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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
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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
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(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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
But by combining
some of the attributes of both communication
forms, programs can
have the advantages
of both.
51
Table of Contents
3.
Provide traininq for the many people who reach or serve older adults.
Materials and information must in many cases stand on its own since professionals
serving older adults may not be familiar with nutrition or behavior change strategies
themselves.
52
Table of Contents
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