Nutritional Needs

Reviewing the needs assessment for the Seniors of Nevada renders two major challenges for this group: Fixing the issues associated with food insecurity and similarly overcoming the challenge of diet changes associated with aging. Food insecurity presents as a major challenge due to the prevalence in the community. 18.8% of the Senior population in Nevada roughly equates to 75,000 citizens affected by food insecurity (1). Food insecurity can have large scale impacts such as health, social, and economic decline. Relating to health, food insecurity in this group is correlated with a 23.9% obesity rate (2). This level of obesity also contributes to 21.9% rate of diabetes within the community (2).  The food insecurity issue often means limited access to food, and as a result, adhering to a special diet for weight management or diabetes management becomes increasingly difficult (2). Compounding these high levels of health issues can also be related to the 28% of Nevadan Seniors who report little to no leisure time or physical activity (2). The primary intervention to these issues revolves around nutrition education. The education program should center around what food-insecurity means while alleviating anxiety associated with food insecurity. The program should focus on the prevalence of the issue and what groups are more susceptible.

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Another nutritional challenge this population faces is the dietary changes they must make as a result of aging. The importance of addressing this challenge is a result of the influence diet quality has over many bodily systems and functions. Primary intervention starts with education of aging and the impact that process has on the diet. Topics should center around which nutrients are of greater importance and how to combat aging effects such as appetite loss and mobility reduction. Intervention could also involve enrolling in the Older American’s Nutrition Program. This organization could prove useful as they require all meals adhere to the current Dietary Guidelines for Americans which would increase the likelihood of consuming nutrient-rich meals. In summary, an intervention for this target population should include nutritional education as the foundation of intervention. The educational component allows the target group to understand their status while also reducing the anxiety associated with their new knowledge on the subject.

Model of Behavior Change

The Health Belief Model is a useful ideology that is appropriate for the target population of Seniors in Nevada. This model utilizes three components in its theoretical framework to draw out the desired new health behavior. The Health Belief Model concludes that the perception of a threat to one’s health, the expectation of certain outcomes, mainly the benefits related to a behavioral change, and the thought that one can make a change to produce desired outcomes are all components that lead to adopting a new behavior. This model contains six key concepts that need to be assessed: Perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. An Evaluation of nutrition education interventions for older adults: a proposed framework developed by Nadine Sahyoun R.D. and Charlotte Pratt R.D. focused on identifying nutritional interventions and nutritional education programs that were effective for older adults (4). The findings of their study found that the Health belief model is the most applicable to older adults (4). The evaluation reasoned that the applicability of this model to older adults is a result of their perception that they may become ill at their stage of life.

Table 1: Health Belief Model as Applied to Seniors in Nevada

Concept

Need for Nutrition Education

Strategies for Change in Lesson

Perceived Susceptibility

Older adults do not believe they are at risk for diet related issues and do not see the need to change or modify their diet as their age increases. This group lacks general knowledge about the risks of food insecurity and failing to conform to new diets with age increase.

Define the major health related risks associated with food insecurity. (L1)

Limit nutrition messages to one or two issues that are practical and specific.

Perceived Severity

The prevalence of health related issues in the elderly is rising every year as their beliefs regarding the severity of issues such as untreated diabetes and obesity is not fully conscious of the true consequences.

Specify long term and short term consequences of prevalent conditions and actions to remedy or maintain these issues. (L1, L6)

Perceived Benefits

Senior populations are often not convinced that their behaviors will do them any good in reducing the risk of developing conditions or alleviating symptoms of their conditions.

Detail how to take effective action and what the outcomes will be. Stress working and acting smarter not overworking aimlessly.

(L1, L4, L5, L6)

Perceived Barriers

The diverse socioeconomic status of Nevadan Seniors forces some to believe that treatment of any sort is not worth the financial burden that will accompany taking action towards improving their health.

Offer information on assistance programs designed for this target population.

Dispel any incorrect information regarding the cost associated with taking action. (L4, L5)

Cues to Action

The target population is constantly reminded of the drawbacks associated with poor nutrition as a result of physician office visits, community based living, and family members.

Promote awareness that signals change.

Engage in systems that suggest and encourage change. (L2, L3)

Self-Efficacy

Older populations may not be comfortable changing diets on their own or seeking out food assistance programs on their own.

Teach about healthy diets associated with aging.

Demonstrate how to prepare simple, inexpensive, yet nutrient dense meals. (L6)

Intervention Strategy

 Utilization of the Health Belief Model allows for the seamless implementation of an intervention program aimed at the Senior population of Nevada. The social health program, “Sumida TAKE10!”, which incorporates the “TAKE10! For Older Adults” program will be used as intervention for this group during the three-month time-frame needed for completion. The main goal of this program is to decrease the risk for long term nursing home care by increasing physical activity and better dietary habits as it fits the needs of this target population. The primary objectives of this intervention program can be measured by changes in food intake frequency, dietary variety score, and the frequency of walking and exercise (5). Secondary objectives and outcomes are measured in changes to self-rated health, and appetite (5). The program upholds certain criteria for inclusion that are as follows: Participation in “Sumida TAKE10” conducted by Sumida Ward, age greater than or equal to 65 years, understanding of main objectives and provision of informed consent, ability to travel independently (5). The program also holds exclusion criteria that are as follows: Heart attack or stroke within 6 months, acute hepatic dysfunction or chronic active viral hepatitis, fasting blood glucose greater than 200mg/dL, diastolic blood pressure above 180 and/or systolic blood pressure less than 100 and medical advice that prohibits exercise (5). The program occurs at community centers where researchers are needed for lectures and staff members needed for questionnaires and other program components.

 Although not designed with a specific model of behavior change in mind, it is clear to see the connection this program possesses with the Health Belief Model. The program first deals with the construct of perceived susceptibility by detailing that the elderly population is in fact at risk for several conditions; this is achieved in the objectives of the program which all participants must be cognitive of. Perceived severity is appropriately dealt with during the lecture component of the program by detailing recommended action to alleviate the consequences of the conditions present. The lectures also help explain how to take action and what the results can look like which deals with the construct related to perceived benefits. The program overcomes the barriers section of this model by introducing the extensive list of exercises that can be completed in the home environment with no equipment necessary thus rendering the cost side of that argument invalid. The construct of cues to action is nearly the make-up of the program as it is designed with many informative lectures that help promote awareness and processes to help change behavior. Last, self-efficacy can be visualized in the program by the training given by staff members as well as reinforcing progress through simple comments on the check sheets.

Nutrition Education Component

The social health program was consistent of a general lecture led by a researcher on dietary variety and the importance of this matter as well as 5 educational sessions led by researchers and staff (5). The sessions dealt primarily with the TAKE10! Program with 30 minutes allocated to practicing good dietary habits followed up with one hour of exercise.

Lesson 1: Dietary Variety: This dietary lecture focuses on dietary variety and the association with health status in older populations. Simple ideas such as over consumption of energy dense foods that are nutrient poor, high in fat, sugar, and salt are risk factors for serious conditions and diseases.

Lesson 2: TAKE10! Check Sheet Overview: The first session included each participant to receive an explanation into using the check sheet. This sheet was then to be used for the following ten days to gauge a better understanding of the participant’s dietary habits.

Lesson 3: TAKE10! Check Sheet Review: The check sheets were brought with the participants and then analyzed in the lecture to help identify which the food groupings that were not well represented as well as encouragement to increase the food intake of the missing groups.

Lesson 4: Stretching: One component the exercise program emphasizes is proper stretching. During the program, participants are instructed how to stretch properly as well as the rationale behind each stretching exercise. After instruction, the stretching exercises are performed two times to the right and to the left at a slow pace.

Lesson 5: Exercise: Participants were instructed proper exercise form and how to perform each move. There are 8 muscle strengthening exercises total including plantar flexions, knee flexions, side leg raises, squats, and sit ups to name a few. Participants recorded exercise on check sheets for evaluation.

Lesson 6: Nutrition for the Elderly: Nutrition for the elderly details to participants the change in diet as age increases and which nutrients become more important. This lesson also details oral care, incontinence, and food safety as relevant topics for this target population.

To determine the readability of the program, the contents of the TAKE10! Booklet were measured in Microsoft word and yielded 5 for the Flesch-Kincaid Grade Level and 70 for Flesch Reading Ease. Given the program is designed for older adults, the readability score is appropriate for similar groups and the target population since seniors in Nevada have an 85% attainment of a high school degree or equivalent status (6). The TAKE10! Exercise and stretching program has been integrated into the elementary school system. The program states on the “Who?” heading that it is intended for all ages, however, this may not be suitable for children who do not possess a 5th grade reading level as they may not be able to comprehend the objectives, specified muscle groups to be stretched, or the process to be completed.

Regarding the programs attention to cultural diversity, this curriculum is amenable to all cultures. The components of this program are simple, dietary education and exercise education. Diets do vary by culture but the inclusion or exclusion of certain food groups is not prohibited so this does not conflict with participants who observe different dietary customs. The exercise component is relatively non-vigorous as well so even cultures who are sedentary can benefit from static movements and those participants who have little to no physical activity habits are under direct assistance from researchers and staffers during this portion of the program.

Other Program Components

 The program educated very well but could address some key concepts to strengthen the overall effectiveness. First, the program should have integrated lectures or lessons on how to prepare this newly discovered variety of food that was introduced. The program could have also used the TAKE10! Check sheets to monitor outcomes versus merely serving as motivational and self-realization tools. Last, the curriculum is aimed at reducing the likelihood of moving to a long-term care facility such as a nursing home by increasing physical activity levels and better dietary habits. The objective may be better accomplished if the program aimed to reduce and measure biochemical markers such as fasting blood glucose and total cholesterol numbers.

References:

“Elder Issues in Nevada.” Aging and Disability Services Division Commission on Aging, 2015,adsd.nv.gov/uploadedFiles/adsdnvgov/content/Boards/COA/SubLegIssues/COA%20Elder%20Issues%202014%202v.pdf. Accessed November 10th, 2018.

“NUTRITION PROGRAMS GAP ANALYSIS FOR OLDER NEVADANS.” Dpbh.nv.gov,dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Programs/OFS/GCFS_Meetings/2017/SNPGA%20Report%20draft%20for%20GCFS%2011-7-17.pdf. Accessed November 10th, 2018.

T. Baranowski et al., “How Individuals, Environments, and Health Behavior Interact: Social Learning Theory,” in Health Behavior and Health Education—Theory, Research, and Practice, 3rd ed., eds. K. Glanz et al. Copyright © 2002 by Jossey-Bass, Inc., Publishers. Used with permission.

Sahyoun, Nadine R., et al. “Evaluation of Nutrition Education Interventions for Older Adults: a Proposed Framework.” Journal of the American Dietetic Association, vol. 104, no. 1, 2004, pp. 58–69., doi:10.1016/j.jada.2003.10.013.

Kimura, Mika, et al. “Community-Based Intervention to Improve Dietary Habits and Promote Physical Activity among Older Adults: a Cluster Randomized Trial.” BMC Geriatrics, vol. 13, no. 1, 2013, doi:10.1186/1471-2318-13-8.

Data Access and Dissemination Systems (DADS). “Your Geography Selections.” American FactFinder – Results, 5 Oct. 2010, factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_DP_DPDP1&src=pt. Accessed November 10th, 2018.