Prevention, prevention, prevention: nutrition for successful aging.
- Journal of nutrition in gerontology and geriatrics. 02/2011; 30(1):24-8.
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ABSTRACT: Food intake is often poor within the older population and many are at nutritional risk. Food intake is complex, as there are multiple individual, social, and environmental determinants that may interact and change over time. Social isolation has long been recognized as a key factor predicting nutrition risk in this population. However, the mechanisms by which social relationships influence diet among older adults remain poorly understood. The purpose of this review is two-fold: ( 1 ) to identify and, where possible, clarify the social concepts used in older adult nutrition research over the past two decades, specifically, the concepts of social integration, social support, companionship and commensality; and ( 2 ) to provide a review and summary of the empirical literature on social factors and diet among cognitively well older adults living in the community. Finally, challenges to studying social concepts in older adult nutrition and areas of future research will be discussed.Journal of nutrition in gerontology and geriatrics. 02/2011; 30(1):2-23.
Prevention, Prevention, Prevention:
Nutrition for Successful Aging
NANCY S. WELLMAN, PhD, RD, FADA
Medicare and Medicaid costs for older people and poor
people explode. Nonpartisan Congressional Budget Office
data show that if nothing changes, skyrocketing health
care costs could consume the entire federal budget by the
year 2050 (1). Thus, the multiple facets of nutrition com-
prising primary, secondary, and tertiary prevention (Fig-
ure) recently have been “discovered” as our nation ad-
dresses not only its obesity epidemic, but also its
impending age wave (2,3). Although there are several
nutrition prevention models and there is overlap in all of
them, the Figure depicts a spectrum of nutrition as pre-
vention in relation to aging (4,5).
Prevention at long last has taken center stage nation-
ally, and nutrition has become part of or has received
increased emphasis in all recent major health-promotion
and risk-reduction initiatives. This underscores the grow-
ing national awareness of nutrition’s vital role in prevent-
ing, delaying onset of, and managing costly and debilitat-
ing chronic diseases. The 2005 Dietary Guidelines for
Americans (6) recognize people over age 50 years as one of
the specific population groups that need special consider-
ation. The additional key recommendations provided for
them are in sync with the overall Dietary Guidelines’
emphasis on the promotion of health and the prevention
of disease. Steps to a HealthierUS, a US Department of
Health and Human Services initiative, encourages Amer-
icans to live longer, better, and healthier lives by eating a
nutritious diet as one of its four Steps (7). The Older
Americans Update 2006: Key Indicators of Well-Being
lists dietary quality and obesity as two of the seven mod-
ifiable health risks and behaviors (8). The 2005 White
House Conference on Aging included a nutrition recom-
f “location, location, location” is the real estate axiom,
“prevention, prevention, prevention” is the nutrition
mantra for successful aging. Alarms are sounding as
mendation for the first time in decades (9). The “Healthy
Nutrition” recommendation emphasized the importance
of nutrition in health promotion and disease prevention
and management. Among its suggested strategies are
nutrition education and therapy delivered by registered
dietitians (RDs). Older people want to hear the good news
about nutrition—that it is indeed never too late and that
even small steps can make a difference at any age. RDs
are recognized as those best qualified to provide nutrition
services to older adults (10).
The new reality of aging says that both the quantity
and quality of life count. A healthful lifestyle and being
active lead to greater longevity, add more years of inde-
pendence, and compress morbidity in later years. People
do not want to live longer only to have more years of
illness and unhappiness; the added years must be health-
ier ones. Good nutrition not only adds years to life, but life
to years (5). Thus, the timing is ripe for positioning nu-
trition more broadly in health promotion and risk reduc-
tion, especially with older Americans.
As nutrition services for older adults move out of hos-
pitals and institutions and into homes and communities,
RDs must become more proactive in health promotion
and risk reduction while promoting universal access to
quality nutrition services for disease treatment. The
three articles about older adults in this issue of the Jour-
nal exemplify efforts that strengthen the nutrition evi-
dence base for successful aging (11-13). Each illustrates
nutrition as primary and/or secondary prevention. It is
notable that none focus on medical nutrition therapy
(tertiary prevention), although disease treatment has
typically been considered RDs’ predominant role when
providing care for older adults.
The study by Zizza and colleagues (11) suggests a new
emphasis on snacking in nutrition education (primary
prevention) for older adults. Using the nationally repre-
sentative National Health and Nutrition Examination
Survey sample, their study found that snacking is an
important source of calories for those aged 65 years and
over. Despite America’s obesity epidemic, many older
adults eat too little, resulting in unintentional weight
loss. Underweight is a recognized risk factor for disease
and disability. The investigators conclude that snacking
is an important dietary behavior among older adults and
propose promoting the consumption of healthful snacks.
They suggest that nutrition education may be easier and
more effective when it encourages increased energy in-
takes between meals rather than during meals. Practical
advice on healthful snacking from RDs would be well
received by older adults, who are eager for nutrition guid-
N. S. Wellman is a professor and director, National
Resource Center on Nutrition, Physical Activity,
and Aging, Department of Dietetics and Nutrition,
Stempel School of Public Health, Florida International
Address correspondence to: Nancy S. Wellman, PhD,
RD, FADA, National Resource Center on Nutrition,
Physical Activity, and Aging, OE 200, Florida Interna-
tional University, Miami, FL 33199. E-mail: Nancy.
Copyright © 2007 by the American Dietetic
© 2007 by the American Dietetic Association
Journal of the AMERICAN DIETETIC ASSOCIATION
ance that will help them maintain their health and inde-
The study by Almanza and colleagues (12) illustrates
the vital nature of secondary nutrition prevention in risk
reduction among older adults. Many older adults are
more susceptible to foodborne illness because of a com-
promised immune system, decreased hydrochloric acid in
the stomach, and lessened senses of smell and taste. The
study shows the need to increase the knowledge of home-
delivered meal recipients regarding proper food handling
and storage at home to reduce the risk of foodborne ill-
ness. To protect frail, homebound meal recipients, those
involved in meal preparation and delivery should be
trained to adhere strictly to safe food handling practices.
However, too few Older Americans Act Nutrition Pro-
grams employ RDs in direct service, training, or program
administration (14). The evidence by Almanza and col-
leagues can be used to justify the need for greater avail-
ability of bona fide nutrition expertise within the largest
federal community nutrition assistance program for older
Another study in this issue of the Journal provides an
example of the need for nutrition as both primary and
secondary prevention. In the study by Desai and col-
leagues (13), the environmental change or primary pre-
vention was a modification in the type of food service in a
long-term care facility from a traditional centralized pre-
plated service to a cafeteria-like system. As a result, and
perhaps more importantly, there was a secondary preven-
tion impact also. Residents at risk (ie, those with cogni-
tive impairments and low body mass indexes) increased
their average energy intake by 265 kcal daily when they
were allowed to choose the types and amounts of food to
be eaten. The evidence by Desai and colleagues can be
used to help justify the need for full-time RD positions in
long-term care, assuming of course that the RD would
participate in all aspects of nutrition prevention in the
facility. Thus, the RD would be not only the medical
nutrition therapist, but also the foodservice administra-
tor and the feeding assistance supervisor as well.
Aging, a multifaceted natural phenomenon, is dramati-
cally changing the landscape of our country. We RDs have
not only the opportunity but also the obligation to
broaden the nutrition services that we provide to older
persons. Although medical nutrition therapy has always
been all-inclusive, chronic disease treatment has usually
taken precedence over primary and secondary nutrition
prevention. The urgency today is to show the pivotal
importance of nutrition for successful aging and increase
the availability of our services that promote health and
reduce risk, as well as to treat diseases. Doing so will
positively impact longevity in general, improve the qual-
ity of life of older adults and prolong their independence
in later years, and conserve the health care resources of
our nation. Nutrition as prevention, the mantra for suc-
cessful aging, fits a life-affirming view of aging.
This article was supported in part by grant 90AM2768
from the Administration on Aging, US Department of
Health and Human Services, Washington, DC. Grantees
undertaking projects under government sponsorship are
encouraged to express freely their findings and conclu-
sions. Points of view or opinions do not, therefore, reflect
official Department of Health and Human Services
1. Orszag PR. The Budget and Economic Outlook: Fiscal
Years 2008 to 2017. Congressional Budget Office Tes-
timony before the US Senate Committee on the Budget,
January 25, 2007. Available at: http://www.cbo.gov/
Accessed January 25, 2007.
2. American Dietetic Association. Position of the Amer-
ican Dietetic Association: Nutrition across the spec-
trum of aging. J Am Diet Assoc. 2005;105:616-633.
3. Federal Interagency Forum on Aging-Related Statis-
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US Government Printing Office; 2006. Available at:
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In: Kaufman M, ed. Nutrition in Promoting the Public’s
NutritionPrimary prevention Secondary preventionTertiary prevention
Health promotionRisk reductionTreatment/therapy
Prevent disease and disability by
reducing or eliminating potential
Lessen health risks by screening
and early treatment before
Treat or remediate those with
diagnosed health conditions
Enhance/maintain wellness through
behavioral or environmental
Maintain/improve nutritional status
and/or avoid illness among
those susceptible because of
genetics, lifestyle, age, etc
Prevent/delay disease progression,
disability, pain, premature death
Generalized education or facilitation
of healthful diets
Anticipatory screening, detection,
Individualized nutrition therapy for acute
conditions and chronic diseases
Figure. The spectrum of nutrition as prevention in aging.
May 2007 Volume 107 Number 5
Health: Strategies, Principles, and Practices. Sudbury,
MA: Jones and Bartlett Publishers; 2007:1-12.
5. Wellman NS, Kamp BF. Add life to years. In: Kaufman
MK, ed. Nutrition in Promoting the Public’s Health:
Strategies, Principles, and Practices. Sudbury, MA:
Jones and Bartlett Publishers; 2007:219-257.
6. US Department of Health and Human Services, US
Department of Agriculture. Dietary Guidelines for
Americans, 2005. 6th ed. Washington, DC: US Gov-
ernment Printing Office; 2005. Available at: http://
January 25, 2007.
7. US Department of Health and Human Services.
Steps to a HealthierUS. Available at: http://www.
healthierus.gov. Accessed January 25, 2007.
8. Federal Interagency Forum on Aging-Related Statis-
tics. Older Americans Update 2006: Key Indicators of
Well-Being. Federal Interagency Forum on Aging-Re-
lated Statistics. Washington, DC: US Government
Printing Office; May 2006. Available at: http://
www.agingstats.gov/. Accessed January 25, 2007.
9. 2005 White House Conference on Aging. The Boom-
ing Dynamics of Aging: From Awareness to Action.
Report to the President and the Congress. December
11-14, 2005. Available at: http://www.whcoa.gov/
press/05_Report_1.pdf. Accessed January 25. 2007.
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vices for Medicare Beneficiaries. The Role of Nutri-
tion in Maintaining Health in the Nation’s Elderly:
Evaluating Coverage of Nutrition Services for the
Medicare Population. Washington, DC: National
Academies Press; 2000.
11. Zizza CA, Tayie FA, Lino M. Benefits of snacking in
older Americans. J Am Diet Assoc. 2007;107:800-806.
12. Almanza BA, Namkung Y, Ismail JA, Nelson DC.
Clients’ safe food-handling knowledge and risk be-
havior in a home-delivered meal program. J Am Diet
13. Desai J, Winter A, Young KWH, Greenwood CE.
Changes in type of foodservice and dining room en-
vironment preferentially benefit institutionalized se-
niors with low body mass indexes. J Am Diet Assoc.
14. Wellman NS, Rosenzweig LY, Lloyd JL. Thirty years
of the Older Americans Nutrition Program. J Am
Diet Assoc. 2002;102:348-350.
May 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION