J Table of Contents J _ ' ;_; _._,Nutrition Education for Older Adults: A Review of_Research _--'::--__'_:_ rl _% : · .... _ 7)_ _7 - ,-' I / "- ? i g _ · ] i' ' k _ ?' /?' .'p ? - .. - ) 7 ' ; -. __ - Table of Contents - ............. . . f /_ _ , _._ - - - ...... - _-_1_ - C x -_ ' - .- -- .% ' M-_- ' --_-_ _: - - : .... _- !-_ . _ :- - _ ._-- .... Q'IfVlG_. __ _ - _-_::_-'__' - :-i_--_-_'-*-'-' :-: -- - T- -_'r"'_"_'''4' _ _ .i ?_ J__ - ___t_' ._ / % _ . 'r -_ ' -- --'- _: =_ ' - [ '-: /: --:'= ;t _' ,........... .', . -,P- _ '_._ ' - - f ' _. . -_ ..... " _ .. -_ .-' _L . .-- =. _, _ - -: - "- '_ :- - - -._,:.-_. '_- - _ - ._ - _ -: _ _' _7.' .... , - _ . :_--'":_ - - - . L -: ' . , _.. - - -__-- :____-_-__:_-_;_.'_%-_q'_;' t:: - _. . ..: , ::._ ,:% >- - . - , v ._ _ _ .. _ .? _ -_¢ '-7 , .:'> - _ .__ ' , L -.' -z . . _. _. -. , J '...-74-, f- _ _ =..p - --'> q _ / ..' a_. z - _ Table of Contents NUTRITION EDUCATION FOR OLDER ADULTS: A Review of Research Susan K. Maloney, M.S. Sara L. White, M.S. September, Prepared For: U.S. Department of Agriculture Food and Nutrition Service Office of Analysis and Evaluation 3101 Park Center Drive Alexandria, VA 22302 Project Officer: Jill Randell 1994 Table of Contents BIODATA Susan K. Maloney has been actively engaged in the development and management of health promotion and disease prevention programs for twenty four years with specialized experience designing programs and materials for older, youth, and hard to reach groups. She currently works as an independent consultant doing strategic planning for communications programs and conducting qualitative research. Her current research is examining the long-term care decision making process of elderly people and their families, managed care choices of Medicare beneficiaries, and information needs of older adults with funding from the Robert Wood Johnson Foundation, HCFA, and the Public Health service. At the Office of Disease Prevention and Health Promotion, Ms. Maloney directed the Healthy Older People Program, the first National communications program targeting health promotion for older adults. She conducted similar programs for the National Institute of Alcohol Abuse and Alcoholism. Ms. Maloney has been instrumental in increasing the interest of many voluntary organizations in drug and alcohol abuse prevention and health promotion activities. Ms. Maloney has an MHS from the Johns Hopkins School of Hygiene and Public health. She was instrumental in establishing an Alcohol and Drug Section (now Alcohol, Tobacco, and Other Drugs) within the American Public Health Association. She served as a section chair and on the Governing Council of that organization. Sara L. White, M.S. is an independent consultant in health communication, with special expertise in health promotion and disease prevention issues for high risk populations. Formerly she was Health Communication Advisor with the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services. In this capacity, Ms. White worked with the agencies of the Public Health Service and national organizations on cross-cutting public education programs. While at ODPHP, she also was responsible for aging and disability prevention policy issues. Prior to that, Ms. White was the Deputy Director of Communications for the U.S. Senate Special Committee on Aging and the manager of public information programs for not-for-profit organizations. Ms. White holdsa B.A. from the University of California at Santa Cruz, a M.S. in Mass Communications from San Jose State University, and will soon begin studies at the University of Pittsburgh School of Law. TABLE OF CONTENTS CHAPTER PAGE EXECUTIVESUMMARY I, INTRODUCTION ...................................... Search Methodology 10 ................................... of the Literature .............................. 11 THE PRACTICEOF NUTRITION EDUCATION FOR OLDER ADULTS .................................. 13 Historical Perspective: Nutrition Education (Prior to 1980) ...................................... 13 ................................. Overview of Nutrition Education Today 13 ...................... 14 Nutrition and Health Promotion Goals for the Year 2000 ................................. 15 OVERVIEW OF THE PROBLEM ........................... 16 Link Between Diet and Health in the Aging Population ............................... 16 Nutritional 17 Status of the Older Population Dietary Recommendations Summary IV. 10 10 Health Promotion Ill. 5 Purpose of the Review .................................. Limitations II. ................................. .................... ............................... ........................................... 19 20 THE THEORETICAL BASIS FOR NUTRITION EDUCATION WITH OLDER ADULTS ................................ 21 Social Psychology 21 .................................... Table of Contents Health Education ..................................... 22 Communications ..................................... 23 The Nutrition Marketing Communication ....................... 24 ........................................... Adult Education V. Model 25 ...................................... 25 EFFECTIVENESS OF NUTRITION EDUCATION WITH OLDER ADULTS: Review of the Literature ............... 27 Studies of Factors that Facilitate or Impede Information Transfer and Mediate the Translation of Knowledge and Behavior Change ...................... 27 Older Adults May Have Difficulty Applying Nutrition Knowledge ............................... 27 What Older Adults Say They Want Know About Nutrition .............................. 28 Credible Sources of Nutrition Information ................ Studies to Identify those Factors that Cause Changes in Dietary Practices ............................ Some Studies Nutrition Suggest Education Motivators Should 29 30 ..................... Target Age Groups 30 ........... 31 Nutrition Education Should Be Culturally Appropriate ............................. 31 Studies that Identify, Develop, and Evaluate Effective Strategies for Delivering Nutrition Information to Older Adults ...................... 32 Preferred Formats for Nutrition Education Nutrition Education in the Congregate Meal Setting .................................... ............... 32 33 Table of Contents Nutrition Education in the Dining Room Nutrition Classes Education ................ ......................... 36 Active learning ............................. Peer educator approach ...................... Nutrition Education Through the Print Medium Brochures ................................. Preferred formats for print materials Direct mail ................................ Newspapers ............................... Nutrition Education Through Nutrition Education Contests Broadcast Clinic-Based Programs Health Education VII. ........... ........... ........................ Plus: Innovative Approaches 39 39 40 40 41 41 41 ............ ............................ Gardening and nutrition ....................... Computerized nutrition education programs ........................ VI. 37 38 .............. Media Use of Tests to Increase Nutrition Awareness 35 42 43 ........... 44 44 45 SUMMARY: Successful Elements of Nutrition Education for Older Adults .............................. 47 CONCLUSIONS: Implications for Nutrition Education Policy, Research, and Program Implementation ....................................... 49 Nutrition 49 Education Policy ............................... Nutrition Education Research Program Implementation BIBLIOGRAPHY ............................ ................................ ...................................... 50 51 53 Table of Contents EXECUTIVE SUMMARY PURPOSE The primary purpose of this report is to present the U.S. Department of Agriculture (USDA) with in-depth information on the effectiveness of current nutrition education interventions for older people. This review of the literature examines nutrition education interventions that have demonstrated improvements in one or more of the following areas: knowledge, attitudes, skills, behaviors, or health outcomes. Two central questions are addressed: o o Does nutrition education work? What additional information is needed to develop policies and plan effective programs? nutrition education While nutritional issues have been long associated with aging, only in the past two decades has the scientific community begun to focus attention on the nutritional status and nutrition-related needs of older people (U.S. Department of Health and Human Services, 1988; Dwyer, 1991; Berg and Cassells, 1992). Still lacking is a consensus on what the dietary guidelines should be for this rapidly expanding population. For example, what is the upper age range for dietary guidance intended for the general public? Should nutrition education emphasize nutritional excesses or deficits? Should nutrition messages be targeted to this population based on health status? Programs at the federal level have primarily addressed supplemental feeding needs and advocacy efforts have been largely confined to expanding these programs (Dwyer, 1991). Within this context, nutrition education activities for older adults have been limited to patient education for specific medical conditions, limited health education offered through the meals programs, and isolated, mostly undertested, health promotion interventions in the community. METHODOLOGY Seven computerized databases were searched for relevant research articles about nutrition education and older adults. In addition, federal agencies, health and aging organizations, trade associations, and a university research center were contacted for additional references. The literature yielded a paucity of evaluations of interventions with older adults. Only a few studies met specified for this review. Therefore, studies which had suggested promising approaches were included in the qualitative research. nutrition education the methodological criteria some design limitations but review, including survey and Table of Contents Despite these qualifications, this review provides a useful assessment of the past and current state of nutrition education for older adults. Successful strategies are suggested from the literature and the implications of the review for nutrition education policy, research, and programs discussed. OVERVIEW OF NUTRITION EDUCATION TODAY Nutrition interventions for older people generally fall into three categories: nutrition education, nutrition counseling and nutrition support (Nutrition Screening Initiative, 1992). This review focuses on nutrition education. Sims (1987) characterizes nutrition education that involves a deliberate effort to improve nutritional information or other types of educational/behavioral feature of nutrition education is its implicit emphasis result of the educational intervention." as "a form of planned change well-being by providing interventions. One fundamental on dietary behavior change as a Nutrition education in the community is offered most often in a group setting (NSI, 1992; Rakowski, 1992), either through senior meal programs or other programs. Increasingly, the clinical setting is being recognized as an important source of health information, including dietary advice (Woolf, Kamerow, Lawrence, Medalie, and Estes, 1989; U.S. Preventive Services Task Force, 1988). The primary source of nutrition information for older people, however, as with other populations, is through the mass media. The media can also be a source of confusion to many people, including older people, who perceive conflicting reports and advice about nutrition. (NSI, 1992; Kivela and Nissinen, 1987; Maloney, Fallon, and Wittenberg, 1984) SUCCESSFUL ELEMENTS FROM THE LITERATURE REVIEW Sims (1987) provides a useful framework for organizing the nutrition education studies identified by the literature search. She characterizes nutrition education research to include: o o o Studies of factors that facilitate or impede information transfer and of those that mediate the translation of knowledge into behavioral change. Studies to identify those factors (technological, educational, sociocultural, motivational etc.) that cause change in dietary habits and food consumption behavior. Studies that identify, develop, and evaluate effective strategies for delivering nutrition information to various target groups under varying nutrition education objectives. Table of Contents Most of the studies found for this review evaluated instructional strategies. Few studies looked at underlying factors that cause older people to change dietary practices (motivational, educational, or sociocultural) or transfer knowledge into behavioral change. A meta-analysis of nutrition education research for all populations (Johnson and Johnson, 1985) measured the frequency of use of instructional strategies reported in the literature. Lectures and written materials were the most popular methods (76% and 69% respectively), followed by directed small group activity (50%), displays (45%), individual counseling (33%), audiovisual presentations (31%), mass media (11%), and computers (2%). Similarly, most nutrition education programs for seniors involve didactic education, distribution of pamphlets and brochures, the provision of meals, or authoritative counseling from a doctor or dietician (Hackman and Wagner, 1990). In recent years, however, a few innovative approaches have been tested that combined traditional approaches with interactive strategies, such as computer use or gardening activities. Successful elements that emerge from this review are: 1. Use audience-centered planning approaches. Program planning, development, implementation, and evaluation can benefit from the input and guidance of the program participants. Focus groups or surveys can clarify older adult's "wants," needs, and special interests. Reports of using these techniques are beginning to appear in the nutrition education literature (Crockett, Heller, Merkel, and Peterson, 1990; Shepherd, 1990; Krinke, 1990; Goldberg, Gershoff, and McGandy, 1990). 2. Use personalized approaches to support generalized messaqes. The empirical evidence for community-based health promotion programs indicates that mass media messages supplemented with personal interaction and reinforcement yields the greatest changes in health-related behaviors (USDHHS, 1990). This is consistent with information processing theory that suggests audiences move from the stage of general awareness to one of seeing the personal relevancy of a meassage and then to decision-making and action. Evaluations of HealthTrac and computer-based interventions showed promising results. All used individualized assessment to tailor nutrition information. 3. Utilize known motivators. interaction and social support, that can be utilized in nutrition 4. Interest in maintaining health, opportunities for social good taste and ease of preparation are all motivators education emerging from the literature review. Encourage older adults to be active learners. 7 Adult education theory and Table of Contents I. INTRODUCTION PURPOSE OF THE REVIEW The Food and Nutrition Service of the U.S. Department of Agriculture has commissioned a series of papers to review what is known about the effectiveness nutrition education with different populations. This paper examines the scientific literature on nutrition education with older adults. of While nutritional issues have been long associated with aging, only in the past two decades has the scientific community begun to focus attention on the nutritional status and nutrition-related needs of older people (Berg and Cassells, 1992; Dwyer, 1991; DHHS, 1988). Still lacking is a consensus on what the dietary guidelines should be for this rapidly expanding population. For example, what is the upper age range for dietary guidance intended for the general public? Should nutrition education emphasize nutritional excesses or deficits? Should nutrition messages be targeted to this population based on health status? Programs at the federal level have primarily addressed supplemental feeding needs and advocacy efforts have been largely confined to expanding these programs (Dwyer, 1991). Within this context, nutrition education activities for older adults have been limited to patient education for specific medical conditions, limited health education offered through the meals programs, and isolated, mostly undertested, health promotion interventions in the community. This review examines nutrition education interventions that have demonstrated improvements in one or more of the following areas: knowledge, attitudes, skills, behaviors, or health outcomes. Two central research issues defined the scope of the search: o Does nutrition education work? What are effective nutrition education o interventions? Are these effective methods replicable? What are the successful elements across interventions? What additional information is needed to develop nutrition education policies and plan effective programs? What additional research, evaluation tools, demonstrations, or data are needed? SEARCH METHODOLOGY Articles published between 1980 and 1994 were identified through searches of seven computerized databases (AgeLine, CHID, ERIC, AGRICOLA, CRIS, HNRIMS, and MedLine), reference citations, and expert consultation. Reports and additional information were requested from federal agencies (DHHS: National Institute on Aging, National Cancer Institute, National Heart, Lung, and Blood Institute, Office of Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Table of Contents Administration on Aging; USDA: Nutrition Education Research Branch, Extension Service), national health and aging organizations (American Association of Retired Persons, National Eldercare Institute on Health Promotion and Aging, National Eldercare Institute on Nutrition and Aging, National Association of Meals Programs, Center for Science in the Public Interest, Public Voice for Food and Health Policy, American Red Cross), the Food Marketing Institute, the National Nutrition Screening Initiative, the USDA Human Nutrition Research Center on Aging at Tuffs University, and USDA grantees identified through HNRIMS. The project requirements called for the selection of studies with strong evaluation designs, i.e., those that included some measure of instrument reliability and validity, random assignment or strong quasi-experimental designs. However, few nutrition education studies with older adults meet these requirements, as has been observed by others (Sims, 1987). Therefore, studies that had design limitations but suggested promising approaches also have been included. For example, survey and qualitative research are included since they contribute a relatively large proportion of the research in this area. LIMITATIONS OF THE LITERATURE Very little has been published on the effectiveness of nutrition education with older people. A systematic analysis that takes into account effect size, strength of the relationship, moderating variables and so forth is not possible due to the limitations of the data. In a review of nutrition education research articles published since 1980, Sims (1987) found that 1) school-age children were the focus of more published surveys than any other population group and 2) when experimental methods were used, the subjects tended to be adults enrolled in weight-control programs. Furthermore, major studies of dietary intake and national clinical health trials often exclude older adults from the data collection or do not include sufficient numbers of older adults to distinguish among subgroups. (U.S. Department of Health and Human Services, 1988) The discrete body of research on health promotion for older adults yielded some additional insights but many of these are descriptive studies, lacking the desired scientific rigor. (Rakowski, 1992; Simmons et. al., 1989) The shortage of well-designed, randomized interventions in geriatric health promotion broadly, or nutrition education specifically, makes it difficult to generalize results to other settings and populations. Follow-up studies are rare and if they are done, tend to be over the short-term, e.g., six months. Consequently, short-term outcome measures are used, such as attitude and knowledge change, rather than changes in behavior or health status. 11 Table of Contents An additional limitation to this review is the lack of agreement on a conceptual framework for nutrition education with this population. Without consensus on the direction that nutrition education should take, it is difficult to assess the relative value of research findings found in the literature. The lack of consensus can be seen in the multiplicity of educational objectives found in this literature review. Few programs explicitly stated what dietary changes, if any, were appropriate for older participants. Among those programs that did have clearly established objectives, there were differences regarding what aspects of diet were emphasized. For example, one program stressed making Iow cholesterol, Iow calorie choices; another emphasized increasing consumption of vitamin C foods, iron rich foods, dark green leafy vegetables, water, and other healthy food choices; still others stressed getting good value for your food dollar and cooking for one or two. The variation in what is being taught makes it difficult to draw comparisons across studies. Despite these qualifications, this review provides a useful assessment of the past and current state of nutrition education for older adults. Successful strategies are suggested from the literature and the implications of the review for nutrition education policy, research, and programs discussed. 12 Table of Contents II. THE PRACTICE OF NUTRITION EDUCATION FOR OLDER ADULTS HISTORICAL PERSPECTIVE: NUTRITION EDUCATION (PRIOR TO 1980) Until the late 1960s, national nutrition policies for older adults were directed almost exclusively to the nutritional support of institutionalized patients. By the early 1970s, the need for a broader approach to nutrition for the elderly was being advocated. The Nutrition Program for Older Americans was mandated by the 1972 Title VII Amendment to the Older Americans Act of 1965. Initially the program was directed toward provision of food to community dwelling elderly, whether or not they were disabled. In 1977 Congress approved funding for home-delivered meals. Since then, funding of both congregate sites and home-delivered meals has been provided through Title III-C of the Older Americans Act. Additional funding has come from states and private sources. (Roe, 1994) Nutrition education was among the nutrition services authorized by Title III-C of the Comprehensive Older Americans Act Amendments of 1978. Area agencies on aging could include outreach and nutrition education as a component of their meals program. A wide range of activity was undertaken under these provisions. Unfortunately, evaluations of such efforts were not required. A survey of State Units on Aging found that 69% indicated that they lacked a method to evaluate the effectiveness of their nutrition education program (Nestle, 1983). When the impact of congregate meal programs on nutrition knowledge or dietary intake have been studied, no significant differences have been found (Thomas, Kendrick, and Eddy, 1990). A survey of the aging network found that reasons most frequently cited for lack of nutrition education were inadequate funds, lack of qualified nutrition educators, and the lack of specific program standards and guidelines (Hickman, 1980 cited in Chapman and Sorenson, 1988). Health Promotion The 1970s also brought attention to the need for disease prevention and health promotion (USDHHS, 1979). Discussion of behavioral factors in chronic disease was stimulated by a landmark report published in Canada (Lalonde, 1974, as cited in McEIroy and Crump, 1994) and by the 1977 publication of John Knowles' Doing Better and Feelinq Worse: Health in the United States. During the same year, the Senate Select Subcommittee on Nutrition and Human Needs suggested major changes in the diet of Americans and proposed goals for the nation. (McEIroy and Crump, 1994) 13 Table of Contents The publication of the Surgeon General's report, Healthy People, in 1979 marked the inception of a decade-long campaign to reduce risk factors for disease. The report emphasized the value of individual behavior change and the importance of health promotion by suggesting that 50 percent of mortality was related to lifestyle factors. A goal of healthy aging was set for adults age 65 and older: "To improve the health and quality of life and ... to reduce the average annual number of days of restricted activity due to acute and chronic conditions by 20 percent, to fewer than 30 days per year." (USDHHS, 1979; McEIroy and Crump, 1994) Much of the literature on disease prevention and health promotion specifically with older people that was published in the late 70s and early 80s described demonstration-type programs conducted in the community. Senior centers, hospitals, geriatric clinics, churches, schools and other public facilities, and congregate housing were among the most common settings. Generally these programs were modest in design and scope. The research elements of the programs were given less emphasis than the service components, reflecting the priorities of the funding sources. (Rakowski, 1992) OVERVIEW OF NUTRITION nutrition Initiative, EDUCATION TODAY Nutrition interventions for older people generally fall into three categories: education, nutrition counseling and nutrition support (Nutrition Screening 1992). This review focuses on nutrition education. Sims (1987) characterizes nutrition education as "a form of planned change that involves a deliberate effort to improve nutritional well-being by providing information or other types of educational/behavioral interventions. One fundamental feature of nutrition education is its implicit emphasis on dietary behavior change as a result of the educational intervention. As Guthrie has suggested, 'If nutrition education is to be effective, it must focus on communicating clearly defined pieces of information with a goal of influencing behavior.'" Nutrition education in the community is offered most often in a group setting (NSI, 1992; Rakowski, 1992), either through senior meal programs or other programs. Increasingly, the clinical setting is being recognized as an important source of health information, including dietary advice (Woolf et. al., 1990). The primary source of nutrition information for older people, however, as with other populations, is through the mass media. Nutrition information from the media can also be a source of confusion to many people, including older people, who perceive reports and stories as providing conflicting dietary advice. (NSI, 1992; Kivela and Nissinen, 1987; Maloney et. al., 1984) 14 Table of Contents Nutrition and Health Promotion Goals for the Year 2000 One of three overarching goals established in Healthy People 2000, the 1990s edition of Healthy People (1979), is to "increase the span of healthy life for Americans." Nutrition is one of 22 priority areas identified for improving health and preventing disease. Nutrition objectives for all adults include reducing the prevalence of overweight, reducing dietary fat intake, increasing intake of fruits, vegetables, and grains, adopting sound weight loss practices, and reducing salt and sodium intake. The only nutrition objective specific to older Americans is Objective 2.18, "Increase to at least 80 percent the receipt of home food services by people aged 65 and older who have difficulty in preparing their own meals or are otherwise in need of homedelivered meals." 15 Table of Contents III. OVERVIEW OF THE PROBLEM LINK BETWEEN DIET AND HEALTH IN THE AGING POPULATION The nutrition problems that affect the elderly range from nutritional deficiencies to nutrient excesses (American Dietetic Association, 1993). Recent comprehensive reviews have identified obesity, hypercholesterolemia, hypertension, and, among the Iow-income elderly, limited income for food as widespread diet-related problems with well-established adverse health or social consequences. Calcium and vitamins D, B6, and B12 are the micronutrients most commonly deficient from diets of the elderly. (Dwyer, 1991 ) Table 1 shows the prevalence of health problems among older adults. Dietary patterns affect not only the disease, hypertension and obesity, but also some forms diabetes mellitus, hepatobiliary disease, alcoholism and 1988; Berg and Cas.sells, 1992) with nutritional implications incidence of cardiovascular of cancer, osteoporosis, dental caries. (USDHHS, Inappropriate diet also contributes to the dysfunction and disability associated with many chronic conditions common in older people. Fractures, osteoporosis, dental disease, physical inactivity, depression, social isolation, and sensory loss all have nutritional implications (Berg and Cassells, 1992). Inappropriate dietary intakes may exacerbate conditions such as diabetes mellitus, advanced renal insufficiency, hypercholesterolemia, certain forms of hypertension, constipation, gastrointestinal problems due to lactose intolerance and congestive heart failure. 16 Table of Contents Prevalence Nutritional TABLE 1 of Selected Health Problems Implications among Americans with Over 55 Years of Age Age Group and Prevalence Per 100 Persons Disease or Condition m 55-64 { 65-74 75-84 85+ DiabetesMellitus 7.2 9.4 8.7 8.1 CerebrovascularDisease 2.7 4.2 8.1 9.9 Chronic Digestive Disorders 3.7 5.8 6.3 8.9 30.7 39.3 39.8 39.2 Ischemic Heart Disease 9.3 13.7 13.5 12.2 Emphysema 3.1 4.4 4.1 1.7 Orthopedic Impairment 15.0 16.5 16.2 21.1 Arthritis 35.1 47.6 49.8 52.0 HealthFair or Poor 24.2 31.7 33.6 36.2 Unable to carry on a major activity 11.3 10.9 7.9 19.9 cited in Dwyer, Hypertension Source: National Center for Health Statistics 1991. Furthermore, increased wasting may occur with chronic obstructive pulmonary disease, cancers of the gut and paralytic strokes if the nutritional implications of these conditions are not recognized and treated by appropriate dietary interventions. (Dwyer, 1991) NUTRITIONAL STATUS OF THE OLDER POPULATION The prevalence of health problems with nutritional implications in the older population suggests that immediate benefits could be gained through improved nutritional status. However, most discussion of diet in the aging population focuses on the extent of malnutrition and deficiencies rather than the prevalence of dietary practices that contribute to chronic disease. Furthermore, methodological limitations of dietary intake studies make it difficult to be definitive about the nutritional status of older adults. Analysis of data from the National Health and Nutrition Examination Survey's 17 Table of Contents (NHANES) Epidemiologic Followup Study (data collected 1982-1984) indicated that adults age 65 and over ate fewer than recommended servings of dairy and grain products and adequate servings of fruits, vegetables, and proteins. (Murphy, Everett, and Dresser, 1989) Analysis of data from NHANES III, Phase 1 (data collected between October, 1988 and October, 1991) indicates that older adults, like other age groups in the population, are consuming higher than recommended amounts of total dietary fat and saturated fat. According to this analysis for adults ages 50 and over, 33.15 percent of total food energy was from dietary fat and 11.25 percent was from saturated fat. These amounts are higher than current dietary recommendations though slightly lower than for the population as a whole. (NCHS, 1994) Daily total food energy intake, as well as total dietary fat and saturated fat intake, appears to decrease with age, as can be seen in Table 2. (NCHS, 1994) TABLE 2 Mean Daily Total Food Energy Intake (TFEI) and Mean Percentages of TFEI from Total Dietary Fat and from Saturated by Age Group, NHANES III, 1988-91 Age Group Daily TFEI in kcal % TFEI from Total Dietary Fat Fat, % TFEI from Saturated Fat Total 2095 34.0 12.0 50-59 1967 34.7 11.6 60-69 1822 33.0 11.2 70-79 1624 32.9 11.2 80+ 1484 32.0 11.0 Source: National Center for Health Statistics, 1994. A review by Horwath (1991) of 90 dietary surveys conducted throughout the world found that dietary patterns of older persons were generally similar to those of younger adults with intakes above recommended levels for total fat, saturated fat, refined carbohydrates and sodium and below recommended levels for complex carbohydrates and fiber. Horwath points out that in some studies intake of vitamin C, vitamin A, riboflavin, and thiamin were also Iow. This seemed especially true among frail, inactive, less healthy or Iow income elderly. 18 Table of Contents In the U.S., comparison of the 1977-78 and 1987-88 National Food Consumption Surveys for persons over age 65, indicated that older adults as a group have made dietary changes that parallel those made by the rest of the population during the same time period. Those changes include decreased consumption of high fat meat and high fat milk and eggs and increased use of Iow-fat milk, Iow-fat poultry, meat, and fish, and Iow calorie beverages. (Popkin, Haines, and Patterson, 1992) Analysis cited in Dichter (1992) indicates that age 70 may be critical for food consumption patterns with adults ages 60-69 having food consumption patterns more similar to younger adults than to those ages 70 and over. Various conditions can negatively influence older adults' dietary intake. Low social status, including Iow income, education level, and occupation status, being a man living alone (Horwath, 1992) and bereavement (Rosenbloom and Whittington, 1993) can produce negative effects on nutrient intake. Nutritional status in older persons is also affected by physiological changes associated with aging. Alcohol, prescription drugs, and over-the-counter medications can have adverse affects on the body function and serve to lower food and nutrient intake. Reduced bone and muscle mass, glucose tolerance, lipid metabolism, production of digestive enzymes, and sense of taste and smell are just a few of the changes that can affect nutrient intake. (ADA, 1993) Nutrition problems among the older population may be compounded by inadequate access to sound nutrition information. Lower knowledge of nutrition is associated with relatively poor perceived health in the elderly. (ADA, 1993) DIETARY RECOMMENDATIONS Nutrient requirements and dietary guidelines for older persons are based almost entirely on values extrapolated from data from studies of younger adults. The Surqeon General'sReport on Diet and Health (1988) recommends that older people should be advised to maintain at least moderate levels of physical activity so as to increase caloric needs and maintain adequate nutrient intake. Those who cannot (or will not) consume adequate levels of nutrients from food sources and those with dietary, biochemical, or clinical evidence of inadequate intake should receive advice on the proper type and dosage of nutrient supplements. Self-prescribed supplementation, especially in large doses, should be discouraged as potentially harmful. Older people with diet-related chronic diseases are advised to receive nutrition counseling and those on medications are advised to seek counsel on diets that minimize food-drug interactions. (USDHHS, 1988) The U.S. Preventive Services Task Force Report (1989) recommends 19 that Table of Contents clinicians should provide periodic counseling regarding dietary intake of calories, fat, cholesterol, complex carbohydrates and fiber, and sodium; patients should receive a diet and exercise prescription designed to achieve and maintain a desirable weight; and patients should be given dietary guidance on how to reduce total fat intake to less than 30 percent of total calories and dietary cholesterol to less than 300 mg/d by eating a variety of foods, with emphasis on the consumption of whole grain products and cereals, vegetables, and fruits. Clinicians who lack the time or skills to fulfill these recommendations are advised to refer patients to a registered dietician or qualified nutritionist. (Woolf, Kamerow, Lawrence, Medalie, and Estes, 1989) SUMMARY The prevalence of health problems with nutritional implications in this population suggests that there are significant health benefits to be gained from nutrition education targeted at different stages of prevention. For healthy older adults, sound dietary practices can maintain health and vigor and help prevent problems from developing. For older people with chronic health problems, a healthy diet can control some chronic disease, prevent further problems and help maintain health. Finally, for people with acute health problems, dietary interventions can preserve strength and functioning and make treatment more effective. 20 Table of Contents IV. THE THEORETICAL BASIS FOR NUTRITION EDUCATION WITH OLDER ADULTS No single academic discipline or theoretical framework forms the basis for nutrition education with older adults. Rather, nutrition education interventions draw on theory from many fields -- gerontology, psychology, education, communications, marketing, and health education. Following is a summary of the multiple theoretical streams used to design nutrition education programs (or health promotion programs) for older adults. In addition, the Nutrition Communication Model, which applies many of these theories its design, is discussed although it does not address older adults specifically. in Examples from the literature review are cited, when possible, to demonstrate how a particular model or theory has been applied. But it should also be noted that very few articles cited any theoretical basis for the research. This synopsis is not intended critique of these theories. to be a comprehensive review, discussion, or SOCIAL PSYCHOLOGY The parameters of the social science study of behavior were pioneered by theorists such as Kurt Lewin working around the time of World War II. Lewin's empirical studies of dietary change examined family food habits noting different forces in food selection and purchasing among high, middle, and Iow economic groups; described channels through which food reaches the table, identifying gatekeepers, such as housewives, in those systems; and demonstrated the effectiveness of group discussion and decision-making over lectures alone in changing food selection habits. Lewin cited factors such as active involvement of participants, the act of group decision-making, and expectations of being asked by the group leader if new foods were introduced into the family's diet as forces for change among housewives participating in nutrition education programs during and after World War II. It is striking that these themes dominate the literature today. (Lewin, Kurt, 1952) Social psychologists and learning theorists emphasize the role of attitudes as they develop, change, and influence behaviors. In general, knowledge alone is not thought sufficient to change behavior. 21 Table of Contents Grotkowski nutrition education well as increasing measuring attitudes correlated with the and Sims (1978, cited in Lank and Vickery, 1987) recommend that efforts be directed toward changing attitudes about nutrition, as nutritional knowledge. By applying a method they developed for about nutrition, they found that nutrition knowledge was positively attitude that nutrition is important. Peer education and programs using role models derive from social psychology theorists such as Bandura and his social learning theory (Lewin, 1986). The theoretical model suggests that one's behavior develops through observation of both one's own and other's behavior and through the reaction of others to behavior. Examples of peer education programs are discussed in further detail on page 56. A central concept of Bandura's social learning theory is the notion of selfefficacy, one's belief or feeling that he or she can perform a behavior successfully. Another expansion of the knowledge-attitude-behavior continuum stems from the work of Ajzen (1975) and Fishbein (1988) that postulates it is a combination of individual attitudes and subjective norms which an individual combines into intentions to behave and ultimately into behavior. The utility of measuring intentions rather than actual behavior has made this theoretical base one frequently used in evaluations. HEALTH EDUCATION Although careful examination of knowledge and attitudes can help clarify objectives of nutrition education, health education models remind planners that health-related behaviors take place in complex social environments. The Health Belief Model suggests that compliance with health advice is a factor of a person's knowledge of an issue, perception of vulnerability to a disease threat, belief in the efficacy of the proposed treatment or intervention, belief in one's ability to carry out the proposed treatment or intervention and the perception of the difficulty of taking recommended actions. The Health Belief Model has chiefly been used medical settings to evaluate interventions with obese patients, hypertensives, and family planning patients (Becker, 1974). Community-based health interventions have been planned using Green's PRECEDE model which encompasses the personal characteristics cited above, in this model called "predisposing factors," as well as "enabling" and "reinforcing" factors. Enabling factors include, for example, access or barriers to recommended services and reinforcing factors include social norms and views of significant others. Public health agencies examine these elements when planning interventions. Though they do not cite this planning model, nutrition education programs that include grocery shopping trips and food tastings or patient education programs that include educational sessions for the wife of a heart patient are attending to elements 22 Table of Contents explicated in this model. (Green, 1991) COMMUNICATIONS The field of communications offers nutrition educators practical theories for understanding the audience and influencing people's knowledge, attitudes, and behaviors regarding nutrition. Communication is defined as an exchange between the message sender and the message receiver. Communicating is not the same as '_elling." Communications reminds us that the recipient of a message plays an active role and can ignore, misunderstand or reject a nutrition message, as well as accept it and act on it. Communications about nutrition take place within a complex environment with multiple "senders" trying to reach consumers often with conflicting messages and messages that have changed over time. Confusion arising from conflicting messages from multiple sources was reported by older focus group participants in developmental work for the Healthy Older People program (Maloney et. al., 1984). The concept of an active listener suggests a full range of audience-centered formative evaluation activities such as focus groups, surveys, and pretesting educational materials. Many examples of using these techniques were found in the nutrition education literature. Two examples are the use of focus groups by Crockett, Heller, Merkel, and Peterson (1990) and the use of a consumer survey about topics of interest by Goldberg, Gershoff, and McGandy (1990). William McGuire has worked extensively on the theory underlying mass communication campaigns. His work draws attention to five variables in any communication: the source, message, channel or medium, receivers or target audience, and the destination or action toward which the communication is aimed (McGuire, 1978). McGuire is also known for the Information Processing Model by which persuasive communications campaigns lead an audience through a 12-step process toward behavior change: 1. 2. 3. 4. 5. 6. 7. 8. Exposure to a message Attention to a message Liking or finding the message personally relevant Comprehending or understanding the message Learning how to incorporate the behavior Accepting the change Remembering the content and that one has decided to do it Being able to retrieve the information from memory 23 Table of Contents 9. 10. 11. 12. Making decisions based on the retrieval of information Behaving in accordance with the message Having the behavior reinforced Undertaking post-behavioral activities, such as reorganizing personal beliefs This enumeration reminds us of the complexity of moving an audience from information to behavior and of the necessity of continuing communications over time. This model has been used by public health communication planners to help determine "where the audience is" regarding a certain message. The Healthy Older People program provides an example. Healthy Older People program market research indicated that for some topics, older adults simply needed to be reminded of something they already claimed to know. For other topics, new information needed to be communicated to achieve program objectives. (Maloney et. al., 1984) Rogers and Shoemaker have studied how new ideas or products (innovations) are diffused through a population and the factors that facilitate or impede diffusion of innovations. They categorize audience members into innovators, early adopters, early majority, late majority, and laggards as they go about adopting new behaviors. These categories can be used to segment audiences for planning purposes. (Rogers and Shoemaker, Communication of Innovations, Free Press, 1971, New York, NY and Rogers, Diffusion of Innovations, Free Press, 1983, New York, NY) For example, the National High Blood Pressure Education Program has moved from a general message in 1972 of "get your blood pressure checked" to more tailored messages which remind aware hypertensives to take their medication and follow diet and exercise recommendations. (USDHHS, 1990) THE NUTRITION COMMUNICATION MODEL Gillespie and Yarbrough (1984) and Gillespie (1987) offer a conceptual model for communicating nutrition that integrates many of the theoretical ideas presented above. Other theoretical perspectives are added from sociology and psychology about social roles and relations (Lazarsfeld and others; Katz and Lazarsfeld) and how people interpret content according to implicit rules (i.e., Watzlawick's pragmatics approach). Their model includes three major components: inputs, intervening process, and outcomes. Communicators determine the channels through which the message is conveyed, identify the source of the information, choose the message content, and decide on the treatment of these ideas. Messages can be sent through interpersonal or mass-mediated channels. The audience brings to the message a set of skills, beliefs, attitudes, and habits that will influence their response. These are called "receiver inputs" and include nutrition and non-nutrition related factors. Gillespie and Yarbrough argue 24 that Table of Contents different responses to a single message according to the receivers' inputs. are not random but can be predicted Between the delivery of the message and its effects is the intervening process which consists of attention (to the message), comprehension, and interaction. Interaction can be between the receiver and sender or between receivers and their peers and enhances the likelihood of a response. The desired outcome of nutrition communication is the receivers' acceptance of a message, according to the model. Drawing on Fishbein and Ajzen, the model allows for four different levels of acceptance: cognitive, affective, behavioral intent, and behavioral. A response is not an either/or proposition. The conceptual framework offered by Gillespie and Yarbrough is a comprehensive, predictive model for nutrition education which could be applied to nutrition education with older adults but, based on this search, has not been to date. MARKETING Marketing techniques can be applied when there is a good understanding of the target audience's wants and needs. Marketing approaches can help fashion appeals that the audience will find relevant, focus on getting the message to the audience through multiple channels, and fashion rapid information and feedback systems. (Fleming, 1987) Social marketing suggests being precise in understanding and targeting audience segments. The National Cancer Institute's 5 A Day program bases its target audience on a psychographic profile, not a demographic one, i.e., an audience defined by what they do, not what demographic attributes they have (including age). Their target group is seeking opportunities to eat better but suffers from time constraints and value convenience when it comes to meal preparation. The market segment that NCI compares to their target group is more likely to take a traditional approach to eating (e.g., three meals a day). They also tend to be older, ages 55 plus, compared to the target group (ages 25-55). (National Cancer Institute, 1993) ADULT EDUCATION Characteristics of adult learners have implications for nutrition educators. According to Knowles, adults learners have self-concepts different from young students. Adults see themselves as self-directing and doers rather than full-time learners. Older adults have a lifetime of experience on which to draw and may be prompted by retirement or other role changes to want to learn something new. Adults' orientation to learning is immediate and practical, desiring explanations of how to use information rather than just being taught facts. In addition, several 25 Table of Contents program evaluations have demonstrated the benefits of learning in a mutually supportive and socially meaningful setting. (Knowles, 1974) Sensory and cognitive changes in older learners may require special attention in nutrition programs. Good lighting, non-glare paper, bold, high-contrast lettering, and slow, Iow-pitched speech are some considerations. Kicklighter (1991) has summarized information about adult learners for dietetics practitioners. 26 Table of Contents V. EFFECTIVENESS OF NUTRITION EDUCATION WITH OLDER ADULTS: Review of the Literature Nutrition education research attempts to determine the most effective means of conveying dietary recommendations to the public. Nutrition education research is not intended, according to Sims (1987), to determine the scientific validity of the message but to design appropriate messages for target audiences and to determine the most effective means for message delivery within a given context. She divides nutrition education research into four categories, three of which are used below to organize the literature review. As was stated earlier, only a few studies met the methodological criteria specified for this review, i.e., those that included some measure of instrument reliability and validity, random assignment or strong quasi-experimental designs. Those studies are identified, when appropriate, first in each category. Then other studies which do not meet the review criteria, i.e., surveys, qualitative research, descriptive studies, or those with other design limitations, are included for additional insights. STUDIES OF FACTORS THAT FACILITATE OR IMPEDE INFORMATION TRANSFER AND MEDIATE THE TRANSLATION OF KNOWLEDGE INTO BEHAVIORAL CHANGE: i.e., Public Awareness and Interest in Diet and Health All of the published research examining public awareness diet and older people were non-empirical, descriptive studies. factors specific to Research has found that older people are an eager audience for health information, including nutrition information (Maloney et al, 1984). They also report higher frequencies of most health-seeking behaviors (Walker, Volkan, Secrist, and Pender, 1988) and are active participants in community health promotion programs (Rakowksi, 1992). The complexities of nutrition, however, make it difficult for many older people to comply with dietary recommendations, as is the case for many of the general public. Older Adults May Have Difficulty Applying Nutrition Knowledge Hand, Antrim, and Crabtree (1990) administered 27 a 30-minute nutrition Table of Contents knowledge test to 96 retiree volunteers in the Cincinnati area. The study demonstrated that although the participants had good technical nutrition knowledge their ability to apply the knowledge was limited. For example, most knew sodium could be associated with high blood pressure and that salt was the major dietary source of sodium, but were less able to identify foods that contained sodium. Findings were similar about dietary fats and fiber. Hand et. al. conclude that '_[eaching people to judge the nutritional value of a food for themselves" should be a goal of nutrition education and point to grocery shopping tours and programs to combat misleading advertising as important components of nutrition education. Focus groups with older adults conducted for the Office of Disease Prevention and Health Promotion (Maloney, et. al., 1984) indicated that many older adults had been exposed to nutrition messages, paid attention to them, felt the information was relevant (especially as a means of maintaining health), and were acting on it as they understood it. However, confusion over conflicting messages from multiple sources hindered their ability to carry out dietary advice. The specifics of a "good" or "balanced" diet were largely lacking. Older participants were more conversant with what not to eat, i.e., avoiding fats, salt, sugar, caffeine, junk and processed foods, than what to eat. What Older Adults Say They Want to Know About Nutrition Surveys and focus group research have questioned older adults about which nutrition-related topics are of most interest. Popular topics are those related to modifying diet to maintain health, getting "your money's worth" when shopping for food, and food safety. Goldberg, Gershoff, and McGandy (1990) surveyed 459 members of local AARP chapters in Massachusetts ages 55 to 89 about their interest in seeing a nutrition education video on nine topics. Interest was high for the topics: "shopping economically," "safety of the food supply," and "food safety at home." Interest was also high for health topics presenting evidence that changes in dietary behavior can have health benefits. These included "salt," "weight control," "sugar," and "serum cholesterol." Fewer older adults were interested in "supplement use" or the "nutritional adequacy of the diet." Consumers of a home-delivered grocery program were interviewed about their nutrition- and food-related interests as part of planning a nutrition education program. (Krinke, 1990) These frail older adults (N= 116) living independently in an urban community were asked to identify which of nine topics were of interest. Topics of greatest interest were: money-saving food purchases; preparing meals to retain food value; and special diets for special physical conditions. Focus groups were used to assess the interests 28 of 68 active North Dakotans Table of Contents ages 60 and over who lived in rural areas (Crockett, Heller, Merkel, and Petersen, 1990). The focus group members reported that healthy food choices, basic nutrition, incorporating fiber in diets, snacking, new ideas for preparing tasty foods, and cooking for one or two were appropriate topics for nutrition education for older adults. Four focus groups with 38 healthy, non-institutionalized adults ages 60 and over were conducted by Shepherd (1990) for USDA to gather audience reaction to a proposed set of consumer education materials. The topics covered by the materials were generally well received, though "sorting out nutrition facts, fads, and fiction" caused some confusion and was judged least favorably. Topics viewed favorably included: · · · · · · Credible What you should know about fat, cholesterol, sodium, and fiber Shopping and planning meals for one or two Special advice for older adults Food choices and challenges: snacks, desserts, and eating out Questions older people ask Tips and recipes Sources of Nutrition Information Source credibility was assessed in two studies. Crockett, Heller, Skauge, and Merkel (1993) found the family doctor, public health nurses, family members, and one's own judgement to be influential sources of health advice. Other influential people or institutions included younger seniors, family members, community organizations, and governmental agencies. The survey cited earlier by Goldberg et. al. (1990) reported physicians, audiovisuals, and the print media as important sources of nutrition-related information. Focus groups with older adults for Healthy Older People identified magazines, television, pamphlets found in drug stores and grocery stores, and physicians as credible sources of health information. However, participants did not believe physicians were well-informed sources on the subjects of nutrition, fitness, and medications. (Maloney et. al., 1984) In a survey of adults age 60 and older in central Texas (Briley, Owens, Bellham, and Sharplin, 1990), magazines, newspapers, physicians, and cookbooks were the most frequently cited source of nutrition information. Cookbooks were cited more frequently as a source among rural respondents and dieticians were more frequently cited by urban residents. In a study in eastern Finland (Kivela and Nissinen, 1987), television and radio were identified as main sources of nutrition information with women also obtaining 29 Table of Contents nutrition information in newspapers, magazines, and books. STUDIES TO IDENTIFY THOSE FACTORS THAT CAUSE CHANGES IN DIETARY PRACTICES: i.e., Motivational, Educational, Sociocultural Factors Studies to identify underlying factors for dietary change were scarce population. Most of those found were surveys or qualitative research. for this Nutrition knowledge and attitudes were found to be positively associated with the general adequacy of dietary intake in a group of 22 congregate meal site participants (Thomas, Kendrick, and Eddy, 1990), but the authors cited other studies in which the relationship was not found. Other studies have looked at the relationship of knowledge and attitudes to supplement use (Mclntosh, Kubena, Walker, Smith, and Landmann, 1990) adherence to cancer prevention dietary guidance (Ho, Lee, and Meyskens, 1991) and nutritional adequacy among rural older adults in two age groups (Fischer, Crockett, Heller, and Skauge, 1991 ). Judgments of self-efficacy for dietary fat, exercise, weight control, smoking and alcohol consumption were measured among Medicare beneficiaries in a managed care setting (Grembowski, Patrick, Diehr, Durham, Beresford, Kay, and Hecht, 1993) Older adults with high self-efficacy had lower health risk in all behaviors and better health. Intentions, self-efficacy and other dimensions were measured by Fischer, et. al. (1991) in rural adults in North Dakota. The 60-through 70 year-old group expressed significantly more positive attitudes for efficacy, intention, and outcome expectation than the older group. Fischer et. al. conclude that nutrition education should focus on positive messages that are age-appropriate, practical, and achievable. Some Studies Suqqest Motivators nutrition A few studies examine motivational education with this population. factors influencing the effectiveness of Colson and Green (1992) examined the effectiveness of an eight week nutrition education program designed for sodium reduction in hypertensive versus normotensive elderly. Two treatment groups (N= 12 hypertensives and N= 10 normotensives) participated in classes and informal discussion groups. Nine hypertensives and 10 normotensives served as controls. Three-day dietary intakes, 24-hour urine, pre- and post-tests of knowledge and a 14-week knowledge follow-up test were administered. They found that the program was more effective in the hypertensive group than in the normotensive group, as measured by statistically 3O Table of Contents significant increases in knowledge and reductions in dietary sodium. These findings suggest that older people with a medical need for dietary modification may be more positively affected by an education program than those without a medical need. Examining compliance with dietary guidance for cancer prevention, Ho, Lee, and Meyskens (1991) determined that among 30 elderly white men and women, taste and health benefits were shown to be motivators for these older people to follow dietary guidance. Respondents differed in their reports of anticipated success and willingness to follow various dietary recommendations. All anticipated success and willingness to moderate use of alcohol and most anticipated success and willingness to eat dark green or deep yellow vegetables daily and to eat fruits and vegetables high in vitamin C. There was a lower percent of agreement between anticipated success and willingness to eat whole grain daily, eat cruciferous vegetables, limit smoked and cured products, and to eat a Iow fat diet. Toner and Morris (1992) found that dietary quality was related to the personality trait of being internally motivated and the presence of social support in a study of the social and psychological influences on nutritional quality in 100 older adults. Nutrition Education Should Target Age Groups Age may make a difference in seniors' willingness to change dietary practices. In a survey of older adults ages 75 to 85 (N=363) and adults ages 60 to 70 (N=335), the younger group were more positive than the older group that eating habits lead to certain health outcomes and had a more favorable attitude of intending to change eating habits. The younger seniors also had a more positive perception of their own ability to change eating habits than the older seniors. The authors suggest that nutrition education messages should be age appropriate for younger and older groups of seniors. (Fischer et. al., 1991) Nutrition Education Should be Culturally Appropriate In the U.S., ethnic minorities bear a disproportionate burden of ill health. Few studies specifically address the health status of older ethnic minorities and no evaluated studies on the effectiveness of nutrition education programs for minority elders were located in this review. The Gerontological Society of America (1991, cited in Yee and Weaver, 1994) noted that much more could be accomplished in promoting health and preventing disease among the segments of the population for whom health promotion and disease prevention efforts have been inadequate, inappropriate, or irrelevant. Yee and Weaver (1994) call for a culturally competent agenda for health promotion that encompasses the health beliefs and practices of ethnic minorities. 31 Table of Contents Jackson and Mead (1990) suggest recognizing the central role foods play in reaffirming American Indian cultural heritage. AARP has sponsored focus groups with African-American and Hispanic elders to provide some direction for the establishment of health promotion programs with these populations (Henderson and Kensinger, 1992; Hispanic Market Communications, 1990). STUDIES THAT IDENTIFY, DEVELOP, AND EVALUATE EFFECTIVE STRATEGIES FOR DELIVERING NUTRITION INFORMATION TO OLDER ADULTS A meta-analysis and synthesis of nutrition education research for all populations measured the frequency of use of the range of instructional strategies reported in the literature (Johnson and Johnson, 1985). TABLE 3 Frequency of Use of Instructional Strategies in 303 Nutrition Education Studies, 1910-1984 I I Percent Lectures 75.7 Written materials 69.4 Directed small group activity 50.3 Displays 44.8 Individualcounseling 33.1 Movies, slide shows, closed circuit TV 31.3 Commercial massmedia 11.0 Computers Source: Johnson 1.9 and Johnson, 1985 Most nutrition education programs for seniors involve didactic education, distribution of pamphlets and brochures, the provision of meals, or authoritative counseling from a doctor or dietician. (Hackman and Wagner, 1990) Preferred Formats Krinke for Nutrition (1990) asked Education interview respondents 32 what formats they preferred for Table of Contents nutrition education classes. These frail elders were interested in demonstrations, inperson discussions, and literature or written materials. Few in this audience found phone discussion, cooking classes, or field trips of interest. The commonly used lecture and group discussion format was of interest to 13 percent of these respondents. Focus group participants living in rural areas interviewed by Crockett et. al. (1990) were favorable to methods or activities such as a potluck event to share nutritious dishes, a nutrition newsletter sent directly to a senior at home, and nutrition classes. They were mixed in their interest in videotaped lessons in doctor's offices, coupons as incentives to learn about good eating habits, samples of nutritious foods in grocery stores, information available in restaurants, and a recipe contest. Nutrition Education in the Conqre_qate Meal Settin.q Current federal programs support the functional independence of older people in ambulatory care centers, adult day care centers, hospices, and home settings, as well as in the community. These food and nutrition services include the USDA's Food Stamp Program, which serves more than 2 million older Americans, and AoA's congregate meals programs, serving approximately 2 million individuals, and its home-delivered meals programs, which serves 0.5 million. (USDHHS, 1988) The Title III-C nutrition program (i.e., congregate nutrition services, homedelivered nutrition services, and school-based meals for volunteer older individuals and multigenerational programs), funded under the Older Americans' Act of 1965 and its subsequent amendments, requires that a minimum of two nutrition education sessions per year be provided to program participants. According to Hutchings and Tinsley (1991), the objective of this requirement is to increase participants' awareness and knowledge of nutrition. 1992 amendments to the Older Americans' Act (Title II1F) added additional funding for health promotion and disease prevention programs, including nutrition education. A recent survey of State Units on Aging found that 42 percent of 55 States and territories have applied Title III-F funds for nutrition screening and educational services (National EIdercare Institute on Health Promotion and Aging, 1994). Despite the widespread delivery of such programs, and reports of research activities (Newhouse, Scott, Hertzler, and McAuley, 1989), few evaluations have been reported in the literature. Generally, these programs have been demonstrated to improve the dietary intake and nutritional status of participants, despite limitations in size and scope (USDHHS, 1988). However, the most comprehensive evaluation, a 1983 nationwide study commissioned by the Administration on Aging, found that nutrition education activities offered by meal sites have no discernible impact upon participants' dietary intakes away from the site. (Kirschner, 1983) In fact, social, psychological, and physical activity improvements may be their main benefits, more 33 Table of Contents than the targeted 1990) nutritional benefits. (Kohrs, 1982, cited in Hackman and Wagner, Lack of nutrition education training may be one reason why nutrition education efforts have been unsuccessful in congregate sites. Of 30 center managers in a five° county area in Nebraska, one-third described themselves as mainly self-taught in the area of nutrition while 29% indicated they had attained a background in nutrition from workshops and training courses. Only 17% had taken a nutrition course in college. (Stanek and Fox, 1989) A survey to identify the role and activities of USDA Cooperative Extension Service professionals in congregate nutrition programs for the elderly was reported in 1989 (Newhouse, et. al., 1989). Although both programs share similar mandates and missions, no systematic interaction is required. A total of 331 extension professionals, from 45 states, were identified who had been involved in program efforts in consumer economics and/or nutrition targeting an older adult audience. A survey sent to this sample yielded a response rate of 73.4. The results showed that extension personnel performed a wide variety of roles at such sites ranging from teaching (90%) and dissemination of materials (69%) to membership on advisory boards (16%) and formation of support groups (6%). Large proportions also engaged in instructional support roles such as identifying resources (50%), coordinating with other agencies (45%), and consulting (30%). Nutrition topics taught by Extension Service professionals were the dietary guidelines (80%), nutrition and aging (70%), food buying (68%), nutrition-related diseases (68%), food preparation _cchniques (61%), managing food dollars (59%), food safety (58%), food/drug interaction (6%), and food preservation (3%). Health and safety topics included exercise and fitness (54%), stress management (18%), and home safety (2%). Consumer information topics included consumer education, budgeting, community resources, health care costs and insurance, taxes, wills, and estates. The survey found that extension personnel also were involved in the development or adaptation of educational program materials to use at the program sites. Nearly two-thirds (64%) knew of someone in their states who had developed, adapted, or directly adopted educational program materials for use in congregate meals settings. Innovative techniques were reported in 41% of these programs, including games, computer simulation, films, videos, or demonstrations. In 55% of the cases, materials were field tested prior to use and in 75% of cases, an evaluation of the materials was done. Typical evaluation measures were counts of attendance (88%), enjoyment (60%), and knowledge change (57%). More direct measures of effect were less frequent, i.e., change in practices (38%) and skills change (32%). However, when respondents were asked a general question as to whether extension programs for participants at congregate nutrition program sites had been evaluated in the past five years, only 16% responded positively. 34 Table of Contents The study found that despite the use of some different approaches, extension personnel largely employ their traditional instructional method. Implications for future programming are offered: 1) extension staff will need to select roles which will maximize impact; 2) instruction needs to be tailored to the cognitive, economic, social, and motivational characteristics of the audience; 3) the logistical obstacles to providing serious, educational programming in the mealtime environment need to be overcome; and 4) sporadic involvement of extension staff make it difficult to evaluate program outcomes. A package of pretested programs for extension staff to use in the congregate setting is proposed. This package, which could also be used by volunteers, would include: information about the target group; a variety of program topics presented in an interactive format; follow-up activities to add depth to brief presentations; and simple evaluation tools. Newhouse et. al. observe that while most survey respondents perceived work with this elderly population to be a priority, little guidance from extension or the aging network is given as to how these two systems might interact most effectively. They conclude that there is a need for new models and innovative approaches for nutrition education and evaluation. One such possibility may be an extension service program, "Healthy Aging," admir_istered in a congregate meal setting that combined 12 weekly one-hour nutrition and fitness lessons with a daily walking program (Hermann, Kopel, McCrory, and Kulling, 1990). Significant decreases in blood pressure, total cholesterol, and body weight were demonstrated. These effects are attributed to increased exercise and altered type of dietary fat intake as a result of the program. Long-term compliance was not measured. Nutrition Education in the Dining Room A strategy that has been widely used in the worksite and in restaurants nationwide is the identification of healthy menu selections and dissemination of nutrition information on tables and throughout the dining area. Only two studies emerged from the literature search of a similar strategy with the older population. The first intervention took place in the dining room of an independent living facility. Psychologists Stock and Milan (1993) wanted to encourage three residents who had medical problems complicated by their dietary practices to select better choices at mealtime. Supplementary data were collected on all diners' choices for each course of the four-course dinners served at the facility. Three intervention packages were added and removed in sequence in an experiment designed to assess their effects on the food choices of the three primary participants and the group as a whole. The interventions consisted of: 1) enhanced prompts, feedback, and social reinforcement; 2) a lottery; and 3) serving as a confederate. Prompts included the American Heart 35 Table of Contents Association heart on the menu to designate the Iow-cholesterol calorie-modified selection, media information, buttons, verbal prompts, table tents, menu fliers, and weekly "health hour" class information. A chart displayed in the dining room showed how many healthy items were chosen each night and a weekly summary was published in the facility's newsletter. The hostess made a point of praising those participants who reported they had made healthy selections and reminding those who said they had not to have a good evening and pick a heart selection at dinner. The lottery game, called the "heart game," included immediate and delayed reinforcers contingent upon choices of heart items on the menu. The confederate procedure involved recruiting residents who consistently made healthy choices to encourage others to improve their dietary practices. The three primary participants each demonstrated a marked increase in choices of healthy food items in response to enhanced prompts, feedback, and social reinforcement. The addition of the lottery and serving as a confederate did not increase their healthy choices. However, the addition of the lottery resulted in the highest percentage of healthy choices observed for the other diners. Analysis of the group's food choice data attributed most of these effects to better dessert choices. It is suggested that the lottery and confederate role model had less effect on the three participants than on the group because of the initial impact of the first intervention. Component analyses were not done so their relative effects are not known. Finally, the percentage of healthy choices returned to baseline levels when the intervention was discontinued. The other intervention reported in a dining room setting was a case study in which table tents were used in a congregate meal setting to demonstrate the four food groups and increase healthy food choices (Park, Izurieta, Unton and I_arsonBrown, 1993). A "few" seniors noted "some" positive changes in their diets as a result of having read the nutrition information, such as remembering to eat more fruits and vegetables or to cut back on Iow nutrient-density foods like donuts. Nutrition Education Classes For older adults, most health promotion program delivery generally, and nutrition education specifically, has followed a didactic model. Participants are brought together for presentations and skills training and encouraged to adopt what they have learned and adapt their lifestyles. (Rakowski, 1992) Group sessions are popular with older adults because they provide a social environment for the learning process. Problems can be shared and addressed collectively. Groups encourage learners to become teachers to others -- peers, friends, spouses, neighbors, children. (Haber and Lacy, 1993; NSI, 1992) Group methods can be especially effective when used in preexisting group settings such as senior centers and churches (NSI, 1992). However, groups aren't for everyone. 36 Studies find that the group learning Table of Contents environment appeals more to women than to men (Rakowski, 1992). To reach older men, alternative approaches may be necessary (AARP, 1994). As the evaluation of the federal nutrition program cited earlier found, group learning interventions may also be ineffective. The Dairy Council of Metropolitan New York developed a packaged program which included a series of single-concept nutrition topic teaching modules. Each module included a script for the teacher, handouts, work sheets, a game or activity to reinforce learning, and formative and summative evaluation instruments. At a senior housing project in New York, the program was tested for effectiveness in increasing knowledge and improving eating behaviors of older adults. The experimental group attended four one-hour classes over a two-week period. No significant differences were found between the experimental and a control group. (Bedell and Shackleton, 1989) Long-term outcomes are thought to be especially difficult to sustain, although they are seldom measured. This assumption is confirmed by a two-year follow-up of the Wallingford Wellness Project, a health promotion program for the elderly. The follow-up study found that while improvements in nutrition practices were sustained above the pretest levels, they had dropped from the six-month follow-up. Information related to nutrition was shown to have declined back to pretest levels from immediate and six month posttests. The declines are attributed to the lack of peer support for behavior change. (Lalonde, Hooyman, and Blumhagen, 1988) Active learning: An accepted principle for group learning, particularly older adults, is that the student needs to be involved in the process. with Mitic's Nutrition Instruction Model is one theory-based educational approach which incorporates needs assessment and problem solving to enhance the effectiveness of nutrition education (Mitic, 1985). Mitic's model was used by KupkaSchutt and Mitchell (1992) to design a four-week nutrition education program for older adults. The first session evaluated the subjects' dietary intake. The second and third sessions offered information based on participant needs and interests. In the final session, subjects set goals and developed a plan for improving their dietary intake. Seniors from a local hospital's senior program were randomly assigned to one of three groups: experimental, control A, and control B. The experimental group received the program described. Control group A received four one-hour lectures on the dietary guidelines. Control group B received no educational intervention. The experimental subjects showed the greatest degree of positive dietary behavior changes, including decreased fat and increased fiber intake. However, all subjects were eating a diet that was nutritionally adequate originally, so large changes in dietary behavior were not expected, or necessary. Mitic (1985) did find the model to be effective in maintaining short-term dietary change for subjects whose diets were of lower nutritional quality. Haber and Lacy (1993) employed a single-blind 37 (i.e., interviewers did not know Table of Contents the hypotheses being tested, but did know the group to which participants were assigned), randomized control group design to test a didactic health education program augmented to increase student involvement in the learning process. The experimental group attended health education classes and also received a peer support group intervention led by student nurses for 30 minutes after each of ten weekly classes. During these group sessions, health behavior contracts were completed using a wellness prescription that had been completed by the participant's physicians suggesting areas for behavior change. The control group received only the educational intervention. The largest differences between the two groups were apparent for eating behaviors and least apparent for body movement, with those who received the enhancements more likely to change eating behaviors in the desired direction. The evaluation did not attempt to separate out the relative importance of the three additional components -- peer support, behavioral contracting, and physician guidance. The study's authors noted that the small sample size (N=57) was not large enough to "consistently offer power to detect the observations significant at p=0.05." The Staying Healthy After 50 program, a comprehensive health education program designed by the American Association of Retired Persons (AARP) and the American Red Cross, used teaching and learning methods to foster active participation including group discussion, small group activity, individual and pair participation, role-playing and/or skits, skill practice, and exercise breaks. (Simmons, Nelson, Roberts, Keller, Kane-Williams, Salisbury, and Benson, 1989) A more recent health education program developed by AARP and the American Heart Association, "Eating for Healthy Tomorrows," targets older AfricanAmerican adults. The one-time, two-hour intervention was tested in seven pilot sites. Participants were surveyed to measure reactions to content and methods. The program uses a combination of lecture, group discussion, interactive games and exercise breaks to help increase awareness and understanding of nutrition's role in preventing heart disease, high blood pressure, and stroke. Of the 527 pilot site respondents, 84% were female and 16% were male; 55% had high blood pressure, 20% diabetes, 15% heart disease, 7% cancer, and 6% had had a stroke. The majority agreed on the importance of changing lifestyle habits to improve health. Those aged 76+ were somewhat less likely to perceive the importance of changing lifestyle habits. Overall, participants learned from and enjoyed the program; handouts were reported to be easy to understand; activities were helpful, and most would recommend the program to friends. The 76+ group in particular liked the mini-market which simulated a trip to the supermarket; 72% said they enjoyed it compared to 53% of those aged 50 to 60. (American Heart Association and AARP, 1994) Peer educator approach: With group learning methods, age peers are often trained as leaders or coleaders. This method is most successful when the instructor 38 Table of Contents is most like the participants, i.e., of similar age, background and experience level with those receiving instruction, and has a peer relationship with their audience. (Lank and Vickery, 1987; Shannon, Smiciklas-Wright, Davis, and Lewis, 1983; Penn State Nutrition Center, 1988) Furthermore, individuals with prior leadership experience or a strong level of self confidence are more readily accepted by their peers as leaders than those who only had nutrition training. (Ho, Waltz, Ramstock, Honoki, Kligman, Meredith, Cohen, and Meyskins, 1987) A case study of a peer educator project conducted by Penn State University (1988) recommended that peer educators should be recruited who have a positive attitude toward nutrition, have some knowledge of nutrition, have had some experience in formal or informal leadership and/or education roles, and are well-liked by their peers. They also concluded that the availability of a strong system to provide sound nutrition information and educational materials is critical to the success of such an approach. While peer leader programs seem popular, only one evaluation looked at the effect peer educators had on dietary practices. A pilot study in three Iowa counties of the Peer Network (Nutrition Education Training with Older Resource Knowhow) found that volunteers trained by extension home economists were effective in improving dietary intake of 70 percent of their homebound clients. In addition, nutrition knowledge, self-concept, and social interaction of older adult volunteers and clients increased. (Hans, 1992) A peer educator program in Alberta, Canada, expanded from home visits to strategies that reached a broader audience including nutrition presentations to senior groups in the community, a meals program at a local drop-in center, local hearthealthy restaurant programs, nutrition education through grocery store tours, and other community health initiatives. They have even published their own cookbook. (Ness, Elliott, and Wilbur, 1992) Nutrition Education Through the Print Medium The print medium has been recognized as an important component of nutrition education with older adults (Lank and Vickery, 1987; Weiss and Davis, 1985). Written information can reach seniors who do not have access to, or are not willing to participate in, organized group programs. It reinforces oral lessons and helps people retain what they hear. It is also durable and can be saved for future reference. For complex information, as nutrition advice often tends to be, the print medium has the added advantage of being able to adapt to the length of the message. nutrition Brochures: education Print brochures about nutrition topics are commonly used in programs for seniors (Newhouse et. al., 1989; and Lank and 39 --7 Table of Contents to find that 41% of the attendees were adults age 55 or older. This finding led them to conclude that older people are interested in health promotion and that this model may be a good intervention to reach them with health information. An additional component of the intervention was the development of a health promotion directory. Of the 93 organizations identified for this 7-community project, 28 had programs specifically for the elderly. Health Education Plus: Innovative Approaches breaking A few examples were uncovered in the literature of programs through the didactic model of nutrition education. aimed at Gardening and nutrition: A nutrition education-through-gardening program was conducted to encourage dietary behavior change and to promote psychological well-being among seniors. (Hackman and Wagner, 1990; Penn State Nutrition Center, 1988) Participants' involvement in their gardens and their food choices were stressed over the acquisition of gardening and nutrition knowledge. The model is based on related theories from the fields of behavioral and health psychology of perception of control, self efficacy, learned helplessness, and social support. The design also draws on an empowerment model developed by Friere which holds that education is an active and dynamic process that takes place in the context of people's lives. (Friere, 1973.) After a year of pilot work, the program was tested in three sites, a medium-sized metropolitan area in Oregon, a small, economically depressed Pennsylvania town, and a large urban senior center in Pennsylvania. The five-month intervention consisted of weekly contact with the participants, with two group meetings a month (one on nutrition and the other on gardening) and two individual visits at participants' homes each month. The 90-minute nutrition classes were designed to enhance perception of control and social support. A third of the time was spent on each of the following elements: providing nutrition information; developing an action plan to implement dietary improvements; and sharing successes and brainstorming ways to help each other eat well. Group discussion and partner dyads were used to increase interaction. The minimum of information needed to make changes was provided. The nutrition education component included seven topics: dairy products, vitamin C-rich foods, iron-rich foods, dark green leafy vegetables, water, fiber from fruits and vegetables, and fiber from whole grains and dried beans. Discussion of each topic covered why that nutrient was important to health and what practical changes could be made to include enough of the nutrient in one's diet. "Nutrition Bingo" cards were used to graphically depict food categories and the suggested number of daily servings for each of the target nutrient groups. A large-print workbook included 44 Table of Contents information from the lectures, motivational activities, and recipes emphasizing foods from the targeted categories. The first four nutrition meetings ended with a tasting of a recipe prepared from the workbook. The final meeting featured a garden harvest potluck meal prepared with products grown by the senior gardeners. Monthly gardening classes and were primarily didactic. provided technical information needed for growing University students visited participants twice a month to advise on the progress of the gardens, provide social support, and encourage them to eat from the seven targeted categories. Significant changes in dietary intakes and nutrition attitudes were reported by the study. All three sites reported increased consumption of water, with one or more also reporting increased consumption of vitamin C-rich vegetables/fruits, iron-rich foods, vegetables and fruits, whole grains and starchy vegetables, and dairy products. Statistically significant improvements in attitudes and perceptions related to both the nutritional and gardening dimensions of interest and enjoyment, future orientation, perceived competence, and success attribution were reported. Computerized nutrition education programs: The use of computer technology to provide easier access to health information and services is being promoted in the worksite and schools. Increasingly, use of computers to enhance learning and functional performance has been proposed as an intervention strategy with older adults. (OTA, 1985) The rapid expansion of computer networks for seniors such as SeniorNet and the Retirement Living Forum on CompuServe are evidence of seniors' interest in and enthusiasm with computer technology. One study compared the effect on dietary intake and program satisfaction of a nutrition program for seniors with and without microcomputer interaction (Dennison, Dennison, and Ward, 1991). Group 1 (n= 10) received a nutrition education program and used a nutrient analysis software program during class time. Group 2 (n= 11) received the same program but staff entered data for seniors. A third group (n=10) served as the control and did not receive the program or microcomputer interaction. The study sample was drawn from residents of a subsidized housing development or members of a subsidized community center; all were over age 60. The nutrition program consisted of four one-hour classes conducted over 2 weeks. At each class, seniors used printouts to compare their diets with recommended intakes and food choices. They were encouraged to make small changes over drastic ones, by substituting some foods with more appropriate selections, to enhance adherence to change. Both experimental groups significantly 45 and equally lowered their intake of Table of Contents saturated fat from baseline to follow-up, whereas the control group had not. Furthermore, the group which had hands-on experience with the computer was significantly more satisfied with the program than were the others. The majority of Group 1 indicated that learning to use the computer was not difficult and was "somewhat enjoyable" to "very enjoyable." Another application that shows promise with some seniors is described by Levitan and Johnson (1992). The NICE (Nutrition Information for Consumer Education) system is an interactive, touchscreen nutrition education system that was pilot tested in supermarkets to encourage changes in purchasing behavior. Five software modules offered consumers information about nutrition and comparison of foods, calculated daily nutritional allowances, made suggestions for healthy eating, explained how to read a food label, and provided over 175 recipes, cross-indexed for nutritional benefits. To access the five modules, consumers touched the appropriate area or icon on the Main Menu screen of the computer screen. User considered age of 21. groups, of data indicate the system's widespread appeal, including groups generally hard to educate about nutrition: males, minorities, and users under the Although fewer adults 66 years and older used the system than other those who tried it, more used the system repeatedly. 46 Table of Contents VI. Successful SUMMARY Elements of Nutrition Education for Older Adults As evident from the above review, most nutrition education strategies for seniors have involved traditional instructional methods, print materials, meals programs, or counseling. Few have undergone rigorous testing for effectiveness. Methodological limitations were found in most of the articles searched. In the absence of clear findings on the efficacy of nutrition education programs for this population, the current literature does offer some direction and guidance. Successful elements that emerge from the review include: 1. Use audience-centered planning approaches. Program planning, development, implementation, and evaluation can benefit from the input and guidance of the program participants. Focus groups or surveys can clarify older adult's "wants," needs, and special interests. Reports of using these techniques are beginning to appear in the nutrition education literature (Crockett, Heller, Merkel, and Peterson, 1990; Shepherd, 1990; Krinke, 1990; Goldberg, Gershoff, and McGandy, 1990). 2. Use personalized approaches to support generalized messages. The empirical evidence for community-based health promotion programs indicates that mass media messages supplemented with personal interaction and reinforcement yields the greatest changes in health-related behaviors (USDHHS, 1990). This is consistent with information processing theory that suggests audiences move from the stage of general awareness to one of seeing the personal relevancy of a meassage and then to decision-making and action. Evaluations of HealthTrac, a clinic-based intervention, and computer-based interventions showed promising results. All used individualized assessment to tailor nutrition information. 3. Utilize known motivators. Interest in maintaining health, opportunities for social interaction and social support, good taste and ease of preparation are all motivators that can be utilized in nutrition education emerging from the literature review. 4. Encourage older adults to be active learners. Adult education theory and practice tells us that older adults like to be active learners. The practical application of nutrition information will be of more interest to older adults than nutrition facts. Opportunities to be active participants in learning -- food diaries, paper and pencil exercises, food preparations and tastings, mini-markets, making favorite recipes healthier, small group discussions, answers to individual questions -- are more 47 Table of Contents effective techniques than lectures. Examples from the literature show that nutrition educators are testing creative ways of delivering nutrition education to older adults. (American Heart Association and American Association of Retired Persons, 1993; Stock and Milan, 1993; Kapka, Schutt, and Mitchell, 1992; Hackman and Wagner, 1990; Simmons, Nelson, Roberts, Keller, Kane-Williams, Salisbury, and Benson, 1989) 5. Identify and target subgroups of older adults. Age, gender, and cultural background of older adults need to be considered in developing nutrition education programs. The literature indicates differences in dietary intake among "older" older adults (ages 70 plus) and "younger" older adults (Fischer, Crockett, Heller, and Skauge, 1991). Different learning or decision-making styles may be found among individuals or between men and women. Cultural differences and preferences need to be considered. 6. Continue to reinforce changes. Nutrition education is not a one-time Complex decisions about purchasing, preparing, and eating food are made times each day. Finding ways to keep people motivated and informed are Program evaluations that have followed participants over time indicate that erode. (Lalonde, Hooyman and Blumhagen, 1988) Reinforcement may be retain results. activity. many needed. results needed to 7. Be sensitive to age-related changes. Consider changes in sight and hearing when preparing print materials or arranging a room for a small-group session. Take advantage of the range of life experience that older learners offer. 48 Table of Contents VII. CONCLUSIONS Implications for Nutrition Education Policy, Research, and Program Implementation Perhaps the major limitation in the literature regarding the effectiveness of nutrition education for older people is the lack of consensus regarding what the goals of nutrition education for this population should be. Absent such agreement and direction, America's older adults receive fragments of nutrition information from a variety of credible and not-so-credible sources. Older adults are left on their own to figure out how contemporary dietary advice, such as reducing fat and increasing fruit and vegetable consumption, fits in with a lifetime of experience, knowledge, and preferences about food. For many this is further complicated by the onset of chronic health conditions, such as high blood pressure, heart disease, or diabetes, for which dietary interventions can be critical for maintaining health and well-being -- and with the onset of physical and sensory limitations and social losses that can hinder food enjoyment. The effectiveness of current nutrition education efforts is difficult to judge because there is no standard against which to measure results. How should dietary intake change? What new knowledge is needed? What skills are required? What about related issues such as food safety or wise use of food dollars? There is no consistency in the objectives of the nutrition education programs cited in the literature (and some are not clear about their objectives) so assumptions must be made based on what was measured in the evaluations. While there may not be scientific agreement on the exact nutritional requirements of older adults, there is still opportunity for leadership to improve current situation. Policy development is needed before research and program agendas can be fully elaborated. Recommendations implementation follow. Nutrition Education the for nutrition education policy, research, and program Policy 1. Develop a clear, simple framework for the content of nutrition education for older adults. Older adults grew up learning about the four food groups. Many programs reported in the literature were still teaching them. The last decades have provided them with a litany of announcements of what is "bad" to eat. Now the pyramid has replaced the four food groups. The simple act of choosing food in the 49 Table of Contents grocery or for dinner has become an emotionally charged issue where it once provided pleasure. Older adults need a context for their own dietary choices. The food guide pyramid does a good job of encompassing today's dietary advice, but older adults may need to learn how to compare the advice represented by the pyramid with what they are doing and how to apply the guidance to their lives. They may want to know how it applies if they have a chronic health condition. Developing a sound basis for communications, programs, and research does not need to be an elaborate process. Policy statements for similar purposes were prepared for the National High Blood Pressure Education Program, the National Cholesterol Education Program, and the Healthy Older People Program. The primary steps are: 1) gather the relevant literature for review by scientific and technical experts and then 2) prepare a strategy document for scientific and technical review, as welt as practicality and feasibility review by program experts. A policy development process undertaken for the purpose of consumer education can also influence research and practice. It is not meant to dictate procedures and activities at the state or local level, but to provide an overall framework and direction for nutrition education activities wherever they are initiated. 2. Segment the older population on the basis of their need for nutrition education. A major consideration for developing policy will be defining subgroups of the older adult population that can be used in nutrition education. One approach rf_;ght be to distinguish among the general population of older adults who need nutrition education similar to the rest of the adult population, persons with a medical condition that warrants more extensive nutrition counseling, and frail older adults who need assistance maintaining adequate nutrition. These general categories could be applied to wide variety of settings for nutrition education. 3. Emphasize cultural relevancy and local adaptation as the policy is implemented. A policy development process should provide a framework for program development and implementation and should encourage refinements that honor cultural backgrounds, local customs and practices, and personal preferences and learning styles. It should guide program development not dictate practices. Nutrition Education Research 1. Research should support the policy development process. Research can support the policy development process by contributing more information about older adults perceptions of dietary guidance and desires for nutrition information. Consumer-based research can be used to test out assumptions about segments of the older population and to develop information about segments that could be used for program development. 50 Table of Contents 2. Research should support the materials and pro.qram development process. Audience based research should be encouraged as any educational materials or program strategies are developed and tested. 3. Research should provide more information on learnin.q styles and decision-making styles and motivators that will help target programs and educational techniques. Do certain people learn best in groups or individually? Which people like to read information and which like to hear it stated? How do decision making styles influence nutrition behaviors? What are the motivations for improving diet in later life? Are activated consumers making better food choices than others or not? Research should take advantage of the multiple disciplines that can contribute to knowledge about nutrition education. 4. Use national surveys to track results and identify trends. After achieving agreement on what the desired objectives or outcomes of nutrition education for older adults is, progress toward those objectives can be tracked using the existing dietary intake and health and nutrition surveys. Pro.qram Implementation 1. Take advantacte of the existinq federal nutrition services pro.qrams to reach older people with nutrition education. Each day at least two million older adults eat at congregate meal sites supported by the Administration on Aging (AoA) and another half million receive meals in their homes. Simple materials such as those developed for worksites could easily be adapted and disseminated through this network. Table tents, placemats, posters, and tips on healthy snacking could serve as reminders about healthy eating. AoA has established a nutrition initiative and indicated a desire to collaborate with USDA on nutrition education for older adults. While not nutrition education, the nutritional quality of the meals provided to older persons must also comply with current dietary advice. The USDA Extension Service also reaches many older adults. Those programs may already have materials that could be adapted or could serve as another existing network to disseminate information. 2. Apply successful program elements identified in the literature to pro.qram demonstrations. With this population, the more targeted and interactive interventions seemed to generate the best responses. A dilemma of health communication programming is that although interpersonal communication is more effective than mass commuincation for influencing behavior, it is limited in scope. 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