Nutrition Education Needs of Elders in Illinois

The USDA Food Consumption, Ten State, and National Health and Nutrition Examination studies on dietary practices of the elderly have reported dietary intakes of independent-living elderly to be inadequate for many nutrients and high in fat (Bianchetti, Rozzino, Carabellese, Zanetti & Trabucchi, 1990; Walker & Beauchenne, 1991; Koehler, Hunt & Garry, 1992). Reports have suggested that the elderly lack the knowledge and motivation to eat an optimal diet, resulting in poor nutritional status and increased risk for morbidity (Ponza, Ohls & Posner, 1994; Ham, 1991).

These studies could substantiate the need for nutrition education of the elderly in Illinois, they do not adequately reflect Illinois elders. This project represents a cooperative effort between the Illinois Department of Public Health and the Illinois Cooperative Extension Service (ICES) to determine what, if any, nutrition education needs the elders in Illinois have, so that program planning within ICES could be appropriately directed.

Information used in this study was obtained from the Illinois Behavioral Risk Factor Surveillance Survey (BRFSS) which uses standardized questionnaires administered through Departments of Public Health by the Center for Disease Control (CDC). The survey instrument, approximately 55 questions, is organized into subject specific modules. The BRFSS is an established state- based, random-digit dialling telephone survey conducted by trained staff with extensive written back-up.

The nutrition components of the modules were evaluated to determine their usefulness in identifying dietary patterns and nutrition education needs of the elderly. As a result, an additional ten questions were developed and pilot-tested. These additional questions primarily clarified hypertension/hyper- cholesterolemia-related behavior, obesity, and fruit/vegetable and dairy intake issues, and were nested within the appropriate module.

Data were collected for one year from those Illinoisans over 64 years of age who had a telephone in their residence and were willing to answer the telephone survey.

Data analysis focused on selected descriptive statistics (Statistical Package for the Social Sciences, 1990). Differences between genders were determined using t-tests for interval variables and chi-square tests for nominal data. Food intake data were compared to the U.S. Dietary Guidelines (U.S. Department of Agriculture, 1993). Because information was specific for fruit, vegetable, and dairy intake, indications of overall diet quality relative to intake of these foods groups were specifically evaluated as described in Table 1.

The 472 seniors (mean age 74.34 +/- 6.61 years) were predominantly female (67%) and Caucasian (88.6%). Most had an education of some high school or less (49%), were widowed (51%), and had an income of less than $10,000/year (41%). Significant differences between males and females (p<0.05) were found: more males (65.6%) were married; more females (47%) earned an income of less than $10,000/year; and more males (15%) than females (5%) earned more than $35,000/year.

Most respondents felt they were not obese (72%). Of the 40% who reported having hypertension, 89% were told about their high blood pressure more than once and 76% of them were being treated with medication. More females (44%) than males (32%) were told they had high blood pressure. There were statistically significant differences between genders regarding the use of blood pressure medication and being told that blood pressure was high on more than one occasion.

A majority (70%) was not aware of their cholesterol level. Of those who knew their blood cholesterol level, a significantly higher number of females (57%) than males (39%) had a cholesterol level >200 mg/dl. In addition, there was a significant gender difference in those trying to reduce their cholesterol level: 65% females and 49% males. Dietary reports reflected this intent, with more males (40%) than females (22%) consuming >21 high-fat servings/week.

Of 410 participants answering all questions concerning fruit, vegetable, and dairy intake, 21 met the Dietary Guidelines. Thirty-one participants met the fruit/vegetable intake recommendation without consuming the two servings of dairy, while 77 met dairy intake recommendations without consuming adequate fruits and vegetables. Therefore, 108 participants had a moderately adequate diet. However, 281 participants met neither guideline, and could be categorized as having a poor diet (Table 2).

The findings regarding race, sex and marital status are strongly supported by the Illinois Statistics for 1991 (Bureau of Economic Business Research, 1991), suggesting that a representative sample was surveyed. Most subjects were low income (less than $10,000 per year), with a low education level (some HS or less), and vulnerable to social isolation (51% were widowed). These results suggest that the elderly in Illinois are at nutritional risk and should be targeted for nutrition education programs. Kaplan and Keil (1993), found a substantial body of evidence for a consistent relation between socioeconomic status and the incidence and prevalence of cardiovascular risk factors. Similarly, we found that most respondents who were told that their blood pressure was high more than once, earned less than $10,000 per year and were widowed. This finding supports the decision of ICES to target low income groups (Cooperative Extension Services, 1994).

As previously reported by Garry, Hunt, Koehler, VanderJagt, and Vellas (1992), elderly males in our study consumed more high- fat foods than elderly females. Although females had a higher serum cholesterol, their degree of concern about trying to reduce their cholesterol was also significantly higher than males. Hence, this may explain their lower fat intake. Nevertheless, the results of the present study and other studies (Witteman, Willet, Stampfer, Colditz, Sacks, Speizer, Rosner & Hennekens, (1989); Seeman, de Leon, Berkman & Ostfeld, 1992; Shaw, Miller, Romeis, Kargl, Younis & Chaitman, 1994) suggest that serum total cholesterol and blood pressure are higher in elderly females than in males. Our findings demonstrate a need to direct cardiovascular risk reduction education programs in Illinois to the older woman.

Intake of fruits and vegetables was generally less than recommended, and overall diet quality was poor for both genders. Although national goals target the promotion of fruit and vegetable intake, programs may need to be modified to address socioeconomic and physical factors which may be barriers for the elderly concerning purchasing, cooking, and eating larger quantities of fruits and vegetables. In addition, intake of dairy foods was particularly inadequate, and was not compensated for by calcium supplement use.

Much background work has pointed to the essential role of diet and nutrition in determining health status and the quality of life of the elderly (Ryan, Craig & Finn, 1992; Tucket, Dallal & Rush, 1992). The results presented support the need for specific nutrition education programs for the elderly in Illinois. The education programs suggested by this project include those emphasizing dairy, fruit, and vegetable intake and cardiovascular risk reduction.

In addition to documenting educational needs, this project exemplifies successful collaboration between agencies in Illinois. Needs identified through IDPH have been addressed through ICES educational programs. Although each state may not be able to add questions to their state's BRFSS, specialists and educators might learn a great about their audiences' behavior by reviewing the survey results. Knowing which higher risk behaviors are most prevalent in the state allows Cooperative Extension Service to address pertinent problems and issues in a timely manner.

Bianchetti, A., Rozzino, R., Carabellese, C., Zanetti, O., & Trabucchi, M. (1990). Nutritional intake, socioeconomic conditions and health status in a large elderly population. The American Geriatric Society, 38, 521-526.

Walker, D., & Beauchenne, R. E. (1991). The relationship of loneliness, social isolation and physical health to dietary adequacy of independently living elderly. Journal of the American Dietetic Association, 91, 300-304.

Koehler, K. M., Hunt, W. C., & Garry, P. J. (1992). Meat, poultry and fish consumption and nutrient intake in the healthy elderly. Journal of the American Dietetic Association, 92(3), 325 -330.

Ponza, M., Ohls, J. C., & Posner, B. M. (1994). Elderly nutrition program-evaluation of literature review. Department of Health and Human Services.

Ham, R .J. (1991). Nutrition screening initiative: Poor nutrition in the elderly. American Family Physicians, 44(5)/suppl, 10S-11S.

Statistical Package for the Social Sciences (Version 4.0 & 4.1) [Computer Software]. (1990). Chicago: Norusis/SPSS.

U.S. Department of Agriculture, & U.S. Department of Health and Human Services, Human Nutrition Information Services. (1993). Dietary guidelines for Americans. Washington, DC: U.S. Government Printing Office.

Bureau of Economic Business Research. (1991). 1991 Illinois Statistical Abstract (lst ed.). Urbana-Champaign: University of Illinois.

Kaplan, G. A., & Keil, J. E. (1993). Socioeconomic factors and cardiovascular disease: A review of the literature. Circulation, 88(4), 1973-1994.

U.S. Department of Agriculture, Extension Service, & Land- Grant University Cooperative Extension Services. (1994). Shaping our future: A strategic plan for nutrition, diet, and health.

Garry, P. J., Hunt, W. C., Koehler, K. M., VanderJagt, D. J., & Vellas, B. J. (1992). Longitudinal study of dietary intakes and plasma lipids in healthy elderly men and women. American Journal of Clinical Nutrition, 55, 682-688.

Witteman, J. C. M., Willet, W. C., Stampfer, M. J., Colditz, G. A., Sacks, F. M., Speizer, F. E., Rosner, B., & Hennekens, C. H. (1989). A prospective study of nutritional factors and hypertension among U.S. women. Circulation, 80, 1320-1327.

Seeman, T., de Leon, C. M., Berkman, L., & Ostfeld, A. (1992). Risk factors for coronary heart disease among older men and women: A prospective study of community dwelling elderly. American Journal of Epidemiology, 138(12), 1037-1049.

Shaws, L. J., Miller, D., Romeis, J. C., Kargl, D., Younis, L. T., & Chaitman, B. R. (1994). Gender differences in the non- invasive evaluation and management of patients with suspected coronary artery disease. Annals of Internal Medicine, 120(7), 559 -566.

Ryan, S. A., Craig, L. D., & Finn, S. C. (1992). Nutrient intakes and dietary patterns of older Americans: A national study. The Gerontological Society of America, M145-M150.

Tucket, K. L., Dallal, G. E., & Rush, D. (1992). Dietary patterns of the elderly Boston-area residents defined by cluster analysis. Journal of the American Dietetic Association, 92, 1487- 1491.