores correspond to higher diet quality. We computed a social isolation index by summing single status, living alone, and two social engagement difficulty measures (one point for each component met; maximum 4 points). Multivariable linear regression, controlling for demographic and health covariates, estimated differences in HEI scores for dietary intake data, by social isolation score. Over half of HEI scores were < 51, corresponding to "poor" diet quality. Higher social isolation score was associated with lower vegetable and seafood/plant proteins intake. Single status and one of two social engagement measures were associated with lower scores on certain adequacy components. Differences were modest. There was little evidence of effect modification by age or gender. Adults with disabilities are not meeting national dietary standards; improving diet quality is a priority. Whether social isolation is associated with specific dietary components in this population requires further investigation. Further research is also needed among younger adults.

Relationship between age-related decreases in serum 25-hydroxyvitamin D levels and skeletal muscle mass in Japanese women

A clearer understanding of skeletal muscle mass (SMM) in middle-aged and elderly individuals is important for maintaining functionality. In the present study, age-related changes in SMM, the threshold of SMM with walking difficulty, intestinal nutrient absorption rate, and various serum factors were examined in Japanese populations of different ages. We used 24-h creatinine excretion as a measure of total body SMM. Age-related decreases in SMM, intestinal nutrient absorption rates, and serum 25-hydroxyvitamin D [25(OH)D] concentrations were significantly higher in women than in men. The cut-off values for SMM (kg), its percentage of total body weight (BW), the SMM index [SMMI] (Kg / m2), and creatinine height index (CHI) (%) in elderly individuals with walking difficulty were approximately 8-10 kg, 17-20% of BW, 3.9-4.6 kg / m2, and 44%, respectively. Serum 25(OH)D concentrations were closely associated with SMM (kg, % of BW, kg / m2) and CHI (%) as well as the intestinal absorption rates of nitrogen (%) and phosphorus (%) in women, but not in men. The present results demonstrate that vitamin D is an important metabolic factor in skeletal muscle, and contributes to the optimal management of skeletal muscle and the prevention of sarcopenia. J. Med. Invest. 67 : 151-157, February, 2020.

Struggling to maintain individuality - Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY

To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes.

DESIGN AND METHODS

Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes.

RESULTS

The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia.

IMPLICATIONS

Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.

Comparison of Nutritional Status in the Elderly According to Living Situations

AIM

This study aimed to evaluate the nutritional status of elderly individuals living alone and with their families.

PARTICIPANTS AND METHOD

The sample of the study included 872 elderly individuals who agreed to participate in the study, were aged 65 or over, and lived in Ankara. The data were gathered from a survey, using face-to-face interviews. The Mini Nutritional Assessment (MNA) was used in evaluating each individual's nutrition.

RESULTS

The rate of malnutrition in the study population was 5% while the malnutrition risk was 67%. The rate of malnutrition in the individuals living alone was found to be higher than that of those living with their families. The rates of malnutrition in individuals living alone and with their families were, respectively, 7% and 4%, and the rates of malnutrition risk in individuals living alone and with their families were, respectively, 73% and 66% (p<0.05). In both groups, there were significant relationships between individuals' ages, BMI values, mid-upper arm circumference (MUAC), and calf circumference measurements and their MNA scores. While there was a negative and significant relationship between age and MNA scores, the relationships between other parameters and MNA scores were positive and significant (p<0.01).

CONCLUSION

In this study, it was revealed that the nutrition of elderly individuals living alone differs from the nutrition of elderly individuals living with their families. Malnutrition rates were higher in individuals living alone. Raising the awareness of elderly people and their families regarding the need to improve and maintain nutrition would be beneficial.

Nutritional Risk Among Urban, Community-Dwelling Older Hispanics: Influence of Demographic and Cultural Characteristics

This investigation explored nutritional risk and dietary characteristics of older Hispanics (52 years or older) living independently in a large, urban metropolitan area. Fifty-nine participants (93% female) completed a 16-item nutrition assessment questionnaire, and dietary intake data were collected on 49 of these participants. Of participants, 65% were well-nourished, although 35% were at risk of malnutrition or were malnourished. Participants'diets were lacking adequate amounts of dietary fiber, vitamin E, folate, zinc and calcium as well as energy foods, protein, and complex carbohydrates. A culturally sensitive nutrition intervention to meet the needs of older Hispanics should emphasize adequate fluid intake and traditional food sources of fiber, vitamin E, folate, zinc, and calcium. In addition, knowledge of different types of carbohydrates and dietary fats should be incorporated into interventions that also provide opportunities for social interactions among older Hispanics.

Nutritional risk in community-dwelling older men: the Manitoba follow-up study

PURPOSE

The role of nutrition in older men's health and successful aging has been inadequately studied. We examined the relationships among nutritional risk, self-rated health, and successful aging in community-dwelling Canadian older men.

METHODS

The surviving cohort of the Manitoba Follow-up Study (n=690, mean age = 86.8 years) were sent a self-administered nutrition survey in December 2007. The survey consisted of the Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II (SCREEN II), a validated tool for assessing nutritional risk of cognitively intact community-living older adults, and questions about successful aging and health.

RESULTS

Of the 553 surveys returned (80% response), 522 with complete SCREEN II data were included in the analysis. Forty-four percent of respondents were at high nutritional risk, 24% were at moderate risk, and 32% were at low risk. Significant relationships were found between nutritional risk and self-rated health (P<0.0001) and successful aging (P=0.008), with greater nutritional risk associated with lower self-ratings of health and successful aging. Higher use of prescription medication was related to greater nutritional risk (P=0.004).

CONCLUSIONS

Nutritional screening programs for community-dwelling older men are warranted as two-thirds of the study participants were at nutritional risk. Identifying older men at nutritional risk is a critical step in the process of nutritional assessment, and subsequent nutrition interventions and follow-up are required to prevent further health decline.

Relation of serum 25-hydroxyvitamin D status with skeletal muscle mass by sex and age group among Korean adults

The objective of this study was to examine whether high serum 25-hydroxyvitamin D (25(OH)D) concentration was associated with high skeletal muscle mass, taking into account the effects of sex and age among the participants of the Korea National Health and Nutrition Examination Survey (KNHANES) aged 40 years or older. This was a cross-sectional study using data from the 2009 to 2010 KNHANES; a total of 8406 subjects (3671 men and 4735 women) were included. The appendicular skeletal muscle mass index (ASMMI, kg/m2) was estimated to measure the skeletal muscle mass. Hypovitaminosis was classified when the level of serum 25(OH)D was <20 ng/ml. The general linear model adjusted for confounding factors was used to determine differences in means of ASMMI by 25(OH)D status. The mean values of ASMMI were higher for men when compared with women. Women had a greater proportion of hypovitaminosis (71·1%) compared with men (53·2%). After adjusting for multiple factors, men were seen to have significant differences in ASMMI based on 25(OH)D status regardless of age, showing a lower mean value of ASSMI in those with hypovitaminosis. However, there was no difference in ASMMI by 25(OH)D status among women in both younger and older age groups. In conclusion, we found that there might be a positive relationship between 25(OH)D and skeletal muscle mass in men, indicating that interventions to improve 25(OH)D levels that are aimed at increasing muscle mass could be beneficial for men with more rapid decreased rate of skeletal muscle mass.

Iron Deficiency Anemia Prevalence at First Stroke or Transient Ischemic Attack

Background:

Iron deficiency anemia (IDA) has been implicated in the etiology of transient ischemic attack and ischemic stroke. This study aimed to: 1) document IDA prevalence in patients ≥ 65 years of age admitted to hospital with transient ischemic attack or first ischemic stroke, and 2) investigate dietary intake as a predictor of iron status.

Methods:

Ninety-four patients were enrolled. An algorithm containing values for hemoglobin, ferritin, total iron binding capacity, transferrin saturation, and serum transferrin receptor measured at admission was used to identify IDA. Usual dietary intake was assessed with the Clue II food frequency questionnaire.

Results:

Prevalence estimates were 6.4% for IDA, 2.1% for iron deficiency without anemia, and 6.4% for anemia from other causes. IDA prevalence was significantly higher than published National Health and Nutrition Examination Survey III (NHANES III) estimates for gender-specific age groups ≥ 70 years (One-Sample Proportion Test; males p = 0.038 [n= 37]; females p = 0.002 [n=44]). A comparison of IDA prevalence against selected controls from the NHANES III database yielded an odds ratio (OR) of 6.3, 95% confidence interval (CI) 0.8 to 53.7, which was not statistically significant (Fisher's Exact Test; n=94; p = 0.118). Multivariate linear regression analysis of dietary intake with indicators of iron status (n=58) revealed only iron supplements (p = 0.013) and heme iron intake (p = 0.038) as negative predictors of total iron binding capacity (p<0.05).

Conclusions:

These findings support the initiation of a prospective case control study to investigate IDA as a risk factor for ischemic stroke in elderly patients.

Development of a computer-based clinical decision support tool for selecting appropriate rehabilitation interventions for injured workers

PURPOSE

To develop a classification algorithm and accompanying computer-based clinical decision support tool to help categorize injured workers toward optimal rehabilitation interventions based on unique worker characteristics.

METHODS

Population-based historical cohort design. Data were extracted from a Canadian provincial workers' compensation database on all claimants undergoing work assessment between December 2009 and January 2011. Data were available on: (1) numerous personal, clinical, occupational, and social variables; (2) type of rehabilitation undertaken; and (3) outcomes following rehabilitation (receiving time loss benefits or undergoing repeat programs). Machine learning, concerned with the design of algorithms to discriminate between classes based on empirical data, was the foundation of our approach to build a classification system with multiple independent and dependent variables.

RESULTS

The population included 8,611 unique claimants. Subjects were predominantly employed (85 %) males (64 %) with diagnoses of sprain/strain (44 %). Baseline clinician classification accuracy was high (ROC = 0.86) for selecting programs that lead to successful return-to-work. Classification performance for machine learning techniques outperformed the clinician baseline classification (ROC = 0.94). The final classifiers were multifactorial and included the variables: injury duration, occupation, job attachment status, work status, modified work availability, pain intensity rating, self-rated occupational disability, and 9 items from the SF-36 Health Survey.

CONCLUSIONS

The use of machine learning classification techniques appears to have resulted in classification performance better than clinician decision-making. The final algorithm has been integrated into a computer-based clinical decision support tool that requires additional validation in a clinical sample.

Community-based intervention to improve dietary habits and promote physical activity among older adults: a cluster randomized trial

Background

The fastest growing age group globally is older adults, and preventing the need for long-term nursing care in this group is important for social and financial reasons. A population approach to diet and physical activity through the use of social services can play an important role in prevention. This study examined the effectiveness of a social health program for community-dwelling older adults aimed at introducing and promoting physical activity in the home at each individual’s pace, helping participants maintain good dietary habits by keeping self-check sheets, and determining whether long-standing unhealthy or less-than-ideal physical and dietary habits can be changed.

Method

This cluster randomized trial conducted at 6 community centers in an urban community involved 92 community-dwelling older adults aged 65–90 years. The intervention group (3 community centers; n = 57) participated in the social health program “Sumida TAKE10!” which is an educational program incorporating the “TAKE10!® for Older Adults” program, once every 2 weeks for 3 months. The control group (3 community centers; n=35) was subsequently provided with the same program as a crossover intervention group. The main outcome measures were changes in food intake frequency, food frequency score (FFS), dietary variety score (DVS), and frequency of walking and exercise. The secondary outcome measures were changes in self-rated health, appetite, and the Tokyo Metropolitan Institute of Gerontology (TMIG) Index of Competence score.

Results

Compared to baseline, post-intervention food intake frequency for 6 of 10 food groups (meat, fish/shellfish, eggs, potatoes, fruits, and seaweed), FFS, and DVS were significantly increased in the intervention group, and interaction effects of FFS and DVS were seen between the two groups. No significant differences were observed between baseline and post-intervention in the control group. Frequency of walking and exercise remained unchanged in both groups, and no significant difference in improvement rate was seen between the groups. Self-rated health was significantly increased in the intervention group. Appetite and TMIG Index of Competence score were unchanged in both groups.

Conclusions

The social health program resulted in improved dietary habits, as measured by food intake frequency, FFS, and DVS, and may improve self-rated health among community-dwelling older adults.

Trial registration number

UMIN000007357

Nutrition risk factors among home delivered and congregate meal participants: need for enhancement of nutrition education and counseling among home delivered meal participants

OBJECTIVE

The short-term impact of nutrition education and counseling intervention on nutrition risk factors among home delivered (HDM) and congregate (CGM) meal participants using Nutrition Survey Risk Screening was studied.

DESIGN

A two-year intervention was conducted with 355 participants (n=259 CGM, n=96 HDM). Various nutrition behaviors that affect the nutrition risk score were compared.

SETTING

Congregate and home delivered meal locations in a northern county of New Jersey.

PARTICIPANTS

CGM and HDM participants in a northern county of New Jersey age 60 and older.

INTERVENTION

CGM participants received regular topical nutrition education and counseling in a classroom format with cooking demo, discussion, and handouts. The HDM participants only received the printed material (same handouts) and counseling by telephone.

MEASUREMENTS

Demographics, medical condition, risk factors data were collected. All participants completed the 12 items checklist Nutrition Survey Risk Screening. Nutritional behaviors assessed include number of meals eaten per day, servings of fruits and vegetables and nutrition risk score. A score of 6 or more points was defined as persons at high risk nutritionally. The impact of the intervention was evaluated using ANOVA/chi-square on Nutrition Survey Risk Screening.

RESULTS

Nutrition education and counseling intervention improved nutrition risk scores; 5.76 to 5.32 (p=0.14) in CGM, 8.1 to 6.1 (p<0.01) in HDM. A slight improvement in nutrition behaviors was noted: eating ≥ 2 meals in HDM (76 to 81.6 %, p= .310), eating ≥ 5 servings of fruits and vegetables in CGM (38 to 41.4 %, p=. 398).

CONCLUSION

Appropriate nutrition intervention for both HDM and CGM participants can improve health condition and delay chronic diseases. HDM participants need to be a primary focus for more effective nutrition education and counseling.

Prevalence of malnutrition in Parkinson's disease: a systematic review

Parkinson's disease (PD) patients may be at higher risk of malnutrition because of the symptoms associated with the disease and the side effects of the medication used to manage it. A decline in nutritional status is associated with many adverse outcomes related to health and quality of life. It is not clear, however, to what extent this population is currently affected by malnutrition. The objective of this review was to systematically assess the methodology and outcomes of studies reporting the prevalence of malnutrition in PD patients. Studies that attempted to classify participants with PD into nutritional risk and/or malnutrition categories using body mass index, weight change, anthropometric measures, and nutritional screening and assessment scores were included. The prevalence of malnutrition ranged from 0% to 24% in PD patients, while 3-60% of PD patients were reported to be at risk of malnutrition. There was a large degree of variation among studies in the methods chosen, the definition of malnutrition using those methods, and the detail in which the methodological protocols were reported. The true extent of malnutrition in the PD population has yet to be accurately quantified. It is important, however, to screen for malnutrition at the time of PD diagnosis.

Country of origin predicts nutrition risk among community living older people

OBJECTIVES

To assess the nutrition risk status of community living older people and to identify associated risk factors.

DESIGN

A cross-sectional study using convenience sampling.

SETTING

North Shore City, Auckland, New Zealand. Data collection was carried out by a research nutritionist using computer assisted personal interviewing in the participant's own home.

PARTICIPANTS

Fifty-one independently living people aged between 80 and 85 years.

MEASUREMENT

A survey using three validated questionnaires: Practitioner Assessment of Network Type (PANT) to evaluate social networks; Elderly Assessment System (EASY-Care) to evaluate physical and mental wellbeing and Seniors in the Community: Risk Evaluation for Eating and Nutrition Version II (SCREEN II) to assess nutrition risk.

RESULTS

A third of the participants (31%) were at high risk of malnutrition (SCREEN II score <50; range 29-58 out of maximum score of 64). The majority of participants (82%) lived alone and nearly half (47%) had supportive social networks including close relationships with local family, friends and neighbours. Low self-rated health, disability and social factors (being born outside of New Zealand, losing a spouse and loneliness) were key underlying factors associated with being at nutrition risk.

CONCLUSION

Nutrition risk is common among aged individuals living in the community. Health and social factors that shape eating behaviours place older people at increased nutrition risk. Strategies are needed for the early identification of risk factors to prevent nutrition problems. Engaging older people at risk to share meal preparation and dining experiences may foster better outcomes.

The changing face of food and nutrition in Canada and the United States: opportunities and challenges for older adults

Science and technology are modernizing the field of nutrition and are consequently increasing its complexity. New food developments such as fortified foods and functional foods are evidence of its modernization. The increased specificity of nutrient- and food-intake recommendations and the breadth of claims on food packages are evidence of nutrition's growing complexity. Unfortunately, research on the consumer acceptability of new food developments and nutrition education initiatives has not kept pace with advancements in the field. This is especially true for older adults, a subgroup of the population that appears to be under-researched and not commonly targeted with education initiatives. Older adults are the fastest growing segment of the North American population. Research and education aimed at this demographic is warranted to ensure older adults have the right knowledge and skill set to optimize their food selections and dietary patterns with the possibility of improving health and the quality and longevity of life.

Gaining entry-level clinical competence outside of the acute care setting

Traditionally, an emphasis has been placed on dietetic interns' attainment of entry-level clinical competence in acute care facilities. The perceived risks and benefits of acquiring entry-level clinical competence within long-term and acute care clinical environments were examined. The study included a purposive sample of recent graduates and dietitians (n=14) involved in an integrated internship program. Study subjects participated in in-depth individual interviews. Data were thematically analyzed with the support of data management software QSR N6. Perceived risks and benefits were associated with receiving clinical training exclusively in either environment; risks in one area surfaced as benefits in the other. Themes that emerged included philosophy of care, approach to practice, working environment, depth and breadth of experience, relationships (both client and professional), practice outcomes, employment opportunities, and attitude. Entry-level clinical competence is achievable in both acute and long-term care environments; however, attention must be paid to identified risks. Interns who consider gaining clinical competence exclusively in one area can reduce risks and better position themselves for employment in either practice area by incorporating an affiliation in the other area into their internship program.

The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders

STUDY DESIGN

Population-based before-and-after design with concurrent control group.

OBJECTIVE

As continuums of care have been little studied, we evaluated the impact of the Workers' Compensation Board of Alberta (WCB-Alberta) model on sustained return to work, satisfaction with care, and cost.

SUMMARY OF BACKGROUND DATA

Musculoskeletal conditions, such as back pain, continue to be leading causes of disability and work loss. From 1996 through 1997, the WCB-Alberta implemented a continuum of care model to guide rehabilitation service delivery for claimants with soft tissue injury. The model was designed as a decision-making tool to promote a consistent, evidence-based approach to care within the jurisdiction.

METHODS

The model was implemented province-wide so the entire population of workers insured by the WCB-Alberta was studied. Data were extracted from the WCB-Alberta administrative database from 2 years before implementation (1994-1995) to 5 years after (1996-2000). An intervention group was created from patients filing soft tissue injury claims for the low back, ankle, knee, elbow, and shoulder. The comparison group was formed of workers experiencing fractures or other traumatic non-soft tissue injuries. Satisfaction was measured through surveys. Primary outcome was cumulative days receiving wage replacement benefits. Multivariable Cox regression was used to determine the model's effect.

RESULTS

Over the entire study period, 70,116 claimants filed soft tissue injury claims while 101,620 claimants experienced non-soft tissue injuries. Significant improvement was observed in intervention group return-to-work outcomes after model implementation (hazard ratio = 1.54). Median duration of benefits decreased from 13 to 8 days. Little change was seen in the control group's disability duration (median duration, consistently 10 days). The majority of claimants were satisfied with care received. Cost savings over a 2-year full implementation period was $21.5 million (Canadian).

CONCLUSION

Implementation of a soft tissue injury continuum of care involving staged application of various types of rehabilitation services appears to have resulted in more rapid and sustained recovery.

Clients’ Safe Food-Handling Knowledge and Risk Behavior in a Home-Delivered Meal Program

OBJECTIVE

To determine typical handling practices of home-delivered meals, and provide appropriate handling instructions to reduce the risk of foodborne illness by improving consumer handling of home-delivered meals.

DESIGN

Once permission was given by the home-delivered meal site directors, clients were provided a voluntary survey and requested by the delivery drivers to complete the self-administered questionnaire. The completed questionnaire was collected by the driver the following day. Because of the special needs of the home-delivered meal populations, the questionnaire was made as easy and convenient to answer as possible.

SUBJECTS

Two hundred fifty-eight male clients (31%) and 575 female clients (69%) whose mean age was 79 years participated in the study.

MAIN OUTCOME MEASURES

The respondents' safe food-handling practices, food safety knowledge, and demographic information were assessed. Average time for delivery and consumption of meals were also measured.

STATISTICAL ANALYSIS

Descriptive statistics (frequency and chi(2) test) of the participants' handling of home-delivered meals, their general food safety knowledge, and demographic information were reported. Delivery time and consumption time were calculated for each subject.

RESULTS

Five hundred thirty-six of 869 clients (63%) reported that they ate their meals as soon as they were delivered. Of those clients who did not eat their meals immediately, 234 (82%) stored the cold food in the refrigerator and 142 (58%) stored the hot food in the freezer. More than one-third of the clients (n=277, 35%) reported that they had leftovers and only 34 (15%) ate the leftovers within 2 hours. Significant differences among groups on the basis of a derived food safety knowledge score were observed in terms of whether or not they ate their meal immediately (P<or=0.05). Thirty clients did not report their time of consumption, and the remaining 839 clients consumed their meals an average of 1.22 hours after delivery.

CONCLUSIONS

Time in conjunction with temperature can be used as a hazard control measure to reduce foodborne illness caused by improper food-handling procedures. Careful attention should be paid to the entire period of time from onsite preparation to offsite consumption. Therefore, the success of home-delivered meal programs among older Americans highly depends on multifactorial collaborations. Continued efforts from foodservice providers on safe handling of home-delivered meals are needed to help protect older Americans. At the same time, consumers need more information on handling meals in their homes and a better understanding of the importance of proper handling for prevention of foodborne illness.

Life enrichment programme; enhanced dining experience, a pilot project

PURPOSE

The purpose of this pilot project is to highlight how food intake, nutrition status and quality of life could be improved for long stay residents of a community nursing unit and demonstrate that assisted feeding can be a more dignified experience for them.

DESIGN/METHODOLOGY/APPROACH

A good dining experience involves not just the food, but also its presentation and the environment in which it is served. A review of the literature identified projects with similar objectives but differing approaches. A survey of residents informed the planning phase. A home style dining room was created with a more traditional ambiance and decoration. The pace of dining was leisurely. Personal choice and independence in eating were supported. A schedule of dining activities was delivered by two staff facilitators.

FINDINGS

Eight dining sessions facilitated 23 residents over three months. "Minced" meals were not served, help was given to cut up meat and cues or prompts offered to maximize independence and demonstrate the value of this approach to care staff.

ORIGINALITY/VALUE

The project illustrated the advantages of stepping outside the purely clinical framework in addressing issues around poor food intake. It highlighted and how small but valuable changes can be implemented even where resources and space is limited. Involvement with the project allowed staff to observe and reflect on the benefits of enhancing the social and aesthetic aspects of dining.

Food Safety Guidance for Older Adults

Aging is associated with loss of the physical barriers and immune efficiency that typically control pathogens' access to and multiplication within the body, thus making infection more likely in elderly persons. Chronic diseases and other health factors, such as malnutrition and immobility, may increase susceptibility to and severity of infections, including foodborne illnesses, in elderly persons, as well as associated morbidity and mortality. Prevention is the best way to avoid foodborne illnesses, but older adults have long-established food preparation and handling practices, some of which may increase the likelihood of illness. Elderly persons rely on physicians as trusted sources of health information. Physicians and other health care professionals can help prevent and control foodborne diseases by educating their patients about the risks of foodborne illness, providing sound advice on safe food-handling and consumption practices, making rapid appropriate diagnoses, and reporting cases promptly to public health authorities.

Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions

Undernutrition can be a significant deterrent to healthy aging and can nega tively affect health outcomes in older adults. Researchers have identified the prevalence of undernutrition in older adults and the need for intervention yet the incidence remains high. The purpose of this article is twofold: to emphasize the need for nutritional assessment across the continuum of care a experienced by older adults, and to identify possible barriers to effective treatment. The assessment of nutritional status and the implementation of effective nutritional interventions are essential to the health of older adults.

Nutritional factors, cognitive decline, and dementia

Nutritional factors and nutritional deficiencies have been repeatedly associated with cognitive impairment. Most of the evidence is based on cross-sectional studies, which cannot prove whether a nutritional deficit is the cause or the consequence of an impaired cognitive status. In fact, cognitive impairment, in turn, can determine changes in dietary habits and consequent nutritional deficiencies. We reviewed clinical and epidemiological studies from January 1983 to June 2004. Several cross-sectional and fewer prospective studies reported an association between dietary or supplemental intake of antioxidants and protection from cognitive decline and dementia. There are negative reports as well and some methodological biases might have affected the consistencies across studies. Deficiencies of several B vitamins have been associated with cognitive dysfunction in many observational studies. More recently, deficiencies of folate (B9) and cobalamine (B12) have been studied in relation to hyperhomocysteinemia as potential determinants of cognitive impairment, dementia, and Alzheimer's disease (AD). A small number of studies assessed the association between intake of macronutrients and cognitive function or dementia. Among the others, the intake of fatty acids and cholesterol has received particular attention. Although the results are not always consistent, most studies have reported a protective role of dietary intakes of poly- and mono-unsaturated fatty acids against cognitive decline and AD. We point out that well designed intervention studies are warranted in order to establish specific levels of micro- and macronutrient deficiencies and to set general recommendations for the population.

Nutritional quality of meals in nursing homes and meals on wheels for elderly persons in Croatia

The aim of the study was to evaluate the adequacy of meals provided for elderly residents and non-residents of nursing homes in Croatia. Menus of 44 all-day meals provided for residents from 4 nursing homes and 34 meals on wheels provided for non-residents of low socioeconomic status were selected by random sampling. A questionnaire was used to determine socioeconomic status and attitude of residents (n = 89) and non-residents (n = 80) regarding meals offered. An average energy value of all-day meals and meals on wheels was 96.7 and 39.8% RDA respectively. All-day meals provide adequate amounts of the micronutrients examined (phosphorus, iron, thiamine, riboflavin, niacin and vitamin C) with exception of calcium. Fat provided 35% and 36% of energy for all-day meals and meals on wheels respectively. The body mass index (BMI) under 18.5 kg/m2 had 1.7% residents and 4.0% non-residents. BMI higher than 24.9 kg/m2 were observed in 50% and 47% of residents and non-residents respectively. Gender differences were observed for meal preferences offered to both residents and non-residents. The meals provided adequate amounts of energy and the micronutrients examined. However, a decrease in the energy fraction of fat and decrease in protein content would be advisable.

An approach to the management of unintentional weight loss in elderly people

Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period. A variety of physical, psychological and social conditions, along with age-related changes, can lead to weight loss, but there may be no identifiable cause in up to one-quarter of patients. We review the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and a clinical approach to diagnosis. Screening tools to detect malnutrition are highlighted, and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss in older adults are discussed.

Nutrition concerns in discharge planning for older adults: A need for multidisciplinary collaboration

This survey of 84 case managers (CMs) (88% response rate) in 11 south Florida hospitals, in one for-profit health care system, sought to identify their discharge planning concerns regarding the food and nutrition needs of older patients, how they addressed these concerns, and the degree to which registered dietitians (RDs) were involved. Most CMs were female (82 of 84, 98%), older than age 40 (59 of 84, 70%), and were registered nurses (51 of 84, 61%). Almost all (82 of 84, 98%) reported job barriers, including excessive patient loads and responsibilities and limited community services. Almost all said that nutrition-related diseases and factors (eg, chewing/swallowing problems, poor appetite, modified diets, poor dentition) strongly influenced discharge planning. Many perceived community nutrition resources (eg, congregate meals, food stamps, shopping assistance, outpatient dietitians) as not readily available. While physicians, nurses, social workers, and physical therapists were identified as very important in discharge planning, RDs were not; almost half of CMs consulted them infrequently, if at all. Strategies for the six nutrition-related case scenarios were inconsistent. Home-health agencies were chosen most often and outpatient RDs least often. Comprehensive discharge planning must include more attention to nutrition with greater input from clinical, outpatient, home health, and community RDs through, for example, attendance at hospital discharge planning rounds, inservices for CMs, and better marketing of RD services. More RDs can and should become CMs to help serve the number of older adults with nutrition-related chronic conditions.

Position paper of the American Dietetic Association: Nutrition across the spectrum of aging

It is the position of the American Dietetic Association that older Americans receive appropriate care; have broadened access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies across the spectrum of aging. Food and water and nutritional well-being are essential to the health, self-sufficiency, and quality of life for the fast growing, heterogeneous, multiracial, and ethnic populations of older adults. Many people, as they age, remain fully independent and actively engaged in their communities; however, others fare less well and need more support. A broad array of appropriate, culturally sensitive food and nutrition services, physical activities, and health and supportive care customized to the population of older adults are necessary. National, state, and local policies that promote coordination and integration of food and nutrition services into health and supportive systems are needed to maintain independence, functional ability, chronic disease management, and quality of life. Dietetics professionals can take the lead by researching and developing national, state, and local collaborative networks to incorporate effectively the food and nutrition services across the spectrum of aging.

The Meaning of Mealtimes: Connection to the Social World of the Nursing Home

Food that reflects our family backgrounds is a source of comfort that can play an important part in recovery from illness or adaptation to the nursing home, especially for older individuals. However, no studies could be found that explored residents' perspectives on how their food and food service preferences are, or are not, met in nursing homes. This exploratory qualitative study examined dietary preferences acquired during the course of a lifetime, and the meaning of mealtimes to 20 nursing home residents, and attempted to connect that meaning with their social world. Exploring the meaning of food and food service to nursing home residents could furnish insights for improving nutritional status, adaptation to the nursing home, and quality of life through promotion of individualized nutritional care.

Aging in community nutrition, diet therapy, and nutrition and aging textbooks

Using content analysis, this study evaluated the aging content and context in 11 nutrition sub-specialty textbooks: community nutrition (n = 3), diet therapy (n = 4), and nutrition and aging (n = 4). Pages with paragraphs on aging were identified in community nutrition and diet therapy textbooks, and 10% random samples of pages were evaluated in nutrition and aging textbooks. Paragraphs were assigned to one of four categories: gerontology, nutrition as primary, nutrition as secondary, or tertiary prevention. A total of 310 pages was qualitatively analyzed using NUD*IST 5 software and quantitatively with percentages. Only 7% of community nutrition and 2% of diet therapy pages were devoted to aging. There was little integration of aging beyond the chapters on aging. Community nutrition had the most gerontology (30%) and primary prevention (43%) content. Diet therapy and nutrition and aging had more secondary prevention (33% and 42%, respectively) and tertiary prevention (27% each) content. Some important databases and studies were absent. Of the 1,239 ageism words, 10% were positive, 53% neutral, and 36% negative. Photographs were generally positive. Women, but not minorities, reflected current older adult demographics. Future textbook editions should address aging more comprehensively and positively to better prepare dietitians for the job market. Recommendations for authors, course instructors, and publishers are given.

Do we need a nutrition-specific quality of life questionnaire for dialysis patients?

Food, eating, and quality of life are intimately related. Available generic and disease-specific health-related quality of life (HRQOL) instruments address nutrition only with respect to the ability to eat and omit more dynamic components of nutrition such as sensory enjoyment of food and food intake. For improved assessment and monitoring of nutrition-related quality of life in hemodialysis patients, a nutrition-specific questionnaire is recommended, consisting of two tools: the Appetite and Dietary Assessment Tool (ADAT), already used in many dialysis clinics, and the nutrition-specific Food Enjoyment in Dialysis (FED) questionnaire which asks 10 additional questions on sensory changes, thirst, gastrointestinal symptoms, side effects from medications and/or dialysis, and feelings of satisfaction and control. This nutrition-specific information should permit comprehensive evaluation and monitoring of changes in nutrition related quality of life. When coupled with generic and disease specific tools, it will provide a complete picture of quality of life in hemodialysis patients.

A Questionnaire to Examine Food Service Satisfaction of Elderly Residents in Long-Term Care Facilities

The purpose of this study was to develop a survey tool for assessing the satisfaction of elderly long-term care (LTC) residents with the meals and food services they receive, as well as to assess quality of life issues related to eating. Food service delivery should be provided in an environment that fosters autonomy, interpersonal relations, and security. The questionnaire was administered as face-to-face interviews with 205 residents (> or = 65 years of age) of 13 LTC facilities in Saskatoon, Saskatchewan, Canada (participation rate = 67%). Residents expressed some concern with food variety, quality, taste, and appearance, and with the posting of menus. Quality of life issues were mostly positive; however, residents were less satisfied with areas related to their autonomy such as food choice and snack availability.

Needs and Preference Assessment for an In-Home Nutrition Education Program Using Social Marketing Theory

Nutrition education programs for elder caregivers (CG) and their elder care recipients (CR) are important in preventing malnutrition. Using Social Marketing Theory, this study assessed the needs and preferences for nutrition education in elder CGs and their CRs in Guilford County, NC. Thirty-two pairs of community-residing elder CGs/CRs and three focus groups (FGs) participated. Health and diet questionnaires were administered to all CGs/CRs during in-home interviews. CGs/CRs and FGs evaluated nutrition education materials. Questionnaires were analyzed using SPSS v9. Ethnograph v5.0 was used to code the interviews regarding the education materials. The CGs were middle age (58.9 years), overweight (BMI = 28.8) Caucasian women. The CRs were old (79.4 years), overweight (BMI = 26.0) Caucasian women. Identified malnutrition risk factors of CGs and CRs included inadequate fluid and dietary intake, polypharmacy, and chronic disease. Identified nutrition needs and education preferences of CGs/CRs were similar. Perceived nutrition education preferences of the FGs did not reflect the interests of the CGs/CRs. This information is being used to revise the education materials and develop an in-home nutrition education program for CGs and CRs in Guilford County, NC.

Nutritional support and stroke

Following stroke poor nutritional status is common, under recognized and associated with worse outcomes. This article explores existing assessment and management strategies aimed at recognizing and reducing the impact of malnutrition in stroke patients.

Nutritional risk and body composition in free-living elderly participating in congregate meal-site programs

Early detection of nutritional risk in free-living elderly is critical in healthcare, yet comprehensive measurements are time consuming and can be frustrating to both health professionals and elderly. In addition, body composition measurements provide information regarding fat and fat-free mass that have been linked to morbidity and mortality in elderly. In this study, nutritional risk was assessed in 69 elderly, aged 50-90 years, attending congregate meal-site programs, using Mini Nutritional Assessment, and body composition was assessed by bioelectric impedance. Analysis revealed that 31.9% of the elderly were at risk for malnutrition and 2.9% were malnourished. Males had significantly greater body weight, height and fat-free mass, and females had significantly greater body fat as percentage of body weight, but there was no gender difference in nutritional risk. Of elderly, 36.2% had body mass index > 85th percentile and 8.7% < 15th percentile using national population reference standards. Age-related decline in fat-free mass was an early indicator of changes in body composition.

Nutrition care of older adults with chronic disease: attitudes and practices of physicians and patients

OBJECTIVES

Eighty percent of older adults have at least one chronic disease. Most conditions could be improved with nutritional intervention. This scientific study assessed physician and patient knowledge of, and behaviors about nutrition, resulting in tools to guide physicians in nutrition management of chronic diseases.

METHODS

Surveys were conducted of 300 practicing physicians and 600 older adults to identify current attitudes and practices regarding the role of nutrition in chronic disease management.

RESULTS

Ninety percent of physicians surveyed recognize the relationship between nutrition and chronic disease. Yet nutrition care occurs only sporadically in primary care settings.

CONCLUSIONS

Most physicians are aware of nutrition in managing chronic disease, but a significant percentage do not routinely include nutrition in their practice. This research led to the development of tools to assist in identifying and managing the nutritional aspects of chronic disease.

Assessing the need for hot meals: a descriptive Meals on Wheels study

According to recent literature, delivering chilled Meals on Wheels to seniors increases food quality and safety. The purpose of this study was to determine the acceptability and/or feasibility of a cook-chill delivery system for participants in the Maimonides Geriatric Centre Meals on Wheels program in Montreal, Quebec. The authors also evaluated whether the meal was eaten upon delivery, documented where the meal was stored if consumption was delayed, determined what cooking/heating appliances were used and if the recipients were capable of heating up their meals, and assessed preferences for receiving chilled versus hot meals. Upon receiving the meal, 89% of the 60 seniors did not eat it immediately. Those who ate the meal later stored it in the refrigerator. All had some appliance available to heat the delivered meal; 55% used a microwave. Approximately 75% did not object to receiving meals chilled. The majority of recipients did not require delivery of hot meals, as most delayed consuming the meal until later in the day. Other meal-delivery program planners can use these findings when deciding if a cook-chill system is appropriate for their client populations.

Nutrition education in six congregate meal sites improves participant's nutrition knowledge

Providing relevant nutrition education at federally funded senior centers is one way of increasing nutrition knowledge of older adults. The purpose of this study was to present three nutrition education sessions on the revised Food Guide Pyramid, dietary protein, and dietary fiber to older adults at six senior centers in Atlanta, Georgia. Three 20-minute lesson plans were developed and delivered at six senior centers over the course of 3 weeks. Forty-eight matched pre- and post-nutrition knowledge tests were analyzed and a significant difference (p < .01) in nutrition knowledge was found for the total score and three subtest scores.

Position of the American Dietetic Association: use of nutritive and nonnutritive sweeteners

Sweeteners elicit pleasurable sensations with (nutritive) or without (nonnutritive) energy. Nutritive sweeteners (eg, sucrose, fructose) are generally recognized as safe (GRAS) by the Food and Drug Administration (FDA), yet concern exists about increasing sweetener intakes relative to optimal nutrition and health. Dietary quality suffers at intakes above 25% of total energy (the Institutes of Medicine's suggested maximal intake level). In the United States, estimated intakes of nutritive sweeteners fall below this, although one in four children (ages 9 to 18 years) can surpass this level. Polyols (sugar alcohols), GRAS-affirmed or petitions filed for GRAS, add sweetness with reduced energy and functional properties to foods/beverages and promote dental health. Five nonnutritive sweeteners with intense sweetening power have FDA approval (acesulfame-K, aspartame, neotame, saccharin, sucralose) and estimated intakes below the Acceptable Daily Intake (level that a person can safely consume everyday over a lifetime without risk). By increasing palatability of nutrient-dense foods/beverages, sweeteners can promote diet healthfulness. Scientific evidence supports neither that intakes of nutritive sweeteners by themselves increase the risk of obesity nor that nutritive or nonnutritive sweeteners cause behavioral disorders. However, nutritive sweeteners increase risk of dental caries. High fructose intakes may cause hypertriglyceridemia and gastrointestinal symptoms in susceptible individuals. Thus, it is the position of The American Dietetic Association that consumers can safely enjoy a range of nutritive and nonnutritive sweeteners when consumed in a diet that is guided by current federal nutrition recommendations, such as the Dietary Guidelines for Americans and the Dietary References Intakes, as well as individual health goals. Dietetics professionals should provide consumers with science-based information about sweeteners and support research on the use of sweeteners to promote eating enjoyment, optimal nutrition, and health.

Tailoring of nutritional support for older adults in the community

A study in Ontario, Canada of 137 elderly home delivered meal recipients, 90 women and 47 men, confirmed the expected nutritional risk factors of living situation, functionality, morbidity and medication use. They were more pronounced among women than men. Seven-day food records showed energy intakes below the average for healthy Canadians of a similar age and gender. The probability of nutritional risk was highest for calcium, magnesium, zinc and folate with some gender differences, except for folate. While home delivered meals, if fully utilized, can provide considerable nutrition support, energy/nutrient inadequacies may persist among recipients unable to complement the meal appropriately. These older adults may require diet counseling and additional support including targeted nutritional supplementation.