Nutrition and health for older persons in rural America: a managed care model

Nutrition risk among an ethnically diverse sample of community-dwelling older adults

Objective

To assess the prevalence of nutritional risk among an ethnically diverse group of urban community-dwelling older adults and to explore if risk varied by race/ethnicity.

Design

Demographic characteristics, Katz’s activities of daily living and health-care resource utilization were ascertained cross-sectionally via telephone surveys with trained interviewers. Nutrition risk and nutrition symptomology were assessed via the abridged Patient Generated Subjective Global Assessment (abPG-SGA); scores of ≥6 points delineated ‘high’ nutrition risk. Descriptive statistics and logistic regression analyses were conducted.

Setting

Urban.

Participants

White, Black or Hispanic community-dwelling adults, ≥55 years of age, fluent in English or Spanish, residing in the city limits of Chicago, IL, USA.

Results

A total of 1001 participants (37 % white, 37 % Black, 26 % Hispanic) were surveyed. On average, participants were 66·9 years old, predominantly female and overweight/obese. Twenty-six per cent (n 263) of participants were classified as ‘high’ nutrition risk with 24, 14 and 31 % endorsing decreased oral intake, weight loss and compromised functioning, respectively. Black respondents constituted the greatest proportion of those with high risk scores, yet Hispanic participants displayed the most concerning nutrition risk profiles. Younger age, female sex, Black or Hispanic race/ethnicity, emergency room visits, eating alone and taking three or more different prescribed or over-the-counter drugs daily were significantly associated with high risk scores (P<0·05).

Conclusions

One in four older adults living in an urban community prone to health disparities was classified as ‘high’ nutrition risk. Targeted interventions to promote healthy ageing are needed, especially for overweight/obese and minority community members.

Effects of a multi-component nutritional telemonitoring intervention on nutritional status, diet quality, physical functioning and quality of life of community-dwelling older adults

This study aimed to evaluate the effects of an intervention including nutritional telemonitoring, nutrition education, and follow-up by a nurse on nutritional status, diet quality, appetite, physical functioning and quality of life of Dutch community-dwelling elderly. We used a parallel arm pre-test post-test design with 214 older adults (average age 80 years) who were allocated to the intervention group (n97) or control group (n107), based on the municipality. The intervention group received a 6-month intervention including telemonitoring measurements, nutrition education and follow-up by a nurse. Effect measurements took place at baseline, after 4·5 months, and at the end of the study. The intervention improved nutritional status of participants at risk of undernutrition (β(T1)=2·55; 95 % CI 1·41, 3·68;β(T2)=1·77; 95 % CI 0·60, 2·94) and scores for compliance with Dutch guidelines for the intake of vegetables (β=1·27; 95 % CI 0·49, 2·05), fruit (β=1·24; 95 % CI 0·60, 1·88), dietary fibre (β=1·13; 95 % CI 0·70, 1·57), protein (β=1·20; 95 % CI 0·15, 2·24) and physical activity (β=2·13; 95 % CI 0·98, 3·29). The intervention did not have an effect on body weight, appetite, physical functioning and quality of life. In conclusion, this intervention leads to improved nutritional status in older adults at risk of undernutrition, and to improved diet quality and physical activity levels of community-dwelling elderly. Future studies with a longer duration should focus on older adults at higher risk of undernutrition than this study population to investigate whether the impact of the intervention on nutritional and functional outcomes can be improved.

Use of Telephone-Administered Survey for Identifying Nutritional Risk Indicators Among Community-Living Older Adults in Rural Areas

The ability of Elderly Nutrition Programs, especially in rural areas, to address increasing needs for disparate program services is linked to determining which older people are most likely to be at nutritional risk and what constitutes the potential risk. The purpose of this study is to characterize nutritional risk factors in a probability sample of rural elders (n = 152) through telephone interviews using a 67-question modified version of the Nutrition Screening Initiative's Level I and II screens. Participants reported high levels of unintentional weight loss, medication use, multiple health conditions, and depression. This study demonstrates that comprehensive information on general health, eating habits, living environment, and functional status can be collected from rural elders by telephone. Because much of the reported nutritional risk in this sample occurs in residents living in areas not receiving nutrition services, expanded nutritional risk data can be used to anticipate need for programs and services in areas not presently served.

Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings

BACKGROUND

Given the prevalence of under-nutrition and reports of inadequate nutritional management of patients in hospitals and the community, nutritional screening may play a role in reducing the risks of malnutrition. Screening programmes can invoke costs to health systems and patients. It is therefore important to assess the effectiveness of nutritional screening programmes.

OBJECTIVES

To examine the effectiveness of nutritional screening in improving quality of care (professional practice) and patient outcomes compared with usual care.

SEARCH METHODS

We searched the following databases: CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL up to June 2012 to find relevant studies.

SELECTION CRITERIA

Randomised controlled studies, controlled clinical trials, controlled before-after studies and interrupted time series studies assessing the effectiveness of nutritional screening were eligible for inclusion in the review. We considered process outcomes (for example patient identification, referral to dietitian) and patient outcomes (for example mortality, change in body mass index (BMI)). Participants were adult patients aged 16 years or over. We included studies conducted in different settings, including hospitals, out-patient clinics, primary care or long term care settings.

DATA COLLECTION AND ANALYSIS

We independently assessed the risk of bias and extracted data from the included studies. Meta-analysis was considered but was not conducted due to the discrepancies between the studies. The studies were heterogeneous in their design, setting, intervention and outcomes. We analysed the data using a narrative synthesis approach.

MAIN RESULTS

After conducting initial searches and screening the titles and abstracts of the identified literature, 77 full text papers were retrieved and read. Ultimately three studies were included. Two controlled before-after studies were conducted in hospital settings (one in the UK and one in the Netherlands) and one cluster randomised controlled trial was conducted in a primary care setting (in the USA).The study conducted in primary care reported that physicians were receptive to the screening intervention, but the intervention did not result in any improvements in the malnutrition detection rate or nutritional intervention rate. The two studies conducted in hospitals had important methodological limitations. One study reported that as a result of the intervention, the recording of patients' weight increased in the intervention wards. No significant changes were observed in the referral rates to dietitians or care at meal time. The third study reported weight gains and a reduction in hospital acquired infection rate in the intervention hospital. They found no significant differences in length of stay, pressure sores, malnutrition and treatment costs per patient between the two hospitals.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support the effectiveness of nutritional screening, although equally there is no evidence of no effect. Therefore, more high quality studies should be conducted to assess the effectiveness of nutritional screening in different settings.

Obesity is a risk factor for reporting homebound status among community-dwelling older persons

OBJECTIVE

To test the a priori hypothesis that obesity is a predictor of risk for reporting homebound status.

RESEARCH METHODS AND PROCEDURES

A longitudinal cohort study was conducted with 21,645 community-dwelling men and women 65 to 97 years old. A nutrition risk screen was administered baseline between 1994 and 1999 and again 3 to 4 years later. Univariate analyses identified baseline variables associated with subsequent reporting of homebound status. Multivariable logistic regression models were created to identify baseline variables that were significant independent predictors of reporting homebound status.

RESULTS

At baseline, 24% of the cohort had BMI > or = 30. There were 12,834 (45% men) respondents at follow-up (68% response). Non-responders at follow-up differed little from responders except for greater baseline age (72.2 +/- 6.2 vs. 71.4 +/- 5.6 years, p < 0.001) and reporting of any functional limitations (9.2% vs. 4.9%, p < 0.001). At follow-up, those who reported homebound status (n = 169) were significantly (p < 0.001) older (80.3 +/- 7.3 vs. 75.1 +/- 5.5 years) and more likely to report functional limitations (83.4% vs. 10.8%). Univariate analyses identified 16 baseline variables that were eliminated stepwise until five significant independent predictors remained: age > or = 75 years (2.21, 1.55 to 3.15/odds ratio, 95% confidence interval), BMI > or = 35 (1.75, 1.04 to 2.96), poor appetite (2.50, 1.29 to 4.86), low income (1.59, 1.00 to 2.56), and any functional limitation (10.67, 7.36 to 15.46).

DISCUSSION

Obesity remained a significant independent predictor for reporting homebound status and should be considered in screening of older populations and in the planning, implementation, and evaluation of services for homebound older persons.

More favorable dietary patterns are associated with lower glycemic load in older adults

OBJECTIVE

Glycemic load represents the total glycemic effect of the diet and may reduce the risk for chronic disease by affecting the risk for obesity and by altering metabolic endpoints. The food choices associated with lower-glycemic-load diets have received little investigation. Therefore, the purpose of this research was to examine the food patterns associated with lower-glycemic-load diets to establish targeted intervention messages.

SUBJECTS/SETTING

A random sample (n=179; 81 male and 98 female subjects) of older adults > or =65 years of age in the Geisinger Rural Aging study, a nutritional risk screening study.

METHODS

Standardized methodology was used to calculate the glycemic load from data obtained in five 24-hour recalls. Statistical analysis t tests compared dietary patterns between male and female subjects from two eating pattern clusters identified in previous cluster analysis based on food group intake.

RESULTS

The mean (+/-standard deviation) glycemic load for the entire sample was 115.6 (+/-39.9). Two clusters were identified, and male and female subjects in one cluster had a lower glycemic load (113.7+/-44.2 and 94.0+/-27.5, respectively) than male and female subjects in the second cluster (139.9+/-38.8 and 110.7+/-35.9, respectively) ( P <.01). Participants in the lower-glycemic-load cluster consumed more carbohydrate from cereal, fruits, vegetables, and milk, whereas those in the higher-glycemic-load cluster consumed more breads and desserts.

CONCLUSIONS

Promoting appropriate portions of nutrient-dense carbohydrate foods, particularly whole grain, fruits, vegetables, and dairy foods, may offer reasonable guidance for lowering the glycemic load of the diet among older adults. A lower-glycemic-load diet may reduce the risk for obesity and many chronic diseases.

Nutritional risk assessment and obesity in rural older adults: a sex difference

BACKGROUND

Many older Americans are overweight or obese, but it is unclear whether obesity is associated with other nutritional risk indicators.

OBJECTIVE

This study investigated sex-associated differences in nutritional risk among community-dwelling, rural older adults and determined whether weight status [body mass index (BMI; in kg/m(2)) and waist circumference] was related to other measures of nutritional risk.

DESIGN

This cross-sectional study explored relations between weight status and nutritional risk, which was determined on the basis of the Level II Screen, overall diet quality, nutrient intakes, and plasma biomarkers.

RESULTS

Of the 179 subjects, 44% were overweight (BMI 25-29.9) and 35% were obese (BMI > 30). There were few differences in nutrient intakes between older men and women after we controlled for energy intake. In women, BMI was directly associated with multiple additional nutritional risk indicators, including the number of Level II items (r = 0.30), intakes of fat (r = 0.26) and saturated fat (r = 0.21), and homocysteine concentration (r = 0.25). Weight status in women was inversely associated with intakes of carbohydrates (r = -0.25), fiber (r = -0.35), folate (r = -0.24), magnesium (r = -0.29), iron (r = -0.22), and zinc (r = -0.23); Healthy Eating Index scores (r = -0.22); and plasma pyridoxal 5' phosphate (r = -0.30). Associations with waist circumference were similar. In men, weight status was associated only with plasma cobalamin (r = -0.33 for BMI) and pyridoxal 5' phosphate (r = -0.24 for waist circumference).

CONCLUSIONS

Overweight and obese older women, particularly those living alone, may be at greater nutritional risk than are men with a high BMI. Targeted nutritional intervention emphasizing nutrient-dense food choices to improve dietary patterns may be warranted.

Obesity is associated with functional decline in community-dwelling rural older persons

OBJECTIVES

This investigation sought to examine potential gender differences in the relationship between body mass index (BMI) and functional decline.

DESIGN

Cohort study.

SETTING

Rural Pennsylvania.

PARTICIPANTS

Medicare managed-risk program participants (aged > or =65) in the Geisinger Health Plan. Mean age at study baseline was 71. Final analyzable sample was 2,634 participants.

MEASUREMENTS

Self-reported weight, weight change, living and eating habits, alcohol and medication use, depression, dentition, and functional status were obtained upon enrollment and again between 3 and 4 years later. Measured height and weight were also recorded at enrollment. Functional decline was defined as any increase in reported limitations in activities of daily living or instrumental activities of daily living over the study period. Logistic regression was used to evaluate the relationship between BMI, as defined by current National Institutes of Health categories, and risk of functional decline while controlling for age, depression, and polypharmacy. The referent category was BMI 18.5 to 24.9.

RESULTS

Women had a higher prevalence of reported functional decline than men at the upper range of BMI categories (31.4% vs 14.3% for BMI > or =40). Women (odds ratio (OR) = 2.61, 95% confidence interval (CI) = 1.39-4.95) and men (OR = 3.32, 95% CI = 1.29-8.46) exhibited increased risk for any functional decline at BMI of 35 or greater. Weight loss of 10 pounds and weight gain of 20 pounds were also risk factors for any functional decline.

CONCLUSIONS

Obesity was a risk factor for functional decline in older persons of either gender. Change in body weight did not benefit function for many older persons.

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

Scientific evidence increasingly supports that good nutrition is essential to the health, self-sufficiency, and quality of life of older adults. With the population of the United States living longer than ever before, the older adult population will be more diverse and heterogeneous in the 21st century. The oldest-old and minority populations will grow more quickly than the young-old and non-Hispanic white populations, respectively. For the current 34 million adults 65 years of age and older living in the United States, there are about 12 million caregivers who provide formal or informal care. A broad array of culturally appropriate food and nutrition services, physical activities, and health and supportive care customized to accommodate the variations within this expanding population of older adults is needed. With changes and lack of coordination in health care and social-support systems, dietetics professionals need to be proactive and collaborate with aging-services and other health care professionals to improve policies, interventions, and programs that service older adults throughout the continuum of care to ensure nutritional well-being and quality of life. The American Dietetic Association supports both the provision of comprehensive food and nutrition services and the continuation and expansion of research to identify the most effective food and nutrition interventions for older adults over the continuum of care.

The validity of nutritional status as a marker for future disability and depressive symptoms among high-risk older adults

OBJECTIVE

To measure the validity of the DETERMINE Checklist as a marker for future functional disability, depressive symptoms, and mortality among high-risk older adults.

DESIGN

A Cohort study.

SETTING

An Urban-suburban Midwestern community.

PARTICIPANTS

Community-dwelling Medicare beneficiaries at high risk for hospital admission who received geriatric evaluation and management (GEM) (n = 251).

MEASUREMENTS

Demographic, health-related, functional, psychosocial, survival, and nutritional data were collected through telephone and in-home interviews.

RESULTS

GEM recipients with baseline Checklist scores of four or higher were found to be significantly more likely than those with lower scores to have functional disability or high levels of depressive symptoms a year later. Checklist scores did not predict mortality.

CONCLUSIONS

The 10-item Checklist could be used as a secondary screen to identify older persons who, without treatment, are at especially high-risk to have disability or depression a year later.