The National Policy and
Resource Center on Nutrition and Aging
Innovative
research provides
food for thought
Dian
Weddle, Nancy Wellman and Victoria Castellanos
|
Food.
It fuels all that we do. It makes life
possible. For most individuals it's such
a routine part of everyday life that it's
simply taken for granted. |
For many Americans, however, hunger and malnutrition
remain a reality of day-to-day life. And the
problem is most severe among those individuals
least able to cope with it: the elderly.
According to Nancy Wellman, Florida International
University (FIU) professor of Dietetics and
Nutrition, three out of every five Americans
age 65 and older 60 percent are
"at high to moderate nutritional risk." This
alarming figure is based on the result of 30
national studies covering 66,000 adults; individuals
at risk met three to five "warning signs" on
a 10-point checklist developed by the Nutrition
Screening Initiative, a program promoting routine
assessments to achieve better nutrition among
the elderly.
The problem and the paucity of research dedicated
to solutions prompted the establishment of the
National Policy and Resource Center on Nutrition
and Aging at FIU. The center was founded by
Wellman, who serves as its director, and Dian
Weddle, associate professor of Dietetics and
Nutrition and its co-director.
Created in 1995 under funding from the U.S.
Administration on Aging (AoA), the center promotes
healthy aging by working to reduce malnutrition
among older adults, especially minorities with
health disparities. The goal is to improve quality
of life, promote independence and decrease early
nursing home admissions and hospitalizations
through better nutrition. The center helps modernize
Elderly Nutrition Programs (ENPs), which are
the cornerstone of the Older Americans Act,
and also provides educational and research opportunities
for FIU students.
The center the only one of its kind in
the nation works with the Aging Network,
which includes more than 4,000 local nutrition
projects serving congregate and home-delivered
meals (popularly known as Meals on Wheels);
57 state and territory agencies on aging; 227
tribal organizations; and 650 area agencies
on aging. With the rapidly increasing numbers
of frail older adults, the center promotes risk-based
nutrition screening to identify and serve the
most needy and provides technical training,
policy analysis and outcomes research. The center
and its applied, community-based research has
fostered vital links between faculty/researchers,
professional care providers and patients.
The center has three current areas of focus:
* to
help Meals on Wheels programs;
* improve
the quality of nutritional care in nursing homes;
and
* help
cooperative extension programs to assist older
adults in rural communities.
"With
more attention to good nutrition you have a
better quality of life with greater independence,"
said Wellman, former president of the American
Dietetics Association and current president
of the Nutrition Screening Initiative. "We're
a practical center looking for ways to help
Americans age well, actively, gracefully."
Wellman's leadership in professional organizations
and the applied research and service activities
of the department were key factors leading to
the center's formation. In 1994, Weddle worked
with the Florida Department of Elder Affairs
on nutrition screening pilot projects, utilizing
the Nutrition Screening Initiative checklist
at sites serving different ethnic populations:
Hispanic in Little Havana, African American
in Liberty City, and Jewish in Miami Beach.
"The project demonstrated that older adults
are at risk for malnutrition and some have diet-related
disorders," Weddle said.
The next research project focused on how good
nutrition could be integrated into an overall
continuum of care. The study was conducted at
sites in Miami, Broward County and Osceola County
to consider the differences in populations
and services in urban, suburban and rural areas
and a model was developed to incorporate
nutrition as an integral element in care assessment.
"It proved to be a successful model," Weddle
commented. "There are things you can fix if
you target appropriately. What was needed was
a focus on nutrition beyond the meals. We need
to hook clients up to services to enable them
to successfully meet nutritional needs."
The interdisciplinary, community-based approach
of the projects was a key factor that attracted
the AoA funding to formally establish the center.
"We were able to develop local solutions that
were realistic and practical," Weddle said.
Jean Lloyd, the AoA nutrition officer in Washington
who works collaboratively with the center, said
the center plays a unique national role designing
interdisciplinary, community-based nutrition
programs for the elderly. She noted that the
center's work can help impact state and federal
policies to provide quality nutritional services.
"A lot of social service people don't understand
the role nutrition plays to keep people healthy
and independent and some nutritionists
don't understand the role of social services,"
she explained. "The center bridges the social
service and nutrition service networks. It is
helping to create a positive future for older
adults that connects nutrition, health and independence."
Meals on Wheels: a
nutritional lifeline
Debbie
Kleinberg and Stacey Reppas of the North
Miami Foundation for Senior Citizens' Services.
|
One
of the center's current AoA-funded initiatives
is Nutrition 2030, a dynamic partnership
with the Meals on Wheels Association of
America that aims to help ENPs expand and
better serve needy older adults. Current
funding allows ENPs to deliver nutrition
services to only about 7 percent of the
high-risk older population overall, including
up to about 25 percent of low-income and
minority older adults.
A project within the center has been the
Morning Meals on Wheels (MMOW) |
Breakfast
Program, an innovative public/private partnership
between the center, the AoA and General Mills
Foodservice Inc. to better meet the needs of the
at-risk homebound older adults.
MMOW provides breakfast in addition to the traditional
lunchtime meal so participants receive two-thirds
of their recommended dietary intakes. The center
conducted a nationwide study to evaluate the effectiveness
of adding the second meal. In this six-month study,
the center worked with 1,500 frail homebound older
adults served by the 20 organizations selected
from the 100 local projects that applied to participate.
Adding breakfast proved to be a cost-effective
way of reducing malnutrition risk, increasing
nutrient intake, and improving health and appetite.
Caregiver duties were reduced, and it helped enable
clients to meet the cost of medicine, heat and
rent.
"Breakfast is a wonderful opportunity to double
the nutrition provided to clients," said Debbie
Kleinberg, executive director of The North Miami
Foundation For Senior Citizens' Services, Inc.,
one of the organizations chosen to participate
in the research project. "It seemed like an efficient
mechanism to increase nutrition for clients at
risk."
Thirty of the 200 elderly clients who receive
Meals on Wheels lunch deliveries were selected
to receive the additional meal. The breakfasts
typically include cereal, milk, bread, fruit and
a hard-boiled egg or yogurt. The at-risk clients
receiving the breakfasts are homebound and rely
on Meals on Wheels as their nutritional lifeline.
Kleinberg said they have heard of instances where
clients would only eat a portion of their lunch
and save the rest to stretch it for another meal.
They would like to offer breakfast to even more
clients, but tight public funding limits any expansion.
While the AoA funds the lunch meals, support from
the North Dade Medical Foundation makes the breakfast
meals possible.
Stacey Reppas, an FIU master's student in Dietetics
and Nutrition and nutrition program administrator
with the North Miami Foundation, has been planning
the menu cycle for the breakfasts. In addition,
she has been collecting data and providing client
interventions that she is using for her thesis,
"Nutrition and Oral Health in Older Adults." Among
the interventions are providing nutrition tip
sheets and a "chopster" food processor, which
chops up food and makes it easier to eat.
"FIU is offering a unique opportunity," Kleinberg
said. "We haven't experienced anything like it
from other universities."
Reaching
out in rural America
Under a $220,000 grant from the U.S. Department
of Agriculture's Fund for Rural America, the center
has been developing model programs that demonstrate
effective case studies between older adult organizations
and cooperative extension services that focus
on the nutritional needs of rural populations.
The project is being conducted in part with cooperative
extension services at Kansas State University,
Montana State University and the University of
Florida. In Kansas, efforts have focused on designing
a nutrition program to complement Meals on Wheels,
while at the University of Florida a nutrition
education program has been developed.
"Traditionally, these programs have not worked
with older adults. They now recognize the great
need in rural communities and they want to do
something about it," said Weddle.
The Montana State University Cooperative Extension
Service has been working closely with Montana
Aging Services on the project, which will have
an educational focus. They are in the process
of collecting and analyzing data throughout the
state to assess needs; then interventions will
be developed and instituted.
"It's all based on education we'll see
what will hit home to help clients make behavioral
changes," said Marnie Cranston, state nutritionist
with Montana Aging Services. "The interventions
are very practical: How can we make changes in
their diet that they will like? The cooperative
extensions will provide the community resource
connections. ...Our goal is to keep folks in their
communities as long as possible."
The
dining room at The Palace, site of a center
demonstration project.
When
Victoria Castellanos, assistant professor of Dietetics
and Nutrition, had a post-doctoral fellowship
at Penn State, she conducted research on obesity.
When she subsequently came to FIU in 1996, she
was determined to apply what she knew about why
people overeat but use it to help people
eat more. The venue for her work would
be nursing homes.
"People are literally starving to death in nursing
homes," Castellanos said. "Many middle-aged people
can afford to lose five to 10 pounds but
not someone who is 75 years old. They often can't
gain it back."
Castellanos applied for funding from the Health
Care Financing Administration through the AoA
to conduct research on ways to reduce dehydration
and malnutrition in nursing homes. She secured
a $75,000 one-year grant and a demonstration project
was launched at The Palace at Kendall Nursing
and Rehabilitation Center, a 180-resident facility.
She soon discovered that the structure and financing
of nursing homes were a fundamental part of the
problem.
"The biggest problems don't concern appetite,"
Castellanos explained. "It's mostly a staffing
problem in long-term care. Most nursing homes
need more hands to feed people who can't feed
themselves. Most facilities don't even pay a dietitian
to be there full time. To solve this problem it's
going to require more hands to feed people. Health
care professionals will bend over backwards to
give residents medicine. It is just as important
that they buy into the fact that people need to
eat to stay healthy."
Armando
Triana and Sharon Clewis
|
The
first step in the project was to have the
nursing home's dietitian on site an additional
16 hours a week (up from the previous four
hours per week). The dietitian was charged
"to do whatever needed to be done" to improve
nutrition in the facility. A variety of
approaches were adopted. They trained the
certified nursing assistants to better recognize
signs of |
malnutrition
and dehydration; more staff members were trained
to provide feeding assistance; computer technology
was used to enhance the dining program; and they
introduced a new snack program. Throughout the
project they tried to involve the nursing home
residents' families. A set of outcome measures
was developed to determine the effectiveness of
the various actions; these included patient records,
food intake studies and family satisfaction surveys.
"We looked at what was going to have the greatest
impact," Castellanos explained. "We found that
education and assessment tools are only useful
if the physical environment in the nursing home
accommodates a behavior change in the health professionals
being educated, if the data that is used in the
nutritional assessment is accurate and up-to-date,
and if staffing levels and supervision are adequate."
Several FIU master's students have worked on the
program, including Armando Triana, who has been
collecting outcome data, some of which he may
use for his thesis on increasing appetite and
food intake by reducing dehydration.
"This has been an excellent experience for everyone
involved," said Jeff Nusbaum, administrator of
The Palace. "I think one of the most important
things in a facility is nutrition and hydration.
It impacts our residents' general overall health.
The program definitely impacted our overall operation
here. There is a better understanding of residents'
nutritional needs and an appreciation of those
needs."
Sharon Clewis, the dietitian and FIU alumna (B.S.
Dietetics and Nutrition, 1982) at The Palace and
consultant on the FIU project, believes that it's
important for the nursing home industry and academia
to work together on solutions.
"This research can validate better programs, systems
and measures," commented Clewis. "Other facilities
can utilize these tools and really effect an improvement
in nutrition and hydration for nursing home patients.
The problems we have addressed here are universal
at nursing homes." |
