Spring 2015 Supplement

In this Issue … and The Older Adult, Part 2: Early Interventions to Prevent Deficiencies Micronutrients and the Older 1 Adult, Part 2: Early Interventions Vijaya Jain, MSc, MS, RD, CDN To Prevent Micronutrient Deficiencies Abstract continue to be affected by chronic health and medical conditions such The ongoing increase in the number Spotlight: Vijaya Jain, 13 as undernutrition, heart disease, hy- MSc, MS, RD, CDN of older adults worldwide makes ad- pertension, and dementia.3 These dressing their nutritional needs more CPE P Navigating the Urban 16 conditions all impact the micronu- challenging. Aging is associated Food Environment: Challenges trient status of older adults, result- with numerous changes and factors And Resilience of Community ing in deficiencies of vitamins and Dwelling Older Adults that affect the lives of older adults. minerals.4 The age-related changes The nutritional status of older adults Clearing the Confusion on 27 in adults’ nutritional needs are well is an important determinant of qual- Probiotics, Prebiotics, and documented.5,6 The food intake of ity of life, morbidity, and mortality. Flavonoids for Healthy Aging older adults tends to decrease with Although good nutrition and healthy advancing age to compensate for lifestyle habits must start early in the diminished energy needs associ- Editor’s note: The Spectrum is life to achieve wellness later in life, ated with lower energy expended pleased to present the second in- dietary modifications are often nec- in physical activity and basal meta- stallment of this two-part series about essary to adjust to the physical and bolic rate.7 The need for micronutri- the micronutrient needs of older metabolic changes that occur with ents, however, remains constant or adults. The Healthy Aging DPG and age. Appropriate and timely inter- increases. Thus, it is particularly chal- the Women’s Health DPG worked ventions are essential for enabling lenging for older adults to maintain closely with author Vijaya Jain (MSc, older adults to achieve these goals. MS, RD, CDN) to make this series optimal nutritional status, health, and relevant to the needs of both our Introduction well-being. memberships. Special thanks to the Access to food is a basic human Older adults constitute the fastest- editorial teams of Women’s Health right and a necessity. However, 8.1% growing population segment Report and The Spectrum for their of households with older adults are worldwide. In the United States, the invaluable guidance and hard work. reported to have food insecurity.8 Mi- population segment of those aged cronutrient deficiencies continue to — Robin Dahm, RDN, LDN 65 and older reached 43.1 million in be a major health problem for older Editor in Chief, The Spectrum 2012, and it is projected to increase adults in many developing countries to 79.7 million by 2040.1 The process lacking health and nutrition supple- of aging is characterized by dimin- mentation programs available to ished functionality of organ systems, Americans. Adequate access and changes in body composition, and availability of nutrient-dense foods, weakened homeostatic controls; all paired with a varied diet, is essential of which are influenced by genetic for older adults to lead healthy lives. and environmental factors. Aging In fact, a general consensus already is also associated with physiologi- exists in support of the concept that cal and economical changes that a healthy dietary pattern, including compromise nutritional status. Ad- foods that provide micronutrients ditionally, the aging population is di- in adequate amounts, supports the verse, exhibiting large ranges in age, health and survival of older adults. activity level, fitness, dependency, and frailty. While today’s older adults In light of the importance of provid- have an increased life expectancy ing adequate nutrition care to older of approximately 30 years relative to adults, it is the position of the Acad- 2 that of previous generations, many Continued on page 2

THE SPECTRUM • Spring 2015 Supplement 1 Micronutrients common. Carotenoids are reported a deteriorated nutritional status and Continued from page 1 to have a possible protective effect micronutrient deficiencies in older Soy and Health againstThere is oxidative solid clinical stress, evidence and subse that - adults. Identifying mental health emy of Nutrition and Dietetics that quently sarcopenia.13 In Canadian problems and helping older adults continued from page 17 soyfoods reduce the risk of cardiovas- all Americans aged 60 years and adults aged 60 to 75 years, the odds get connected with necessary medi- cular disease through multiple mecha- olderthe prognosis receive appropriate of breast cancer nutrition sur- for sarcopenia were greater in those cal and counseling services are ef- care; have access to coordinated, nisms. Benefits may be particularly vivors,110–116 by far the three largest who reported failing to meet recom- fective strategies. comprehensive food and nutrition mendedpronounced dietary for young allowances postmeno for -the and longest are the Shanghai Breast services; and receive the benefits antioxidantspausal women. selenium Prospective and vitaminsdata do of Aging 110 ofCancer ongoing Survival research Study to (SBCSS), identify the the A, C, and E.14 In the Women’s Health show an inverse relationship between Anorexia of aging, defined as loss most-effectiveWomen’s Healthy food Eating and andnutrition Living and Aging Study (WHAS) of nearly soy intake and coronary events in of appetite and/or reduced food programs,(WHEL) study, interventions,111 and the andLife Afterthera - 700 community-dwelling women 9 women; however, this relationship has intake, affects a significant number pies.Cancer Epidemiology (LACE) study.112 aged 70 to 79 years, a high plasma not been observed in men. Prospective of older adults. It is more prevalent 117 carotenoid and -tocopherol (a MicronutrientsIn 2012, Nechtua of importance et al. pooled to older re- α among frail elderly individuals, espe- formdata ofalso vitamin show E)an status inverse were relationship as- adults,sults from their these requirements, three studies, deficien which- ciallyAbout among the Author nursing-home residents sociated with reduced odds for low cies, sources, and nutritional status in between soy intake and fracture risk andDr. Messina hospitalized is the patients, co-owner18 ofincreas Nutri-- included 9,514 breast cancer patients 15 16 older adults has been described in muscleamong strengthAsian women, and butfrailty. most Diets long- ingtion the Matters, risk for Inc., undernutrition a nutrition consult and - (approximately half were Caucasian high in fruits and vegetables may the first article of this two-part series: term clinical data have not found that micronutrienting company; deficiencies.an adjunct associate The main and half were Chinese) who were fol- be beneficial due to increased po- “Micronutrients and the Older Adult, isoflavone supplements affect BMD in strategyprofessor is atto Loma optimize Linda nutritional University in tassium intake, which may reduce Partlowed 1: Micronutrientsfor a mean of 7.4of Importance years. When status by including small, frequent, metabolicWestern women. acidosis. Still, Magnesium because they may California; and the executive director tocomparing Older Adults.” the highest Part 2 isoflavoneof this series in- nutrient-dense meals. Oral nutrition alsoprovide be preventativehigh-quality protein, in limiting which skel is- of the Soy Nutrition Institute. Dr. Mes- discussestake group appropriate with the lowest interventions (≥10 mg/ supplements are a good interven- to reduce micronutrient deficiencies etalimportant muscle for decline bone health, by contributing and be- sina devotes his time to the study of day vs. <4 mg/day), the risk of total tion for older adults who are unable during the aging process. tocause adenosine many soyfoods triphosphate are good and sourc cell - the health effects of soyfoods and soy- mortality, breast cancer–specific mor- to obtain their nutrient needs with structure.es of well-absorbed Additionally, calcium, vitamin they D maycan mealsbean isoflavones.and snacks, He and writes the extensivelyuse of tality, and breast cancer recurrence play an important role in the main- Strategies to Reduce the help to protect against osteoporosis. megasterolon these subjects, acetate having (an appetitepublished tenance of muscle function for older Incwasid reducedence o byf M13%icr (HRonu 0.87,trie 95%nt stimulantmore than that 100 may peer-reviewed promote weight articles adults.10 DeCIf i0.70,cienc 1.10),ies 17% (HR 0.83, 95% CI Isoflavone supplements are effective gain)for health may professionals. also be helpful. Dr.4 Messina 0.64–1.07) and 25% (HR 0.75, 95% at alleviating hot flashes in postmeno- is also the chairperson of the editorial The numerous changes associ- Chronic Illness and Disease atedCI 0.61–0.92), with the normal respectively. aging process pausal women, but some women, Sadvisorymell and board Taste and Disorders writes a regular increase nutritional risks for older Increasingespecially womenlevels of at chronic increased illness risk of Changescolumn for in The smell Soy and Connection taste occur, a Finally, similar benefits were found in and disease can lead to and exac- adults. An older adult’s nutritional breast cancer or those who have this asquarterly a natural newsletter part of thatthe agingreaches pro over- a meta-analysis published in 2013 erbate poor nutritional status. The needs are determined by multiple disease, are fearful of using soyfoods cess,250,000 but age-relatedhealth professionals. loss in taste He has factors,that included including the threespecific studies health in presence of chronic illness and dis- sensitivity is most common in older abilitybecause increases of the concerns with age. that Most soy olderphy- given over 500 presentations to health problemsthe pooled and analysis related plus organ-system two small adults on prescribed medications.19 adultstoestrogens have mightone or stimulate more chronic breast professionals and has presented in 48 compromise,Chinese studies. activity118 Not level, surprisingly, energy Changes in flavor perception begin diseases,tumor growth. with 85%However, having clinical at least data countries. expenditure,given the clinical and andcaloric epidemiologic require- to diminish around 50 years of age, ments; the ability to access, prepare, oneshow chronic that isoflavone disease exposureaffecting does the data, both the American Institute for withNOTE: the Turn sense to ofpage taste 19 continuingfor a soyfood- ingest and digest foods; and per- absorption,not adversely transport, affect markers metabolism, of breast to decline with the passage of time. Cancer Research119 and the American and excretion of nutrients.4,17 For summary handout. sonal food preferences. Strategies to cancer risk, and prospective epide- In addition, olfaction (the sense of 120 many older adults, this will result in a reduceCancer the Society impact have of these concluded age-re that- smell)References declines with age, with more reducedmiologic abilitystudies to indicate complete that post-normal latedsoyfoods changes are safe are for discussed breast cancer below. thanClick 70%here of to adults see the over references the age for of activitiesdiagnosis of isoflavone daily living, intake and reduces it is more patients. 1 ofrecurrence a problem and particularly mortality. for those this article. Sarcopenia continued on page 19 Summary and Conclusions living alone or with a disabled or ill Continued on page 3 Sarcopenia, a reduction in muscle The clinical and epidemiologic data Soyfoods have been recognized for partner. Promoting a healthy diet mass and function, not only results suggest that the consumption of two Healthy Aging dietetic decades as good sources of high- and lifestyle among older adults is in decreased functional ability and theto three optimal daily approach servings of for soyfoods the pre -is Practice Group quality protein10,11 and a variety of nu- strength, but also has an im- ventionsufficient and to derive incidence health reduction benefits. Anof trients, but in recent years they have Our Mission pact on a person’s ability to chew chronicupper limit diseases. of four servings is recom- foodbeen properly intensively (particularly investigated in forfrail their Empowering and supporting members mended to avoid placing too much olderability people), to reduce thus the limiting risk of chronictheir food Mental Health to be food and nutrition leaders choices and contributing to an in- emphasis on one food. Minimally disease. Much of the interest in this re- promoting life-long wellness. adequate and poor-quality dietary Mentalprocessed health soyfoods problems should are comprise com- gard is because soyfoods are uniquely mon in the aging population. They intake.12 While a decreased dietary the bulk of the soyfoods consumed, Our Vision rich sources of isoflavones. include depression, anxiety, demen- Optimizing longevity and wellness in intake of protein leading to sarco- although more highly processed soy- tia, cognitive decline, and alcohol/ aging through food and nutrition. penia is well documented, literature foods can still serve as good sources examining the influence of non- substance abuse. Some of the symp- n protein nutrients on sarcopenia is less tomsof high-quality (such as apathy, protein. anorexia, and refusal of food and fluid) can cause 1The references for the take-away points on page 19 can be found throughout the body of this article. THE SPECTRUM • Spring 2015 Supplement 2 THE SPECTRUM • Fall 2014 18 Micronutrients food prices, nutrition labels, or reci- take due to oral health problems Continued from page 2 pes may affect the ability to grocery reduces the variety of foods avail- shop, prepare food, and eat. Re- able, which can lead to 80 years having a major olfaction search has concluded that people and deficiencies of essential micro- impairment.20 Some of the reasons with a higher intake of green, leafy nutrients in older adults.27 Modifying for decline in olfaction are gradual vegetables and foods that contain the texture and consistency of foods losses of the nasal nerve cells that antioxidants (including carotenoids by chopping, grinding, puréeing, or detect aromas, hormonal changes, but not vitamin E) are associated blending foods may help older adults a decline in nerve signals to the with a reduced risk for macular who have chewing or swallowing brain, and reduced mucous produc- degeneration.24 The National Eye problems. These modifications must tion in the nose.21 Losing the sense Institute’s Age-Related Eye Disease provide the same nutritive value of of smell may impact a person’s Study (AREDS) found that taking a solid foods and can be just as tasty enjoyment of food, leading to a specific high-dose formulation of an- and appealing. Foods modified into reduced food intake and therefore tioxidants and zinc (beta-carotene; a thickened liquid are often required a decreased nutrient intake. Taste vitamins A, C, and E; copper; and for older adults with dysphagia. Older disorders (including loss of taste) are zinc) significantly reduces the risk of adults and their family members must more common among older adults advanced age-related macular de- seek the guidance and advice of a with chronic conditions who are generation and its associated vision registered dietitian nutritionist, speech consequently taking multiple medi- loss.25 However, later studies reported therapist (for patients with dyspha- cations; this polypharmacy often inconclusive findings. Older adults gia), and/or an occupational thera- leads to loss of appetite, changes in who need assistance with perform- pist for the planning and preparation food preferences, weight loss, and ing daily activities such as cooking, of special meals and foods. For more .22,23 A declined ability shopping, and reading instructions information about oral health and to detect sour taste can lead to a must be provided with the necessary older adults, see “The Relationship Be- failure to recognize unripe or spoiled help by family members and care- tween Oral Health, Nutritional Status, foods. Adding appropriate spices givers, and/or get connected with and Food Intake in Older Adults” in and herbs can enhance a food’s fla- community support services. the fall 2014 edition of The Spectrum. vor, increasing its appeal to an older Table 1 lists the micronutrients im- palate. Similarly, improving the visual Oral Health Problems pacted by changes during the pro- presentation by incorporating bright cess of aging. colors, a variety of shapes, and suit- Oral health problems may limit food able textures can help increase in- choices, diminish the pleasure of eat- take as well. ing, and impair the ability to bite and Interventions to Reduce chew foods. These problems can Micronutrient Deficiencies negatively affect the nutritional and Impaired Vision Older adults can face many socio- health status of the aging population. economic barriers to meeting their Impaired vision can result from age- Older adults who have missing teeth, nutritional needs, such as those dis- related eye changes or from dis- gum problems, or wear dentures usu- cussed below. eases that affect the eyes, such as ally avoid eating foods such as raw cataracts, glaucoma, diabetes, or vegetables, whole fruits, and meats. Social and Physical Factors macular degeneration. Loss of visual Foods most commonly avoided by acuity may lead to less physical ac- older adults are whole apples, whole Social and physical factors affect tivity or a fear of cooking, especially nuts, raw carrots, and grilled or fried food choices and eating patterns. of using the stove. Inability to read meats.26 A decrease in dietary in- They include cultural and religious beliefs, level of education, budget- Table 1: The micronutrients impacted by changes during the aging process. ing skills, nutritional knowledge, food Changes in Body Physiology and Impact on Micronutrient Need preferences, cooking skills and facili- Functions ties, social situations, whether living Decreased bone density Increased need for calcium, vitamin D alone or with family, and immobility. These factors should be considered Decreased immune function Increased need for vitamin B vitamin E, 6, when planning suitable nutrition zinc interventions to improve dietary in- Increased gastric pH Increased need for vitamin B , folic acid, 12 take and overall nutritional status. calcium, iron, zinc Enabling older adults to participate Decreased calcium bioavailability Increased need for calcium, vitamin D in meal programs such as Meals Decreased hepatic uptake of retinol Decreased need for vitamin A on Wheels not only improves their food and nutrient intakes, but also Increased levels of homocysteine Increased need for folate, , provides an opportunity to promote vitamin B12 Increased oxidative stress Increased need for vitamin C, beta- health and well-being. carotene, vitamin E Continued on page 4

THE SPECTRUM • Spring 2015 Supplement 3 Micronutrients mon among older adults, as they smoking, and using vitamin/mineral Continued from page 3 are more likely to be taking more supplements is strongly associated prescription medications than are with more frequent consumption Income younger adults. Polypharmacy, un- of fruits and vegetables.43 The in- The effect of income on nutritional necessary and/or excessive use of take data of older-adult subjects in status has been reported in several both prescribed and over-the-coun- southern California and Oklahoma studies. Lower-income older adults ter medications, is a common prob- suggest that marginal deficiencies in were reported to have reduced lem among older adults. Over-the- intakes of micronutrients relate to lo- intakes of several micronutrients, in- counter and prescribed medications cation (such as midlands vs. coastal can potentially cause side effects southern California) as well as to cluding vitamin C, vitamin B6, folate, iron, and zinc.28,29 The third National that can impact dietary intake and age.36 They reported deficits for fo- Health and Nutrition Examination the nutrient status of older adults. late, vitamin A, vitamin E, potassium, Survey (NHANES III) found that pov- These side effects include altered and calcium; and excessive intakes erty has a very significant impact sense of taste and smell,35 fatigue, di- of sodium and phosphorus among on micronutrient intake and nutri- arrhea, and other symptoms. A num- older adults in both southern Califor- tion status. Seventy-nine percent of ber of medications also interact with nia and Oklahoma. The addition of those estimated to have inadequate food and result in a reduced absorp- breakfast to traditional home-deliv- food consumption lived below the tion of nutrients, and can have an ered meal services to homebound, poverty line.30 Helping older adults adverse effect on the nutritional sta- frail elderly participants was shown enroll in nutrition assistance programs tus of older adults. Care providers of to significantly increase the intake (to be discussed in detail later) such older adults must be aware of these of the micronutrients potassium, as Meals on Wheels, senior nutrition interactions and monitor the intake calcium, iron, magnesium, and zinc; programs, the Supplemental Nutrition of medications by older adults. An- additionally, there was a tendency Assistance Program (SNAP), farmers’ other critical part of intervention for toward a greater consumption of vi- 44 market programs, and other services older adults is frequent, thorough re- tamins A, B6, B12, and D. help bridge the nutrition gap. views of all medications with discon- tinuation of nonessential therapies. Other Interventions to Food Insecurity Prevent Micronutrient Food insecurity has a significant im- Dietary Patterns and Depletion in Older Adults Micronutrient Intake of Older pact on the nutritional status of older Many older adults do not obtain suf- adults in the United States. It is the Adults ficient amounts of micronutrients.4,45 position of the Academy of Nutri- Numerous studies have been con- Nationwide surveys have shown that tion and Dietetics that systematic ducted to determine the dietary a large percentage of older adults and sustained action is needed to patterns and nutrient intakes of do not meet their nutrient needs achieve food and nutrition security older adults. Data from 1999–2000 from their daily food intakes and for all Americans.31 Older adults expe- intakes of many micronutrients by need other options that help bridge riencing food insecurity have lower older adults in the United States sug- the nutrition gap.46 Multinutrient sup- intakes of micronutrients and calories gest that older Americans may be plements and/or oral supplements in spite of age-related, normal reduc- deficient, either marginally or more are often necessary to improve the tions in caloric needs; more health severely, in a few micronutrients due nutritional status of older adults, es- problems; and functional limitations to low intake.36 Older Americans pecially during illness or after surgery. related to loss of independence.32 who take multivitamin and mineral Data analyzed from NHANES III and supplements have considerably Oral Nutrition Supplements the Nutrition Survey of the Elderly in higher circulating levels of practi- Older adults unable to obtain ad- New York State in 1994 showed that cally all micronutrients compared equate nutrition from consuming a food-insecure older adults had sig- 37 to non-users. Older adults from regular diet often need commercially nificantly lower intakes of macronu- low-income households eating con- prepared oral supplements (liquid, trients, and the micronutrients niacin, venient, nutrient-sparse foods have pudding, and/or powder) to bridge , vitamins B and B , magne- 6 12 higher energy and lower nutrient the nutrient gap. Oral supplements sium, iron, and zinc.33,34 Older adults 38 intakes. Several studies indicate are usually formulated to provide an who are identified as being food- that although older adults consume array of micronutrients along with the insecure must be referred to nutrition more fruits and vegetables (excel- macronutrients and calories to meet assistance programs and other sup- lent sources of vitamins and minerals) the nutritional needs of older adults port services to help reduce malnutri- than do younger adults, only 21–26% experiencing or recovering from ill- tion and micronutrient deficiencies. of men and 29–37% of women ness, surgery, unintentional weight ages 65 and over actually met the loss, cancer, and other medical con- Medications recommended number of servings ditions. A variety of supplements is 39–42 Impact of medications on food per day Healthy lifestyle factors, available, including those formulated intake and nutritional status is com- such as being physically active, not Continued on page 5

THE SPECTRUM • Spring 2015 Supplement 4 48 Micronutrients promised hepatic function. Large adults be encouraged to consume 52,53 Continued from page 4 doses of vitamin A consumed over a B12-fortified foods. long period of time can overwhelm for specific conditions such as chronic the liver’s capacity to store vitamin A, Folic Acid obstructive pulmonary disease, 4 eventually leading to liver disease. Folic acid (also known as folate or diabetes, renal disease, and other Sebastian et al.48 reported that 25% folacin) is rarely found naturally in medical conditions. A liquid nutrition of older adults studied had inade- foods and is typically used in vitamin supplement can be thin, moderately quate intakes of vitamin A from foods supplements and fortified foods. Fo- thick (a milkshake), or very thick (a alone; however, 5%–9% of women ex- late levels among older adults have pudding). Powdered supplements ceeded the upper limits for vitamin A improved since 1998, when the Food are designed to be mixed into liquid from both foods and dietary supple- and Drug Administration (FDA) man- or solid foods such as soups, juices, ments. As part of intervention efforts, and puddings. These supplements are dated folate fortification of breakfast older adults should be encouraged cereals and other grain products. not designed to replace meals; they to consume at least one serving daily should be included in between meals of a carotenoid-rich food, and avoid Folate and vitamin B12 status should and as snacks to increase nutrient taking multivitamin supplements that be assessed in older adults with or intake, improve dietary compliance, provide vitamin A solely as a pre- suspected of having depression, and and avoid satiety that would result in formed compound; a safer alterna- also among those using medications poor intake during mealtimes. tive is to provide a portion as beta- such as histamine-2 blockers, proton- carotene or as mixed carotenoids.4 pump inhibitors, and antibiotics.4 Vitamin/Mineral Supplementation Multivitamin/mineral supplementa- tion can improve B-vitamin status Inadequate micronutrient intake Vitamin C and reduce plasma homocysteine among older adults is common de- Many older adults take a vitamin concentration in older adults already spite the increased availability of forti- C supplement in conjunction with consuming a folate-fortified diet.52 fied foods in the American diet.45 Di- a daily multivitamin supplement in etary sensitivities such as lactose intol- the belief that the additional dose Vitamin D erance, food preferences, and other of vitamin C will prevent colds and factors previously discussed necessi- reduce the risk of infections. The ad- Vitamin D insufficiency is now widely tate the need for dietary supplements ditional vitamin C supplementation recognized as a global epidemic, to obtain the needed micronutrients. has not been shown to be effective especially among older adults. Micronutrient deficiencies have been in clinical trials.49,50 It is recommended Given the current increase in recom- reported in nursing-home populations, that older adults include foods rich in mendations to 20 micrograms per and it has been suggested that all vitamin C to best meet their require- day, especially for older adults over institutionalized older adults receive ments for this vitamin. Foods rich in age 70, dietary sources of vitamin a multinutrient supplement for gen- vitamin C are a superior choice over D alone may not be adequate; eral nutritional prophylaxis.46,47 When vitamin C supplements, as whole supplements providing vitamin D 4 considering the addition of vitamin/ foods provide additional nutrients, and vitamin D3 are recommended. mineral supplements for older adults, calories, and possibly fiber. Caretak- Encouraging older adults to increase it is important to make sure that the ers and health professionals should physical activity and exposure to chosen supplement does not exceed encourage older adults to include sunlight is also important. Vitamin D the upper limits of recommended al- several servings of fruits and vegeta- toxicity, which occurs from excessive lowances. It is vital that caretakers bles in their daily diet to meet their consumption of supplements, results and health professionals review toxic- daily vitamin C needs. in hypercalcemia, loss of bone mass, ity side effects from excess intakes of and loss of appetite. (Part 1 of this all fat-soluble vitamins. Vitamin B two-part series discusses vitamin D in 12 detail.) Caretakers must monitor their Supplementation can improve micro- Vitamin B deficiency affects 30% of 12 patients’ intakes of vitamin D supple- nutrient status in healthy older adults older adults over 60 years of age.51 to levels above those obtained with ments and have their vitamin D lev- Many older adults are unable to els checked regularly. a fortified diet alone. This improve- consume animal proteins (the main ment in micronutrient status is helpful source of dietary B ) because of 12 Calcium in reducing the risk for chronic diseas- poor dentition, the high cost of es and current nutritional deficiencies animal protein foods, or dysphagia. An older adult’s calcium bioavail- among older adults. Specific nutrients ability typically decreases with age. Since the synthetic vitamin B12 added of concern include calcium, zinc, to fortified foods is more easily ab- Vitamin D absorption decreases as 45 iron, and B-vitamins. sorbed and may be the best source part of the aging process, and a of this micronutrient, both the Insti- reduced production of skin cholical- Vitamin A tute of Medicine and the National ciferol means that the skin cannot Vitamin A requirements for older Institutes of Health Office of Dietary produce as much vitamin D from adults are reduced because of com- Supplements recommend that older Continued on page 6

THE SPECTRUM • Spring 2015 Supplement 5 Micronutrients meatloaf with tomato sauce; and to enhance the absorption of iron. Continued from page 5 snacks such as chips, pretzels, and Consumption of iron-rich foods must popcorn.56 This is a concern since also be encouraged among older sunlight exposure. For optimal health, the food choices for many older adults. the Institute of Medicine’s recom- adults include soft and easy-to-eat mended calcium intake for adults foods such as rolls and soups. Ad- Zinc 51 years of age and older is 1,200 ditionally, the Dietary Approaches to Zinc adequacy is important among mg/day, with the maximal dose of Stop Hypertension (the DASH diet) is older adults to prevent or reduce elemental calcium not to exceed a healthy alternate for many older infections, and for wound healing. 500 mg at any time.53 The most ef- adults who need to reduce their Zinc supplementation reduced the fective form of calcium is calcium blood pressure, as it is rich in potas- frequency of infections among older carbonate, as it is well absorbed sium, magnesium, and calcium, with adults.59 Zinc has also been identified and tolerated by most people when 57 a few other restrictions. However, as a factor in the development of consumed with a meal. However, low-sodium diets are often not well age-related macular degeneration calcium citrate is the preferred form tolerated by older adults, especially (AMD). As mentioned earlier, zinc to be used for older adults with intes- by frail elderly adults, and may lead supplementation in combination tinal problems, such as achlorhydria to hyponatremia, loss of appetite, or inflammatory bowel disease. Sup- with antioxidant vitamins reduced and confusion. Decreases in dietary 24 plementation of both calcium and the incidence of AMD. The zinc intakes resulting from the intake of a Estimated Average Requirement vitamin D can help reduce fractures low-sodium diet may lead to dete- in older adults. Adequate nutrition (EAR) for males over 50 years is 11 riorated nutritional status, weight loss, milligrams per day, and for females and regular participation in physical and other medical complications. activity are important interventional over 50 years the EAR is 8 milligrams The 2002 position paper of the Acad- per day. The best way to obtain factors in achieving and maintaining emy states that the quality of life and optimal bone mass. adequate zinc in the diet is to eat a nutrition status of older residents in wide variety of foods. long-term-care facilities may be en- Magnesium 58 hanced by a liberalized diet. Older Improving Dietary Intake Magnesium along with calcium and adults must be encouraged to read vitamin D is essential for maintaining food labels for information about Improving dietary intake is one of the bone health. A few studies have as- foods’ sodium content, reduce their most optimal interventions for pro- sessed the impact of supplemental consumption of processed foods, use moting health, preventing diseases, magnesium on bone metabolism. less salt in cooking, add flavoring with reducing the risks for chronic condi- Improvements in bone mineral den- spices, and increase their intake of tions, and preventing micronutrient sity were noted in osteoporotic post- fresh foods and home-cooked meals. deficiencies. Several organizations menopausal women who received Additionally, older adults receiving including the Academy, U.S. Depart- magnesium supplementation.54,55 foods from Meals on Wheels or an- ment of Agriculture (USDA), National other nutrition program must select Cancer Institute, and American Heart Association all promote com- Sodium low-sodium meals if they are hyper- tensive or need to reduce dietary mon guidelines to achieve goals to Sodium is usually consumed in ex- sodium because of other medical increase lifespan and improve life cess of what is needed by older conditions. quality. The Dietary Guidelines for adults. Reduction of dietary sodium Americans, 201060 outlines the basic reduces hypertension and the risk of Iron strategies for healthy living and also cardiovascular disease, congestive encourages older adults to include heart failure, and kidney disease. Salt Iron requirements for women de- foods fortified with vitamin 12B . added at the table and in cooking crease slightly after menopause. provides only a small proportion of Although somatic iron stores are Nutrition Education the total sodium intake. Most dietary thought to increase with age, ab- sodium actually comes from the sorption of iron from foods is im- Nutrition education can be a suc- consumption of restaurant foods and paired in older adults with atrophic cessful intervention when the meth- processed foods, since salt is added gastritis. Oral iron supplementation ods and messages are targeted and 61 during food processing. More than is effective for the treatment of iron- simple. Nutrition education must 40 percent of sodium intake comes deficiency anemia, and can replen- be offered to older adults in familiar from the following ten types of foods: ish total iron body stores after a few venues with easy access. breads and rolls; cold cuts and cured months of therapy. Iron is available in Nutrition Screening and Assessments meats; pizza; fresh and processed several forms, of which ferrous sulfate poultry; soups; sandwiches such as is the most commonly used form. Older adults typically have one or cheeseburgers; cheese; pasta mixed Ferrous iron is best absorbed in an more chronic health conditions that dishes (not including macaroni and acidic environment; hence vitamin cheese); mixed-meat dishes such as C is often added to iron supplements Continued on page 7

THE SPECTRUM • Spring 2015 Supplement 6 ents (namely vitamins D, B , B ; and tervention. MNT includes conducting Micronutrients 6 12 Continued from page 6 the minerals calcium, iron, and zinc) a nutrition assessment; establishing must also be included as an inter- a nutrition diagnosis; and selecting can affect their dietary intakes and vention in the screening process. appropriate nutritional interventions, micronutrient statuses. It is recom- counseling, and management of nu- mended that nutrition screening be Medical Nutrition Therapy (MNT) trition therapy for older adults. MNT a mandatory part of the geriatric Providing MNT to older adults by reg- can be provided in home settings, as health screening process. Addition- part of residential health care, and in ally, pertinent assessments for pos- istered dietitian nutritionists is a very cost-effective and result-oriented in- assisted-living facilities. MNT interven- sible deficiencies of select micronutri- tions enable older adults to make necessary dietary modifications, Table 2: Community and transitional-care models. (Reprinted with permission manage the treatment of chronic from the Academy of Nutrition and Dietetics.) diseases, and reduce malnutrition Community and and micronutrient deficiencies. Description Transitional-Care Models Several models used for transitional Geriatric Resources for Includes a nurse practitioner and a social worker who care and ongoing community care Assessment and Care of cares for low-income elders in partnership with the primary for older adults are effective inter- Elders (GRACE) care provider and interdisciplinary team. The team devel- ventions as part of the total care for ops an individualized care plan and determines the priority older adults. Table 2 describes some sequence for each component that incudes protocols de- of these models and the services of- veloped for the treatment of 12 targeted geriatric condi- tions (including protocol for malnutrition and weight loss). fered, and includes the roles of nutri- tion professionals. Program of All-Inclusive Capitated managed care benefit for elderly persons who Care for the Elderly use an adult day health center supplemented by in-house Older Americans Act Nutrition (PACE) and referral services to meet participants’ needs. A regis- tered dietitian is an integral member of the team. Programs (OAA) The Guided Care Model Targets older adults with chronic conditions and compli- OAA is the largest community nutri- cated health needs. Driven by a physician/nurse team tion services program for older adults and designed to focus on quality of life, improve the effi- administered by the Administration ciency of use of health care resources, and reduce cost. on Aging of the U.S. Department of Patient-Centered Provides comprehensive primary care for people of all Health and Human Services, through Medical Home (PCMH) ages and medical conditions. Registered dietitians “can Title III-C. These programs include be an integral part of the team that provides patient-cen- congregate meals, Meals on Wheels tered care to individuals through the medical home.” (which provides home-delivered Accountable Care New model of care under Health Care Reform (The Af- meals), nutrition screening and nutri- Organizations (ACOs) fordable Care Act). This model of care is similar to PCMH in tion education, and other services. that it allows a group of providers to manage and coordi- This program serves as an excellent nate the care of individual patients. As the recommended intervention service for older adults, model within the framework of health care reform, ACO is as the meals provide at least one- perceived as the upcoming model for cost saving and pa- third of the Dietary Reference Intakes tient care. ACO providers will be held to high quality stan- for older adults, thus reducing the dards and must secure better patient care and improved gap for nutritional deficiencies that health outcomes. If ACOs do not meet the standards set, they will be required to pay back Medicare for failing to might otherwise occur. Other pro- provide efficient cost-effective care. Food and nutrition grams such as SNAP and the Senior practitioners must take the initiative in identifying ACO net- Farmers’ Market Nutrition Program works within their markets and ensure their inclusion within enable older adults to purchase them. fruits, vegetables, and other healthy Transitional Care Model This model provides in-hospital planning and home follow- foods that provide necessary micro- (TCM) up for older adults with chronic conditions hospitalized for nutrients and boost the nutritional common medical and surgical conditions. The American status of their meals. Geriatrics Society defines this care model as “a set of ac- Although nutrition education is rec- tions designed to ensure the coordination and continuity of healthcare as patients transfer between different loca- ommended in most federal food tions or different levels of care within the same location.” and nutrition programs for older adults, it is not routinely provided. Community-based care A wide range of resources and services is available to older adults in the community. This includes home care, The OAA programs reach fewer than services such as caregiver support, community-based 5% of all older Americans, but the services such as adult day care, home hospitals, and tele- Supplemental Nutrition Program for medicine; and community-based services that require a Women, Infants, and Children (WIC) change of residence such as assisted living facilities, group homes, and continuing care communities. Continued on page 9

THE SPECTRUM • Spring 2015 Supplement 7 Table 3: Summary of federal food and nutrition assistance programs for older adults. (Reprinted with permission from the Society for Nutrition Education.)

Eligible Older Program Purpose Appropriation Target Population Services Participation Eligibility Adults Served US Department of Health and Human Services—Administration on Aging Older Americans Act Grants to state, tribal $1.49 billion total Age ≥60 y in greatest Nutrition, array of 9.5 million older Age is sole 18.5% Titles I–VII and community Fiscal year (FY) economic and/or social need, other supportive adults FY 2006 requirement programs on aging 2009 with particular attention to low- and health (see also (e.g., research, income minorities, those in rural services, protection Target demonstration areas, those with limited English of vulnerable older population projects) proficiency Americans column) Older Americans Act Title III $649 million Age ≥60 y; age ≥60 y and Congregate and 2.6 million older Same as 5.1% of all eligible Titles I–VII Nutrition services to FY 2009 disabled living in elderly home-delivered adults above older adults older adults housing, disabled living meals; nutrition 236 million meals but only at home and eating at screening, FY 2007 homebound congregate sites or receive assessment, eligible home-delivered meals with education, for home- older adults, volunteers during counseling delivered meal hours meals Older Americans Act Title IV $36 million Age requirement determined Congregate and 70,000 older Age is sole Not available Titles I–VII Tribal and native FY 2009 by Tribal organizations or Native home-delivered adults requirement organizations for Hawaiian Program meals; nutrition 4 million meals aging programs and screening, FY 2006 services education, counseling; array of other supportive and health services Nutrition Services Provides proportional $161 million Same as Title III Cash and/or Same as Title III Not available Incentive Program share to states and FY 2009 commodities to tribes of annual supplement meals appropriation based on number of meals served prior year US Department of Agriculture—Food and Nutrition Service Supplemental Nu- Assists low income $40 billion US citizens and legal residents Coupons or elec- 28.4 million (67%) ≤130% of the 30% of eligible older trition Assistance families to buy food FY 2008 who are most in need, gross tronic benefits to 51% children federal pover- adults participate; Program that is nutritionally income ≤130% federal poverty purchase breads, 41% adults ty guidelines 75% of these live adequate level; up to $2,000 countable cereals, fruits, 8% age ≥60y alone. resources, $3,000 if age 60+ y vegetables, meats, FY 2008 8% of all or disabled fish, poultry, dairy Supplemental products; seeds Nutrition Assistance and plants that Program participants produce food for are older adults households Commodity Food and $140 million Pregnant and breastfeeding Participants 466,180 Age ≥60 y, Not available Supplemental Food administrative funds FY 2008 women, mothers up to 1-y receive a monthly FY 2007 ≤130% federal Program to states and tribes postpartum, infants, children food package poverty 433,000 older to supplement diets. up of age 6 y guidelines adults Available in 33 states 33,000 women, Women, and two tribes infants, children infants, children 92% of those are ≤185% federal age 60 y and poverty older guidelines Seniors’ Farmers Grants to states and $20 million Low income older adults: Coupons or 46 agencies ≤185% federal Not available Market Nutrition tribes to provide FY 2008 at least aged 60 y and who vouchers to be FY 2006 poverty Program fresh foods and have household incomes of exchanged for guidelines 825, 691 older nutrition services not more than 185% federal fresh fruits and adults while providing poverty vegetables at FY 2006 the opportunity for local farmers farmers to enhance markets their business Child and Adult Healthy, nutritious $2.4 billion Children <12 y, homeless Nutritional meals 1.9 billion meals ≤185% federal Not available Care Food Program meals for children FY 2008 children, migrant children <15 and snacks FY 2008 poverty and adults in day y. Disabled citizens regardless guidelines 2.9 million children centers of age. Age ≥60 y; functionally 86,000 older impaired; reside with family adults members FY 2007

THE SPECTRUM • Spring 2015 Supplement 8 Micronutrients parts of crops. Efforts to produce and About the Author Continued from page 7 accumulate carotenoids, iron, zinc, and other micronutrients in staple serves more than 60% of needy foods such as , cassava, and women, infants, and children.32 The even some fruits and vegetables are success of the WIC program has underway in Africa and Asia. Biofor- been attributed to its strong empha- tification may offer cost-effective sis on targeted and effective nutri- and sustainable solutions to reduce tion education, the provision of nutri- micronutrient deficiencies. tious foods as prescribed by trained nutritionists, cost effectiveness, and Summary the provision of necessary resources and support to the participants. While good nutrition is a key factor Adequate funding and resources at every stage of life for maintaining are essential for increasing older good health and personal productiv- adults’ participation in senior nutrition ity, it is especially important for older programs. These include extensive adults because of the numerous outreach efforts, referral systems, changes that occur during the aging Vijaya Jain, MSc, MS, RD, CDN, is cur- educational programs, and effective process. The process of aging gener- rently a nutrition consultant in New program management. ally increases the risk of not obtaining York and an active board member adequate nutrition due to the onset of the New York State Women, In- Table 3 (previous page) includes a of illnesses, chronic diseases, decline fants and Children (WIC) Association. summary of federal food and nutrition in physical abilities and cognitive As a registered dietitian since 1979, assistance programs for older adults. skills, and other socioeconomic fac- she has over 30 years of experience tors. Undernutrition along with chronic in planning, directing, and coordi- and Enrichment conditions that interfere with the nating nutrition programs in diverse Over the years, specific micronu- maintenance of health and nutrition settings. At the University of Illinois, trients have been added to foods status is fairly common among older Ms. Jain served as the director of the and beverages around the world as adults. Micronutrient deficiencies are Graduate Internship Program and as public-health measures, and as cost- also referred to as “hidden hunger” for a senior nutrition specialist. She has effective ways of reducing proven a very good reason: They do not oc- led the efforts to enhance school micronutrient deficiencies and ensur- cur because of a lack of calories, but lunch programs with soy-protein ing the nutritional quality of the food rather from a chronic lack of vitamins foods in India and Central America, supply. Among the best examples of and minerals in the diet. Older adults in partnership with the World Initiative these interventions are the addition have a difficult time obtaining ade- for Soy in Human Health, the primary of vitamin D to milk to prevent , quate levels of several micronutrients, goal of which is to create sustain- iodization of salt to prevent goiter, namely the vitamins A, D, E, K, B12, B6, able solutions to the problem of pro- and fluoridation of water to prevent and folate; and the minerals calcium, tein malnutrition around the world. dental caries. In other intervention magnesium, iron, and zinc. Nutrition Ms. Jain also coordinated research measures, multiple micronutrients interventions must be designed to and education efforts in Central are added to foods such as cereals meet all aspects of the needs of older America for the introduction of soy to improve micronutrient intake and adults, including food preferences, and whey-based multi-micronutrient prevent deficiencies. Older adults coping skills, food insecurity, and the supplements, and for the develop- must be encouraged to consume current health and nutritional statuses ment of microenterprise projects for some of these fortified and enriched of older adults. Although a varied diet families afflicted with HIV/AIDS. She foods to reduce and prevent micro- containing nutrient-dense foods can was actively involved with Illinois Soy, nutrient deficiencies. meet daily micronutrient requirements, which aims to improve the nutritional a daily multinutrient supplement spe- profile of the Illinois elementary and Biofortification cifically designed for older adults may secondary school lunches and re- be necessary to help meet the RDAs.4 duce obesity among school-aged Biofortification is a newer technology The current community-based nutrition children. As a clinical nutritionist at that combines the best traditional programs for older adults play a vital the New York Presbyterian Hospital breeding practices and modern role in helping to meet the nutritional of Columbia and Cornell Universities, technology62,63 to enable the delivery needs and address nutritional gaps for Ms. Jain provided nutrition counsel- of micronutrients via micronutrient- older adults. Easy access to these pro- ing to nutritionally vulnerable groups dense crops. Biofortification is a cost- grams, along with adequate nutrition and individuals. At the Ossining Open effective way of using cutting-edge services, will go a long way toward Door Health Center in New York, she plant-breeding methods and genet- helping to reduce micronutrient defi- was Director of the WIC program. ic modifications to deliver adequate ciencies among older adults and help micronutrient levels inside the edible them lead healthy lives. Continued on page 10

THE SPECTRUM • Spring 2015 Supplement 9 Micronutrients United States. J Am Diet Assoc. modifiable risk factor for frailty. Continued from page 9 2010;110:1368–1377. Nutrients. 2013;5:4126–4133. She received her MSc degree from 9. Position of the Academy of 19. Boyce JM, Shone GR. the University of Madras, her MS de- Nutrition and Dietetics: Food Effects of ageing on smell gree from the University of Illinois at and nutrition for older adults: and taste. Postgrad Med J. Urbana-Champaign, and her BSc promoting health and wellness. 2006;82(966):239–241. degree from the University of Ban- 2012;112(8):1255–1277. 20. Duyff RL. Aging tastefully: galore. Ms. Jain is the recipient of 10. Payette H, Hanusaik N, Boutier Exploring flavor perception, Distinguished Service Awards from V, Morias JA, Gray-Donald K. culinary techniques, health the New York State WIC Association Muscle strength and functional and aging. Food and Nutrition. (2005) and the New York State Metro- mobility in relation to lean 2014;3(1):15–17. politan WIC Association (2000). She is body mass in free-living frail 21. Schiffman SS, Graham BG. also a certified cardiovascular nutri- elderly women. Eur J Clin Nutr. Taste and smell perception tionist and has served as co-chair of 1998;52(1):45–53. affect appetite and immunity the nutrition committee of the Ameri- 11. Scott D, Blizzard L, Fell J, Jones G. in the elderly. Eur J Clin Nutr. can Heart Association. The epidemiology of sarcopenia 2000;54(3):S54–63. in community living older adults: Back to table of contents 22. Imoscopi A, Inelmen EM, Sergi G, What role does lifestyle play? J Miotto F and Manzato E. Taste Sarcopenia Muscle. References loss in the elderly: Epidemiology, 2011;2:125–134. causes and consequences. Aging 1. Center for Disease Control. 12. Mioche L, Bourdiol P, Peyron M. Clin Exp Res. 2012;24:570–579. Profile of older Americans: Influence of age on mastication: administration for community 23. Stringham JM, Hammond BR. Effects on eating behavior. Nutr living. U.S. Department of Dietary lutein and zeaxanthin: Res Rev. 2004;17:43–54. Health and Human Services. Possible effects on visual function. http://www.cdc.gov/aging/ 13. Semba RD, Lauretani F, Ferrucci Nutr Rev. 2005;63(2):59–64. emergency/general.htm. 2013. L. Carotenoids as protection 24. National Eye Institute. The AREDS Accessed May 26, 2014. against sarcopenia in older formulation and age-related adults. Arch Biochem Biophys. 2. United Nations Department macular degeneration. http:// 2007;458:141–145. of Economic and Social www.nei.nih.gov/amd/summary. Affairs Population Division. 14. Chaput JP, Lord C, Cloutier M, asp. Accessed August 10, 2014. World population ageing. et al. Relationship between 25. Quandt SA, Chen H, Bell RA, et 1950–2050. http://www.un.org/ antioxidant intakes and class 1 al. Food avoidance and food esa/population/publications/ sarcopenia in elderly men and modification practices of older worldageing19502050/index.htm. women. J Nutr Health Aging. rural adults: Association with oral Accessed May 26, 2014. 2007;11:363–369. health status and implications for 3. Chernoff R. Invited commentary: 15. Semba RD, Blaum C, Guralnik service provision. Gerontologist. Issues in geriatric nutrition. Nutr JM, Moncrief DT, Ricks MO, Fried 2009;50(1):100–111. Clin Prac. 2009;24:176–178. LP. Carotenoid and vitamin status 26. Ritchie CS, Joshipura K, Silliman are associated with indicators of 4. Marian M, Sacks G. Invited RA, Miller B, Douglas CW. sarcopenia among older women review. Micronutrients and Oral health problems and living in the community. Aging older adults. Nutr Clin Prac. significant weight loss among Clin Exp Res. 2003;15:482–487. 2009;24(2):179–195. community-dwelling older adults. 16. Michelon E, Blaum C, Semba J Gerontol A Biol Sci Med Sci. 5. Chernoff R. Effects of age on RD, Xue QL, Ricks MO, Fried LP. 2000;55(7):M366–371. nutrient requirements. Clin Geriatr Vitamin and carotenoid status in Med. 1995;11:641–651. 27. McGandy RB, Russell RM, older women associations with Harz SC, et al. Nutritional 6. Lichtenstein AH, Rasmussen H, frailty syndrome. J Gerontol A Biol status survey of healthy non- Yu WW, Epstein SR, Russell RM. Sci Med Sci. 2006;61:600–607. institutionalized elderly: Energy Modified MyPyramid for older 17. Drewnowski A, Shultz JM. Impact and nutrient intakes from adults. J Nutr. 2008;138:5–11. of aging on eating behaviors, three-day diet records and 7. Williamson DF. Descriptive epide- food choices, nutrition, and nutrient supplements. Nutr Res. miology of the body weight and health status. J Nutr Health 1986;6:785–798. weight change in U.S. adults. Ann Aging. 2001;5:75–79. 28. Fanelli MT, Woteki CE. Nutrient Intern Med. 1993;119:646–649. 18. Martone AM, Onder G, Vetrano intakes and health status of older 8. Position of the American Dietetic DL, et al. Anorexia of aging: a Association: Food insecurity in the Continued on page 11

THE SPECTRUM • Spring 2015 Supplement 10 Micronutrients 38. Serdula MK, Coates RJ, Byers should clinical intervention await Continued from page 10 T, Simoes E, Mokdad AH, Subar a research consensus? J Am Coll AF. Fruit and vegetable intake Nutr. 1995;14:563–564. Americans. Ann N Y Acad Sci. among adults in 16 states: Results 1988;94–103. 47. Drinka P, Goodwin J. Prevalence of a brief telephone survey. Am J and consequences of vitamin 29. Sahyoun N, Basiotis PP. Food Pub Health. 1995;85(2):236–239. deficiency in the nursing home: insufficiency and nutritional 39. Subar AF, Heimendinger J, A critical review. J Am Geriatric status of the elderly population. Patterson BH, Krebs-Smith SM, Soc. 1991;39:1008–1017. Nutrition Insights. 2000;18:1–2. Pivonka E, Kessler R. Fruit and 48. Sebastian RS, Cleveland LE, 30. Position of the American Dietetic vegetable intake in the United Goldman JD, Moshfegh AJ. Older Association: Food insecurity in States: The baseline survey of adults who use vitamin/mineral the United States. J Am Diet the Five A Day for Better Health supplements differ from nonusers Assoc. 2010;110:1368–1377. Program. Am J Health Prom. in nutrient intake adequacy 31. Position of the American Dietetic 1995;9(5):352–360. and dietary attitudes. J Am Diet Association, American Society for 40. Krebs-Smith SM, Cook A, Subar Assoc. 2007;107:1322–1332. Nutrition, and Society for Nutrition AF, Cleveland L, Friday J. US 49. Waters DD, Alderman EL, Hsia Education: Food and nutrition adults fruit and vegetable J, et al. Effects of hormone programs for community-residing intakes, 1989 to 1991: A revised replacement therapy and older adults. J Am Diet Assoc. baseline for the Healthy People antioxidant vitamin supplements 2010;110:463–472. 2000 objective. Am J Pub Health. on coronary atherosclerosis in 32. Lee JS, Frongillo EA. Nutritional 1995;85(2):1623–1629. postmenopausal women: a and health consequences are 41. Li R, Serdula M, Bland S, Mokdad randomized controlled trial. J Am associated with food insecurity A, Bowman B, Nelson D. Trends in Diet Assoc. 2002;288:2432–2440. among US elderly persons. J Nutr. fruit and vegetable consumption 50. MRC/BHF Heart Protection 2001;131(5):1503–1509. among adults in 16 US states: Study of antioxidant vitamin 33. Dixon LB, Winkleby M, Radimer Behavioral risk factor surveillance supplementation in 20,536 high- KL. Dietary intakes and serum system, 1990–1996. Am J Pub risk individuals: A randomized nutrients differ between adults Health. 2000;90(5):777–781. placebo-controlled trial. Lancet. from food-insufficient and food 42. Sahyoun NR, Xinli LZ, Serdula MK. 2002;360(9326):23–33. sufficient families: Third National Barriers to the consumption of 51. Baik HW, Russell RM. Vitamin B Health and Nutrition Examination 12 fruits and vegetables among deficiency in the elderly.Annu Survey, 1988–1994. J Nutr. older adults. J Nutr Elder. Rev Nutr. 1999;19:357–377. 2001;131:1232–1246. 2005;24(4):5–21. 52. McKay DL, Perrone G, 34. Brownie S. Why are elderly 43. Gollub EA, Weddle DO. Rasmussen H, Dallal G, Blumberg individuals at risk of nutritional Improvements in nutritional JB. Multivitamin/?Int J Nurs Pract. intake and quality of life among supplementation improves 2006;12(2):110–118. frail homebound older adults plasma B-vitamin status and 35. Anderson JJB, Suchindran CM, receiving home-delivered homocysteine concentration in Roggenkamp KJ. Micronutrient breakfast and lunch. J Am Diet healthy older adults consuming intakes in two US populations: Assoc. 2004;104:1227–1235. a folate-fortified diet.J Nutr. Lipid research clinics program 44. McKay DL, Perrone G, 2000;130:3090–3096. prevalence study findings.J Nutr Rasmussen H, et al. The effects 53. Food and Nutrition Board, Health Aging. 2009;13(7):595–600. of a multivitamin/mineral Institute of Medicine. Vitamin 36. Block G, Jensen CD, Norkus EP, supplement on micronutrient D. Dietary reference intakes: et al. Usage patterns, health, status, antioxidant capacity Calcium, phosphorus, and nutritional status of long- and cytokine production in magnesium, vitamin D, and term multiple dietary supplement healthy older adults consuming fluoride. Washington, DC: users: A cross-sectional study. a fortified diet.J Am Coll Nutr. National Academies Press. Nutr J. 2007;6:30–41. 2000;(19)5:613–621. 1999:250–287. 37. Ledikwe JH, Smiciklas-Wright H, 45. Park S, Johnson M, Fischer 54. Tucker KK, Hannan MT, Felson DT. Mitchell DC, Miller CK, Jensen JG. Vitamin and mineral Magnesium intake is associated GL. Dietary patterns of rural supplements: Barriers and with bone-mineral density (BMD) older adults are associated with challenges for older adults. J Nutr in elderly women. J Bone Miner weight and nutritional status. J Elder. 2008;27(3-4):297–317. Res. 1995;10:S466. Am Geriatr Soc. 2004;52:589–595. 46. Bales C. Micronutrient deficiencies in nursing homes: Continued on page 12

THE SPECTRUM • Spring 2015 Supplement 11 Micronutrients the Nutrition Committee of the December 2010. Continued from page 11 American Heart Association. 61. Sayhoun NR, Pratt C, Anderson A. Circ. 2000;102:2284–2299. Evaluation of nutrition education 55. Stendig-Lindberg G, Tepper 58. Position of the American Dietetic interventions for older adults: A R, Leichter I. Trabecular bone Association: Liberalized diets for proposed framework. J Am Diet density in a two year controlled older adults in long-term care. J Am Assoc. 2004;104:58–69. trial of per oral magnesium Diet Assoc. 2002;102(9):1316-1323. in osteoporosis. Magnes Res. 62. Nestel P, Bouis HE, Meenakshi 1993;6:155–163. 59. Prasad AS. Zinc: mechanism JV, Pfeiffer W. Symposium: of host defense. J Nutr. food fortification in developing 56. CDC. Sodium: The facts. http:// 2007;137:1345–1349. countries: Biofortification of www.cdc.gov/salt/pdfs/Sodium_ staple food crops. J Nutr. Fact_Sheet.pdf. Accessed May 60. U.S. Department of Agriculture 2006;136:1064–1067. 26, 2014. and U.S. Department of Health and Human Services. Dietary 63. Mayer JE, Pfeiffer WH, Beyer P. 57. Krause, RM, Eckel RH, Howard Guidelines for Americans, 2010. Biofortified crops to alleviate B, et al. AHA dietary guidelines: 7th Ed. Washington, DC: U.S. micronutrient malnutrition. Curr Revision 2000; A statement for Government Printing Office; Opin Plant Biol. 2008;11:166–170. healthcare professionals from

Free Guideline! Prevention of Type 2 Diabetes The Academy of Nutrition and Dietetics’ Evidence Library has released the Prevention of Type 2 Diabetes guideline.

The focus of this project is on medical nutrition therapy (MNT) for individuals who are at high risk for type 2 dia- betes, focusing on individucals with prediabetes (including children and adolescents) and adults with metabolic syndrome.

Highlights of this project include: • Seventeen (17) evidence-based recommendations • Evidence analysis under eleven (11) topic areas • A unique look at separate MNT interventions, without the influence of weight loss • Confirmation that the RDN plays a key role in the prevention of type 2 diabetes Available at www.andeal.org.

Call for Information: Conferences and Events

The Healthy Aging DPG calendar contains events of interest to RDNs and NDTRs who work with older adults. If you would like to suggest a conference or event for our calendar, please email Robin Dahm ([email protected]) with your information. The event must focus on the nutritional and physical health of older adults.

THE SPECTRUM • Spring 2015 Supplement 12 On Your Colleagues

MonicaInterview Sathyamurthy, by Wendy Baier MS, RD, Cartier, CDN RDN; HA DPG Membership Director Spotlighting:Spotlighting VijayaHolly Kellner Jain, M Greuling,Sc, MS, RD R,d CDN, Ld/N

THE HEALTHy AGING dpG is delighted and honored to highlight Holly Kellner Vijaya Jain, MSc, MS, RD, CDN, has My graduate education at the Uni- daycare Greulingfocused RD,the LD/N,majority a government of her career and businessversity strategist of Illinois with provided over 25 me years with of re achievement- centers inand healthcare administration andon improvingfood service the retail. nutritional Holly is status currently of employedsearch training, as a natio andnal innutritionist my thesis with work the Uschools.S. Department to of Health and Humanwomen, Services infants, (HHS), children, Administration and vulner on- AgingI studied (AoA) the within nutritive the valueAdministration and ac- for Communityimprove Living (ACL). This position attestsable populations to her administrative both in the expertise, United leadership ceptability initiative, of soy clinical foods. knowledge I went on for to assessingtheir meals the needs of older adults, abilityStates to and devise in several solutions developing and take decisive complete actions to facilimy internshiptate cooperation in San José,between diverseand food parties, service, and and attain to unified incorpo - countries. She is currently a nutrition California, worked as a supervisor in rate nutrition education activities for goals reflective of the organizational vision. She enjoys policy development and believes she can positively affect cultural consultant in New York and an ac- a clinical setting, and ended up with children and parents. After having andtive businessboard member models. of the New York the Visiting Nurses Association as a spent a significant part of my career AsState a national Women, nutritionist, Infants, and Holly Children assists in thenutrition administration consultant of federal in California regulations and relatedwith toWIC, federally I now fundedserve as nutrition a board (WIC) Association. Vijaya is a mem- then in New York. This last position member and advocate for the New programs. Her primary responsibilities center on the Title IIIC programs of the Older Americans Act. In her position, she ber of several Academy groups, in- challenged me to create sustainable York State WIC Association. I am coordinatescluding the nutrition-related Women’s Health, responses Healthy to policystrategies makers, for meetingacademic the and nutritional health professionals, actively theinvolved media, in and improving public andand privateAging, organizations. and Vegetarian Her Nutrition involvement in variousneeds committeesof homebound such olderas the adults. 2015 Dietaryadvocating Guidelines for for the American policies Revision, of WIC theDPGs. Office Additionally, of Dietary Supplements,she is a member the U.S.I DRIlearned Subcommittee, the incredible the HHS value Million of Heartsat Initiative, both the and state the and HHS federal Palliative levels. Workgroupof the Asian has Indians provided in Nutrition resources and to help teamworkassist the growth in delivering of community comprehen nutrition- services.I am also working with several inter- Dietetics Member Interest Group sive, effective home health care. national organizations dedicated to MS:(MIG), What as arewell some as the aspects Fifty Plus of yourin Nutri - thatLater, list aswould director be too of long.a WIC However, program USDAserving grant the for needs SNAP of outreach. groups vulner The - careertion and (such Dietetics as education MIG. and previ- I inmust Ossining, mention NY, how I focused much Jean more Lloyd inten - pilotable was to malnutrition.called “The Assisted Tele- ousPlease experiences) tell us about that your best professionalprepared hassively done on forpractical me. Ms. ways Lloyd, to the develop other phoneWhat Nutritionare your Assistancegoals for the Application future? youbackground for your current and the job path as a that national led to nationalnutrition-education nutritionist at toolsAoA, and has thenpro- PilotFollowing Project myfor internationalthe State of Florida.” work your incredibly diverse, international train instructors about these tools. I nutritionist for AoA? vided me with a great deal of training, Theinvestigating grant permitted micronutrient elderly Floridians supple- dietetics career. also advocated at the policy level background, guidance, and assistance inments, 35 of theI have 67 countiescontinued to applyto collabo for - HG:As an One undergraduate of the best aspects and graduateof being for the broad needs of the WIC rate with professional colleagues in the few short years we have worked SNAP over the phone and “sign” their astudent registered in India, dietitian I was is thatfortunate the field not population. Most recently, at the and organizations. Their focus is to University of Illinois, my work involved doesonly notto receive limit your a veryworking comprehen experi- - together. She has been in her current applicationsimprove the by nutritional speaking aprofile particular of sive education, but also to partici- jobplanning, for over coordinating, twenty years, andand I impleam - phrase.meals andThe pilotsnacks was being a success, provided and ences. I have had the good fortune menting school lunch and comple- ofpate working in numerous in a variety community of different pro - privileged to work with her. I tobelieve children this projectand adults. was expanded A major goal grams. We students were required mentary feeding programs. In this of these efforts is to improve the MS: What are your proudest profes- statewide after I left the department. settings.to implement I have appropriateworked as a clinicalnutrition role I also conducted intervention micronutrient intake of older adults dietitian,projects food-serviceand develop director, educational military sionalstudies accomplishments, using a soy- and and whey-based why? MS:in the Can home you share setting. with Comprehensive us your dietitian,materials. psychiatric Some of dietitian,these projects retail di - micronutrient supplement aimed ideaseducation about professionalhelps people develop make -better HG:at reducing I am proud malnutrition when I am in able several to etitian,were in skilled-nursing rural areas, and consultant, we had and the ment?optimal choices, and simpler food helpcountries. either individualsI have also or served groups. as a OAAopportunity State Unit to onlearn Aging first-hand dietitian. the preparation is crucial to achieving challenges people of all ages faced Whenmentor I help and individuals, preceptor I tolike both how grad I - HG:better I suggest nutritional that dietitiansstatus. This should is a goal Eachin terms of these of meeting experiences their hasnutritional helped receiveuate and immediate undergraduate feedback. students To help at startto which their careers I am dedicated as clinical ondietitians. an on- shapeneeds. me These in one challenges fashion or included another anSan individual José State accomplish University, a weightNew York or Ingoing my opinion, basis. clinical dietetics is the Medical College, the University of forthe the lack position of potable I am currently water and hold - other health goal is so rewarding. It is foundation for all other dietetic em- Illinois, and several other institutions. How do you feel dietetics practitio- ing.electricity; The variety inadequately of my experiences equipped has especially rewarding when a patient/ ployment.ners can Afterimprove that, the an qualityRD should of care health clinics; chronically ill infants, My varied work experiences have best prepared me for my current job. clientsustained is initially my dedicationdowntrodden to about reducing thinkand abouthealth what outcomes they like for to an do, aging or children, and older adults; and food population? Asshortages. a nutritionist Learning working how in tothe find ag- both hismicronutrient or her situation. deficiencies Helping that and per mal- - not do. The field is SO WIDE OPEN ingpractical network, and I need economical to be proficient solutions sonnutrition succeed in vulnerableis a major accomplish populations.- rightDietetics now; dietitianspractitioners can cango in play so a into a resolve multitude some of areas. of these Even problems with all mentWhat for are them some and of a your proud current moment roles manycritical fulfilling role by and acquiring financially adequate satisfy- mywas experiences, one of the Imost believe valuable many have lessons foras mea nutrition as the clinician. consultant? ingscience-based arenas. The medical knowledge community and is practical training, and also by ac- helpedfor me me as abecome young astudent. more proficient This life- I work with several non-profit orga- now waking up to the fact (a fact RDs changing experience inspired me I enjoy working on policy improve- tively participating in the special field national nutritionist. I would like to nizations that can benefit from the have long known) that “let food be thy to focus on strategies for reducing ments since they help a multitude of of geriatric nutrition as the nutrition give a shout-out to all the RDs in the expertise of a nutritionist, and am medicineexpert in and a team medicine setting. be thyThey food” should: malnutrition both in domestic and people.a guest For speaker example, for differentI headed comup a - fieldinternational who have settings.assisted me so far, but teammunity that organizations. applied for and I also obtained work witha continuedContinued on onpage page 17 14

THE SPECTRUM • Winter 2015 16 THE SPECTRUM • Spring 2015 Supplement 13 Spotlight: Jain What do you want dietetics leagues and mentors, and strive to Continued from page 13 practitioners to learn from your work in teams. professional experiences? Are there any other lessons you have • Strive to review and keep up to We work in a profession that is grow- learned during your career that you date on the latest science on geri- ing rapidly and will continue to do would like to share? atric nutrition. so. It is very important that dietetics I have learned that we can achieve • Participate as much as possible in practitioners keep up with new infor- more when we take the initiative, stay community settings that work with mation, be able to demonstrate their focused on a project’s mission, and older adults and need nutrition ex- knowledge of geriatric nutrition, and remain persistent. These approaches pertise. translate this knowledge into practi- help us find appropriate solutions to • Participate actively in the realm of cal, evidence-based recommenda- eliminate barriers and accomplish our advocacy and promoting policy tions that are easy to implement. In endeavors successfully. • changes. addition, we should continually learn from the experiences of our col- Back to table of contents

Nutrient Supplementation Tour our Marketing Center Project Now Available Today! The Academy of Nutrition and Dietetics’ Evidence The Marketing Center was developed to provide Analysis Library has released the Nutrient free marketing resources to help promote your Supplementation Project. services to potential clients and physicians. This project, updated from 2008, focuses on Included are the following: Vitamin E and Vitamin D supplementation in the • Promotional resources including radio scripts, adult population. videos and ready-to-use presentations. Highlights from this project include: • Customizable handouts and RD/RDN fl yers • Vitamin E and anti-coagulant interaction • Physician marketing resources including fl yers • Vitamin D and bone health in adult and older and free brochures populations • Eat Right Vista Print Solutions: Save 10% on The Academy’s Nutrient Supplementation a number of pre-designed customizable Position Paper is being developed and will be promotional pieces including fl yers, brochures available from this site when it is published in and posters the Journal of the AcademyTour ofour Nutrition New and MarketingAccess the Center Marketing Today! Center today at Dietetics. www.eatright.org/members/marketingcenter.

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Access the Marketing Center today at www.eatright.org/members/marketingcenterTHE SPECTRUM • Spring 2015 Supplement. 14 Improving Quality of Life for Older Adults: A Resource List Jamillah-Hoy Rosas, MPH, RD, CDN, CDE

Myriad physical, biological, and psychosocial changes accompany the aging process. Understanding these normal changes, their relationships to disease and disability, and how best to help older adults avoid or cope with these issues is essential for healthcare practitioners and researchers. Dietetics practitioners can keep abreast of these topics by being attuned to various resources, a few of which are listed below. Promoting Good Nutrition and Age-Appropriate specifically designed for those practitioners working with older Physical Activity adults on health and aging issues. An essential task for dietetic practitioners is connecting older- • To improve the likelihood that patients understand their medi- adult patients with resources that address key nutrition and cation regimens and stick to them, there are tools, reminders, physical activity messages specific for this age group. and resources available at Script Your Future. • The National Institute on Aging provides an interactive • The Institute of Medicine has a roundtable on health literacy resource, “What’s on Your Plate: Smart Food Choices for with an ongoing series of meetings and reports. Healthy Aging.” Smoking Cessation • The “Go for Life” campaign includes physical activity ideas and videos for the older adult. Quitting smoking is one of the best things people can do to pro- long their lives and improve their healthcare outcomes. Smoking Clear Communication Between Patients and cessation will also save the aging smoker thousands of dollars Healthcare Providers every year that could be better spent on healthy activities, such as buying nutritious food or increasing physical activity. It is vital for patients to choose healthcare providers with whom they can communicate comfortably. Clear communication im- • The American Cancer Society provides a flyer that discusses proves patient-provider relationships and patient outcomes. the hidden costs of smoking. • On its Clear Communications website, the National Institutes • Those looking to quit the habit can visit the National Cancer of Health provides a variety of resources about how patients Institute or call 1-877-44U-QUIT. Trained counselors are avail- can better communicate with their healthcare providers. able to provide information and help in English and Spanish. • The National Women’s Health Institute offers a simple handout Important Health-Related Lab Values on the topic. A person’s blood sugar, blood pressure, and blood cholesterol • The Conversation Project is a public engagement campaign numbers give vital information about disease risk. launched in collaboration with the Institute for Healthcare Im- provement specifically to promote “’kitchen table” conversa- • The American Diabetes Association and the American Heart tions with family and friends about wishes for end-of-life care. Association both provide excellent resources on ways to re- It offers a starter kit for initiating this difficult but important con- duce risk and improve health through lifestyle changes. versation. HIV Status Improving Medication Adherence and Health Literacy Adults aged 55 years and older are one of the fastest-growing populations to be newly infected with HIV. In older individuals As patients grow older, they are more likely to be diagnosed these infections are often diagnosed when the virus is already with multiple illnesses and have large medication burdens. Limit- in the later stages, which results in delayed treatment and the ed health literacy is associated with a number of health dispari- potential for poorer prognoses. Getting tested and beginning ties, poor health outcomes, and medication errors. treatment as soon as possible helps both the affected individu- • In 2009 the CDC developed a panel report with recommen- als and the overall spread of the disease. dations for improving health literacy in older adults. • Information about reducing risky behaviors and proper con- • The U.S. Department of Health and Human Services created dom use is available at the Administration on Aging’s website, the useful Quick Guide to Health Literacy and Older Adults whose HIV Testing Sites and Care Services Locator tool allows one to search for testing centers and service providers close to home.

Advance Directives There are two types of advance directives. A living will allows a healthy person to document his or her wishes concerning end- of-life medical treatments. A health care proxy is a person desig- nated to honor another person’s wishes for medical treatments in the event that he or she is unable to make these decisions. • The National Cancer Institute provides a very informative fact sheet, as well as additional resources and contacts to help individuals complete their advance directives. • State-specific information about completing a living will and/ or healthcare proxy is available at the Caring Connections website.

THE SPECTRUM • Spring 2015 Supplement 15 Navigating the Urban Food Environment: Challenges and Resilience of Community Dwelling Older Adults

Corrine E. Munoz-Plaza, MPH; Kimberly B. Morland, PhD; Jennifer A. Pierre, DrPH; Arlene Spark, EdD, RD; Susan E. Filomena, BA; Philip Noyes, MPH, MA

We thank the Journal of Nutrition Education and Behavior for allowing The Spectrum to reprint this continuing- education article. We welcome these kinds of partnerships that let us provide our members with quality CPE opportunities. INTRODUCTION and Aging Study for 1,002 disabled Approved for CPE Credit women aged ≥ 65 years residing in P Previous studies indicated that en- Baltimore, Maryland, indicates that vironmental factors influence indi- ABSTRACT 49.5% of minority women and 13.4% vidual behaviors, specifically food of white women reported financial Objective: Identify factors involved intake patterns.1,2 Different features difficulty obtaining food.37 in food shopping among older urban of local food environments, such as adults. variations in the costs of foods and To date, most US studies that de- Design: A qualitative study of 30 in- the types of foods available within scribe the relationship between local depth interviews and 15 “tagalong” markets, as well as the distance food environments and health be- shopping trip observations were con- traveled to obtain food, are of in- haviors or health status focus on chil- ducted. creasing interest to researchers.3–8 In dren or middle-aged adults, whereas research related to older adults in Setting: Brooklyn, New York. addition, the presence or absence of particular types of retail food out- this arena remains sparse.38–40 Rec- Participants: Black, white, and Latino lets is known to be a function of the ognizing the lack of understanding men and women aged 60-88 years. racial and economic makeup of surrounding factors that influence Main Outcome Measure: Transcripts some areas, particularly in the United older adults and food access, Wolfe were coded inductively to identify States (US).9–25 et al38 suggested a conceptual analysis of food insecurity among emergent themes. Moreover, public health professionals older adults based on in-depth inter- Results: Older adults shopped at mul- and clinicians alike are increasingly views with older adults from upstate tiple stores to obtain the quality of weighing how environmental ob- New York. The researchers defined foods preferred at prices that fit their stacles influence the ability of adults a model that includes the concept food budgets. Participants often to meet recommended nutritional of community characteristics—such traveled outside their neighborhoods guidelines.26–31 This is a particular as grocery store availability and to accomplish this, and expressed concern for older adults, many of prices, transportation services, and dissatisfaction with the foods locally whom are managing diet-related the availability and features of food available. Adaptive food shopping chronic diseases such as hyperten- programs—as factors that relate to behaviors included walking or the sion, diabetes, and heart disease.32,33 older adults’ ability to obtain and use of public transit to purchase food Furthermore, more than a third of prepare food. In addition, research in small batches, as well as reliance older adults in the US had a disability from Canada suggests that the el- on community resources and social in 2010.34 Research on the elderly in derly have unique needs and tend network members. New York City public housing docu- to confine their shopping to their ments both the health challenges Conclusions and Implications: local environment, which leaves and vulnerability of this population.35 Participants identified a number of them at a disadvantage for obtain- The authors report that approximate- multilayered factors and challenges ing competitively priced food items ly two thirds of the older adults in involved in procuring food. These available elsewhere.41–43 More recent their study indicated a health status factors conform to elements of eco- research includes a study linking of fair or poor; most suffer from one logical behavioral models described food insecurity among older adults or more chronic diseases; roughly a as intrapersonal, social, and environ- to the walkability of their immediate third had a diabetes diagnosis or ex- mental level influences and have re- neighborhood.44 perienced limitations in activities of sulted in adaptive behaviors for this daily living; and one in five reported To better understand the challenges population. These findings provide food insecurity. In addition to physi- older adults face, qualitative inter- evidence that can be used to devel- cal limitations, many older adults rely views with older New York City resi- op more effective programs, as well on a fixed income, which is also likely dents were conducted to explore as promote testable interventions to influence their food choices, be- their experiences navigating local ur- aimed at keeping older adults inde- haviors, and consumption patterns.36 ban neighborhoods to obtain food. pendent and capable of acquiring For instance, an analysis of the base- Participants shared their perspectives food that meets their age-specific line data from the Women’s Health needs. Continued on page 17

THE SPECTRUM • Spring 2015 Supplement 16 Navigating purposefully for their heterogeneity in not reported anywhere in the data; Continued from page 16 terms of the neighborhood in which instead, pseudonyms were substi- they resided at that time (i.e. racial/ tuted for all of the names (selected on a number of complex challenges ethnic makeup and wealth of the from a list of common male and fe- that they face when shopping for neighborhood). Thus, the 30 partici- male names). food and/or using food-related pants completing the first qualita- community resources, including in- Qualitative Observations tive interview represent 17 Brooklyn come, transportation, functional mo- neighborhoods, or 30% of the total Information about participants’ bility, and social support. Study par- neighborhoods in the borough. home environments and immediate ticipants also shared their attitudes neighborhoods, as well as their per- Eligibility criteria for inclusion in this and perspectives about the sources sonal affect, demeanor, and physi- qualitative component required of food that are available in their cal resilience, were documented in that each individual be fluent in neighborhoods, such as food stores, the form of observational field notes English, have completed the base- restaurants, community centers, and at the time of the first interview. line measurements for the parent food banks or pantries. These observations were dictated study, have reported in the baseline onto audiotape immediately post- interview that they were the primary METHODS interview. food shopper in their household, and Participants and Recruitment have consented to be contacted for Shopping-Trip Observations the qualitative interview. Informed Participants (n = 30) were selected Approximately four to six weeks af- consent was obtained from eligible from a larger prospective cohort ter the first interview, participants participants at the first scheduled of 1,453 older adults enrolled in the were asked to allow the researcher interview. Once a sample of 30 indi- Cardiovascular Health of Seniors and to shadow them during a regularly viduals agreed to participate, no ad- the Built Environment study (CHBE), scheduled food shopping trip at the ditional cohort members were con- in which men and women aged establishment that they had previ- tacted. The Mount Sinai School of 59–99 years were enrolled between ously identified as their “primary” Medicine Institutional Review Board January, 2009 and June, 2011. Par- food store. Half of the original co- reviewed and approved the quali- ticipants for the CHBE study were re- hort (n = 15) agreed to participate tative research component, which cruited from New York City communi- in this component of the study (the included both the baseline and tag- ty social service centers located in all “tagalong” shopping trip). Reasons along interviews. areas of Brooklyn. Participants were for refusal included illness, time con- eligible for the study if their reported straints, and competing priorities, as Instruments and Procedures race/ethnicity was black, white, or well as changes in shopping patterns Latino; they spoke English or Spanish; In-Depth Qualitative Interviews (some individuals were no longer the and they were judged able to under- Face-to-face, audiotaped interviews primary shoppers in their household stand the purpose of the study and were conducted at participants’ because of declining health or ill- the respondent’s burden (n = 1,453). homes between September, 2010 ness). The purpose of this component The population enrolled reflects the and April, 2011. A semi-structured of the research was to: (1) identify race/ethnicity of the base popula- guide directed the discussion dur- modes of transportation to the food tion of older adults from the neigh- ing each interview. The interview or shopping location(s); (2) observe borhoods sampled within 10%. guide contained four key sections store characteristics; (3) describe A list of eligible cohort members with a series of questions and probes purchasing patterns; and (4) docu- was used for block sampling by exploring participants’ shopping, ment the total bill and source of pay- geographic area across Brooklyn, cooking, and eating habits (Table 1, ment (i.e., Supplemental Nutrition As- New York. Although it was not fea- next page). Participants also listed sistance Program debit card, cash, sible to sample older adults from the members of their social network credit). Observational data were every Brooklyn neighborhood in (including individuals and institutions) collected through descriptive field this qualitative study, attention was and the types of support provided notes, which were dictated onto au- paid to recruiting participants from by each network member, including diotape immediately post interview. a number of distinct neighborhoods, informational, emotional, instrumen- Each tagalong trip lasted 1.5-2 hours. both to capture the diversity of ex- tal, and appraisal support.48–50 Inter- periences across Brooklyn and to views lasted one to two hours. Socio- Data Analyses sample enough participants to likely demographic information was col- All audiotapes were transcribed achieve saturation in the data, as lected as part of the baseline exam verbatim. Dialogue of the discus- defined by the point at which ongo- from the CHBE study (parent study), sions related to social networks ing data collection does not con- as was the index (cal- was recorded but not transcribed. tinue to yield new information within culated from standardized questions Social network lists were coded for the conceptual categories of inter- from the US Department of Agricul- the number and types of network est.45–47 Participants were recruited ture).51 Participants’ real names were Continued on page 19

THE SPECTRUM • Spring 2015 Supplement 17 Table 1: Shopping, Cooking, and Eating Patterns of Participants in the Brooklyn Seniors Built Environment Qualitative study: Interview Guide (n = 30).

Where do you regularly shop for groceries and food? Please be specific and tell me all the places that you shop. (Probe: grocery stores, food carts, food pantries, bodegas, corner grocery stores, etc.) Related questions: • How often do you shop at each location? • How do you get your groceries home? • Where are each of these stores/bodegas located? • How much does your transportation to the store cost? • Which of them would you say that you use most often to get your groceries/food? • Are there ever times that you do not go shopping Why do you prefer this bodega to others? because you do not have the money to go shopping? • How do you get to each store? • How long have you lived here? • How hard is it for you to get to the store? Why is it hard for you to get to the store? Are there family concerns?

What types of food/groceries do you typically purchase at each store? Related questions: • How do you decide what to buy? • Can you read the food ingredients on the labels? How do you decide what to buy? (Probe: cost, seasonality, freshness, quality, etc.) Do you read these labels to decide what to buy? (Probe: cost, seasonality, freshness, quality, etc.) If so, what is it on the label that will make you Do• Do you you have have dietary dietary restrictions restrictions related related to to any any medical conditions? decide whether or not to buy the item? medicalIf so, whatconditions? are the medical condition(s) and what are your dietary limitations? If so,How what do are these the restrictionsmedical condition(s) affect your and ability what to shop for groceries and food? Canare you your read dietary the limitations?food ingredients on the labels? HowDo do you these read restrictions these labels affect to yourdecide ability what to toshop buy? If so,for whatgroceries is it on and the food? label that will make you decide whether or not to buy the item?

How often do you eat outside your home? Please be specific and tell me all of the places that you eat food outside the home. (Probe: restaurants, fast food, prepared foods from bodegas or stands, senior centers, etc.) Related questions: How often do you eat at each location? What types of food does each location provide? • How often do you eat at each location? • Does anyone go with you to eat or do you typically What do you typically get to eat at this location? go there by yourself? • WhatWhy types do you of food select does the each particular location dish provide?or dishes? Who goes with you? (Probe: cost, portion size, flavor, specialty at that location, etc.) • What do you typically get to eat at this location? When you eat out with this person, who typically Does anyone go with you to eat or do you typically go there by yourself? Why do you select the particular dish or dishes? pays for the meal? Who goes with you? (Probe: cost, portion size, flavor, specialty at that When you eat out with this person, who typically pays• How for the much meal? do you usually spend at each location location, etc.) How much do you usually spend at each location when youwhen eat youther e?eat there?

To what extent do you prepare meals at home? Related questions: Do you prepare mdoes that person help you prepare food specifically? What• Do youtypes prepare of food/dishes meals by do yourself you typically or does cook? someone What are• Are your there favorite certain things foods to preparethat you ateat home? based on help you and/or cook for you? family traditions or religious reasons? WhomIn what do waysyou eat doese dietary that person restrictions? help you prepare If so, what? • Besides for medical reasons, are there certain foods food specifically? you prepare meals based on recipes? To what extent do that you DO NOT eat for any reason, such as religious Where do those recipes come from? • What types of food/dishes do you typically cook? restrictions? (Probe: handed down from family/friends, cookbooks, magazines, Web sites, etc.) What are your favorite things to prepare at home? (Probe: cultural taboos, grew up in another country Are there certain foods that you eat based on family traditions or religious reasons? where certain foods were not available, etc.) Besides• Whom for do medical you eat reasons, with at are home? there certain foods that you DO NOT eat for any reason, such as religious restrictions? (Probe:Do they cultural have taboos, dietary grewrestrictions? up in another If so, what? country where• Arecertain there foods certain were foods not available,you would etc.) prepare, but cannot because you do not think you can afford to Are• To there what certain extent foodsdo you you prepare would meals prepare, based but oncannot because you do not think you can afford to purchase purchase them at the store? themrecipes? at the store? DidWhere your doctor do those ever recipes put you come on a from? diet? • Did your doctor ever put you on a diet? (Probe:What handed kind of diet?down from family/friends, What kind of diet? cookbooks,Was it hard magazines, for you to Web follow sites, the etc.) diet? Why or why not?Was it hard for you to follow the diet? Why or why How long did you stay on the diet? not? How long did you stay on the diet?

THE SPECTRUM • Spring 2015 Supplement 18 Navigating Older Adults and Food physical challenges posed by having Continued from page 17 Shopping: “It Is a Struggle” to carry their groceries home by hand or in a wheeled shopping cart. The members, as well as for the types This population of older adults ad- majority of those who did not take of food-related support provided dressed a myriad of challenges advantage of this service said they by each network member. All data when navigating their local environ- wanted to avoid the delivery fee were stored securely on Mount Sinai ments to acquire food. Foremost, (stores typically require a minimum School of Medicine servers. Tran- they relied on their ability to shop purchase to waive the fee). Older scripts, including those obtained for groceries and prepare their own adult men tended to cite their desire from both the interviews and obser- meals at home. Successfully accom- to remain independent as the reason vations, were prepared and import- plishing these tasks was important they avoided delivery. Bill (age 80 ed into ATLAS.ti qualitative software to their sense of identity, because years) observed a kosher diet and (version 4.1, Scientific Software De- it epitomized their ability to func- was proud of the fact that he did all velopment GmbH, Berlin, Germany, tion independently. Barbara (age of the shopping for his household. He 1997) to assist with the analysis. Initial 84 years) offered an example of an chose not to have the store deliver coding categories, more descriptive older adult with just this perspective. his groceries because “to exercise is in nature, were generated from our She used a walker to get around, to do something” and he wanted “to preliminary research questions and yet could carry up to four bags of keep myself occupied.” key domains of inquiry to create a groceries home from a single trip start list of codes.52 Next, repeated to the grocery store. Describing her Food Shopping Frequency and review and coding of the transcript motivation, she explained, “I tell you Patterns data was conducted, relying on something. It is difficult, but I don’t Older adults described typically shop- a grounded theory approach to want to have an aide. I want to do ping (at least once a week) and pur- generate additional coding cat- everything myself.” chasing items in small batches. Buy- egories (known as “open” and “in Transportation: Getting To and From ing fewer items, with more frequency, vivo” codes in ATLAS.ti) and highlight The Food Market was a food-shopping strategy partici- thematic patterns, including areas pants employed to avoid purchasing of divergence and convergence in Few older adults reported that they more groceries than they could carry participants’ responses.52–57 Observa- drove a vehicle or wanted to spend and minimize the chance that their tions obtained during the tagalong their resources on delivery or cab food would spoil. The total amount shopping trips provided additional fare to grocery shop; therefore, most spent on groceries by each partici- information, as well as an opportu- of them depended on public trans- pant at the tagalong visits ranged nity to triangulate the data during portation or walking as their mode of from $21.29 to $164.42, with an aver- the analysis.58 The data were coded travel to food stores. Rarely did these age bill of $54.00. Final bills were not initially for predetermined thematic older adults rely on store delivery ser- content, and then for emergent the- vices as a strategy to overcome the Continued on page 20 matic trends. Data were repeatedly coded and categorized by the re- Table 2: Community and transitional-care models. (Reprinted with permission searcher, and areas of convergence from the Academy of Nutrition and Dietetics.) and divergence in participant re- Characteristics Mean (Range) sponses were determined, as well as Age, y 73 (60–88) salient patterns in the data. n (%) RESULTS Race Characteristics of Participants Black 14 (47) White 12 (40) Most participants were women (80%) Latino 4 (13) and were 60–88 years of age. Two thirds were black or Latino and most Women 24 (80) were unmarried and living alone. Married or living with a partner 3 (10) In addition, most of the older adults Annual income > $30,000 7 (23) had annual incomes of < $30,000, al- Participation in government economic assistance programs 8 (27) though only 26.7% received govern- ment income assistance (Table 2). At least one meal eaten at home per day 27 (90) Nearly all participants reported eat- Perceptions of food cost ing at least one daily meal at home. Healthy foods are more expensive 11 (37) Furthermore, one third of participants Healthy foods are more expensive in their neighborhood 12 (40) reported finding healthy foods more Never worry about the cost of food 11 (37) expensive, and only half experi- Avoid some food stores because of cost 13 (43) enced high food security (Table 2). High food security 16 (53)

THE SPECTRUM • Spring 2015 Supplement 19 Navigating produce markets near his neighbor- were foods she could not find in Continued from page 19 hood to purchase fresh fruits and the stores near her home. Asked to vegetables at more affordable further explain what specific types confirmed for 2 of the 15 tagalong prices. He shopped “European style” of food she had trouble finding, she shopping trips (n = 13), and the aver- for the freshest food and the best stated, “Nice, fresh vegetables!” Sim- age bill calculation was rounded to deals, but said that walking to mul- ilarly, Louise (age 64 years), who was the nearest whole number. tiple stores was becoming increas- proud of her authentic Italian cook- Functional Limitations Challenged ingly difficult as he aged and his legs ing, stopped buying meat at both The Food Shopper became weaker. He also reported her local butcher and one of the heart problems and said that he ex- local chain supermarkets near her Loretta (age 67 years) had lived perienced labored breath whenever home because of the poor quality. in a New York housing project for he exercised. Getting winded in this more than two decades. Citing Participants, especially those indi- way upset him, because he used to viduals living in less affluent neigh- numerous health conditions that pride himself on being able to walk compromised her mobility, includ- borhoods, commonly reported briskly. He felt frustrated at having to that some or all of the stores they ing diabetes, a back injury, and avoid the full service grocery store chronic knee pain, she used a cane shopped at regularly were located that was located closest to his apart- outside their immediate neighbor- and was in visible discomfort when ment because it was too expensive moving around her apartment. Even hoods. One participant pointed out and carried fruits and vegetables he that she was different from many of with these significant mobility issues, believed were of poor quality. she regularly walked seven blocks her friends her age or older, because she had no chronic health conditions to a vegetable and fruit market for Dissatisfaction with Food Sold produce, even though there was a that limited her mobility. Chanelle At Local Markets Complicates explained: grocery store adjacent to her apart- Shopping Behaviors ment complex. She traveled the I drive. But I know others who extra distance to the vegetable and One of the most challenging issues don’t drive. They take the bus. fruit market because she preferred participants faced in trying to ob- They say I am not buying my the cost, quality, and variety of the tain food was the need to shop at meat in Coney Island, they get produce at this store. During the multiple stores to obtain the quality on the train, they get on the bus tagalong shopping trip, Loretta strug- of foods they wanted at prices they … They’ll tell me I go to Flatbush gled to walk and push her shopping believed fit their food budgets. Every to get fresh fish … I said, wow. cart, and she frequently stopped participant shopped at a minimum They are old, they get on the to lean against a tree or sit at a bus of two food stores, and most regu- train and then you got to carry stop to rest. Her physical ailments larly purchased food at ≥3 establish- these bags. What? But that is and the bumpy, uneven sidewalks ments (range, 2–6). Whereas all par- how serious [they are] … they are made traveling to the store difficult, ticipants identified a primary store at black and Hispanic, and they will and she expressed fear of falling. which they shopped most frequently, go ... to whatever neighborhood the main reason cited for shopping they have to go to … [to get Like Loretta, other participants de- at multiple stores mirrored the ratio- scribed or exhibited the physical food] fresh! ... not stale stuff. Not nale articulated by Nathanial, who beat-up looking chicken. challenges of walking and taking avoided the supermarket closest to public transit when shopping for his home—namely, that the avail- Finally, African American and Latino food. As was typical of many of the ability, quality, and/or prices of at participants, in particular, reported older adults who were observed least one major food category (i.e., that grocery and supermarket chains shopping, Abigail (age 66 years) fruit, vegetables, meats, fish, and/ located in their neighborhoods of- used a small shopping cart to trans- or dairy) was unacceptable at their fered poorer quality produce and port her groceries. Pushing her cart primary store. meat compared with the same home, loaded with her purchases, stores located in neighboring and Abigail almost tripped when she Rebecca (age 83 years) followed more affluent white neighborhoods. caught the front end of the cart on a strict kosher diet. She pointed out A number of participants became a strip of raised concrete. She used that she and her husband made visibly upset when they talked about the opportunity to tell the researcher a concentrated effort to eat more the historically poor quality of fruits about a friend of hers who severely fresh vegetables about a year ago, and vegetables sold at food stores injured her arm after tripping and after she resolved to lose 30 pounds. in their neighborhoods. Janet (age then falling over her grocery cart on When asked why she did not pur- 61 years) expressed frustration when the way home from shopping. chase fresh produce at her primary she shared a story about the chain store, she remarked, “The [local supermarket located directly across Nathanial (age 75 years) walked stores] know that they can charge about a quarter of a mile (five city the street from her apartment. She more.” During her interview, Emily explained that her son eventually blocks) to his primary food store, but (age 77 years) mentioned that there also frequented several other smaller Continued on page 21

THE SPECTRUM • Spring 2015 Supplement 20 Navigating or past the printed sell-by dates on or advertised as such at the point Continued from page 20 the packaging. Sarah (age 77 years) of sale. In addition, observations of and her friends started noticing a the checkout process during these spoke to the manager at the store suspicious pattern at her local su- same trips indicated that the Supple- because permarket regarding advertised sale mental Nutrition Assistance Program, That [junk before] should have items. Specifically, sale prices and coupons, and store “rain check” been in the garbage! And they store specials were not ringing up at vouchers were heavily relied upon to shouldn’t sell that to you. I mean, the register. Suspecting wrongdo- purchase food. I ain’t trying to be funny or smart, ing, Sarah spoke repeatedly to the you may be poor people, but you store manager about the problem. Restaurants as a Source of Food Reflecting on the experience, she don’t give people [food like that]. Older adults in this study consistently noted: Later in her interview, Chanelle said that restaurant meals do not connected the quality of food in They would just say things like, oh make up a large proportion of their neighborhoods to the racial makeup we didn’t put it in the computer. food intake each month. In fact, of the community. Explaining that But you heard that over and they claimed to limit the frequency she frequented a store outside her over and over again, [and] that with which they ate at restaurants own neighborhood because of the sounds like a gyp to me. because eating out was expensive better quality of merchandise, she Researcher observations of partici- and they could not control the nu- said, “[That store]—they cater to a pants’ shopping style and behavior tritional content of the food served different level of people, I notice. during these trips also documented (e.g., sodium). In addition, some par- And I would, well, let me just put it to that some participants distrusted the ticipants said that there were few, you like this—that is more of a white stores where they shopped. These if any, restaurants located in their neighborhood.” participants typically checked the neighborhoods that offered healthy food options. Janet mentioned that Researcher observations during the sell-by dates on items while shopping she had lived in her Brooklyn neigh- tagalong trips also documented and/or reviewed their sales receipts borhood for more than 35 years. differences in the food stores in before leaving the store, to ensure She had cut way back on going terms of cleanliness and organiza- they were not charged full price on out to restaurants for both cost and tion, as well as the quality of food sale items. Louise was one of those health reasons, and lamented the sold. For instance, a few stores were shoppers; she casually commented lack of “decent” places to eat in her observed selling food with expired to the researcher while selecting neighborhood, exclaiming, “Honey! sell-by dates. More commonly, stores a box of oatmeal squares that she What! I am telling you, you find fast displayed fruits and vegetables out “religiously” checks sell-by dates on food around here before you find a on the floor that were visibly wilted, merchandise because she had pur- decent gallon of milk.” Wilma (age bruised, and/or moldy; of the 20 chased expired food in the past. 65 years) felt similarly about the res- stores visited, 6 (30%) were observed taurant choices near her home. As to have multiple produce items for Food Shopping on a Fixed Income opposed to the fast food restaurants sale that fell into this category. In Because the majority of the par- that dominated her local food envi- addition, a number of the stores ticipants were no longer employed, ronment, she said that she dreamed appeared dirty and unorganized their reliance on a fixed monthly of a neighborhood establishment because of the presence of food, income had a reverberating effect where she could order a piece of debris, and litter on the floors, as on their food shopping patterns baked chicken with “no skin” and a well as having produce sections and purchasing decisions. Relying salad. that smelled of mold, disorganized mostly on Social Security income (a shelves, unmarked items and poor few participants receive pensions Older Adults Rely on Community signage, and barren shelves. as well), they generally received Resources and Support to Stretch a check at the beginning of the Their Food Dollars Distrusting the Business Practices of month and sometimes struggled Neighborhood Food Stores to budget their food-shopping re- Food Banks and Pantries Several participants suspected sources. Participants spoke in depth About 15% of the older adults report- their local neighborhood markets and often about the need to be ed relying on food pantries for food. of deceptive sales practices, such mindful of what groceries they A 66-year-old woman, Ellen, proudly as purposefully avoiding ringing up purchased, as well as the amount reported she spends only $50–$100 advertised sale items at checkout; they spent on particular items. In each month on groceries because bundling fruits and vegetables in addition, during tagalong grocery the food pantry in her neighborhood bulk packaging that hides old, wilt- trips, the researcher observed many helped her stretch her food dollars. ing, and/or molding produce under participants making the majority of However, other participants who sim- a top layer of the food item that their purchasing decisions based on ilarly relied on food pantries for as- appeared fresh; and selling food at which food items were listed as sale items in the weekly store circulars Continued on page 22

THE SPECTRUM • Spring 2015 Supplement 21 Navigating take home and eat for dinner or a of one of the male participants (age Continued from page 21 meal the following day. 74 years) “prepares and brings meals that I can heat and eat,” whereas sistance expressed concerns about Despite the regularity with which the older adults in this study reported a female participant (age 69 years) these programs as a source of food had a friend who “shops or brings for older adults. For example, Nina eating at local community centers, they described a number of limita- food or things that I might need.” (age 60 years) commented that The sister of another older adult (age most food pantries “give only shelf or tions to relying on these organizations as sources of food. First, the center 63 years) is described as not always canned stuff, or pasta...unfortunately having the resources to help, but “if a lot of the foods from the food pan- meals were not available on the weekends, when centers are closed, she has it, she will give [me] food.” tries are not conducive to weight loss Overall, friends and neighbors were or to keep you fit.” Marcie (age 73 and meals were typically only of- fered once a day during the week. just as likely as family members to years) also frequented several of the be credited with having provided local food pantries in her neighbor- Lunch was the most common meal provided at these organizations, al- this type of instrumental support. A hood and was disappointed that smaller proportion of the participants most food pantries did not provide though a few older adults said their center offered a light breakfast as pointed out that they depended on “nothing fresh” and gave away “a family and/or friends for help obtain- lot of canned stuff.” well. Second, individual food prefer- ences varied and it was common for ing food only when they were ill. Meal Programs at Community participants to complain about the Centers taste, quality, and lack of culturally Summary of Key Findings In addition to food pantries, meal appropriate meals provided, even Factors that were reported by par- programs at local community cen- when they reported eating at their ticipants as influencing their related ters were another source of food. respective senior centers regularly. shopping, cooking, and eating be- Third, several participants expressed haviors were summarized into intra- Almost all of the participants re- concern that their local community personal, social, and environmental ported taking at least one meal centers frequently served pasta categories in Table 3. each week at a senior center, and and other carbohydrate-rich foods, half (50%) said that that they regu- Intrapersonal issues that influence which they wanted or needed to larly ate at their center at least three food purchases described by the avoid because of health concerns times a week. For most of the par- older adults in this study include (e.g., diabetes) and/or concerns ticipants, the primary reasons they concerns related to their physical about maintaining their weight. took advantage of the meals at their and mental health, as well as at- center were the value and the social Sources of Food-Related Assistance titudes and perception about food interaction. When asked how much And Support from Individuals available to them. The participants also described struggling with fixed centers charge, participants said The number of individuals named in incomes. Social level influences that they paid $1.00–$1.50 for a meal social networks ranged 1 to 10, with identified as important included help consisting of a protein (meat or fish); an average of 5 network members. in obtaining and preparing meals, as starch (e.g., rice or potato); veg- Independent of the size of social well as social contact during meals. etable and/or fruit; and milk, tea/ networks, two thirds of the partici- The environmental factors can be coffee, or juice. Several participants pants reported food assistance as summarized into two categories: also stated that some community one of the areas supported by their transportation to places to obtain centers sold leftover plates of food networks. For instance, the daughter each day, which they purchased to Continued on page 23 Table 3: Multilevel factors related to food acquisition for older urban adults. Intrapersonal Factors Social and Cultural Factors Environmental Factors Adaptive Behaviors Physical health Physical aid in meal Transportation Shop frequently Functional limitations preparation Walking Shop where prices and Comorbid conditions Social support in sharing Public transportation quality are desirable Mental health meals Food stores Travel out of immediate Resilience for Social support purchasing Variation in availability of area for food independence food foods sold Limit visits to restaurants Challenges with food Variation in cost and Use food pantries for prices quality of foods sold groceries Dissatisfaction with healthy Community centers Use community centers for food availability Provide affordable meals meals Dissatisfaction with food Limited availability Help from social network quality Meals vary in taste and members for meals Deceptive sales practices desirability

THE SPECTRUM • Spring 2015 Supplement 22 Navigating to date, both in the US and abroad. IMPLICATiONS FOR RESEARCH Continued from page 22 For instance, other researchers have AND PRACTICE documented challenges to food Environmental determinants of eat- food and the types of foods avail- acquisition among this population ing are newly investigated and able. Whether obtaining prepared that include transportation barriers, the population of older adults has foods at community centers or pre- difficulty food shopping because of received little attention. Therefore, paring foods at home, this popula- functional limitations, and problems examining these findings within tion reported relying on the ability to with the grocery store environment, the context of existing behavioral walk to these places or use public as well as older adults’ reliance on models may inform developing pro- transportation. Issues related to the both informal and formal commu- grams and interventions through quality and cost of foods varied, nity food programs and services to the translation of research. Finan- and therefore shopping and eating bridge these gaps.39,61–65 Studies also cial constraint was also a theme where foods are affordable and of indicate that a lack of access to for many of our participants, which good quality, even if those places competitive prices within the limited other studies previously mentioned are far away, was an important confines of their immediate environ- have documented as well. This may behavioral theme identified by this ment contributes to food insecurity in be an important intrapersonal fac- group of older adults. the elderly population,41,42 and simi- tor to consider as new programs are lar to our findings, that some older In addition to identifying factors that developed. For older adults living in adults experience a monthly cycle influence the behavior of food shop- the US in 2010, the median income such that they tend to run low on ping, the participants also described reported was $18,819, which is similar financial resources for food toward specific behaviors used as strate- to participants in this study.66 There- the end of the month. gies to respond to these factors. For fore, reported concerns regarding instance, their functional limitations These data are robust in the explor- food prices, as well as the need to resulted in more frequent, shorter atory nature of food shopping prac- use social services to procure food, shopping trips. Dissatisfaction with tices of older adults living in urban may be a function of the econom- the price and quality of foods at environments well into their eighties. ics of aging. The issues related to local markets resulted in shopping Nevertheless, there are some limi- shopping at multiple stores, including at food stores farther away. Foods tations to this study that should be stores located outside participants’ served within social service settings raised. First, qualitative research neighborhoods, may promote sec- that were not perceived as culturally is by its nature naturalistic and ex- ondary beneficial effects by keeping sensitive or tasteful led to underuse ploratory, and therefore, is typically older adults active. In fact, some of of these services. Understanding the driven by central research questions, the older adults in this study stated interdependencies between the in- rather than by a specific hypothesis the desire to conduct these activi- trapersonal, social, and environmen- or theory. Thus, although the findings ties of daily living to remain active tal factors that influence obtaining from this study nicely conform to and independent. Nevertheless, as food and eating for older adults will ecological models, they must be has been shown with other popula- lead to more sensitive programs by interpreted as exploratory. Second, tions, individuals are more likely to local and state governments, as well the participants sampled for this have healthy diets if nutritious foods as provide the preliminary evidence 28 qualitative component were from a are available more conveniently. needed to develop testable inter- larger cohort of older adults. This co- Therefore, considering how multiple ventions. hort of seniors was obtained from so- levels of influence interact and lead cial service settings and is represen- to complex behaviors of eating DISCUSSION tative of the base population (older among older adults may inform clini- Throughout the interviews, partici- adults living in Brooklyn, New York). cal care, as well as the expansion pants’ responses to questions with Although the participants sampled of future nutrition programs for older regard to their shopping, cooking, came from a diverse range of Brook- adults. and eating behaviors were com- lyn neighborhoods, the findings from plex and multilayered. The issues this study are based on a small sub- ACKNOWLEDGMENTS described can be applied to eco- set of that population, and therefore Funding for this study came from logical models of health behavior, may not be generalized to all older the National Heart, Lung, and Blood which can be useful in developing adults in the cohort. Despite this, the Institute of the National Institutes of future health behavior interventions fact that the older adults in this study Health (grant R01 HL 0865507). The for this population.59 The application were sampled from a wide variety sponsor had no role in the study of these models to eating behaviors of Brooklyn neighborhoods acknowl- design, data collection, analysis or has been described previously.60 edges and honors the diversity of ex- interpretation of data, or the writing The multilevel themes identified in this perience among these participants, of this report. The authors thank all research are similar to several other and also emboldens those findings in of the Brooklyn residents who partici- studies that have been conducted which we found consensus among study participants. Continued on page 24

THE SPECTRUM • Spring 2015 Supplement 23 Navigating Food Environments. Am J Public to Healthy Food Options in South Continued from page 23 Health. 2005;95:1575–1581. Los Angeles Restaurants. Am J Public Health. 2005;95:668–673. pated in this research for graciously 7. Morland K, Filomena S. The Utiliza- sharing their time, experiences, and tion of Local Food Environments 18. Ayala G, Mueller K, Lopez- stories. In addition, they thank the by Urban Seniors. Prev Med. Madurga E, Campbell N, Elder J. directors and staff at participating 2008;47:289–293. Restaurant and Food Shopping senior centers for their important 8. Sharkey JR, Johnson CM, Dean Selections Among Latino Women contributions to the study. WR. Food Access and Percep- in Southern California. J Am Diet tions of the Community and Assoc. 2005;105:38–45. This article was published in the Jour- Household Food Environment as 19. 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THE SPECTRUM • Spring 2015 Supplement 25 Navigating Influential Factors for Food Ac- Among Older People. Int J Retail Continued from page 25 cess Described by Low Income Dist Mgmt. 2004;32:109–122. Seniors. J Hunger Environ Nutr. 65. Bernstein M, Munoz N. Position of Cambridge University Press; 1987. 2006;1:27–44. the Academy of Nutrition and 57. Strauss A, Corbin J. Basics of 62. Vesnever E, Keller H, Payette H, Dietetics: Food and Nutrition for Qualitative Research. Newbury, Shatenstein B. Dietary Resilience Older Adults: Promoting Health CA: Sage; 1990. as Described by Older Com- and Wellness. Academy of Nutri- 58. Creswell J, Plano Clark V. Design- munity Dwelling Adults from tion and Dietetics. J Acad Nutr ing and Conducting Mixed Meth- the NuAge study: “If there is a Diet. 2012;112:1255–1277. ods Research. Thousand Oaks, will—there is a way!” Appetite. 66. Administration on Aging, US CA: Sage; 2007. 2012;58:730–738. Department of Health and Hu- 59. Sallis J, Owen N, Fisher E. Ecologi- 63. Lumpkin J, Greenberg B, Gold- man Services. A Profile of Older cal Models in Health Behavior. stucker J. Marketplace Needs Americans: 2011. Web site. Avail- In: Glanz K, Rimer B, Viswanath K, of the Elderly: Determinant Attri- able at: http://www.aoa.gov/ eds. Health Behavior and Health butes and Store Choice. J Retail. aoaroot/aging_ statistics/Pro- Education: Theory, Research and 1985;61:75–105. file/2011/docs/2011profile.pdf. Practice. 4th ed. San Francisco, 64. Wilson L, Alexander A, Lumbers Accessed February 14, 2013. CA: Jossey-Bass. 2008:465–482. M. Food Access and Diet Variety 60. Glanz K, Lankenau B, Foerster S, Temple S, Mullis R, Schmid T. CPE Credit Environmental and Policy Ap- CPE Credit proaches to Cardiovascular This article has been approved for 1 hour of CPE credit upon successful Prevention Through Nutrition: completion of a quiz. At the conclusion of each month, the quizzes are re- Opportunities for State and Lo- viewed and those successfully scoring 80% will receive their CPE certificate cal Action. Health Educ Behav. via email. 1995;22:512–528. This free CPE credit is available for all Healthy Aging DPG members until 61. Keller H, Dwyer J, Senson C, June 30, 2018. Edwards V, Edward G. A Social Ecological Perspective of the Click here to take the quiz.

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THE SPECTRUM • Spring 2015 Supplement 26 Clearing the Confusion on Probiotics, Prebiotics, and Flavonoids for Healthy Aging

Christine Rosenbloom, PhD, RDN, FAND; Sarah Romotsky, RDN

Overview purchasing decisions.2 When trying ing firm Mintel notes that consumers to consume specific ingredients or investing in prevention was a top Aging is a global phenomenon. In food components, older consumers trend in 2014. For example, consum- the near future, people aged 65 look for functional components such ers report drinking juices to increase years and older will outnumber chil- as whole grains, fiber, and omega-3 servings of fruits and vegetables, and dren under the age of 5 years for the fats. They are not considering other they look for food products with forti- first time in history.1 By 2040 the world important components such as pro- fied nutrients that both taste good population will contain an estimated biotics, prebiotics, and flavonoids. and are healthful.9 Global industry 1.3 billion older adults (about 14% This population clearly desires to seek analysts expect the global market of the population), which is double out healthful foods, but there may for probiotics to exceed $28.8 billion the current percentage.1 Maintain- be an awareness gap about the role dollars in 2015.10 ing the health of older adults will be these types of functional foods can a challenge to healthcare practi- The IFIC Foundation survey found play in healthy aging and improving tioners, and nutrition and physical that about half of the polled con- overall health.2,3 activity will continue to be the cor- sumers say they consume some pro- nerstones of good health. Functional This article provides dietetics practi- biotics but are not sure if the levels foods such as probiotics, prebiotics, tioners with recent research on the are high enough to confirm health and flavonoid-containing foods pro- health benefits of prebiotics, probiot- benefits.3 Only 25% of those surveyed vide the macro- and micronutrients ics, and flavonoid-containing foods. consider probiotics when purchasing that older adults need; older adults foods or beverages, with 18% saying who utilize these functional foods Gut Microbiome “they try to get a certain amount or 2 may also benefit from improved One of the hottest topics in health as much as possible in foods.” health outcomes. and wellness is the gut microbiome. Probiotic literally means for life. A The International Food Information The human gastrointestinal tract is more precise definition from the Council (IFIC) Foundation conducts host to one of the most complex International Scientific Association online surveys of U.S. consumers in ecosystems on the planet, contain- for Probiotics and Prebiotics (FAO/ order to gauge consumer percep- ing more than 100 trillion individual WHO) is “live microorganisms that, tion and behavior on food and microorganisms.4 The “healthy” mi- when administered in adequate health issues. The 2014 Food and crobiome is largely dominated by amounts, confer a health benefit Health Survey revealed that older three bacteria phylas: Bacteroidetes, on the host.”11 Of the many health consumers (ages 65 or older) are the Actinobacteria, and Firmicutes.5,6 claims concerning probiotics, the most likely to be influenced by the A number of factors influence the two claims with the strongest science healthfulness of a food when making gut microbiome, including genetics, are their support of a healthy diges- age, diet, and medical treatments tive tract and a healthy immune such as drug therapies. Changes in system.11 Foods, beverages, and sup- the gut microbiome, called dysbio- plements with bacteria that promote sis, has been linked to inflammatory a healthy gut microbiome mostly gastrointestinal disorders including contain Bifidobacterium and Lacto- irritable bowel syndrome, inflam- bacillus.12 However, not all bacteria matory bowel disease, cancer, car- are the same, because not all the diovascular disease, and obesity.4 bacteria present in these foods have Gastrointestinal issues, motility disor- a desired health effect.13 Bacterial ders, and constipation are among strains must impart clinical health the most common complaints heard benefits and contain more than 108 by physicians from their older adult organisms/gram at the time of con- patients.7,8 Because probiotics and sumption.13,14 Some of the specific prebiotics support a healthy microbi- health benefits linked to probiotic ome, they should be tools in an older intake include:11 adult’s nutritional arsenal. • Normalization of bowel habits. • Reduction of occasional gut symp- Probiotics toms. Consumption of foods and bever- • Increased resistance against the ages containing probiotics and pre- common cold. biotics is growing. Consumer market- Continued on page 28

THE SPECTRUM • Spring 2015 Supplement 27 Probiotics mend consumption of a wide variety all naturally occurring carbohydrates Continued from page 28 of probiotic foods as part of an over- in foods. Many other soluble fibers all healthful diet. In addition, many such as polydextrose and complex • Decreased gastrointestinal inflam- products are fortified with probiotics, plant carbohydrates may also have mation. and probiotic supplements are an- prebiotic properties. Since these car- • Reduced risk of allergic diseases other way to get these substances. bohydrates cannot be digested by when consumed during early life. ISAPP recommends consumption humans, because we lack the nec- essary enzymes, they arrive intact at • Reduced symptoms of lactose in- of 109 colony-forming units (CFUs) the gut, where the gut microbiome tolerance. of probiotics a day, which can be achieved by consuming approxi- ferments them for energy and nutri- • Reduced colonization of patho- 15 11 ents. To date there is no compre- genic bacteria. mately one cup of yogurt. It is im- portant to remember that the starter hensive database of the amount • Improved inflammatory bowel cultures used in making “normal” yo- of prebiotics in foods, but ranges conditions. gurt and other standard fermented for some foods are found in a 1999 18 • Reduced incidence of antibiotic- products are not typically probiotics, Journal of Nutrition article. The dose associated diarrhea. since they do not survive gastrointes- of prebiotics for good health is esti- mated to be from 2–30 g/day, and Some of these health benefits are tinal transit. However, many of these products contain healthful nutrients it can take several weeks to obtain salient for older adults. For example, the beneficial health effects.16 Arti- complaints about bowel habits and and should still be included in the diet of older adults. chokes, asparagus, bananas, chick gastrointestinal distress are com- peas, garlic, honey, leeks, oats, on- mon in older females.7 Age-related Prebiotics ions, and whole grains are examples functional gastrointestinal issues in- of foods that contain prebiotic-like clude decreased motility, bacterial Prebiotics act as foods for the gut carbohydrates. Inulin, one of the overgrowth, and constipation, which bacteria. Prebiotics target the bac- substances that fit the criteria for a could all be helped with probiotic teria already present in the gastro- prebiotic, is frequently used in sup- 8 use. intestinal tract, acting as selective plements. Clinical effectiveness for food with beneficial effects on the inulin had been estimated at 2–4 g/ Sources of Probiotics organisms.15 Prebiotics are a comple- day17 (for comparison, one small ba- Today many products claim to con- ment to probiotics. The strength of nana [100 g] has 500 mg of inulin).18 tain probiotics, but too often they do evidence for prebiotics is not as However, a recent European Food 15 not meet the minimum criteria.11 The strong as for probiotics. At the pres- Safety Authority opinion is that the consensus panel of the International ent, researchers believe that prebiot- effective dose for normal stool func- Scientific Association for Probiotics ics have the potential to reduce the tion is higher, at about 12 g/day.19 As and Prebiotics (ISAPP) recommends prevalence and duration of infec- with probiotics, seeking a variety of that the term probiotic be used only tious and antibiotic-associated diar- sources of prebiotics, including prebi- for products that deliver live microor- rhea, reduce inflammation and the otic supplements and fortified foods, ganisms with a suitable viable count symptoms of inflammatory bowel dis- may be ideal for some consumers to of well-defined strains. These strains eases, protect against colon cancer, ensure sufficient prebiotic intake. should have a reasonable expecta- enhance the absorption of calcium tion of delivering clinical benefits for and magnesium, and produce sati- Advice for Dietetics 16 the individual consuming these prod- ety and weight loss. The ISAPP (In- Practitioners Working with ucts.11 ternational Scientific Association for Older Adults Probiotics and Prebiotics) identifies The foods with the highest amounts three criteria for a prebiotic effect:16,17 Registered dietitian nutritionists of live, active cultures are those (RDNs) and dietetic technicians, reg- • Resistance of the prebiotic to that are naturally fermented. The istered (DTRs) working with the older breakdown by gastric acid, mam- following foods are rich in naturally adult population can suggest easy malian enzymes or hydrolysis in the fermented probiotics: buttermilk, ways to incorporate prebiotics and upper small intestine. kefir, kimchi, kombucha, microalgae, probiotics into meals. While there is miso, sauerkraut, tempeh, and yo- • Fermentation of the prebiotic by a multitude of science to “digest” gurt. microbes. on the microbiome, probiotics, and There is still uncertainty regarding the • Selective stimulation of the growth prebiotics, the take-home message dose of a probiotic and the length and/or activity of probiotics. for dietetics practitioners is simple: of time needed to see a health ben- Probiotics and prebiotics play essen- At the present time, foods that fit the efit. This uncertainty is attributed to tial roles in healthy aging. Synbiosis criteria mentioned above include the lack of a standardized dose, the (the synergy resulting from combined those containing fructooligosac- different probiotic sources, and an probiotic and prebiotic use) is an charides (FOS), galactooligosac- individual’s unique microbiome. For emerging area of research, with chrides (GOS), and inulin, which are these reasons, it is best to recom- Continued on page 29

THE SPECTRUM • Spring 2015 Supplement 28 Probiotics Table 1: Meals that combine probiotics and prebiotics. Consuming beneficial Continued from page 28 microbes simultaneously with their food sources encourages synbiosis.

the goal of optimizing the effect of Meal Combinations probiotics on the gut microbiome.20 Breakfast • Yogurt with live and active cultures Examples of meals that are synbiotic • Pancakes topped with flavored yogurt and fresh fruit are found in Table 1. • Oatmeal prepared with buttermilk and honey • Bananas and yogurt Supplements may be an alternate way for clients to obtain probiot- Lunch • Peanut butter and honey sandwich on whole grain bread ics and prebiotics in their diets. In • Spinach, leek, and artichoke dip with whole pita bread a meta-analysis of 11 clinical trials, Dinner • Garlic tomato sauce with fortified whole wheat penne pasta probiotic supplements decreased • Hamburger on a whole grain bun with sauerkraut slaw intestinal transit time, with the great- • Kabobs with onions, pineapple, peppers and lean beef est effects seen in older adults with constipation.21 However, a food-first Snack • Banana with drizzled honey approach guarantees the delivery • Smoothie with yogurt, orange juice, honey and banana of other nutrients needed by older adults for good health. For example, Flavonoids Flavonoids are one of the most com- yogurt contains probiotics and is Dietetics practitioners working with mon and largest groups of phyto- also a good source of protein, cal- the older population already know nutrients found in the diet, and to cium, , zinc, and vitamin that fruits and vegetables are good date more than 4,000 varieties have D (if fortified).22 Moreover, the 2010 for our clients, but there may be been identified.24 Flavonoids share Dietary Guidelines for Americans rec- even more reason to encourage a common chemical structure, and ommends increasing the intake of clients to eat these foods on a daily in the context of the human diet, fat-free or low-fat milk and milk prod- basis. They contain flavonoids, a they can be divided into six primary ucts, such as milk, yogurt, cheese, or large and diverse group of com- subclasses: flavonols, flavones, fla- fortified soy beverages, which may pounds naturally present in a variety vanones, flavan-3-ols (or flavanols, contain these beneficial compo- of plant-based foods. Emerging sci- as simple forms and more-complex nents.23 ence associates their consumption chains known as proanthocyanidins), with a range of health benefits. isoflavones, and anthocyanidins. Though these subclasses share com- Table 2: The major classes of dietary flavonoids, and some common food mon structural features, each class sources. has unique chemical and biologi- Flavonoid Food Sources Food and Beverages That May cal properties. Thus it is important to Group Be Enjoyed by Older Adults know not only that a food or bever- age contains flavonoids, but also Anthocyanidins Berries, cherries, • Cherries covered in dark what forms are present. The United eggplant, red onion, chocolate States Department of Agriculture red potatoes • Roasted red potatoes and (USDA) has created several compre- onions hensive, public-access databases of • Eggplant parmesan flavonoids that provide a detailed • Mixed-berry fruit salad view of some of the most common Flavan-3-ols, Dark chocolate, natural • Dark-chocolate squares flavonoid-containing foods in the hu- Flavanols cocoa powder, black • Iced black or green tea man diet: tea, green tea, cherries • Cherry compote • USDA Special Interest Databases Flavonols Apples, kale, leeks, • Vegetable soup with kale, on Flavonoids onions leeks, or onions • Applesauce or baked apples • USDA Database for the Proan- thocyanidin Content of Selected Flavanones Citrus fruits and juices • Orange juice Foods—2004 (orange, grapefruit, • Orange or grapefruit sections lemon) • Lemon wedges served with • USDA Database for the Isoflavone hot vegetables Content of Selected Foods, Re- Flavones Celery, cherries, • Diced celery in potato or lease 2.0. parsley, strawberries macaroni salad As evidenced by these databases, • Strawberry and cherry significant amounts of flavonoids are shortcake found in a variety of foods, as shown Isoflavones Soybeans, soy flour, • Vanilla soymilk lattes in Table 2. soymilk • Veggie burger or soy Continued on page 30 sausage

THE SPECTRUM • Spring 2015 Supplement 29 Probiotics About the aUTHORS References Continued from page 29 1. Kinsella K, He W. An Aging World: Epidemiological evidence strongly 2008 International Population supports that the consumption of at Reports. Washington, DC: U.S. least five servings of fruits and veg- Census Bureau; 2009. Available etables a day is associated with a at: http://www.census.gov/ lower risk of mortality from a variety prod/2009pubs/p95-09-1.pdf. Ac- of causes.25,26 While the mechanisms cessed September 2, 2014. underlying these benefits are not fully 2. International Food Information understood, it may be in part due to Council. 2014 Food & Health the flavonoids commonly found in Survey. The Pulse of America’s these foods.25,26 Many studies have Christine Rosenbloom, PhD, RDN, Diet: From Beliefs to Behaviors. shown that the consumption of FAND, is a professor emerita of nutri- Available at: http://www.foodin- higher levels of flavonoids is associ- tion at Georgia State University in At- sight.org/surveys/2014-food-and- ated with a range of benefits to hu- lanta, Georgia. She holds a gerontol- health-survey. Accessed Septem- man health, including a lower risk of ogy certificate from Georgia State. ber 2, 2014. cardiovascular disease mortality and Christine has taught courses about 3. International Food Informa- stroke.27,28 Emerging research also health and aging for 15 years. She tion Council. 2013 Functional suggests that flavonoids, specifically is a contributing editor for Nutrition Foods Consumer Survey. Avail- those found in berries, may be asso- Today and has written many book able at: http://www.foodinsight. ciated with a reduced rate of cogni- chapters on aging athletes and nu- org/2013_Functional_Foods_Con- tive decline in older adults.29 trition. sumer_Survey. Accessed Sep- tember 2, 2014. Conclusion 4. Panda S, Guarner F, Manichanh From cosmetics to food, products C. Structure and function of the associated with healthy aging has gut microbiome. Endocr Metab received increased attention and Immune Disord Drug Targets. July promotion. As dietetics practitioners 2014; Epub ahead of print. working with older adults, we are well positioned to educate clients on the 5. Eckburg PB, Bik EM, Bernstein CN, scientifically proven benefits of foods et al. Diversity of the human in- such as prebiotics and probiotics for testinal microbial flora. Science. healthy aging. Even though we may Sarah Romotsky, RDN, is employed 2005;308(5728):1635–1638. not be able to “turn back the clock,” by the International Food Informa- 6. Mariat D, Firmesse O, Levenez F, providing clients with the knowledge tion Council (IFIC) Foundation. The et al. The Firmicutes/Bacteroide- of how to seek out and eat foods Foundation is dedicated to the tes ratio of the human micro- with health-promoting components mission of effectively communicat- biota changes with age. BMC may help improve overall health go- ing science-based information on Microbiology. 2009;9:123. ing forward. health, nutrition and food safety for 7. Zuchelli T, Myers SE. Gastrointes- the public good. It receives support tinal issues in the older female Back to table of contents from government agencies; other patient. Gastroenterol Clin North foundations and associations; and Am. 2011;40(2):449–466. the broad-based food, beverage, Additional Resources and agricultural industries. The Foun- 8. Firth M, Prather CM. Gastrointes- dation does not lobby or promote tinal motility problems in the el- Visit these sites to learn more any company, brand, or product. derly patient. Gastroenterology. about the information discussed It brings together, works with, and 2002;122:1688–7000. in this article: provides information to consumers, 9. Erickson EH. Mintel releases con- health and nutrition professionals, • The International Scientific sumer trends for 2014. Available educators, and government officials; Association for Probiotics and at: http://www.foodprocessing. as well as food, beverage, and ag- Prebiotics. com/articles/2014/mintel-con- ricultural industry professionals. The sumer-trends/. Accessed Sep- • Functional Foods Fact IFIC Foundation has established part- tember 10, 2014. Sheet: Probiotics and nerships with a wide range of cred- 10. Probiotic business trends. BioMed- Prebiotics, available from the ible professional organizations, gov- Trends. Available at: http://www. International Food Information ernment agencies, and academic biomedtrends.com/GetDetails. Council Foundation. institutions to advance the public understanding of key issues. Continued on page 31

THE SPECTRUM • Spring 2015 Supplement 30 Probiotics 3963. Available at: http://www. cardiovascular disease mortality: Continued from page 30 efsa.europa.eu/en/search/ a prospective study in postmeno- doc/3951.pdf. Accessed January pausal women. Am J Clin Nutr. asp?CatName=Probiotics. Ac- 15, 2015. 2007;85:989–909. cessed September 10, 2014. 20. Alonsa VR, Guarner F. Linking the 29. Devore EE, Kang JH, Breteler MM, 11. Hill C, Guarner F, Reid G, et al. gut microbiota to human health. Grodstein F. Dietary intakes of The International Scientific As- Br J Nutr. 2013;109:S21–S26. berries and flavonoids in relation sociation for Probiotics and 21. Miller LE, Ouwehand AC. Probi- to cognitive decline. Ann Neurol. Prebiotics consensus statement otic supplementation decreases 2012;72:135–143. on the scope and appropriate intestinal transit time: meta-anal- use of term probiotic. Nat Rev ysis of randomized controlled Gastroenterol Hept. Advance trials. World J Gastroenterol. online publication 10 June 2014; 2013;19(29):4718–4725. DOI:10.1038/nrgastro.2014.66. 22. El-Abbadi NH, Dao MC, Meydani 12. Bourlioux P, Pochart P. Nutritional SN. Yogurt: role in healthy and and health properties of yogurt. active aging. Am J Clin Nutr. World Rev Nutr Diet. 1988;56:217– The Unintended Weight 2014;99(suppl):1263S–1270S. 258. Loss in Older Adults 23. Dietary Guidelines for Americans 13. Adolfsson O, Meydani SN, Russell 2010. Available at: http://health. Toolkit RM. Yogurt and gut function. Am gov/dietaryguidelines/2010.asp. J Clin Nutr. 2004;80(2):245–256. Created by experts in the field of Accessed September 15, 2014. 14. Picard C, Fioramonti J, Francois older adult nutrition, this practical 24. Kumar S, Pandey AK. Chemis- A, et al. Review article: bifido- toolkit includes a wide variety of try and biological activities of bacteria as probiotic agents -- resources to assist RDs, including: flavonoids: an overview. Sci- physiological effects and clinical entific World Journal. 2013;Vol • Referral process tools benefits.Aliment Pharmacol Ther. 2013:1–16. Open Access jour- 2005;22(6):495–512. • Screening and assissment nal available at: http://dx.doi. 15. Prebiotics: A Consumer Guide org/10.1155/2013/162750. Ac- • Assessing height, weight, and for Making Smart Choices. Inter- cessed July 31, 2014. BMI national Scientific Association 25. Dauchet L, Amouyel P, Hercberg • Enteral and end-of-life for Probiotics and Prebiotics. S, Dallongeville J. Fruit and veg- Available at: www.isapp.net. Ac- decisions etable consumption and risk of cessed September 9, 2014. • Patient education and coronary heart disease: a meta- 16. Slavin J. Fiber and prebiotics: analysis of cohort studies. J Nutr. professional resources mechanisms and health benefits. 2006;136:2588–2593. • Outcomes management Nutrients. 2013;5(4):1417–1435. 26. Wang X, Ouyang Y, Liu J, et al. Member price: $20 17. Bouhnik Y, Raskine L, Chamption Fruit and vegetable consumption K, et al. Prolonged administra- and mortality from all causes, Available at tion of low-dose inulin stimulates cardiovascular disease, and www.eatright.org/shop. the growth of bifidobacteria in cancer: systematic review and humans. Nutr Res. 2007:27(4):187– dose-response meta-analysis 193. of prospective cohort studies. 18. Moshfegh AJ, Friday JE, Gold- BMJ. 2014 Jul 29;349:g4490. Avail- man JP, Anuga JKC. Presence able online at: https://www. of inulin and oligofructose in ncbi.nlm.nih.gov/pmc/articles/ the diet of Americans. J Nutr. PMC4115152/. Accessed Sep- 1999;129:1407S–1411S. tember 8, 2014. DOI: 10.1136/ bmj.g4490. 19. European Food Safety Authority. Scientific Opinion on the substan- 27. McCullough ML, Peterson JJ, tiaion of a health claim related Patel R, et al. Flavonoid intake to “native inulin chicory” and and cardiovascular disease maintaineance of normal def- mortality in a prospective cohort ecation by increasing stool fre- of U.S. adults. Am J Clin Nutr. quency pursuant to article 13.4 2012;95:454–464. of Regulation (EC) No. 1924/2006. 28. Mink PH, Scrafford CG, Barraj EFSA Journal. 2015;13(1):3951– LM, et al. Flavonoid intake and

THE SPECTRUM • Spring 2015 Supplement 31 HA Executive Committee Practice Directors 2015–2016 Communications Sponsorship Chair: Nancy Munoz, DCN, MHA, RDN, LDN, FAND Sarah Feasel-Aklilu, MEd, RD, CNSC, FAND Maureen Janowski, RDN, CSG, LDN [email protected] [email protected] [email protected] Membership Professional Development Chair-Elect: Monica Sathyamurthy MS, RD, CDN Katie Dodd, MS, RD, CSG, LD Judy Simon, MS, RD, LD [email protected] [email protected] [email protected]

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THE SPECTRUM • Spring 2015 Supplement 32