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Nutrition and Health Promotion in Older Adults

^a Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, and Department of Nutrition and Dietetics, University of Arkansas for Medical Sciences, Little Rock

Ronni Chernoff, GRECC (182), VAMC, 4300 W. 7th St., Little Rock, AR 72205 E-mail: chernoffronni{at}uams.edu.

	Abstract

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During recent decades, the concept of health promotion has become a legitimate part of health care because of the aging of the postwar baby boom generation. As this population ages, the potential strain on health care systems will increase because the greatest use of health care services occurs during the last years of life. In older adults there are many correctable health factors that can be assessed through screening protocols. Hypertension, cholesterol, hearing, vision, diabetes, and cancer screening are well integrated into health promotion programs; nutrition promotion programs are not as well integrated. Reluctance to develop health promotion programs for older adults exists because of a perception that they would not follow such plans or change their lifestyles. However, longitudinal studies have shown that health promotion activities extend the number of years of health in older people although the relationship weakens in older age. Changes in diet and exercise patterns are most effective in the prevention of nutrition-related conditions when they are instituted early in life, but positive effects can occur at any age. If nutritional interventions are instituted early, a substantial reduction in health care expenditures may result from a decrease in the incidence or the delayed onset of these conditions. Changes in behaviors (reducing salt and fat intake) were positively associated with a belief that consuming a healthful diet would contribute to better health. The use of a variety of adult education theories and models will enhance behavior changes that lead to more healthful habits and enable a health educator to be successful in effecting change.

IN recent decades the concept of health promotion as a proactive activity has become a legitimate part of health care. The publication of the U.S. Public Health Service agenda, Healthy People 2010, laid out guidelines to support achievement of a vision of improved health for all Americans ⁽¹⁾. Changes in diet and exercise patterns are most effective in the prevention of nutrition-related conditions when they are instituted early in life, but positive effects can occur at any age. Health promotion activities, including changes in dietary habits, can contribute to an increase in life expectancy and better health and can be incorporated into routine care for all older adults ⁽²⁾. Primary prevention, used to prevent the onset of disease, may be a lesser strategy with older adults; secondary prevention, used to identify and treat or cure diseases in their presymptomatic stage or to prevent the progression of disease may be more appropriate and successful for this age group ⁽³⁾⁽⁴⁾.

Health promotion is an important focus in the present health care environment. As the population ages, the potential strain on health care systems will increase because the greatest use of health care services occurs during the last years of life ⁽⁵⁾⁽⁶⁾.

Older women are a particular target group because they live, on average, 7 years longer than men and tend to have disabilities during their later years ⁽⁵⁾. The conditions that contribute the most to disability are heart disease, cancer, stroke, fracture, pneumonia, osteoarthritis, and cataracts, almost all of which may be affected by nutritional interventions ^(3)(7)(8)

Any preventive health care or health care promotion should be based on recommendations derived from sound research or a preponderance of epidemiological data. Conditions that are associated with nutritional habits and that may respond to secondary prevention strategies include obesity, hypertension, diabetes, osteoporosis, and cardiovascular disease ⁽⁹⁾.

There is some reluctance to develop health promotion programs for older adults because of a perception that older adults will not follow such plans or change their lifestyles. Questions about the willingness to alter health behaviors are certainly legitimate. However, longitudinal studies have shown that health promotion activities extend the number of years of health in older people, although the relationship weakens in older age ⁽⁶⁾.

One way to assess the likelihood of instituting change is to examine health beliefs of older adults to determine whether there is a relationship between beliefs and behaviors. Changes in behaviors (reducing salt and fat intake) were positively associated with a belief that consuming a healthful diet would contribute to better health ⁽¹⁰⁾. The use of a variety of adult education theories and models will enhance behavior changes that lead to more healthful habits ⁽¹¹⁾. For older adults, setting goals through a collaborative arrangement that becomes a partnership between the individual and the health care professional may contribute to greater adherence to a health promotion plan because the older individual has participated in setting the goals and the program is individualized ^(12)(13). Successful programs build on existing social support systems and cultural or ethnic beliefs or traditions ⁽¹³⁾. Peer educators, particularly if they have a background similar to that of their clients, often are positive role models but may require training and nutrition information from expert coaches.

Given the opportunity to obtain information and accessible health services that focus on changing health behaviors to improve health status, lower the risk of disability, and improve quality of life, elderly people will participate in health promotion programs and make changes that improve their health behaviors ^(14)(15). Studies indicate that there is a benefit to health promotion and a reduction in health care costs for those who are willing to make changes ^(16)(17).

In a series of studies that examined health promotion programs for rural elderly adults without easy access to health services, Medicare beneficiaries were offered disease prevention and health promotion services including smoking cessation, physical activity, nutrition, alcohol counseling, and immunizations. The investigators found that rural elderly adults will participate in health promotion programs if they are encouraged to do so by their physicians, if it is paid for by Medicare, and if they have post-high school education ^(18)(19). An essential component of these programs involves altering nutritional behaviors to achieve goals that include lowering cholesterol, managing weight, increasing dietary fiber, and increasing the consumption of fruits and vegetables.

	Diet as a Factor in Health

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Diet is a major factor in the development of conditions and diseases, including non-insulin-dependent diabetes, coronary heart disease, atherosclerosis, stroke, and cancer—5 of the 10 leading causes of death in the United States ^(20)(21). There is much speculation that if nutritional interventions are instituted early, health care expenditures will be significantly reduced as a result of a decrease in the incidence or the delayed onset of these conditions ⁽²⁰⁾.

Dietary Fat and Cholesterol as Risk Factors
Despite public health messages that focus on reducing fat intake (and, theoretically, decreasing total energy intake at the same time), the incidence of obesity in the American population has increased ⁽²²⁾. There is strong evidence that obesity is associated with cardiovascular risk as well as a higher incidence of hypertension, hyperlipidemia, and diabetes in both older men and women ^{(23)(24)(25)(26)(27)}.

Several risk factors for coronary heart disease are, for the most part, the same for middle-aged and elderly adults. Female gender has a positive effect up to middle age, but that influence dissipates in later life ⁽²⁸⁾. Although the influence of total cholesterol as a predictor of relative risk for coronary heart disease decreases with age, levels of total, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol are still strong predictors of absolute coronary disease risk. Data from the Framingham study and the Multiple Risk Factor Intervention Trial demonstrate that attributable risk (the risk of those with the lowest cholesterol subtracted from those with the highest cholesterol) increases with age although relative risk decreases ^(29)(30). In the Framingham study, data indicate that for a 1% rise in cholesterol there is a 2% rise in coronary artery disease (CAD), yet for a 1% increase in HDL cholesterol levels there was a 2% fall in CAD. Castelli ⁽²⁹⁾ reports that most physicians aggressively treat patients when cholesterol levels are above 300 mg/dl, but the majority of heart attacks occur in individuals who have cholesterol levels between 200 and 250 mg/dl. Strategies to increase HDL levels while lowering LDL cholesterol to the total cholesterol:HDL cholesterol ratio of 3.5 or less are recommended ⁽²⁹⁾. There appears to be a greater benefit or decrease in attributable risk associated with a decrease in an elevated cholesterol to the midrange of cholesterol levels and less gained by lowering cholesterol levels to below the midrange ⁽³⁰⁾.

Contradictory evidence—a lack of association between cholesterol and coronary heart disease mortality and morbidity in elderly adults—has been reported by others ⁽³¹⁾.

Heart Disease Prevention
Diet is a primary intervention in the prevention of heart disease. Whether dietary interventions will have a measurable benefit in older people has been explored on a limited basis; most intervention trials are conducted on high-risk younger adults ⁽²⁸⁾. One trial that included elderly subjects (age range 50–89 years) was a Veterans Health Administration study that took 8 years to test a cholesterol-lowering diet (40% of energy from fat; two thirds of fat from vegetable sources and one third from animal sources). Although there was less than complete compliance, the results indicated a decrease in cholesterol levels in both middle-aged and elderly subjects if their baseline cholesterol was 233 mg/dL or higher. Subjects who had a baseline cholesterol below 233 mg/dL had no measurable change in their cholesterol levels. The benefit of the dietary intervention appears to be a reduction in atherosclerosis and coronary heart disease mortality ⁽³²⁾.

Other intervention programs that included or were specifically targeted at elderly subjects also demonstrated a reduction in risk factors for cardiovascular disease. The Minnesota Heart Health Program included elderly subjects in communities in Minnesota, North Dakota, and South Dakota. The results of this study indicated that detectable disease rate differences close to the study goal of 15% were achieved after an intervention and education program that spanned a 10-year period. The endpoints included reduction in serum cholesterol, systolic blood pressure, smoking, and saturated fat intake that contributed to a decreased rate of death from coronary vascular disease and stroke; stroke mortality was not affected ⁽³³⁾.

Another community-based study, the Australian North Coast Cholesterol Check Campaign, demonstrated that nutrition counseling and physician referrals contributed to a reduction of blood cholesterol levels in a hypercholesterolemic population ⁽³⁴⁾. The program strategy was to screen, counsel, refer, and retest participants. Other investigators suggested that a 5% reduction in cholesterol levels in Australia would save millions of dollars per year in medical costs; costs for the program were a fraction ($100,000–$150,000) of the projected savings. Participants in the Australian North Coast Cholesterol Check Campaign reduced their cholesterol 6%–10% and maintained lower levels for at least a year ⁽³⁵⁾.

The Rural Health Promotion Project, an intervention study conducted with Medicare beneficiaries in Pennsylvania, reported a significant reduction in serum cholesterol levels with a medication intervention. The reduction in serum cholesterol was 6%, approximately 16 mg/dl, which would be consistent with a 12%–18% decrease in heart attack risk; however, those who demonstrated the greatest decrease in serum cholesterol were those who had the highest risk and were treated most aggressively with medication. Mortality rates were not reported ⁽³⁶⁾.

Cumulative evidence from epidemiological, clinical, and laboratory studies has led to recommendations of a diet low in saturated fat and cholesterol for the prevention or treatment of coronary heart disease. The question remains as to whether treatment to lower cholesterol is reasonable for elderly individuals. Some evidence indicates that cholesterol-lowering therapy may improve quality of life rather than extend life expectancy ⁽³⁷⁾. Often, older individuals have concurrent chronic conditions that may preclude changes in diet or the inclusion of additional medications. For reasonably healthy elderly adults, cholesterol-lowering may extend their healthy years. In a Danish prospective study that followed postmenopausal women for 12 years, the investigators found that a measurement of serum total cholesterol gives a good estimate of long-term cholesterol status, thereby identifying those for whom early intervention should be considered ⁽³⁸⁾. Individuals who have only a few risk factors can be treated conservatively with diet and exercise ⁽²⁸⁾. The American Heart Association (AHA) Step 1 diet is generally recommended, but for such a regimen to be successful in elderly individuals, the diet must be easy to follow and nutritionally adequate. In an examination of the effects of the Step 1 diet followed by a weight-loss regimen in postmenopausal women, the investigators found that although the Step 1 diet improves lipoprotein lipid profiles of obese postmenopausal women, weight loss is necessary to reduce risk factors of obese postmenopausal women with normal lipid levels ⁽³⁹⁾. Others found that a weight-reduction diet with exercise affected measures of body weight but not blood lipid profiles ⁽⁴⁰⁾. In another study conducted on obese middle-aged and older men, the AHA Step 1 weight-maintenance diet contributed to a reduction of lipoprotein lipid levels but HDL cholesterol levels decreased as well; when weight loss was added to this regimen, HDL cholesterol levels were preserved ⁽⁴¹⁾.

Obesity as a Risk Factor for Disease
Obesity is one of the factors associated with disabling conditions and premature death. Evidence exists that excess body weight or weight gain during middle age contributes to the development of chronic conditions (cardiovascular disease, diabetes mellitus, hypertension, and osteoarthritis) in later years ^{(28)(42)(43)(44)(45)(46)(47)}. The evidence for this association is clear in the middle years but is less clear in the older years ⁽⁴⁸⁾. One report that examined mortality risk, body mass index, and age concluded that excess weight increases mortality risk but that the relative risk associated with increased body mass index decreased with age ⁽⁴⁹⁾. However, a relationship appears to exist between body mass index and the relative risk for ischemic stroke ⁽⁵⁰⁾.

The recognition of the prevalence of obesity in older adults is relatively recent ⁽⁴²⁾ and is contrary to the commonly accepted paradigm that older individuals lose weight and are undernourished ^(51)(52)(53). Obesity may occur in the later years for many reasons, including a decrease in physical activity, a decrease in metabolic rate, or altered fat storage mechanisms. Obesity may be considered a form of malnutrition in older people although its incidence decreases with older age (older than 75 years) and is associated with an increased risk of coronary heart disease and myocardial infarction, diabetes, osteoarthritis, hypertension and stroke, and some cancers ⁽⁵⁴⁾. For some elderly individuals, weight loss is advisable to decrease relative risk for deleterious events whereas for others it might not be advisable ⁽⁵⁵⁾. There is some evidence that moderate obesity protects against mortality because of a metabolic reserve against chronic conditions or disease ⁽⁵⁶⁾. Determination of a healthy weight for postmenopausal women, the group that demonstrates the most marked weight gain, is more controversial than it may appear. Definitions of overweight or obesity vary among countries (including the United States, Canada, and Australia), making it difficult to establish clear guidelines ⁽⁵⁷⁾.

Weight management leading to a slow, steady weight loss is more beneficial than a pattern of weight cycling, which contributes to an elevated risk of mortality ^(58)(59). Metabolic rate decreases with age, and body fat increases proportionally ^(60)(61); increased body fat and obesity are risk factors for chronic diseases (heart disease, diabetes, and hypertension). In a study that used the AHA Step 1 diet goals (30% energy from fat, 10%–15% from protein, and 50%–55% from carbohydrates), postmenopausal women were randomly assigned to receive an energy-deficient diet or diet plus exercise. All groups lost weight, but the group that exercised maintained basal metabolic rate better, which makes it easier to continue to normalize weight and body composition ⁽⁶²⁾.

Aside from the potential consequences of early mortality, obesity in older people contributes to functional limitations that lead to an increase in dependency. One factor that may have a role in this syndrome is depression, which is common in elderly adults. Depression must be treated before any other interventions are instituted.

Dietary Supplementation
In recent years the use of vitamin supplementation in disease prevention in healthy individuals has attracted attention. Vitamins are widely used by many people, and the over-the-counter vitamin supplement market is more than $3 billion per year. Vitamin use by elderly adults is generally self-prescribed and is frequently not associated with any medical condition. Although there are ongoing studies of self-administered vitamins, the benefits and toxicities are not yet known and require continuing investigation. Vitamin supplementation is often initiated because older people want to prevent disease and take responsibility for their own health care ^(63)(64). The use of vitamins other than a daily multivitamin to prevent various ailments has not been scientifically supported except in a few instances. Vitamin supplementation to correct vitamin deficiency states is standard practice, but using vitamins as a disease prevention tactic still requires prospective study. Clinical efficacy has been reported for folic acid supplementation of pregnant women to prevent the development of fetal neural tube defects and for antioxidant vitamin supplementation to prevent heart disease and cancer ⁽⁶⁵⁾.

Of interest for older adults is the use of antioxidant vitamins (ß-carotene, vitamin C, and vitamin E) to reduce risk of heart disease and cancer. Lowering relative risk for coronary mortality may include approaches other than reducing total dietary fat intake, and dietary supplements are the newest intervention for prevention or relative risk reduction of coronary heart disease. The cardioprotective effects of antioxidant vitamins were reported almost two decades ago ^(66)(67). Vitamins E and C were reported to reduce the susceptibility of LDLs to oxidation ^(68)(69), so they have been examined for their efficacy ^(70)(71). In a clinical trial with 39,000 men, the data led the investigators to conclude that vitamin E supplementation in doses from 10 to 100 times the Recommended Dietary Allowance might be effective in reducing heart disease risk by lowering the resistance of LDLs to oxidation ⁽⁷²⁾. A similar study involving 87,000 women (The Nurses' Health Study) showed a decreased relative risk for heart disease with a vitamin E supplement of 200 IU/day ⁽⁷³⁾.

Most of the studies conducted have young to middle-aged adult subjects; far fewer studies were conducted in older adults. The Established Populations for Epidemiologic Studies of the Elderly trial examined the use of vitamins C and E supplements in an elderly (67–105 years) population; the decrease in coronary mortality in the group using supplements that were not part of a multivitamin preparation was significant and confirmed observations noted in younger subjects ⁽⁷⁴⁾.

Supplementation with antioxidant vitamins A and E to prevent cancer has become popular in recent years after the publication of studies demonstrating possible benefit ^{(75)(76)(77)(78)(79)(80)}. Diets that are high in fruits, vegetables (good dietary sources of antioxidant vitamins), and fiber have been associated with a lower incidence of colon cancer; this observation led to the National Cancer Institute's Five-A-Day campaign, which recommends at least five servings of fruits and vegetables daily ⁽⁸¹⁾. Indeed, the positive benefits of antioxidant vitamin supplementation have been demonstrated in populations where intake of foods containing these vitamins is low ⁽⁸²⁾. This goal may be difficult to attain for some older adults; therefore, dietary supplementation with these nutrients may be a reasonable alternative ⁽⁶³⁾.

However, there are some doubts about the efficacy of ß-carotene and vitamin E supplements in preventing cardiovascular disease and major cancers from occurring in a well-nourished population. Published results of a primary prevention trial that used a randomized, double-blind design and approximately 29,000 elderly male smokers did not show any cancer prevention effects, particularly for lung cancer ⁽⁸²⁾. In fact, beta-carotene supplements appeared to increase, rather than to reduce, lung cancer incidence and deaths from cardiovascular disease in current smokers and in workers exposed to asbestos ⁽⁸³⁾. Other population studies have also reported disappointing results for cancer prevention ^{(84)(85)(86)(87)(88)}.

Although antioxidant vitamins may have documented chemoprotective effects, the unanswered question is whether a balanced diet that is high in vitamin-rich fruits, vegetables, and other foods can be as effective ⁽⁸⁹⁾. Claims in the media that large doses of antioxidant vitamins will prevent disease or will retard aging have led many elderly individuals to use large doses of vitamin supplements with no monitoring by a health professional. The results of studies examining the potential benefits or toxicities of self-administered vitamin supplements are not yet known, but it is likely that future research reports will provide some answers. The best advice is to recommend a well-balanced and vitamin-rich diet ^(63)(89).

Other vitamins that may have an important antidisease effect are vitamin B₁₂, vitamin B₆, and folate, which are related to homocysteinemia, which may be related to cognitive status in elderly adults ⁽⁹⁰⁾. In recent years there has been some evidence that homocysteinemia is also related to premature occlusive vascular disease ^(91)(92). Elevated homocysteine levels in elderly adults are related to a poor intake of foods that are rich in these nutrients. This does not mean that supplementation with vitamin B₁₂, vitamin B₆, and folate will eliminate cardiovascular disease but rather that individuals with marginal intakes may benefit from a multivitamin supplement. Further investigation to explore a more definitive link between these vitamins and cognitive and cardiac changes in elderly adults would be useful.

	Screening for Nutritional Status

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The maintenance of health requires an ability to define the factors that contribute to a healthful state. In older adults there are many factors that can be assessed through screening protocols. Hypertension, cholesterol, hearing, vision, diabetes, and cancer screening are well integrated into health promotion programs. Nutrition promotion programs are not as well integrated into health maintenance plans.

In 1997 the American Dietetic Association launched a Nutrition and Health for Older Americans campaign that focused on nutrition, physical activity, and quality-of-life issues ⁽⁹³⁾. Healthy older Americans were the focus of this project, and the objective was to keep them healthy; the target audience for this campaign was nutrition professionals, and the materials developed provided information for health professionals as well as materials for use with their clients. A Food Guide Pyramid for older Americans emphasizes nutrient-dense, well-balanced, nutritionally adequate foods and includes recommendations for fluid intake (Fig. 1); there is a companion Activity Guide Pyramid for Older Americans ⁽⁹⁴⁾. The materials emphasize health promotion and the resolution of medical problems early in their course.

View larger version (54K): [in this window] [in a new window]   Figure 1. Food Guide Pyramid for Older Americans. Based on the USDA Food Guide Pyramid. ©1997, American Dietetic Association. Nutrition and Health for Older Americans. Used with permission.

This long-term project was originally designed to raise the awareness of health care and community program workers to potential nutritional problems that may exist. One of the goals of this program was to identify common risk factors that may contribute to malnutrition in independently living older adults (see below). The DETERMINE Your Nutritional Health checklist Level I and Level II screens ⁽⁹⁵⁾ are products of this program. The checklist has been used to identify risk factors for malnutrition in elderly people in an operational way ^{(96)(97)(98)(99)}, but it is not a health promotion tool commonly used. These nutritional tools have been incorporated into many routine screening programs for at-risk elderly adults. Risk factors for malnutrition include:

Techniques exist that can be used to evaluate the need for changes in dietary intake that may contribute to health promotion goals, such as decreasing total fat and cholesterol intake, increasing fiber content, and ensuring adequate fruit and vegetable intake. The challenges of interventions in elderly subjects include issues of motivation, compliance, and effectiveness. Conclusions about appropriate intervention decisions in elderly adults are difficult to draw because only a small amount of data is available ⁽¹³⁾. Diet diary data may be somewhat inaccurate, making it difficult to ascertain what actually was consumed during a study period ⁽³⁶⁾.

A detailed dietary history that provides a thorough picture of the individual's eating habits will make it easier for the nutrition professional to develop recommendations that can be incorporated into the individual's lifestyle and contribute to a reasonable level of compliance. Nutrition professionals frequently overwhelm a client with too much information and too many changes. Older adults can modify their diets if they are given appropriate explanation and instruction, but the changes must be perceived as relevant to their life or necessary to improve their health without imposing major stress. It is more effective if one change can be instituted at a time. If an older client is included in the assessment process and in setting the priorities, the likelihood of achieving the stated goals will be enhanced ⁽¹³⁾.

The challenge of recommending dietary interventions as a secondary prevention measure is that only a few prospective studies have been conducted in older subjects; research is needed to identify appropriate interventions and substantiate them with data. Principles of adult learning support the need for relevance, for explanations that can be related to the individual's experience, for a language level appropriate to the client, and for a rationale that is compelling enough to effect changes in lifestyle. A noticeable improvement in health status will serve as positive reinforcement, and changes will be maintained.

Most policy that addresses nutrition in elderly individuals focuses on malnutrition and frailty; health promotion for older adults is not a priority. General recommendations for lowering fat and cholesterol, increasing fiber, and other health promotion strategies are focused on younger adults. However, Healthy People 2010 identified goals and strategies designed to increase the span of healthy life, reduce health disparities, and increase access to prevention services ^(1)(100). This plan does not include age-stratified strategies, but trained health care professionals can select the objectives that are most relevant to individual health promotion programs. Future policy decisions should focus on stratifying recommendations for older adults and should address issues that contribute to greater compliance with dietary modifications related to achieving goals set by the nutrition professional and the client.

Conclusion
Health promotion is an important focus in health care today. Relevant, easy to adopt, and effective strategies that can be used with older people must be tried and evaluated. Recommendations for enhancing health that focus on elderly adults and comprehend the aging process should be developed. A positive impact on the health of elderly people is possible; they are capable and interested in making appropriate dietary modifications. Older adults should not be dismissed when health promotion programs are developed; they need to be regarded as unique individuals who have exceptional needs and are capable of instituting change.

	References

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1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000.
2. Fishman P, 1996. Healthy people 2000: What progress toward better nutrition?. Geriatrics. 51: (4) 38-43. [Medline]
3. Rubenstein LZ, Nahas R, 1988. Primary and secondary prevention strategies in the older adult. Geriatr Nurs. 19:11-18.
4. Hickey T, Stilwell DL, 1991. Health promotion for older people: all is not well. The Gerontologist. 31:822-829. [Abstract]
5. Chernoff R, 1999. Demographics of aging. Chernoff R, , ed.Geriatric Nutrition: A Health Professional's Handbook 2nd ed. 1-12. Aspen Publishing Company, Gaithersburg, MD.
6. Heidrich SM, 1998. Health promotion in old age. Annu Rev Nurs Res. 16:173-195. [Medline]
7. LaCroix AZ, Newton KM, Leveille SG, Wallace J, 1997. Healthy aging: a women's issue. West J Med. 167:220-232. [Medline]
8. Pizzi ER, Wolf ZR, 1998. Health risks and health promotion for older women: utility of a health promotion diary. Holist Nurs Pract. 12: (2) 62-72. [Medline]
9. Patterson C, Feightner J, 1997. Promoting the health of senior citizens. Can Med Assoc J. 157:1107-1113. [Abstract]
10. Ferrini R, Edelstein S, Barrett-Connor E, 1994. The association between health beliefs and health behavior change in older adults. Prev Med. 23:1-5. [Medline]
11. Caserta MS, 1995. Health promotion and the older population: expanding our theoretical horizons. J Community Health. 20:283-292. [Medline]
12. Fox PJ, Breuer W, Wright JA, 1997. Effects of a health promotion program on sustaining health behaviors in older adults. Am J Prev Med. 13:257-264. [Medline]
13. Contento I, Balch GI, Bronner Y, et al. 1995. Nutrition education for older adults. J Nutr Educ. 27:339-346.
14. Quantock C, 1994. Promoting health with elderly people. Nurs Stand. 8: (25) 30-33.
15. Mayer JA, Jermanovich A, Wright BL, et al. 1994. Changes in health behaviors of older adults: the San Diego Medicare Preventive Health Project. Prev Med. 23:127-133. [Medline]
16. Williams SJ, Elder JP, Seidman RL, et al. 1997. Preventive services in a Medicare managed care environment. J Community Health. 22:417-434. [Medline]
17. Ives DG, Traven ND, Kuller LH, et al. 1994. Selection bias and nonresponse to health promotion in older adults. Epidemiology. 5:456-461. [Medline]
18. Lave JR, Ives DG, Traven ND, et al. 1995. Participation in health promotion programs by the rural elderly. Am J Prev Med. 11:46-53. [Medline]
19. Lave JR, Ives DG, Traven ND, et al. 1996. Evaluation of a health promotion demonstration program for the rural elderly. Health Serv Res. 31:261-281. [Medline]
20. Bidlack WR, 1996. Interrelationships of food, nutrition, diet and health: the National Association of State Universities and Land Grant Colleges White Paper. Am Coll Nutr. 15: (5) 422-433.
21. Appling SE, 1997. Wellness promotion and the elderly. MEDSURG Nurs. 6: (1) 45-46. [Medline]
22. Flegal KM, Carroll MD, Kuczmarski RJ, et al. 1998. Overweight and obesity in the United States: prevalence and trends, 1960–1994. Int J Obes. 22:39-47. [Medline]
23. Van Itallie T, 1985. Health implications of overweight and obesity in the United States. Ann Intern Med. 103:938-988.
24. Pi-Sunyer FX, 1993. Medical hazards of obesity. Ann Intern Med. 119:655-660. [Abstract/Free Full Text]
25. Perry AC, Applegate EB, Allison ML, et al. 1997. Relation between anthropometric measures of fat distribution and cardiovascular risk factors in overweight pre- and postmenopausal women. Am J Clin Nutr. 66:829-836. [Abstract/Free Full Text]
26. Huang B, Rodreiguez BL, Burchfiel CM, et al. 1997. Associations of adiposity with prevalent coronary heart disease among elderly men: the Honolulu heart program. Int J Obes. 21:340-348.
27. Harris TB, Savage PJ, Tell GS, et al. 1997. Carrying the burden of cardiovascular risk in old age: associations of weight and weight change with prevalent cardiovascular disease, risk factors, and health status in the Cardiovascular Health Study. Am J Clin Nutr. 66:837-844. [Abstract/Free Full Text]
28. Srinath U, Jonnalagadda SS, Naglak MC, et al. 1995. Diet in the prevention and treatment of atherosclerosis: a perspective for the elderly. Clin Geriatr Med. 11:591-611. [Medline]
29. Castelli WP, 1988. Cholesterol and lipids in the risk of coronary artery disease: the Framingham Heart Study. Can J Cardiol. 4: (Suppl A) 5A-10A.
30. Malenka DJ, Baron JA, 1988. Cholesterol and coronary heart disease: the importance of patient-specific attributable risk. Arch Intern Med. 148:2247-2252. [Abstract/Free Full Text]
31. Krumholz HM, Seeman TE, Merrill SS, et al. 1994. Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years. JAMA. 272:1335-1340. [Abstract/Free Full Text]
32. Dayton S, Pearce ML, Goldman H, et al. 1968. Controlled trial of a diet high in unsaturated fat for prevention of atherosclerotic complications. Circulation 2: (7577) 1060-1062.
33. Jacobs DR, Jr Russell VL, Mittlemark MB, et al. 1986. Community-wide prevention strategies evaluation design of the Minnesota Heart Health Program. J Chronic Dis. 39:775-788. [Medline]
34. Van Beurden EK, James R, Henrikson D, et al. 1991. The North Coast Cholesterol Check Campaign: results of the first three years of a large scale public screening programme. Med J Aust. 154:385-391. [Medline]
35. Plant A, Pierce JP, Rushworth RL, et al. 1988. Time to lower cholesterol: the potential effect of cholesterol reduction on the incidence of cardiovascular disease. Med J Aust. 148:627-629. [Medline]
36. Ives DG, Kuller LH, Travern ND, 1993. Use and outcomes of a cholesterol-lowering intervention for rural elderly subjects. Am J Prev Med. 9:274-281. [Medline]
37. Denke MA, Grundy SM, 1990. Hypercholesterolemia in elderly persons: resolving the treatment dilemma. Ann Intern Med. 112:780-792.
38. Hetland ML, Haarbo J, Christiansen C, 1992. One measurement of serum total cholesterol is enough to predict future levels in healthy postmenopausal women. Am J Med. 92:25-28. [Medline]
39. Nicklas BJ, Katzel LI, Bunyard LB, et al. 1997. Effects of an American Heart Association diet and weight loss on lipoprotein lipids in obese, postmenopausal women. Am J Clin Nutr. 66:853-859. [Abstract/Free Full Text]
40. Fox AA, Thompson JL, Butterfield GE, et al. 1996. Effects of diet and exercise on common cardiovascular disease risk factors in moderately obese older women. Am J Clin Nutr. 63:225-233. [Abstract/Free Full Text]
41. Dengel JA, Katzel LI, Goldberg A, 1995. Effect of an American Heart Association diet, with or without weight loss in obese middle-aged and older men. Am J Clin Nutr. 62:715-721. [Abstract/Free Full Text]
42. Jensen GL, Rogers J, 1998. Obesity in older persons. J Am Diet Assoc. 98:1308-1311. [Medline]
43. Stevens J, Cai J, Pamuk ER, et al. 1998. The effect of age on the association between body mass index and mortality. N Engl J Med. 338:1-7. [Abstract/Free Full Text]
44. Harris TB, Launer LJ, Madans J, et al. 1997. Cohort study of effect of being overweight and change in weight on risk of coronary heart disease in old age. Br Med J. 314:1791-1794. [Abstract/Free Full Text]
45. Pi-Sunyer XF, 1996. Weight and non-insulin-dependent diabetes mellitus. Am J Clin Nutr. 63: (suppl) 419S-422S. [Abstract/Free Full Text]
46. Huang Z, Willst WC, Manson JE, et al. 1998. Body change, weight change, and risk for hypertension in women. Ann Intern Med. 128:81-88. [Abstract/Free Full Text]
47. Felson D, 1996. Weight and osteoarthritis. Am J Clin Nutr. 63: (suppl) 430S-432S. [Abstract/Free Full Text]
48. Coulston AM, 1998. Obesity as an epidemic: facing the challenge. J Am Diet Assoc. 98: (10; suppl 2) S6-S8. [Medline]
49. Stevens J, Jianwen C, Pamuk ER, et al. 1998. The effect of age on the association between body-mass index and mortality. N Engl J Med. 338:1-7.
50. Rexrode KM, Hennekens CH, Willet WC, et al. 1997. A prospective study of body mass index, weight change, and risk of stroke in women. JAMA. 277:1539-1545. [Abstract/Free Full Text]
51. Ritchie CS, Burgio KL, Locher JL, et al. 1997. Nutritional status of urban homebound older adults. Am J Clin Nutr. 66:815-818. [Abstract/Free Full Text]
52. Whitehead C, Finucance P, 1997. Malnutrition in elderly people. Aust NZ J Med. 27:68-74. [Medline]
53. Wallace JI, Schwartz RS, 1997. Involuntary weight loss in elderly outpatients. Clin Geriatr Med. 13:717-733. [Medline]
54. Ortega RM, Andrés P, 1998. Is obesity worth treating in the elderly?. Drugs Aging. 12: (2) 97-101. [Medline]
55. Carek PJ, Scherer JT, Carson DS, 1997561–562. Management of obesity: medical treatment options. Am Fam Physician. 55:551-558. [Medline]
56. Potter JF, Schafer DF, Bohi RL, 1988. In-hospital mortality as a function of body mass index: an age-dependent variable. J Gerontol Med Sci. 43:M59-M63.
57. Brown WJ, Dobson AJ, Mishra G, 1998. What is a healthy weight for middle-aged women?. Int J Obes. 22:520-528.
58. Peters ETJ, Seidell JC, Menotti A, et al. 1995. Changes in body weight in relation to mortality in 6441 European middle-aged men: the Seven Countries Study. Int J Obes. 19:862-868.
59. Folsom AR, French SA, Zheng W, et al. 1996. Weight variability and mortality: the Iowa Women's Health Study. Int J Obes Relat Metab Disord. 20:704-709. [Medline]
60. Vaughn L, Zurlo F, Ravussin E, 1991. Aging and energy expenditure. Am J Clin Nutr. 53:821-825. [Abstract/Free Full Text]
61. Fukagawa NK, Bandini LG, Young JB, 1993. Effect of age on body composition and resting metabolic weight. Am J Physiol. 264:E450-E455. [Abstract/Free Full Text]
62. Thompson JL, Gylfadottir UK, Moynihan D, et al. 1997. Effects of diet and exercise on energy expenditure in postmenopausal women. Am J Clin Nutr. 66:867-873. [Abstract/Free Full Text]
63. Jylha M, 1994. Ten-year change in the use of medical drugs among the elderly: a longitudinal study and cohort comparison. J Clin Epidemiol. 47:69-79. [Medline]
64. Thurman JE, Mooradian AD, 1997. Vitamin supplementation therapy in the elderly. Drugs Aging. 11:433-449. [Medline]
65. Swain R, Kaplan B, 1995. Vitamins as therapy in the 1990s. J Am Board Fam Pract. 8:206-216.
66. Henriksen T, Mahoney EM, Steinberg D, 1983. Enhanced macrophage degradation of biologically modified low-density lipoprotein. Arterio-sclerosis. 3:149-159.
67. Quinn MT, Parthasarathy S, Fong LG, et al. 1987. Oxidatively modified low density lipoproteins: a potential role in recruitment and retention of monocyte macrophages during atherogenesis. Proc Natl Acad Sci USA. 84:2995-2998. [Abstract/Free Full Text]
68. Witztum JL, Steinberg D, 1991. Role of oxidized low density lipoprotein in atherogenesis. J Clin Invest. 88:1785-1792.
69. Dieber-Rothender M, Puhl H, Waeg G, et al. 1991. Effect of oral supplementation with D-alpha-tocopherol in the vitamin E content of human low-density lipoproteins and resistance to oxidation. J Lipid Res. 32:1325-1332. [Abstract]
70. Jialal I, Grundy S, 1992. The effect of dietary supplementation with alpha-tocopherol on the oxidative modification of low density lipoprotein. J Lipid Res. 33:899-906. [Abstract]
71. Jialal I, Grundy S, 1993. Effect of combined supplementation with alpha-tocopherol, ascorbate, and beta carotene on low-density lipoprotein oxidation. Circulation. 88:2780-2786. [Abstract/Free Full Text]
72. Rimm EB, Stampfer MJ, Ascherio A, et al. 1993. Vitamin E consumption and the risk of coronary heart disease in men. N Engl J Med. 328:1450-1460. [Abstract/Free Full Text]
73. Stampfer MJ, Hennekens CH, Manson JE, et al. 1993. Vitamin E consumption and the risk of coronary disease in women. N Engl J Med. 328:1444-1448. [Abstract/Free Full Text]
74. Losonczy KG, Harris TB, Havlik RJ, 1996. Vitamin E and vitamin C supplement use and risk of all-cause and coronary heart disease mortality in older persons: the Established Populations for Epidemiologic Studies of the Elderly. Am J Clin Nutr. 64:190-196. [Abstract/Free Full Text]
75. Byers T, Perry G, 1992. Dietary carotenes, vitamin C, and vitamin E as protective antioxidants in human cancers. Annu Rev Nutr. 12:139-159. [Medline]
76. Prasad KN, Edwards-Prasad J, 1992. Vitamin E and cancer prevention: recent advances and future potentials. J Am Coll Nutr. 11:487-500. [Abstract]
77. Knekt P, 1991. Role of vitamin E in the prophylaxis of cancer. Ann Med. 23:3-12. [Medline]
78. Wang XD, 1994. Review: absorption and metabolism of ß-carotene. J Am Coll Nutr. 13:314-325. [Abstract]
79. Shimizu H, Nagata C, Komatsu S, et al. 1996. Decreased serum retinol levels in women with cervical dysplasia. Br J Cancer. 73:1600-1604. [Medline]
80. Zheng W, Sellers TA, Doyle TJ, et al. 1995. Retinol, antioxidant vitamins and cancers of the upper digestive tract in a prospective cohort study of postmenopausal women. Am J Epidemiol. 142:955-960. [Abstract/Free Full Text]
81. Barnett R, 1989. Give me 5!. Am Health. 8:140
82. Blot WJ, Li J-Y, Taylor PR, et al. 1993. Nutrition intervention trials in Linxian, China: supplementation with specific vitamin/mineral combinations, cancer incidence, and disease specific mortality in the general population. J Natl Cancer Inst. 85:1483-1492. [Abstract/Free Full Text]
83. Vainio H. Chemoprevention of cancer: lessons to be learned from beta-carotene trials. [Review] Toxicol Lett. 2000;112–113:513–517.
84. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group1994. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med. 330:1029-1035. [Abstract/Free Full Text]
85. Greenberg ER, Baron JA, Karagas MR, et al. 1996. Mortality associated with low plasma concentration of ß-carotene and the effect of oral supplementation. JAMA. 275:699-703. [Abstract/Free Full Text]
86. Kushi LH, Free RM, Sellers TA, et al. 1996. Intake of vitamins A, C, and E and postmenopausal breast cancer: the Iowa Women's Health Study. Am J Epidemiol. 144:165-174. [Abstract/Free Full Text]
87. Omenn GS, Goodman GE, Thornquist MD, et al. 1996. Effects of a combination of ß-carotene and vitamin A on lung cancer and cardio-vascular disease. N Engl J Med. 334:1150-1155. [Abstract/Free Full Text]
88. Cook NR, Le IM, Manson JE, Buring JE, Hennekens CH, 2000. Effects of beta-carotene supplementation on cancer incidence by baseline characteristics in the Physicians' Health Study (United States). Cancer Causes Control. 11: (7) 617-626. [Medline]
89. Hennekens CH, Buring JE, Manson JE, et al. 1996. Lack of effect of long-term supplementation with ß-carotene on the incidence of malignant neoplasms and cardiovascular disease. N Engl J Med. 334:1145-1149. [Abstract/Free Full Text]
90. Ward JA, 1998. Should antioxidant vitamins be routinely recommended for older people?. Drugs Aging. 12: (3) 169-175. [Medline]
91. Riggs KM, Spiro A, III Tucker K, et al. 1996. Relations of vitamin B-12, vitamin B-6, folate, and homocysteine to cognitive performance in the Normative Aging Study. Am J Clin Nutr. 63:306-314. [Abstract/Free Full Text]
92. Selhub J, Jacques PF, Wilson PWF, et al. 1993. Vitamin status and intake as primary determinants of homocysteinemia in an elderly population. JAMA. 270:2693-2698. [Abstract/Free Full Text]
93. Chernoff R, 1996. President's page: nutrition and health for older Americans. J Am Diet Assoc. 96:1053
94. Nutrition and Health for Older Americans. A Campaign of the American Dietetic Association. Chicago: American Dietetic Association; 1998.
95. Nutrition Screening Manual for Professionals Caring for Older Americans. Washington, DC: Nutrition Screening Initiative; 1991.
96. Posner BM, Jette AM, Smith KW, et al. 1993. Nutrition and health risks in the elderly: the nutrition screening initiative. Am J Public Health. 83:972-978. [Abstract/Free Full Text]
97. Saunders MJ, 1995. Incorporating the Nutrition Screening Initiative into dental practice. Spec Care Dentist. 15:26-37. [Medline]
98. Sahyoun NR, Jacques PF, Dallal GE, et al. 1997. Nutrition Screening Initiative checklist may be a better awareness/educational tool than a screening one. J Am Diet Assoc. 97:760-764. [Medline]
99. Spangler AA, Eigenbrod JS, 1995. Field trial affirms value of DETERMINE-ing nutrition-related problems of free-living elderly. J Am Diet Assoc. 95: (4) 489-490. [Medline]
100. Schmidt RM, 1995. Healthy aging mandates integration of conventional and alternative/complementary medical interventions. Altern Ther. 1: (2) 96-97.

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