Older Adult Nutrition Trends and Needs Social Ecological Model

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Nancy Cohen PhD RD LDN FAND
Professor and Head
Department of Nutrition
Univ of Massachusetts Amherst
Shirley Chao PhD RD LD FAND
Director of Nutrition
Massachusetts Executive Office of
Elder Affairs
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Older Adult Nutrition Trends and Needs
Social Ecological Model
Farm Bill programs for Older Adults
OAA programs overview/MA nutrition
program overview
Nutrition education/ Wellness related
programs: Satisfaction survey/outcome
results
Challenges national and in MA
Community Interventions to Increase FV;
Evidence of Impact
The Role of the RDN/DTR to Improve the
Food Environment for Older Adults
MDA, April 2015
Young Children and Older People as a Percentage of Global
Population: 1950-2050
NIA, WHO: Global Health and Aging http //www.who.int/ageing/publications/global_health.pdf?ua=1
www.agingstats.gov
www.agingstats.gov
www.agingstats.gov
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Ziliak and Gundersen. State of Senior Hunger in America 2012. www.nfesh.org
Feeding America. Adverse Health Outcomes of Food Insecure Older Americans. www.feedingamerica.org
Feeding America. Adverse Health Outcomes of Food Insecure Older Americans. www.feedingamerica.org
food
industry
political
advocacy/l
obbying
Distal Leverage Points
family
recreation
facilities
property
owners
local government
social trends
situation or context- physical
and social
stage of change
cooking skills
Enablers of Social Choice
time
Social Influences
nonprofit providers
nongovernmental organizations
home
farmer’s markets
community gardens senior centers
health care settings
health club
community activity
restaurants and
parks, recreation
providers
food outlets
centers
food stores
fresh fruits &
vegetables
social support
intentions
living accommodations
life stage
social roles
culture/habits
Cultural Influences
entertainment
industry
accessibility safety
interpersonal relationships
source of
information
affordability
/cost
convenience
ethnic
identities
educational
attainment
physiology
Psychobiological Core
self-identities
pleasure
hierarchy of needs
life
experience
physical and
health status
cognitive capacity
socioeconomic
status
senior
housing
adult day
health
food quality
neighborhood
social support
Social Ecological Framework for Determinants of Physical
Activity and Eating Behavior in Older Adults
N. Cohen, 7/30/13. Adapted from: Booth et al. Nutr Rev. 59(3): S21-S36, 2001
information
industry
federal,
state, local
government
shopping
malls
shopping
malls
self-efficacy
family
demographics knowledge
community
vehicle of
transport
beliefs
values
genetics
laborsaving
device
industry
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religious organizations
workplace
Behavioral Settings
health care
industry
exercise, physical activity, and sports industry
restaurants and food outlets
developers
Proximal Leverage Points
architecture and
building codes
recreation industry
transportation system
www.agingstats.gov
(agriculture,
elder affairs,
public health,
revenue,
health
health and
care
human
providers
services, etc.)
food stores
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Accessibility
Social Support
Affordability
Living Accommodations
agriculture
industry
employers
foundations,
funders
congregate
meal sites
food banks,
pantries
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A panel of national key informants in community
nutrition research and extension with older adults
(n=12)
The most important enablers facilitating healthy eating
in OA
farms,
farmer’s
markets
insurance
industry
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Sylvie, A.K., Jiang, Q., and Cohen, N. Identification of Environmental Supports for Healthy
Eating in Older Adults. J Nutrition Gerontol Geriatrics 32(2): 161-174, 2013.
12/4/13
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Established in 2002 Farm Bill
Provide low income adults age 60+ (<185%
Poverty) coupons for FV at farmers’ markets,
roadside stands, CSAs
Administered through state agencies
FY 2013:
◦ 835,795 participants
◦ 20,617 farmers
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Benefit: $20-$50/year
Budget:
◦ FY09: $21M
◦ FY14: $19M
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South Carolina 2001
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Survey of participants (n=658)
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86% coupon redemption rate
36% never shopped at farmers’ market before
59% bought extra FV
89% planned to eat more FV all year as a result
Barriers: transportation, market hours, no market in area
Florida 2005
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(Kunkel et al. JADA 2003)
(FL Dept Elder Affairs 2006)
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Agingkingcounty.org
85% coupon redemption rate
95% reported that coupons enabled them to eat more FV
94% reported that coupons enabled them to stretch the food budget
Barriers: transportation, market hours, lack of shopping carts or places to
sit; weather
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NY State
(Bonk et al. JADA 2008)
◦ Compared seniors (n=240) in CSFP housing sites vs.
non-CSFP housing
◦ Fewer seniors at CSFP sites used HDM and Soup
Kitchens
◦ Food security similar in both groups
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Agr.mt.gov
USDA purchases food; state agencies
administer, store and distribute food
Eligibility: WIC (phased out in FY14), low
income (<130% poverty) adults age 60+
Budget $202M in FY14
Dry/UHT milk; cereal; peanut butter; beans;
canned meat, fruits, vegetables
9% of the US population lives in a “food desert”
◦ More likely in communities of color, low income, low education,
and rural areas
◦ Quality within the stores may also be lacking
Some studies show that access to supermarkets or
healthy foods is related to increased FV intake or
reduced obesity
◦ Other studies show mixed or no associations
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Other factors may be important
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Region, rural/urban
Quality of foods, price
Transportation
Food “swamps”
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Rural Texas seniors
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New York City seniors
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(Sharkey et al. 2010)
◦ Increased distance to a supermarket or food store with good
selection or variety of fresh and processed FV was associated with
lower intake of FV
(Deierlein et al. 2014)
◦ Purchasing food at a supermarket related to higher HEI diet
quality scores
◦ Eating one restaurant meal/day related to lower HEI diet quality
scores
(Mercille et al. 2012)
◦ Higher % healthful food stores associated with lower Western Diet
scores, but not higher Prudent Diet scores.
◦ Higher % restaurants as Fast Food outlets associated with lower
Prudent Diet scores
Systematic Review RCTs
(Bandayrel and Wong JNEB 2011)
SENIOR intervention
(Greene et al. Gerontologist 2008)
◦ Transtheoretical Model (Stage of Change) Intervention
(newsletters, reports, coaching calls)
 Increase 0.5-1.0 serving/day F & V
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Montreal seniors
◦ 10 studies provided nutrition education or counseling
◦ 8/10 had positive outcomes re. diet, health habits, nutrition
behaviors
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Systematic Review Behavioral
Interventions to Increase F & V
Food and Nutrition Act 2008; Healthy
Hunger-Free Kids Act 2010
Health promotion and primary prevention to
establish healthy eating habits and a
physically active lifestyle
Target: Low income populations eligible for
SNAP benefits
◦ Emphasis on women and children, but elders
eligible
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$407 M in FY 15
Authorized by OAA, Administered by USDA
Reimbursement for qualifying meals and
snacks in child care, adult day care
◦ 2.9 M children
◦ 86,000 older adults
(Thomson and
Ravia, JADA 2011)
◦ Increase 0.97-1.13 servings/day (adults)
◦ Social support and self-efficacy are important
Older American Nutrition Program
Massachusetts Elderly Nutrition Program Services
Network
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Eligibility
◦ Age 60
◦ A spouse of any age
◦ Disabled persons under age 60 who reside in housing
facilities occupied primarily by the elderly where
congregate meals are served.
◦ Disabled persons who reside at home and accompany
older persons to meals.
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Meal requirement
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Volunteer contribution
◦ DRI, US Dietary Guidelines
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chao
28 nutrition projects across Massachusetts serve 8.8
million meals
75% are home delivered meals provided to frail
elders; 25% are congregate meals. Meals are
provided at 325 congregate sites.
7,000 volunteers contribute 450,000 hours yearly to
the Elderly Nutrition Program.
The program addresses multiple problems faced by
elders – poor nutrition, food insecurity, chronic
disease, and social isolation.
chao
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 Secure
and maintain
maximum independence
 Dignity in a home
environment for older
individuals capable of selfcare with appropriate
supportive services
 Provide a continuum of care
for vulnerable older
individuals.
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The congregate meal
program provides at
least one meal a day at
senior centers,
churches, schools and
other locations.
Provides opportunities
for social interaction
and companionship &
offers programs related
to nutrition education,
exercise activities, and
health promotion
.
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Home delivered meals
provide nutritious meals
to elders who are unable
to leave their homes due
to illness, disability or
frailty
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Cold supper bags and
weekend frozen meals
are also available in
some areas
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 Nutrition
Education/
Community
collaboration for
multi-week, evidence
based nutrition and
health promotion
programs.
 Nutrition Screening
 Nutrition Counseling
 Intervention
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Senior Farmers’ Market Program reach 27,000 elders, studies have found
that this program improves vegetable and fruit consumption.
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Supplemental Nutrition Assistance Program (SNAP) information helps to
increase participation in the program, while the thrifty food/shopping
tips help to stretch food dollars for a healthy diet.
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Nutrition education at brown bag and shelter programs are provided at
more than 11 sites and reach over 3,000 elders. The brown bag program
is funded and administered by the Greater Boston Food Bank, The Food
Bank of Western Massachusetts and the Worcester County Food
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Nutrition education is provided 2x per year at all
congregate meal sites. There are approximately 600
sessions reaching about 20,000 seniors. Participants also
demonstrate retained knowledge from the session with
80% success for the pre-post test and 35-45% of
participants with retained knowledge 6 months later.
Home delivered meals education: education is provided
on the back of menus (typically each month) or sent in
the form of newsletters and flyers. The newsletters reach
approximately 35,000 seniors.
"Water Telephone Education Project"
Food Dollars is an “evidence informed” free six week program of
Action for Boston Community Development (ABCD, Inc.) and is
supported by the AARP Foundation.
Food Dollars promotes healthy eating on a budget and reduces food
and economic insecurity among low income older adults of Boston.
Brandeis University evaluated the program showed that with Food
Dollars, it is possible to improve healthy eating in adults 50+ and for
them to stretch limited budgets.
In the past two and a half years, 46 classes have been conducted
at various sites in Boston.
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Developed in the early 1990s by the Stanford Center for
Research in Patient Education.
Now used internationally in 15 countries and over 39 U.S.
states. Approved by CDC, AoA and NCOA.
chao
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Since March 2010, In MA, 716 workshops have been held, 8049 adults
have attended workshops. Completion Rate: 76.8%
 33%
have Arthritis, 36% Hypertension, and 25% Diabetes.
have multiple chronic conditions
 18.5% Latinos, 11% Black and 6% Asian
 54.5%
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Participants’ Improvements
Exercise
Coping strategies and symptom management
Communication with physicians
Self-reported general health
Decreased fatigue
Decreased disability
Decrease in activity limitation
Many results persist for as long as 3 years!
http://patienteducation.stanford.edu/programs/cdsmp.html
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Action for Boston Community Development, Inc.
Action for Boston Community Development, Inc.
A Matter of Balance:
Managing Concerns About Falls
Proven Outcomes
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97% - more comfortable talking about fear of falling
97% feel comfortable increasing activity
99% plan to continue exercising
99% would recommend A Matter of Balance
81 workshops held in 2011 with a total of 959
participants.
 Workshops have been held in residential settings, senior
centers, adult day health centers, and in rural and urban
settings.
 Proven intervention program in Fall Management
 Developed at BU Roybal Center for Gerontology & New
England Research Institutes
 Adapted by MaineHealth for community-dwelling adults
 Comprehensive in approach
 Low cost & easy to implement
 Facilitated by trained coaches
 Available in Spanish, soon in Chinese & Russian
A Matter of Balance: Managing Concerns about Falls
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All results are combined HDM except where
otherwise indicated
21 agencies submitted data
HDM 15,753 distributed, 5,250 returned (33%)
Cong. 6,6979 distributed, 3,575 returned (51%)
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85% of HDM
100+ HDM: Improve health: 89%, Maintain a condition: 82%
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I can continue to stay home & not fall so often
Provides puree meals so I can eat
Kept me out of nursing home
See other people during meal time, rather than
eating alone.
Everything is wonderful, before the meals I was not
eating, lost 68 lbs.
I was a chef and now I have lost my knack for cooking
a lot of things, since my wife died six years ago.
Would just be eating sandwiches, pizza, etc.
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Demographic changes (aging baby boomers).
Policy Environment (lack of volunteers).
The continue services model (changes in health care system
and early discharge).
Healthy life style and eating habits.
Cultural diversity.
Under 60 disable population
Boomer Health/Nutrition needs (supplements, fitness center,
internet nutrition information, and comprehensive health
care coverage)
Resources
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Mobile Markets
◦ Veggie Mobile NYS 2010
(Abusabha et al JADA
2011)
 Wholesale FV prices; 1 hr stop at senior centers,
public housing
 Older adults consumed 0.6 serving/day more
vegetables
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Brown Bag for Elders
◦ Second Harvest Food Bank
Santa Clara/San Mateo
0
2
4
Child Nutrition
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OAA
Billions 10
$
 Served 15,204 individuals/wk at 78 sites
 87% participants reported eating more FV
www.buylocalfood.org
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Community Gardens for Seniors
◦ Container garden study
Senior FarmShare
◦ Seniors pay $10, receive share of $100 worth of
vegetables from local farms
◦ CISA 2013 results
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365 participants, 12 farms in Western MA
80% reported eating more vegetables
73% tried a new vegetable
55% froze or canned produce
(Austin et al. 2006)
 Increased functional, emotional health indicators in OA
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Farm to Institution Programs
 Farm to Hospital
 Prescription Vegetables
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Faith-based Programs
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Screenings
Nutrition Education
Congregate Meals
Transportation to Grocery Stores
Food Pantry
Garden
http://www.oregon.gov/dhs/spwpd/Publishi
ngImages/sfdnp-02.jpg
www.buylocalfood.org
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Politics
◦ Advocate for OAA and Farm Bill programs to
expand services, coverage
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Policies
◦ Work with local farmers, stores, communities to encourage
more healthy food outlets, farmers markets, healthy foods in
bodegas
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Prices
◦ Work with local farmers, stores, restaurants to increase:
 acceptance of SNAP, SFMNP coupons/EBT
 discounts for CSAs
 Incentives for institutions to purchase locally grown foods
 Lower prices for healthy foods in restaurants
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Prescribe
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Promote
◦ Vegetables!
◦ Nutrition education in communities
◦ SNAP enrollment and outreach
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Plan
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Community gardens
Mobile markets
Mobile pantries
Transportation
Carts and benches in markets
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