HEALTH PROMOTION AND AGING
NUTRITION

Nancy Chapman, R.D., M.P.H.
N. Chapman Associates, Inc.

Ann Sorenson, M.S., Ph.D.
Health Scientist Administrator, NIA

"The trick is to live to be 100. Very few people die after that."

George Burns

Aging is inevitable. Health promotion, including good nutrition, can slow the rate of degeneration
and foster the independence and well-being of older individuals. For years, health promotion
activities targeted only younger adults. Health professionals and adults over 65 simply accepted
the high rate of chronic disease and the concomitant physical and mental impairments.
Health-promoting dietary recommendations were generally viewed as useless. However, a
preponderance of evidence now suggests many potential benefits of good nutrition for older persons:

1) Life expectancy after age 65 has increased in part because of an abundant food supply, which
has eliminated most nutritional deficiencies (1).
2) Reducing body weight and excess intakes of sodium, sugars, fats, and cholesterol can lower the

risk of developing hypertension, diabetes, and heart disease for many individuals and improve
the management of these diseases for older as well as younger individuals (2).

3) Nutritious diets that protect physical and mental health help older people to work longer and
lead independent lives (1).
4) Maintaining a reasonable weight, exercising regularly, and selecting a proper diet may retard

the aging process and delay certain debilitating conditions common in old age (L.e.,
osterporosis, hypertension, dementia, and diabetes) (3).

5) Preventing malnutrition can reduce the need for recurrent hospitalizations and prevent the
occurrence of complicating conditions, thereby, lowering medical costs (3).
6) Selecting the best, most economical foods to meet nutritional needs and using appropriate

nutrition programs can maximize limited financial resources and permit independent living for
the older population.

7) Correcting poor diets for healthy older persons eliminates the need for and avoids the hazards
of high doses of expensive dietary supplements (4).

To design appropriate nutrition strategies for those over 65, decision-makers need to 1) consider
the heterogeneous characteristics of the elderly population, 2) differentiate age-related changes
from effects of degenerative diseases, and 3) recognize the limitations of the current research
base. This paper discusses these factors as well as other related areas -- problems in determining
nutritional status and nutrient requirements of older persons, emerging research issues, and the
effectiveness of current nutrition interventions. Several links between nutrition and other health
promotion areas are identified. The issues identified in this paper, though not exhaustive,
provide a starting point for developing the strategies that will address nutrition concerns in the
rapidly growing, aging population in the U.S.

CHARACTERISTICS OF OLDER PERSONS

Older persons, generally defined as individuals over the age of 65, represent a very diverse group.
The sex and racial composition of specific cohorts change as the subgroup ages beyond 80 years.

The physical and mental capabilities of elders within and among older subgroups also vary widely:
thus the potential benefits of nutrition therapies are not uniform. Attempting to foster
independence and well-being in this heterogeneous population will require that policy makers and
health care professionals examine the distinct characteristics of two to three age strata over 65
before developing broad interventions or formulating policies.

The variations in physiological, physical, and mental functions are greater among older persons
than among any younger cohort. This heterogeneity reflects, in part, the diversity in Lifestyles,
economic and social conditions, food supply, culture, education, and exposure to other
environmental factors experienced during their growing and maturing years. Genetics, of course,
also plays a major role in the rate of funetional loss in various organs and one’s susceptibility
to chronic diseases (such as cancer, coronary heart disease, diabetes, and osteoporosis). A later
section describes more fully the differences in age-related functional changes and occurrence of
chronic diseases.
Psychosocial and economic determinants

Many psychosocial factors affect the food habits and nutritional status of the old. Depression,
loss of self-esteem, loss of spouse, inability to live independently, and loss of a sense of
purpose and motivation adversely affect nutritional status by decreasing appetite and interest in

eating and food preparation (5). Place of residence and economic status can determine access to

food sources and health care services.

In 1985, the majority of those over 65 were white, non-institutionalized women, either living in a
family setting (67%) or living alone (30%). Few (5%) lived in nursing homes, and most of these
were over 85. After age 80 to 85, males and blacks are more likely to survive. Although many
older persons maintain households, many need help with personal care and food purchasing and
Preparation. Older persons tend to reside more frequently in central cities, small towns, and
rural areas where access to social and health services, nutrition programs, and food stores may be
limited. Because older residents in urban and rural areas are often less educated and poorer than
suburban residents, their risk of nutritional problems increases (6). The dletary patterns of
these rural residents include large amounts of salty snacks, heavy sweets-sugar desserts, and high
fat -meat (7).

Older persons are more likely than younger adults to be poor or Live on fixed incomes. Federal
Programs (Medicare, Medicaid, Social Security) have slowed the onset of poverty for some, but more
than two out of every five of those over 65 are poor or economically vulnerable (8). Those over
85, nonwhites, women, and persons living alone experience the highest rates of poverty (8, 9, 10).
As inflation increases, those living on fixed or low incomes find that a larger portion of their
income is spent for food. The recent low inflation rate has partly eased this burden.
Participation in the food stamp program, the nutrition program for seniors, and the commodity
supplemental food program has also improved older persons access to food: but these safety-net
Programs provide protection for only a small Proportion of poor older persons (8).

The cultural and soctal influences on food habits are also important to consider in planning
nutrition strategies (10, 11, 12, 13). Davis and Randall (14) described trends in family
structures and gender roles, in social integration, in employment opportunities, in education and
in economic stability that affected the food habits and food choices of three subgroups of the
population who would be over 65 by the year 2000. For example, individuals born between 1910-1930
experienced food shortages; often Lived close to their food supply; and were less educated. They
may require different food offerings and educational tools than persons born between 1940-1950.
Nutritional problems of the older cohort wha ate more complex carbohydrates and less fat may differ
from the younger cohort who were exposed to more processed foods with more fats and simple sugars.
A lower fertility rate among those born in 1910-30 could Limit family support as they age compared
to those born ten to twenty years later.

Nutritional status
autritional status

The nutritional status of the older persons often reflects lifetime nutrient intakes and food
behaviors, as well as age-related conditions and socioeconomic determinants. Experience with
chronic degenerative diseases and conditions, drug regimens, drug and diet interactions, and
functional status also influences health. To interpret the nutrition data from surveys, caution
should be taken not to confuse cross-sectional data showing secular trends in dietary patterns with
longitudinal data showing within person changes over time (15, 16, 17).

The most recent survey data from NHANES II showed older adults selecting most frequently the
following foods from each specific group: whole and low fat milk and cheese (milk group),
grapefruits and melon (fruit group), potatoes and tomatoes (vegetables), bread, biscuits, and
muffins (breads and cereals group), and ground beef (meat group) (18). The 1977-78 National Food
Consumption Survey data showed that one~third of older adults used whole grain breads and that
older persons were the highest users of eggs, skim milk, vegetables, fruits, soups and lowest users
of soft drinks (19).

National survey data (20) also show that estimated food energy intakes decline with age; the lowest
mean intakes are for those 75 years and over (about 1850 keal for males and 1400 kcal for females).
Adults generally gain weight until age 50; then, relative weights decline. The variance for energy
intakes of those over 65 years of age is great, due to the small numbers in this subset.

Assessments of caloric intake adequacy require data on body size and physical activity.

For some older persons, having been obese and consuming inappropriate levels of sodium and perhaps,
calcium, protein, and fat earlier in life may have raised their chances of developing hypertension,
cardiovascular disease (CVD), diabetes, and cancer. Dietary cholesterol intakes for many over 65
(means are 461 mg for males, 316 mg for females) remain above recommended levels for lowering the
risk of CVD.
Intakes of most nutrients except vitamin C and vitamin A also appear to decrease with age. Foods
consumed by most older adults provided adequate levels of protein, preformed niacin, vitamin C,

folate, and phosphorus. Intakes of calcium iron, vitamin A, thiamin, riboflavin, and potassium for
most adults either approached or failed to meet the RDAs. In general, biochemical or clinical
markers of deficiency were rarely found (<5% on average) in the older persons (21). Of concern are

older women who have high rates of bone fractures and related Lower intakes of calcium and vitamin
D-rich milk products (22, 23).

Usage of dietary supplements, drugs, and alcohol

An appropriate assessment of nutritional status cannot overlook the population’s use of dietary
supplements, drugs, and alcohol. In turn, additional data on the nutritional status and
requirements may stimulate promotion of more dietary supplement use by older persons. {The
elderly as targets of health fraud are discussed later. ]

Usage of supplements by older persons has increased from an estimated 1 percent in 1975 (24) to
estimates of 40 percent natLonwide in 1980 (25). Analysis of national survey results suggests that
those who use supplements may not be the individuals most In need of them (4, 22, 26, 27).
Approximately half of those who use supplemental vitamins take multivitamins, in particular vitamin
C and E (22, 28, 29). Dietary supplementation does not appear to routinely improve nutritional
status for older persons. It may even lead to nutrient imbalances, toxicities and/or interactions
with drugs, especially if megadoses (10 times the RDAs) are taken (4, 22, 30).

Although older Americans constitute about 10 percent of the population, they use about 25 percent

of all prescription drugs. This is not surprising since many chronic diseases are managed with
prescription drugs. Over half of older people take at least one medication daily and many take six
or more a day for multiple diseases. The drug-drug and drug-nutrient interactions may affect body

composition, nutrient balance, ot appetite, as discussed later (31).

Excessive alcohol intakes may also advance nutrient deficiencies (i.e., thiamin, niacin and other
water soluble nutrients), may damage organs and tissues important to nutrient utilization, and may
depress appetite and the desire and ability to eat. The result can be poor mutritional status.
Older persons have a lower tolerance for alcohol which becomes more concentrated as body water
declines with age. Approximately 30% percent of those 65 and over consume alcohol on a regular
basis (at least one time/week). About 15% of this cohort are considered light drinkers, 11%
moderate drinkers, and 6% heavy (32). If the older persons’ drinking habits are reflective of the
adult population, then the 5 percent of the population which drinks most heavily, accounts for
about 50 percent of the total alcohol consumption. Since alcohol is a risk factor for diabetes,
hypertension, cancer, and liver disease, moderation of intake is advisable at any age.

EFFECTS OF AGING AND CHRONIC DEGENERATIVE DISEASES

Normal aging changes body composition, physical performance, organ system function and condition in
all individuals if they live long enough; however, changes occur at different rates in different

people. Even within the same individual, degeneration of various tissues and organs occurs at
different rates (33). There are some 60- or 70-year-olds with organ function tests equivalent to
someone 30 or 40 years younger. Conversely, there are some younger individuals with physiological

capacities in the range of an average elder (34).

Age-related changes

2
Physiological changes in many organ systems naturally accompany the aging process. Examples of

various age-related condirions that can affect the nutritional status of older persons include
sensory impairments, altered endocrine, gastrointestinal, and cardiovascular functions, and changes
in the renal and musculo-skeletal systems (35).

During the aging process, changes in dentation and in the oral cavity (recession of gums and
decreased salivary flow) can occur. These conditions are exacerbated by some medications. Dental
caries, periodontal disease, and trauma have led to the loss of natural teeth in approximately 29%
of those over 65 and 50% of individuals over 80. Being toothless or having ill-fitting dentures
can reduce chewing ability and raise the risk of choking. Well-fitting dentures are essential for
chewing high fiber, nutritionally-rich foods, such as raw fruits and vegetables, whole grain
products, and nuts. The use of fluoridated water, fluoride treatments, regular dental care, and
improved diet may decrease dental problems for the next generation of older persons. Less is known
about prevention of periodontal disease, especially the potential role of nutrients (e.g., sucrose,
fluoride, and calcium). [These Lssues will be considered in background papers prepared for other

working groups.}

Decreased organ or tissue function can be accelerated by anorexia or nutrient imbalances or
deficiencies related to chronic tliness, use of therapeutic regimens, or lack of proper medical
care. Many age-related conditions affect the older person’s ability to ingest, absorb and utilize
essential nutrients, as vell as obtain and prepare faod. Additional age-related changes are

discussed under emerging research issues.

Chronic disease-related changes

osteoporosis, and arthritis increases with
chronic condition and many have multiple
rv persons, is also related to many chronic
ts, drugs, or other therapeutic regimens

The prevalence of hypertension, diabetes, CVD, cancer,
age. Four out of five older persons have at least one
problems. Obesity, affecting approximately 28% of olde
diseases. Many of these conditions require special die
that could further compromise nutritional status.

Mortality and morbidiry rates for diseases differ by gender and race. This may reflect genetic

lifestyle habits, or differences in access to health care. Therefore, when planning
Mutrition strategies, special diet-related problems should be considered by race and sex. Briefly,
1982-84 data (36, 37) show that reported rates of CVD, stroke, and cancer are higher for males than
with the highest incidence among black males. Hypertension and arthritis vates are

The prevalence of diabetes is comparable for white males
females than for white females (36, 38). This may be

differences,

females,
highest among females, especially blacks.

and females, but about 502 higher for black
due to the high prevalence of obesity among older black females (37).

Osteoporosis, generally affects more women than men, measured by the higher Proportion (four to
one) of bone fractures in women than men, and more whites than blacks (36) and Mexican Americans
(39) . Higher bone density initially explains part of these differences; but the potential for
obesity may explain the racial difference and should also be explored. Associated immobility
handicaps an older person’s ability to purchase and Prepare food and thus limits food selections
and independent living. Similarly, resorption of the residual alveolar ridge (bony ridge in which
teeth are positioned) reduces the retention of dentures (40, 41) and may Limit food selections.

MAJOR POLICY ISSUES
Bae SREY ISSUES

The previous descriptions of the socioeconomic factors, nutritional status, usage of drugs, alcohol
and dietary supplements, and specific health problems, serve as background to the major policy
issues. This section highlights the following areas to explore in developing nutrition Policies

for the aging:

1) Nutrition surveillance and monitoring
2) Emerging research issues

3) Nutrition services for older persons
4) Technology advances

5) Food assistance and nutrition programs
6) Nutrition education and information

This listing does not order the importance of these issues, but rather the logical progression from
information gathering to dissemination. For the public, the value of research is best realized
when people learn the consensus on the findings through the mass media or hutrition education

programs.

Nutrition surveillance
aureition surveillance

Several national and state surveys have been conducted on, or include, the older population. These
Surveys are designed to determine the amounts and types of foods consumed, the nutrient content of
intakes, the existence of clinical signs of nutritional problems, and the hematological or
biochemical evidence of sub- clinical nutritional deficiencies. A Limited number of

variations in intake, biochemical, anthropometric, and functional parameters.

Many surveys lack documentation of dietary supplement usage. There has also been minimal nutrition
Surveillance and monitoring among institutionalized elders (those in ambulatory care centers and
Long-term care facilities), homebound, or homeless older persons. Likewise, little is known about
older persons in defined ethnic groups such as Asian Americans, native Americans, and, until
recently, Hispanics. Nutritional data on subgroups of older persons, such as those over 80 years
of age, in whom malnutrition may be more common, are also missing. It is often difficult to
compare nutritional surveys which include or focus on older persons because of differences in
dietary methodology and standards (43).

To date, the nutrition Surveys of older persons in the U.S. have been very Limited in scope, have
frequently excluded the oldest old age groups, and have used varying standards of comparison in
presenting the frequencies of nutrient deficiencies (33). In the NHANES I and NHANES Il, adults
ages 65-74 years comprised approximately 6-8% of the sample. The USDA Nationwide Food Consumption
Surveys (NFCS) also collects data on the food intakes of individuals ages 65-74, representing

G-4
approximately 10% of the 1977-78 NFCS. No information on individuals older than 75 was gathered

from either survey.
e Comparisons of independently-living and institutionalized older persons

The nutritional status of long-term institutionalized and independently living older perso>s needs

co be compared. Older persons in institutions are usually subject te fixed meals which may not

accommodate their individual food preferences, though they often adhere to specified dietary

regimens. Often, individuals in these settings Lose interest in foods and eat sparingly. A

national survey of geriatric patients in institutions in the U.S.- and of homebound individuals

would be instructive. Major areas to research include (44):

1. Food-energy and nutrient needs of sedentary and bedridden patients:

2. The means to best carry out nutritional screening and assessment of geriatric patients in
these facilities;

3. The interpretation of clinical, anthropometric, hematological, and biochemical indices of
nutritional status in chronically sick older patients, with or without age-related conditions
{i.e., skin disease, renal dysfunction, anemia, and muscle wasting);

4. The responsiveness of patients showing one or more indices of malnutrition to nutrient
supplementation; and

5. Acceptable values for nutritional status indicators in nursing home patients.

e Methods of nutritional assessment

Dietary intakes documented Later in life may not correlate with anthropometric, biochemical
measurements, OF clinical evaluations taken at the same time. Often these measurements more
closely describe a myriad of historical experiences and long-term food intakes. Longitudinal
studies provide information that begins to explain possible relationships of intakes to other
measurements. To standardize the results of geriatric nutritional studies, a core set of
assessment tools needs to be identified and then used routinely (a5 4 minimum) for all studies or

surveys.

Nutrient and energy intakes are determined using 24-hour recalls, food records, food frequencies
and dietary histories. Interpretation of the histories requires standards. Appropriate standards
for various age-subgroups of older persons do not exist- Comparisons are made to nutritional data
from NBANES I and II and the 1977-78 NFCS despite Limitations identified earlier. Reliability of
information in these dietary histories has also been questioned. Memory, vision, and hearing may
decline with age, making it more aifficult to recall accurately foods previously eaten. Likewise,

arthritis may impede record keeping.

Anthropometric measurements (e.B-> height, weight, and skinfolds) are affected by aging. For
example, height decreases over time due to changes in the integrity of the skeletal system-
Measurements are often hard to obtain because of poor posture, or the inability of the older
persons to stand erect unassisted. For these {ndividuals, recumbent length, total arm length, knee
height and arm span have been proposed as alternative methods to estimate stature (45, 46). More
research on the reliability of these measurements is needed before they can be recommended as

routine clinical practice.

Actual weight is less difficult to measure than height. For ambulatory people, a calibrated

balance beam scale is used. For the non-ambulatory, wheel chair or bed balance beam scales are
available. Beforg weighing, the patient’s hydration state should be noted, as severe edema or
dehydration can distort actual weight and anthropometric measurements (47).- Skinfold measurements

are also affected by the age-related decrease in lean body mass that results in a larger proportion
of body weight as fat. Fat stores are also redistributed truncally. Changes in skin
compressibility and elasticity hinder interpretation of skinfold measurements (33).

Biochemical parameters may be affected by an age-related decline in renal function, by shifts in
fluid balance, by drug-drug oF drug-nutrient interactions, by the long-term effects of chronic oF
coexisting disease, and by malnutrition. For example, low serum albumin levels often indicate poor
nutritional status; however, kidney and Liver disease, cancer, congestive heart failure, and other
diseases (common among older persons) cause marked reductions in serum albumin (37). Ruling out
these conditions must be done before low serum albumin concentration is associated with

malnutrition alone. For accurate results, biochemical analysis should use several blood and void

samples (48, 49, 50).

The most effective clinical methods of nutritional assessment are based on physical examinations
and observation, and reflect long-term nutritional status. Clinical evaluations must be highly
scrutinized because of the potential for human error, especially when large numbers are evaluated.
For example, several age-related changes in clinical appearance--4ary skin, sensory loss, and sparse
hair -- may appear to be representative of one or more nutrient deficiencies (47). Other
limitations in assessment methodology are discussed later.
Emerging research issues

Nutrition and aging research focuses on two general areas: issues related to interaction of diet
and aging functions (1.e., physiological, psychological, sociological) and dietary relationships
with pathological conditions common to old age. More specifically, much of the current research is
directed toward the following topics:

1) The effects of aging on nutrient digestion, absorption and utilization and the relationship
between these effects and nutrient requirements.

2) The role of dietary restriction in modifying age-related physiological changes or the role of
diet in treating conditions associated with changes in immune and endocrine functions and
changes in body composition.

3) The influence or effects of neurological, environmental, and dietary factors on senile
dementia or sensory deficits in older persons.
4) The influence of physiological, behavioral, and environmental factors (e.g., sensory function,

dental status, culture, cognition, and economics) on the quality and quantity of food eaten by
older individuals, and on the relationship between various patterns of dietary intake and
nutritional and health status.

5) The nutritional changes including changes in food intake which accompany chronic diseases
common in the older person.

6) The role of nutrition and nutritional status during adult years in the etiology and
pathogenesis of diseases and problems of older persons.

7) The effect of therapeutic regimens (i.e., drugs, surgery) on nutritional status and the
effects of nutritional status on the efficacy of therapeutic agents.

8) The association between nutritional status and morbidity and mortality -- examining patterns
of dietary intake and mortality.

9) Valid methodologies for use in assessing nutritional status in older persons and in

establishing age-appropriate norms.

Although recent estimates suggest that 20% of the population in the year 2010 will be over 60, and
that one half of those will be at least 75 years of age, much of the research base on nutrition,
aging, and health is quite immature. An increase in the understanding of these dynamic
interrelationships can improve the quality of life of the aged, provide more effective health care,
and lessen the impact of aging on the health of older persons.

A balance of animal experiments, epidemiaclogic research, and clinical trials is needed to study the
nutritional status and requirements of geriatrics. To assess nutritional status ideally requires
1) determining daily consumption of energy and nutrients, 2) measuring tissue levels of nutrients,
3) clinical examinations including anthropometric measurements, and 4) evaluating physical and

mental function. Current assessments of older persons are handicapped by a lack of appropriate
age-related biomarkers and valid standards for intake and biochemical and anthropometric values to
which survey results can be compared. The related limitation in methodology and gaps in research

knowledge were discussed under the nutrition surveillance section.

Many of the gaps in our knowledge about nutrition and aging are being investigated by NIA-supported
researchers and by researchers at the NIA, the USDA Human Nutrition Research Center on Aging, and
other government and private research centers around the country.

e Effects of aging on dietary intakes and eating patterns

The need for research on socioeconomic influences on eating behaviors of older persons and the
biopsycho¥ocial antecedents of age-related changes in eating habits will be discussed in this
section. There is a need to clearly differentiate generational patterns in selection and eating of
foods from changes in eating habits which are age-specific. Since previous educational, social,
economic, and cultural experiences vary widely among various cohorts of individuals over age 65
years, these influences on food use and preparation patterns need to be separated from late life
modifications in eating habits that result from age-related physical changes, chronic diseases, and
lifestyle changes (51). Little is known about the diets and nutritional status of individuals 75
years of age and older, who are part of the most rapidly growing and frailest segment of the U.S.
population.

Future research also needs to address the differences in dietary patterns associated with various
stages in the late life cycle and with the variety of settings within which older persons live
(i.e., alone, with family, or institutionalized). In addition, the effects of interventions,
social or nutritional, at these various stages and in these settings need to be evaluated (51).

Among the socioeconomic factors, the type and level of income are particularly important. Poverty,
for example, can restrict the amount and frequency of food purchases and also influence housing,
cooking facilities, and overall health (3). Eating patterns and food choices are also determined
by family structure, social situations, emotional status, cultural and religious beliefs, and
living arrangements. Therefore, retirement, children leaving home, divorce or death of spouse, a
move to an {nstitution, a new community, OF 2 residence with Limited cooking facilities, oF

entering or re-entering the labor force later in life can introduce changes in the food purchases,
food preparation methods, and eating environment. These changes, alongs with social isolation and

psychological problems, may cause anorexia or disinterest in food. Boredom can lead to over eating

or snacking. Lewin’s (52) social network analyses and Gifft’s (53) examination of nutrition,
behavior, and change provide approaches to determine what social interactions change with age and
how these changes effect nutritional status. Research that has identified food- and

nutrition-related attitudes and knowledge of older persons will be discussed in the last section.

Age-related sensory impairments and prescriptions for special diets further affect food choices.
Loss of vision may restrict ability to prepare food or obtain food. Loss of hearing may constrain
socializing at mealtime or may make it dif- ficult to get information on menu items or food
products. Loss of smell and taste acuity may directly affect appetite and decrease the desire to
eat (54, 55). Professionally prescribed diets such as low sodium, Low fat, and low sugar may
further depress appetite and increase anorexia. Future research should investigate the effect of
special diets on food intakes and new ways to formulate appetizing foods Lower in specific
nutrients, yet acceptable to the target population. Answers to these questions will certainly
require cooperation among gerontologists, physiologists, and food scientists.

e@ Aging, and energy and nutrient requirements

The nutritional requirements of those over 65 are difficult to determine and are largely unknown.
Undetected disease and use of dietary supplements oF medication complicate the task of defining
population samples that are representative of various strata of older persons. In addition, there
are few controlled metabolic studies in humans related to micronutrient metabolism in aging (21).
An examination of Long-term diets of very old people who have remained healthy until an advanced
age may shed Light on nutrient needs of older persons.

At present, most nutrient requirements are generally age invariant. However, RDAs for all persons
over 51 are extrapolated from data collected mainly on males ages 20 to 30 years of age (48, 56).
Current research on the vitamin nutriture of older persons may provide data to modify the current
recommendations, especially as the relationships between specific nutrients and chronic diseases

unfold or if newer RDAs optimize health and tissue function.

Energy needs decline with age because of decrease in metabolism related to a decrease in physical
activity and loss of lean body mass. Since energy needs decline while nutrient needs remain stable
or perhaps increase, recommending nutrient levels in terms of weight of the nutrient per 49000 keal
or per unit of lean body mass may be particularly useful for those over age 65 years. Conversely,
energy intake restriction and exercise affect aging. This topic will be addressed later.

Protein synthesis appears to decline with age (44, 57), as does the synthesis of muscle tissues,
organ tissue, and other protein moieties (e-8-> collagen, immune system compenents, and enzymes)
(33). Declining protein intakes do not appear to affect deleteriously older populations who have
no evidence of wasting diseases (57). Nitrogen and dietary protein requirements may, however, be
increased in response to physiological stress common in older persons (1i-e., infections, fractures,
surgery and burns) (56). Preventing protein deficiency with attendant hypoal buminemia is most
important in older persons when protein-bound drugs are taken (44). Patients with renal or hepatic
disease may requLre protein restrict- [Lons.- However, the quantity and type of protein best able to
meet the needs of older people has not been ascertained, even for healthy populations.

Present evidence?’ indicates that vitamin A and riboflavin absorption oF tissue Levels do not decline
with age, despite intakes that are lower than the present RDA (17). Research on the role of
carotenoids in cancer etiology may indicate advantages of increased intakes. Age does not appear
to affect folate absorption and/or metabolism, except in individuals with atrophic gastritis (58).
Individuals with hypo- and acholorhydria may compensate for the malabsorption through increased
bacterial folate synthesis.

Some research suggests that the RDAs for vitamin D, B6, and B12 might be too low, at least for

certain groups of older persons (21) - Reduced vitamin D synthesis in the skin, lack of sun
exposure, low intakes, and impaired t-a hydroxylation depress vitamin D production in older persons
(59). For now, increased sun exposure combined with low-dose supplementation (i.e., 10 ug/day)
(21) or twice per” year regimen of 2.5 mg vitamin D2 (60) are recommended for housebound older
persons to maintain adequate serum vitamin Dp. Both human and animal research suggest age-xelated
reductions in vitamin B6 absorption and metabolism (e-8- impaired pyridoxal phosphate formation
or increased urinary excretion), but more conclusive data are needed to suggest changes in the RDA
(21). Serum vitamin B12 levels appear to decline with increasing age, perhaps because of
pernicious anemia andjor atrophic gastritis-related malabsorption (21). Negative health

consequences of these changes have not been documented (61).

There is no consistent evidence for linking vitamin E, thiamin, oF vitamin C requirements with
age. The effect of increasing dietary vitamin E levels on tissue lipid peroxidation and platelet
vitamin E levels (and function) needs further exploration (21). Age-related changes in thiamin
absorption vary depending on the assessment method used; however, it is well known that alcohol
interferes with thiamin absorption and phosphorylation. Age-related declines in vitamin C levels
in the blood, plasma, and leukocytes are reported in most studies; however, changes in tissue
levels are less consistent (21). Smoking (62), medication (63), and environmental stress (64)
combined with low intakes, can compromise vitamin C status, but the health consequences of these
observations are not well-established (34).

Until improved methods for blochemical evaluations of vitamin K and niacin nutriture are available,
it is difficult to determine changes in nutrient requirements for these vitamins. Incomplete food
tables handicap studies on zine, copper, chromium, and selenium status of the older persons. Fluid
intake, especially water, declines in older persons along with a age-related loss of body water.
Adequate water intake (e.g., 30 ml/kg of body weight) or approximately 1 ml of water for each
calorie ingested) (64) is reasonable and important to normal renal and bowel function (5, 65).

Several questions are important to consider in setting nutritional requirements for the aging (44):

1. Can we formulate dietary recommendations that mitigate against development of aging changes in
body composition?

2. Since diseases such as osteoporosis, atherosclerosis, and cancer are in part age-related and
appear to have long latency periods, can we offer guidelines for the diets of younger people
which will protect them from the development of these diseases?

3. What criteria should we use to determine the nutrient needs of elders?

4. What are the specially formulated preventive health goals for the elderly? Should they change

with successive age strata over 65 years?
© Effects of energy intake and expenditures on the aging process

Although some older persons seek the "fountain of youth” in dietary supplements, the answer to
deceleration of the aging process may be found in caloric deprivation or increased energy
expenditure. Energy intake restriction (ER) without essential nutrient deficiency has been the
only intervention in animals that extends maximum lifespan in all species tested and across wide
phylogenetic differences. Long-term national studies of persons on low calorie diets are often
confounded by low levels of nutrients and/or poor personal health habits.

Walford et al. (66) described four phases that trace the history of ER in the study of aging.
Initial work showed that ER slows the biological aging process and favorably affects the incidence
and age of onset of malignancies, arthritis, renal disease, and osteoporosis in animals. Secondly,
animal studies demonstrated that ER animals had slowed age-related changes (not necessarily disease”
related) in the immune system, liver enzymes, age pigments, behavioral and psychomotor patterns.
The third phase is a search for mechanisms that suggest causality that might include altered gene
expression, thymic hormone levels, protection against free radical injury, and DNA repair.
Descriptions of the effect of ER on circulating levels of insulin, somatostatin, thyroxine, and
other hormones are needed. Exploring energy restriction in humans is the next phase.

Increasing energy expenditure through exerckse also appears to influence mortality and morbidity
through a number of complex physiological mechanisms. The effects of inactivity mimic the effects
of aging (67); almost 502% of the functional decline attributed to aging may in fact be related to
inactivity (68). Combined with a calorie-appropriate diet, exercise maintains a reasonable body
weight, lean body mass and good physical performance. This combination also helps to prevent or
reduce fat cell hypertrophy, production of high density lipoproteins (HDLs), hypertension,
osteoporosjs and insulin resistance. {A separate background paper explores exercise in more
detail .j

With the increasing interest in the effects of peroxidation processes on aging, intervention with
various antioxidants, including vitamins A, C, and E and selenium has been tried in both animal and
human trials but the results have been mixed or inconclusive. More research is needed in this

area.
e Drug and nutrient/food interactions

The high use of drugs among the aging may further compromise their health. The average older
person receives more than 13 prescriptions a year and may take as many as 6 drugs at a time.
Cardiac drugs (e.g., diuretics) are most widely used by the aging population, followed by drugs to
treat arthritis, psychic disorders, and respiratory and gastrointestinal conditions. Many of these
diseases are diet- related, and the use of drugs may complement, supplement, or supplant diet

therapy.

Long-term use of a variety of drugs (often at high doses) raises the risk of drug-nutrient
interactions. Individuals with nutritionally inadequate intakes and impaired nutritional status
are at the highest risk. Use of high-potency nutrient supplements may also affect drug efficacy.
explain carefully the potential side-effects when certain drugs and
foods/supplements are taken together. For some older persons, altering the drug therapy may be
more appropriate than recommending dietary changes or food restrictions. Periodic assessments can
identify borderline nutritional status that require appropriate dietary recommendations, nutrient

supplementation, or change in drug regimen.

Physicians need to

Roe (44, 69) has detailed several areas of drug-nutrient interactions. These include 1) diet

effects on drug disposition, 2) drug disposition in malnourished subjects, 3) drug induced
and 4) drug-food and drug-nutrient {incompatibilities. Key interactions relevant to

malnutrition,
the aging population are discussed below and more detail on drug use is provided in a separate
background paper- More research is needed to explain these interactions and to determine their

clinical significance in the aging population.

Foods components and nutrients can affect drug absorption and metabolism. Beavy metals, high fat
intakes and, to & lesser extent, high protein foods delay gastric emptying and, thus, delay the
the small intestines. High protein diets may also accelerate hepatic drug

passage of drugs into
y stomach.

metabolism. A fasting state may hasten drug absorption from an empt
Malnutrition also alters drug absorption, protein binding, drug metabolism and drug clearance.
Protein-bound drugs such as warfarin and diazepam may be more toxic in patients with

. On the other hand, some drugs decrease absorption of nutrients or cause mineral

hypoalbuminemia
aspirin), diuretics,

depletion. Such drugs include laxatives, antacids, anti-inflammatories (e.g-;
antibiotics, analgesics (e-8-; indomethacin), and hypocholesterolemics (e.g-> cholestyzramine).
Appetite can be enhanced by tricyclic antidepressants, reserpine, antihistamines, and anabolic
steroids, whereas amphetamines and related drugs depress the appetite. But the aging process can
reverse these effects. Phenothiazine, a psychotropic agent, that usually increases food intake may
decrease appetite in older persons whose rate of drug metabolism is slowed. Specific foods oF
alcoholic beverages can precipitate adverse reactions to drugs. Some reactions such as the
tyramine reactions with monoamine oxidase inhibitors may be life-threatening, while others such as
the reactions caused by disulfiram and hypoglycemic agents to alcohol are extremely unpleasant.

Guidelines for drug development are needed that include studies in the elderly and consideration of
various drug and food/nutrient interactions. Initially, research must determine how much drug
efficacy and safety might improve with proposed guidelines (70). The quality of such research
depends in part on the reliability of nutritional status assessments conducted and nutritional
standards applied. Education-information transfer about drug-nutrient interactions for the public

and the caregivers also needs consideration (70).

e Diet and chronic degenerative conditions

ec conditions, such as osteoporasis, gastrointestinal disorders, diabetes,

The prevalence of chroni
with age. Questions about

cardiovascular disease, and central nervous system disorders, increases
the role of nutrition in delaying the onset or mitigating the consequences of these conditions are
the focus of NIA- sponsored research and conferences. The following examples are illustrations of

aging and nutrition research topics:

Osteoporosis is defined as an absolute decrease in the amount of bone, leading to

Osteoporosis:
is common, certain older persons

fractures after minimal trauma. Although age-related bone Loss
are at higher risk of developing fractures than others. Riggs (71, 72) suggests that osteoporosis
may be two distinct bonethinning syndromes: 1) a “postmenopausal” form (Type I), associated with
cy and 2) a "senile" form (Type II), highly correlated with aging. Type I,
occurring predominantly in females 15-20 years after menopause, thins trabecular bones (e.8-,
vertebral bodies, ultradistal radius (forearm), and mandibles) that lead to fractures and tooth
loss. Type II, occurring mainly in persons of both sexes over 75 years, thins both the cortical
bone and trabecular bones proportionately, leads to fractures of hip, femur, tibia, and peivis-

estrogen defictt®n

Definitive etiologies for either the early deficit in trabecular bones in Type I or gradual
thinning in Type II need to be determined. Pharmacokinetic studies using calcitonin and
diphosphonates have begun to explain the cellular mechanisms of bone resorption. Other studies
(73, 74) have suggested risk factors including insufficlent bone density at maturity, low levels of
endogenous estrogen and other hormones, prolonged immobility and weightlessness, long term use of
corticosteroids, family history, impaired intestinal or renal function, and diet. Prevention of
osteoporosis has become a public health concern and has brought the promotion of foods high in
calcium (e.8-, milk products), calcium fortified foods (e.g-, cereals, breads, and soft drinks),
high potency calcium supplements, and other nutrient supplements. NIH Consensus Conference (75)
recommended calcium intakes at a level of 1000 to 1500 mg, estrogen therapy, and exercise for

women.
Questions remain about 1) what levels of calcium intakes are most protective against age-related

bone loss and do these levels vary with age or sex of individual, 2) do calcium requirements Vary
with the level and type of physical activity, 3) how does calcium intake/supplementation interact
with estrogen status, 4) do calcium, fluoride, and vitamin D metabolites protect bones
independently or in conjunction with estrogen therapy, weight-bearing exercise, or other
approaches, and 5) how do vitamin D, protein, phosphorus, and even alcohol affect calcium
requirements. Lastly, designing precise methods for measurement of bone mass is eritical for
determining relationships between diet and bone loss for the population or assessing the risk of
bone fractures in individuals so as to use prophylactic therapy most effectively (76).

Osteoarthritis (OA) also causes great pain, immobility, and loss of independence for many aging
individuals. Although nutrient deficiencies or excesses have not been implicated in this disease,
obesity has been found to be associated with OA of the knee and hip but not of the sacroiliac joint
(77).

Glycation in diabetes and cardiovascular disease: Glycation or non-enzymatic glycosylation may
well be involved in the etiology of a number of age-related diseases. Glycosylation describes the
process whereby glucose, fructose, or galactose react with proteins or nucleic acids to form a
Schiff base. The Schiff base undergoes further changes to form advanced glycosylation end (AGE)

products. The excessive accumulation of AGE products in the tissues, especially in the arterial
walls, accelerates progressive stiffening or rigidity of these tissues. This rigidity may be
caused by the cross-linking of proteins (e.g., collagen) and increases with age.

Elevated glucose concentrations characteristic of diabetes promote advanced glycosylation, thus

accelerating stiffness of the tissues. Such rigidity may lead to reduced elasticity in the
cardiovascular system. As a result, cardiac function declines, renal blood flow decreases, and
vital lung capacity and oxygen uptake also decline. Further studies on advanced glycation may

elucidate the mechanisms involved in the formation of senile cataracts, aging peripheral nervous
system, and etiology of atherosclerotic plaques.

Hypochlorhydria: New research initiatives are studying the effects of aging on gastric secretions
and the subsequent impact on nutritional status of the older persons. Hypochlorhydria incidence
increases with age and may affect up to one-third of those people over 60 years of age. Women are
more often affected than men, but the current extent of the problem and those at highest risk for
disease are not known. Future epidemiologic studies of hypochlorhydria must be based on a common
standardized case definition in order to assess the impact of aging on the disease. The causes of
hypochlorhydria and the commonly associated atrophic gastritis are also largely unknown, yet these
disorders have far reaching implications for health maintenance in the older population.

The major clinical implications of hypochlorhydria are altered absorption of nutrients and drugs in
the upper gastrointestinal tract, bacterial over growth resulting in infections and changes in the
immune response, and the predisposition to other diseases and disorders. Defective absorption of
calcium, iron, folate, and vitamin B12 and the related deficiency diseases are of particular
concern in hypochlorhydric patients. Reduced production of hydrochloric acid may affect the
development of gastric cancer.

B-vitamins and central nervous system function: Current knowledge of the extent of interactions of
nutrition and neurology is limited. The effect of B vitamins and other nutritional factors on
brain function, including dementia and motor control, is better established. Deficiencies of
various nutrients, particularly vitamin B12, thiamin, niacin, and folate tmpair cognition.
Rigorously controlled, double-blind, prospective trials may elucidate the cognitive effects of
malnutrition, especially subclinical, or multiple deficiencles of B-vitamins. To date, much
information in this field is based on animal studies that may have Limited applicability to human
conditions,or on clinical pathology complicated by advanced age, alcoholism, and disease.

In addition, analytical methods specific and sensitive enough to measure the levels and metabolism
of B vitamins are only beginning to be developed. However, still more basic methodological
research is needed before further refinement in study design can be attempted. For example, based
on new evidence using updated technology, it appears that folic acid as a naturally occurring
excitatory agent found in the brain may have a mechanistic relationship to neuropathological
conditions such as epilepsy-related brain damage, Lithium neurotoxicity, tardive dyskinesia, and
neuronal degeneration associated with aging.

The study of nutrients’ effect on brain function has not received widespread attention because it
was commonly believed that the brain was well protected from Fluctuating plasma levels of dietary

nutrients by the blood-brain barrier (BBB). Now, it appears that food constituents affect the
synthesis of brain neurotransmitter and thereby modify brain function (e.g., alertness or
depression) and behaviors (e.8-, sleep). Fernstrom (78) and Wurtman (79) have shown that the

levels of serotonin, an appetite-controlling neurotransmitter, can be increased by a
high-carbohydrate, protein-poor meal that elevates brain tryptophan, accellerating serotonin
synthesis. They report similar regulation of brain acetylcholine by ingestion of
choline-containing compounds and of brain dopamine by tyrosine-containing compounds. Besides
macronutrients, Levels of trace minerals in the brain affect formation of synapses, nerve impulses,
and other brain activity in neurotransmitter systems (80). Since the blood-brain barrier serves as
the interface between brain metabolism and diet, understanding the BBB nutrient transport processes
provide insights into the mechanisms by which diet may influence brain functions (81). Research in
this area is still too young to attribute altered behavior solely to nutrient-induced changes in
neurotransmitter levels. Improved study designs are needed that use standardized methods for
measuring behavioral responses and that adequately evaluate the dietary components and nutritional
status of subjects and controls (82).

Although clinical research has not associated the severe senile dementia in Alzheimer’s disease
with aluminum toxicity (83) or other nutritional imbalances, future research in this area may be
promising. Appropriate biochemical testing of individuals suffering mental loss oF other central
nervous system dysfunction may be required for differential diagnosis of these problems.

Also of research interest is the effect of aging on the interaction of B vitamins with other

nutrients in the brain and nervous system. For example, alcohol consumption which can cause
Wernicke’s encephalopathy compromises thiamin pyrophosphate-dependent enzymes and interferes with
thiamin absorption and phos- phorylation. The drug, Dilantin, can increase folate requirements and

Sinemet, used to treat Parkinsonism, can cause niacin deficiency.

Nurritional services in the health care of the older persons

About 85% of older persons have one or more chronic, potentially debilitating diseases and could
benefit from nutrition services. Up to half of older individuals have clinically identifiable
nutrition problems requiring professional intervention (3). If the goal of health promotion is to
assure the older persons’ health, independence, and quality of life, incorporation of nutritional
services into the: continuum of health care ~~ institution, ambulatory, and home-based care ~~ for
older persons is paramount - Since older persons are more susceptible to foodborne poisoning than
younger people, proper sanitation practices are needed in food preparation and service in all these
health care settings.

o Nutritional Assessments

Nurritional services, whether therapeutic, rehabilitative, or maintenance services, include
clinical, educational and foodservice components. As part of clinical services, nutritional
assessments should become routine parts of physical examinations for all older residents of health
care facilities, nursing homes, oF community health centers (84). In turn, the findings of these
assessments shovld guide medical orders including drug regimens, scheduling surgery, dietary
guidance, and other nutritional therapy. (The Limitations of assessments were discussed earlier.)

Complete diet histories provide information on eating habits that can identify nutrient
inadequacies early. Since the food habits of the older persons reflect Long-term patterns, special
attention to the food preferences, cultural and religious beliefs, economic status, drug and
supplement use, and lifestyles can enhance compliance with specific dietary regimens, while
ensuring they obtain enough food and enough of the food they like.

For hospitalized or institutionalized patients, regular documentation of food intake may alert
health professionals to potential nutrition problems (5). Anorexia, jnduced by drug or radiation
therapies or resulting from surgery er chronic conditions, can quickly lead to nutrient
deficiencies, especially in frail older persons. Nutritional therapies, either enteral or
parenteral, formulated feedings, have minimized attendant medical complications (e.g-, infection),
improved therapeutic responses, and sped recovery in some patients. However, the prospective
payment system of financing health care (discussed below) may be a disincentive to use of
nutritional support in hospitals.

For the hospitalized or frail older persons who cannot eat, providing adequate nutrition support
through tube or intravenous catheter can contribute to regaining health and jndependence. Enteral
and parenteral feedings can sustain life for patients who are physically unable to swallow, digest,
or absorb food and fluids taken by mouth and for patients who refuse to eat.

The efficacy of these therapies is not universal across all diseases. Little is known about the
efficacy in older persons, partly because of the lack of information on the nutritional
requirements and standards for the older persons. Nutritionists and other health care
professionals will more frequently participate in debates about withholding and withdrawing
nutritional support and hydradration from terminally ill, comatose, and severely debilitated
people. In addition, health care providers will be faced with questions about when and if to use
these treatments with severely demented persons who cannot decide on the course of their therapy
and may need to be physically restrained (85).

e Education and training for working with older pexssons

With the emergence of diverse health problems among the fast-growing numbers of older persons, the
number of education and training programs on aging and geriatric nutrition have grown. NIA sets

G-1l
as two high priorities: 1) training of clinicians and biomedical researchers to specialize in
nutrition and aging issues and 2) development of centers of excellence in nutrition and aging

research.

Professional societies (86), research centers (87) and programs for medical, nursing, and nutrition
students (88, 89) have offered courses or seminars to address ethical concerns in nutrition for
long-term care patients and to encourage positive attitudes toward the older persons. Although it
may be necessary to train some health professionals to be geriatric specialists, the benefits of
*main-streaming” older persons into generic health care services outweigh the hazards of
stigmatizing and stereotyping their health problems (89). Appropriate funding for ambulatory and
health care services for older persons may also change the perception of students that these jobs

are often Low paying.

e Impact of health care financing on nutritional care of older persons

As the population ages and individuals Live longer, health care expenditure will increase. The
major reason for this increase is that health care utilization is greatest among the older persons,
especially the oldest old -- the segment of our population that is growing the fastest. To date

(1984) major sources of financing the health care of older persons in the United States are: 1)
medicare (49%), 2) out-of-Pocket (25%), 3) medicaid (13%), 4) insurance (7%), and 5) other
government sources (62). The federal government pays for about 68% of all health care expenditures
(90).

Government expenditures are dispersed as follows: 39% to hospital costs, 20% to personal health and
physician services expenditures, and 21% to nursing home and other expenditures. In 1983, due to
escalating health care expenditures, Congress and the Administration proposed reform -~ the
prospective payment system (PPS) for Medicare reimbursement of hospitals.

Under the PPS, Medicare pays for each hospital admission, a rate predetermined on the basis of the
patient’s principal diagnosis and certain ether factors. Each admission is assigned to one of 468
diagnosis related groups (DRGs) for payment. PPS is intended to discourage extended inpatient
stays and encourage the substi- tution of less expensive care outside of the hospital (91). As a
result of the PPS there has been a decline in the average length of stay for Medicare patients, and
therefore an increased demand for postdischarge services. The prospective payment system provides
a financial incentive for hospitals to cut costs below the reimbursable level and adjust inputs,
such as tests, personnel time, and special procedures (92). Studies are determining the impact of
PPS on the quality of care (92) and on access ta in-hospital nutritional support services (93).

The impact of PPS on the nutritional status of post discharge patients also needs examining.
Patients are discharged early in what appears to be poorer states of health and needing extensive
care (94). Health providers are finding it harder to retain patients requiring long term
nutritional support for a long enough time to monitor their status and train them before discharge.
Since October 1983 greater numbers of these patients (40% increase in discharges) are being
transferred to skilled-nursing homes or requiring home health care (95). Often these facilities do
not have the proper equipment, supplies or trained personnel to deliver safe and appropriate tube
or intravenous catheter feeding (5). Hospice programs and some home health care programs include
nutritional services; however, the majority of alternative community-based services do not include
nutritional services (3). The costs of nutrition services provided by hospice programs are
absorbed under the organization’s administrative overhead (3) because medicare and most third party
payment services do not reimburse nutrition services directly.

Cost contAinment pressures are projected to shift more demand from the hospital to the community,
especially to home care services traditionally provided through the nonprofit sector. The number
of Medicare certified home health agencies increased from 2,212 ‘in 1972 to 5,755 in 1985. The
growth has primarily taken place in facility-based and for-profit home health agencies, while the
number of more traditional nonprofit providers -- visiting nurse associations and government
agencies -~- has declined slightly (96). Questions arise as to how the communitycare nonprofit
sector will cope with the increasing demands for delivering of highly technical in-home health care
that drains resources from delivery of more traditional, community-decided, multi-services (e.g-,
transportation, food preparation assistance, primary health care) (97).

Technological advances and feeding the older persons

Changes in the physiology and organ systems of older persons challenge the food industry as it
attempts to serve the growing market of elders. Creativity will be needed to formulate products
that are flavorful, visually attractive, and have high nutrient densities. Products will need to
supply high nutrient levels for their caloric value. Fortified products need to assure high
bivavailability of the added nutrients. For several years, food manufacturers have been gradually
lowering the salt, fat, and sugar content of food, while retaining good flavor in most products.
Manufacturers have also addressed current nutrition research concerns by increasing the fiber,
calcium, and vitamin D content of cereals and other foods. Special diet products that are low
protein, cholesterol-free, Lactose-free, OF very low in sodium are also available (35, 98). An
earlier section also discussed the use of parenteral and enteral feedings-

Supermarkets and food stores are recognizing their responsibilities toward their aging clients.
Some grocery stores are establishing specific shopping hours for senior citizens complete with bus
service, bargain sales, and refreshments. Other ways to reduce barriers to food shopping include:
1) sales on small packages and at off peak-hour times, 2) educational materials written in larger
print that suggest tips for meal planning, budgeting and food preparation for single-person
households; 3) take-home product listings to use with telephone orders, 4) shelf-labels with large
print, 5) uncluttered aisles, and 6) convenient benches and rest rooms (81).

Nurrition and food assistance programs

Over the past 20 years, both the public and private sector have initiated and reformed food
assistance programs to respond to evidence that nutritional deficiencies were prevalent in older
persons, especially those with Low-income or who are socially isolated. A variety of services are
now available to elders with a continuum of functional capacity (99). The Continuum of Community
Nutrition Services model developed by Balsam (100) describes this variety.

Federal nutrition programs include the food stamp program, the commodity supplemental food program,
the congregate feeding program, and the home-delivered meal program. Private charities have teamed
with the public programs to expand food service to elders. Soup kitchens offer breakfasts and
suppers and food pantries provide emergency food boxes. Luncheon clubs (101) have permitted
seniors receiving home delivered meals to congregate in neighbors’ homes. Restaurants have eut
prices for older persons and accepted their food stamps. Food industries have designed packaging
and processing techniques to provide shelf-stable meals for evening and weekend use. Volunteers
offer escort services to supermarkets or deliver groceries to many home-bound persons (102).

Revisions to the USDA Food Stamp Program extended benefits to low income elders by eliminating the
purchase requirement and increased their benefits by allowing for medical and shelter deductions
(103). Nonetheless, many older persons still receive only minimal benefits ($10f/month) and their
participation rates are low (<50% of eligible) (90). For low-income, often frail, elders, who were
uninterested in receiving food stamps and had difficulty in shopping, Congress authorized delivery
of Low-cost commodity packages under the Commodity Supplemental Food Program.

The DHHS National Nutrition Program for Older Americans, 45 specified in Title III of the Older
Americans Act, includes food service for both the ambulatory old (congregate feeding) and the
home-bound old (home-delivered meals) (3). Evaluations (103, 104, 105, 106) of the congregate
feeding pregram and the home-delivered meals (107) generally show that participants have higher
intakes of essential nutrients than nonparticipants-

During recent hearing on program reauthorization, the American Dietetic Association (ADA) (108)
raised concern that future program pudgets must account not only for the annual inflation but also
for the annual rate of increase in the older population. The flexibility in funding for Title III
concerns many because it permits shifting funds from meal programs to supportive services.
Currently, the congregate feeding program reaches only 40% of the eligible population. The need for
home-delivered meals has increased significantly (35% to more than 50% increase in persons
receiving meals) in the first year after the implementation of the new prospective payment system
of health care financing (3). As dietary restrictions become more complex, especially for those
in their late 7Os or 80s, demand for special meals and nutrition information will increase,
requiring additional program resources and qualified professionals.

To formulate policies for food assistance programs requires attention to:

a. Planning and conducting systematic evaluations of food programs to assure they meet the
changing needs (nutritional, social, educational, and economical) of the heterogeneous
older population:
b. Developing new approaches to reach underserved groups of elders, such as the homeless and
soclally impaired elderly, minority and ethnic elders, and to extend food service beyond

weekday Lunches;

ce. Setting and revising (as needed) nutritional guidelines for meals served in senior
citizen feeding programs;

da. Establishing 4 clearinghouse for exchanging information on innovative programs that meet
identified community needs:

e. Assuring that educated and trained nutrition professionals assist with planning and

monitoring these programs at all levels of government.
Nutrition education and information

The tools that promote good nutritional health for older persons are most probably the nutrition
information gained from mass media or education programs. Because of the myriad of nutrition
messages received, sorting out consistent truths from half-truths or conflicting information
frustrates people at all ages. Educators need effective ways to minimize the confusion and also to
relevant research into dietary advice applicable to elders. The great

translate current,
reality that life-long habits are resistant to change

heterogeneity among older persons and the
make designing nutrition messages a challenge for educators.

Key to appropriate, effective nutrition education for this group is understanding the complexities
of aging, applying knowledge of the change process, and assessing cognitive, affective, and
Effective nutrition education also requires knowing the

nutritional status changes (109).
Many older persons, relate food to social

perceptions older persons have toward eating and foods.
interactions and entertainment and also recognize food as a source of nutrients that is important
to health (110). More research on factors that facilitate learning and making dietary changes can

improve nutrition education efforts (111).

Applying communication theory (112) and marketing principles (113) to nutrition education enhances
the chances that the consumer will act on the research-based dietary guidance. Such an approach
allows the audience to identify what they want to know, how they want to receive information, where
and how often they want follow-up. For example, older persons have sought 2

they want to learn,
They have also posed

uniform set of dietary guidelines, appropriate for most chronic diseases.
questions about health fraud, use of vitamin and other dietary supplements, and drug and food

interactions (114).

Though not tailored specifically for older persons, the DHHS/USDA Dietary Guidelines for Americans
provide essential information for motivating dietary changes that promote health. Modifying the
text slightly to be more relevant for older persons, printing copies with Large lettering, and
distributing them through Title III programs could permit wider use. The Healthy Older People
program conducted by the Office of Disease Prevention and Health Promotion promotes good nutrition,
proper exercise, and other health messages through the media and consumer education materials
(115). Combatting health fraud is a priority of the FDA, the Federal Trade Commission (FTC), and
Congress. The two agencies have launched an educational/media campaign against health fraud, and
recently sought stronger court actions against false advertisements for dietary supplements (115).
Since nutrition education has been found to be negatively correlated with misconceptions about
"vitamin/mineral supplements" (116), informing older persons about the benefits and hazards of
dietary supplements could result in more prudent use of these substances. Food labels also provide
good sources of nutrition information; but without close monitoring of the health claims on labels,
older persons could be deceived or adopt false expectations of the food.

Title III of the Older Americans Act is the only federal nutrition program for older people that
reimburses nutrition education. Based on the recent National Association of Area Agencies on Aging
and the Administration on Aging’s survey results (117), nutrition education, though often a high
priority for some program administrators, is not routinely incorporated into all programs. Three
reasons most frequently cited for lack of nutrition education are inadequate funds, the absence of
qualified nutrition educators, and the lack of specific program standards and guidelines for

nutrition education (118).
Other nutrition policy considerations might include (119):

1, What central nutritional message do seniors want - changing the amount of food eaten, eating

more nutritious foods, understanding drug and food interactions, or learning about and using

community nutrition programs?

2. How can the messages delivered by the federal government be better coordinated, and how can
the government messages be coordinated with those of the private sector?

3. What format, language, and style for educational materials are most useful and appealing to
older persons?

4. What medium (e.g., groups, mass media) is most effective to use in reaching older persons as a
group and the various subgroups over age 65?

5. What should be done to assure that qualified nutritionists assist with planning, coordinating,
evaluating, and monitoring nutrition education programs at the federal, state, and local
level?
10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

REFERENCES
U.S. Congress, Office of Technology Assessment. Technology and Aging in America. Health
Promotion/Disease Prevention and Nutrition in the Elderly. Washington, D.C.: Government Printing
Office, 1985. PP- 119-134
Costell, po. Diagnosis of Non-Cardiac Chest Pain in Older Patients. Geriatrics 1985; 40(10): 61-86
Posner, BM., Fanelli, MT., et al. Position of the American Dietetic
Association: Nutrition, Aging, and the Continuum of Health Care. J Am Diet
Assoc 1987; B7(3): 344-347
Guthrie, HA- Supplementation: A Nutritionist’s View. J Nutr Ed 1986: 18(3): 130-132

Chernoff, R- and Lipschitz, DA. Aging and Nutrition. Comprehensive Therapy 19B5; 11¢8): 29-34

Norton, L. and Wozny, MC. Residential Location and Nutritional Adequacy Among Elderly Adults. J
Gerontol 19984; 39: 592- 95

Akin, JS et al. Cluster Analysis of Food Consumption Patterns of Older Americans. J Am Diet Assoc
1986; 936: 616-24

Villers Foundation. On the Other Side of Easy Street. Washington, p.c.: Villers Foundation, 1987

‘Lewis, M. Older Women and Health: An Overview. Women & Health 1985; 10:1-6

Bailey, FE. and Walker, ML. Socio-Economic Factors and Their Effects on the Nutrition and Dietary
Habits of the Black Aged. J Gerontol Nursing 1982; 8(4): 203-7

Newman, JM. Cultural, Religious and Regional Food Practices of the Elderly- J Nutr Elderly 1985;
5(1): 15-19

Netland, PA. and Brownstein, H. Acculturation and the Diet of Asian- American Elderly. J Nutr Eld
1984; 3¢€3): 37-56

Newman, JM. and Ludman, EK. Chinese Elderly: Food Habits and Beliefs. J Nutr Eld 1984; 4(2): 3-13
Davis, MA. and Randall, E. 1981 Social Change and Food Habits of the Elderly. National Institute
of Aging’s Social and Psychological Developments in Aging. Paper for the White House Conference on

Aging 1981.

Schneider, EL., Vining, EM., Hadley, EC., et al. Recommended Dietary Allowances and the Health of
the Elderly. N Engl J Med 1986; 314(3): 157-60

Elahi, VK., Elahi, D., Andres R., et al. A Longitudinal Study of Nutritional Intake in Men. J
Gerontol 19833 162-180

Garcia PL., Battese GE., and Brewer, WD. Longitudinal Study of Age and Cohort Influences on
Dietary Patterns. J Gerontol 1975; 30: 349-56

Dresser, CM, Dietary Status of Community-Based Older Persons. Paper presented at the American
Dietetic Association 67th Annual Meeting, Washington, D.C., Oct. 15-18, 1984

Cronin, FJ.,; Krebs-Smith, SM., Wyse, BW., et al. Characterizing Food Usage By Demographic
Variables. J Am Diet Assoc 1982; 81: 661-73

USDA. Nutrient Intakes: Individuals in 48 States, Year 1877-78. Nationwide Food Consumption
Survey 4977-78 Report No. I-2. Human Nutrition Information Service, USDA, 1984

Suter, PM. and Russell, RM. Vitamin Requirements of the Elderly. Am J Clin Nutr 1987; 45: 501-12

Garry, PJ., Goodwin, JS-; Hunt, WC., et al. Nutritional Status in a Healthy Elderly Population:
Dietary and Supplemental Intakes. Am J Clin Nutr 1982. 36: 319-31

Omdahi, Ji., Garry pJ., Hunsaker, LA., et al. Nutritional Status in a Healthy Elderly Population:
Vitamin D. Am J Clin Nutr 1982; 36: 1225-33

DHHS/FDA. Consumer Nutrition Knowledge Study: A Nationwide Study of Foodshopper’s$ Knowledge,
Beliefs, Attitudes, and Reported Behavior Regarding Food and Nutrition Report II 1975. Washington,
D.C.: Government Printing Office, 1976
25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48,

4g.

5G.

51.

McDonald, JT. Vitamin and Mineral Supplement Use in the U.S.. Clin Nutr 1986; 5(1): 27-33

Stewart, ML., McDonald, JT., Levy, AS., et al. Vitamin/Mineral Supplement Use: A Telephone Survey
of Adults in the United States. J Am Diet Assoc 1985; 85(12): 1585-90

Shank, FR. and Wilkening, VL. Consideration For Food Fortification Policy. Cereal Foods Wild 1986;
31(10): 728-740

Cordaro, JB., and Dickinson, A. The Nutritional Supplement Industry-- Realities and Opportunities.
J Rutrc Ed 1986; 18(3): 128-129

Scheider, CL., and Nordlund, DJ., Prevalence of Vitamins and Mineral Supplement Use in the Elderly.
J Fam Prac 1983; 17: 243-47

Garry, PJ., Goodwin, JS., Hunt, WC., et al. Nutritional Status in a Healthy Elderly Population:
Vitamin C. Am J Clin Nutr 1982; 36: 332-39

Lecos, GW. Diet and the Elderly, Watch Out for Food-Drug Mismatches. FDA Cons 1984/85; 18(10): 7-9

DHHS/NCHS. Health Promotion Data for the 1990 Objectives, Vital and Health Statistics, Washington,
D.C.: Government Printing Office, Sept 1986; Number 126

Chernoff, R- Aging and Nutrition. Nut Today 1987; March/April: 4-11

U.S. Congress, Office of Technology Assessment. McGandy, R. Nutrition and Aging. Final Report for
the Office of Technology Assessment, 1985

Bidlack, WR., Smith, CH., Clemens, RA., et al. Nutrition and the Elderly. Institute of Food
Technologists’. Expert Panel on Food Safety and Nutrition

DHHS/NCHS. Health Statistics on Older Americans. Vital and Health Statistics Washington, D.C.:
Government Printing Office, 1986 series 3(25)

DHHS/NCHS. Health United States 1985. Washington, D.C.: Government Printing Office, 1985

DBHS/NCHS. Prevalence of Known Diabetes Among Black Americans, Vital and Health Statistics,
Washington, D.C.: Government Printing Office, 1987; Number 130

Bauer, RL., Diehl, AK., Barton, SA., et al. Risk of Postmenopausal Hip Fracture in Mexican
American Women. AJPH 1986; 76(8): 1020-21

Atwood, DA. Bone Loss of Edentulous Alveolar Ridges. J Periodontol 1979; 51: 11-21

Tallgren, A. The Continuing Reduction of the Residual Alveolar Ridges in Complete Denture Wearers:
A mixed-longitudinal Study Covering 25 Years. J Prosthet Dent 1972; 27: 120-32

Norris, AH. and Shock NW. Aging and Variability. Annals NY Acad Sci 1966; 134: 591-601
O’Hanlon, P. and Kohrs, MB. Dietary Studies of Older Americans. Am J Clin Nutr 41978; 31: 1257-69
Roe DA. Geriatric Nutrition. Englewood Cliffs, New Jersey: Prentice-Hall Inc., 1983. pp- 1-199

Chumlea, WC., Roche, AF., and Steinbaugh, ML. Estimating Stature From Knee Height for Persons 60
to 90 Years of Age. J Am Geriatr Soc 1985; 33: 116-120

Lipschitz, DA., Mitchell, co. Nutritional Assessment of the Elderly-- Special Considerations.
Wright and S Heymsfield (Eds.), Nutritional Assessment Boston: Blackwell Scientific, pp- 131-39

Fanelli, MT. The ABC’s of Nutritional Assessment in Older Adults. J Nutr Eld 1987: 6(¢3): 33-41

Clemens, RA., and Brown, RC. Biochemical Methods for Assessing the Vitamin and Mineral Nutritional
Status of the Elderly. Food Tech 1986; 40(2): 71-81

O’Neal, RM., Johnson, OC., and Schaefer, AE. Guidelines for Classification and Interpretation of
Group Blood and Urine Data Collected as Part of the National Nutrition Survey. Pediatr Res 1970; 4
103-6

Sauberlich, HE., Dowdy RP., and Skala, JH. Laboratory Tests for the Assessment of Nutritional
Status. Cleveland, OH: CRC Press Inc., 1974.

Howell, S. and Loeb, MB. Nutrition and Aging. Geriatr 1969:9(3): 1-122

G-16
52.

53.

5A.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

National Academy of Sciences, National Research Council. Lewin, K. Forces Behind Food Habits and
Methods of Change. The Problem of Changing Food Habits. Bulletin Number 108, Washington, D.C.:
National Academy Press, 1943

Gifft, HH., Washbon, MV., Harrison, GG. Nutrition, Behavior, and Change. Englewood Cliffs, New
Jersey: Prentice-Hall, Inc., 1872. pp. xLil-xv

Schiffman, SS. Mechanisms of Disease, Taste and Smell in Disease. N Engl J Med 1983; 308(21):
1275-79

Schiffman, SS. and Pasternak, M. Decreased Discrimmination of Food Odors in the Elderly. J
Gerontol 1979; 34(1): 73-79

Bidlack, WR., Kirsch, A., and Meskin, MS. Nutritional Requirements of the Elderly. Food Tech 1986;
40(2): 61-9

Munro, HN., McGandy, RB., Hartz, sc. et al. Protein Nutriture of a Group of Free-living Elderly.
Am J Clin Nutr 1987; 46(4): 586-92

Russell, RM., Krasinski, SD., Samloff, IM. et al. Folic Acid Malabsorption in Atrophic Gastritis:
Compensation by Bacterial Folate Synthesis. Gastroenterology 1986; 91: 1476-82

MacLaughlin, J. and Holick, MF. Aging Decreases the Capacity of Skin to Produce Vitamin D3. J Clin
Invest 1985; 76: 1536-8

Davis, M., Mawer, EB., Hann, JT. et al. Vitamin D Prophylaxis in the Elderly: A Simple Effective
Method Suitable for Large Populations. Age and Ageing 1985; 14: 349-54

Bowman, BB., Rosenberg, IB. Assessment of the Nutritional Status of the Elderly. Am J Clin Nutr
1982; 35: 1142-1151

Pelletier, O. Vitamin C and Cigarette Smokers. Ann NY Acad Sei 1975; 258: 156-68

Sahud, MA. and Cohen, RJ. Effect of Aspirin Ingestion on Ascorbic Acid Levels in Rheumatoid
Arthritis. Lancet 1971; 1(2): 937-8

National Academy of Sciences, Food and Nutrition Board. Recommended Dietary Allowances.
Washington, D.C.: National Academy Press, 1980

Krause, MV. and Mahan, LK. Food, Nutrition and Diet Therapy 7th Edition. Philadelphia,
Pennsylvania: W.B. Saunders Co., 1984. pp. 182, 327, 441, 605,

Wolford, RL., Harris, SB., and Weindruch, R. Dietary Restriction and Aging: Historical Phases,
Mechanisms, Current Directions. J Nutr, in press Oct., 1987.

Drinkwater, BL. The Role of Nutrition and Exercise in Health. Seattle, Washington: Continuing
Dental Education, University of Washington, 1985. pp. 88-92

Nieman, DC. The Sports Medicine Fitness Course. Palo Alto, California:Bull Publishing Co., 1986.
pp. 330-40
Roe, DA. Nutrition and Drug Interactions, Present Knowledge in Nutrition. Washington, D.C.: The

Nutrition Foundation, 1984, pp.797-818

Hartz, SC., (ed). Drug-Nutrient Interactions, proceedings of the International Conference on
Nutrients, Medicines and Aging. New York: Alan R. Liss, Inc. 1985; 4(1/2)

Riggs, BL. and Merton III, LJ. Involution Osteoporosis. N Engl J Med 1986; 314(26): 1676-84

Riggs, BL., Wahner, W., Seeman, K., et al. Changes in Bone Mineral Density of the Proximal Femur
and Spine With Aging. J Clin Invest 1982; 70: 716-723

Kelsey, JL. and Hoffman, S. Risk Factors for Hip Fracture. N Engl J Med 1987; 316(7): 404-6

Johnston, CC., Norton, J., Khairi, MRA., et al. Heterogeneity of Fracture Syndromes in
Postmenopausal Women. J Clin Endocrinol Metab 1985; 61(3):551-6

DHHS/NIH. Consensus Development Conference Statement, Osteoporosis. Washington, D.C.: U.S.
Government Printing Office, 1984

Buchanan, JR., Myers, C., Greer, RB., et al. Assessment of the Risk of Vertebral Fracture in
Menopausal Women. J Bone Joint Surg 1987; 69-A(2): 212-17
77.

78.

79.

80.

81.

82.

83.

B4.

85.

86.

87.

88.

Bg.

90.

91.

$2.

93.

94.

95.

96.

97.

98.

99.

100.

101.

Hartz, AJ., Fischer, ME., Bril, G-, et al. The Association of Obesity With Joint Pain and
Osteoarthritis in the HANES Data. J Chronic Dis, 1986; 39(4): 311-19

Fernstrom, JD. Acute and Chronic Effects of Protein and Carbohydrate Ingestion on Brain Tryptophan

Levels and Serotonin Synthesis. Nut Reviews (Suppl) 1986; 44:25-36

Wurtman, RJ. Ways That Foods Can Affect The Brain. Nutr Reviews (Suppl) 1986; 44: 2-5

Sandstead, HH. Nutrition and Brain Functlon: Trace Elements. Nutr Reviews (Suppl) 1986;44: 37-41
Pardridge, WM. Blood-Brain Barrier Transport of Nutrients. Nutr Reviews (Suppl) 1986; 44: 15-23

Anderson, GH., and Hrboticky, N. Approaches to Assessing the Dietary Component of the
Diet-Behavior Connection. Nutr Reviews (Suppl) 1986; 44: 42~51

Wheater, RH. Aluminum and Alzheimer’s Disease. JAMA 1985; 253(15): 2288
Schaeffer, AE. Nutrition Policies for the Elderly. Am J Clin Nutr 1982; 36: 819-822

U.S. Congress, Office of Technology Assessment. Life-Sustaining Technologies and the Elderly.
Washington, D.C.: U.S. Government Printing Office, 1987

Lipschitz, DA., and Chernoff, R. Nutritional Care a Growing Issue for Providers. Am Health Care
Assoc J Dec 1985: 47-48

Institute for Health and Aging. Health Promotion for the Elderly: Clinical Practice and Community
Resource Series. University of California, San Francisco, 1986

Shoaf, LR. and Kotanchek, NS. Training in Geriatrics for Future Dietitians. J Am Diet Assoc 1987;
87(3): 330-33

Wilson, SL., Whittington, FJ. Preparing Nutrition Students to Work With the Elderly. J Nutr Ed
1985; 17(2): 44-6

U.S. Senate, Special Committee on Aging. Developments in Aging: 1986 Volume 3. Washington, D.C.:

U.S. Government Printing Office, 1987

U.S. Congress, Office of Technology Assessment. Medicare’s Prospective Payment System--Strategies
for Evaluating Cost, Quality and Medical Technology. Washington, D.C.: U.S. Government Printing

Office, 1985

Prospective Payment Assessment Commisssion. Report and Recommendations to the Secretary, U.S.
Department of Health and Human Services, April 1, 1987. Washington, D.C.: Prospective Payment
Assessment Commission, 1987

Adamow, CL. and Clipper, AJ. Is prospective payment inhibiting the use of nutrition support
services? Discussion and research implications. J Am Diet Assoc 1985; 85(12):1616-9

Statements of Eleanor Chelimsky, GAO, Judith Wagner, Office of Technology Assessment, and Donald A.
Young, Prospective Payment Assessment Commission, on "Quality of Care Issues in the Medicare
Program” before the U.S. Senate, Committee on Finance, June 3, 1986.

2
U.S. Senate, Special Committee on Aging. Developments in Aging: 1986 Volume 1. Washington, D.C.:
U.S. Government Printing Office, 1987
U.S. General Accounting Office. Medicare: Need to Strengthen Home Health Care Payment Controls and

Address Unmet Needs. Washington, D.C.: Government Printing Office, 1986
Estes, CL. The Aging Enterprise: In Whose Interests?. Int J Health Serv 1986; 16: 243-251

Leveille, GA. and Cloutier, PF. Role of the Food Industry in Meeting the Nutritional Needs of the
Elderly. Food Technology 1986; 2: 82-88

Posner, B. and Karachenfels, M. Optimal Nutrition Services for Older Americans, Boston: Mass Dept
of Public Health, 1985

Balsam, A. and Osteraas, G. Instituting A Continuum of Community Nutrition Services:
Massachusetts Elderly Nutrition Programs. J Nutr Eld. accepted for publication in Spring, 1987

Balsam, AL. and Duffy, M. Elderly Luncheon Clubs: Bridging the Gap Between Congregate and Home
Delivered Meals. J Nutr Eld 1983; 2(4): 31-35
102.

103.

104.

105.

106.

107.

108.

109.

110.

111.-

112.

113.

114.

115.

116.

117.

118.

119.

Steele, MF. and Bryan, JD. Dietary Intake of Homebound Elderly Recipients and Non-Recipients of
Home Delivered Meals. J Nutr Eld 1985/6; 5(2): 23-34

Weimer, JP- The Nutritional Status of the Elderly. J Nutr Eld 1983; 2(&): 17-25

Kirschner Associates, Inc. and Opinion Research Corporation. An Evaluation of the Nutrition
Services for the Elderly, prepared for the Administration on Aging, DHHS, Washington, D.C.:

Government Printing office, 3 Vols., 1983

Harrill, I., Bowski, M., and Kyler, A. The Nutritional Status of Congregate Meals Recipients.-
Aging 1980: 311, 312 : 36-41

Balsam, A.-, Osteraas, G-; Bass, S-, et al. An Evaluation of the Congregate Nutrition Program for

the Elderly. Boston: Univ Mass Ger Program, 1985

Yessian, M- and Monier, c. Follow Up on the Home Delivered Meals Program Service Delivery
Assessment. DHHS, Office of the Inspector General, 1982

American Dietetic Association. ADA Testimony on the 1987 Reauthorization of the Older Americans Act

of 1965. J Am Diet Assoc 1987; 87(7): 943-4

Shannon, B- and Smiciklas-Wright, H. Nutrition Education in Relation to the Needs of the Elderly.

J Wut Ed 1979; 11: 85-89

Axelson, L.- and Penfield, Mp. Food and Nutrition-Related Attitudes of Elderly Persons Living
Alone. J Nut Ed 1983;15(1): 23-27

Sims, LS. Nutrition Education Research: Reaching Toward the Leading Edge. J Am Diet Assoc (Suppl)

1987; 87(9): 10-18
Gillespie, AH. Communication Theory as a Basis for Nutrition Education. J Am Diet Assoc (Suppl)
1987; B7(9): &4-52

Fleming, PL. Applications of the Marketing Perspective in Nutrition Education. J Am Diet Assoc
(Suppl) 1987; 87(9): 64-8

Maloney, SK., Fallon, B., and Wittenberg, CK. Study of Seniors Identifies Attitudes, Barriers to
Promoting Their Health. Promot Health 1984; Sept- Oct: 6-8

u.S. Senate, Special Committee on Aging- Developments in Aging: 1986 Volume 2-Appendixes.-
Washington, p.c.: U.S. Government Printing Office, 1987

Grotkowskl, ML. and Sims, LS. Nutritional Knowledge, Attitudes and Dietary Practices of the
Elderly. J Am Diet Assoc 1983; 47: 263-68

Aging Health Policy Center. Nutrition Policy and the Elderly, Policy Paper No. 2. San Francisco:
University of California, 1983

Hickman, D. Nutrition Education, Past, Present and Future. Aging 1980; 311, 312: 17-20

Posner, BM.» Nutrition Education for Older Americans: National Policy Recommendations. J Am Diet
Assoc 1982; go: 455-8