Duration: 10/01/2009 to 09/30/2014

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

• The need, as indicated by stakeholders

Inadequate diet and lack of physical activity are the roots of many of the chronic diseases and disabilities that plague our older population. Approximately 35% of adults over the age of 75 have 3 or more chronic conditions, including, hypertension, heart disease, diabetes, arthritis, and macular degeneration/blindness. Ethnic minorities and low income populations are most at risk. Older adults fall short of meeting both nutrition (fruit, vegetable and whole grain) and physical activity goals of Healthy People 2010 (USDHHS, 2000). Only 6% of older adults consume at least three daily servings of vegetables (with at least one-third of these servings being dark green or orange vegetables) and only 4% of older women and 11% of older men consume at least six daily servings of grain products (with at least three being whole grain). Currently, only 10% of adults 64-74 years, and 7% of those 75+ years engage in physical activities that enhance and maintain strength and endurance 2+ days per week. Similar statistics describe those who engage in physical activities promoting development and maintenance of cardiorespiratory fitness. Evidence is mounting to demonstrate that changes in diet and exercise that are implemented in the later years can be effective in both extending life and improving quality of life. However, there is also the need to examine factors in earlier years that may curb the chronic conditions affecting quality of life for our elders.

The project described herein builds on earlier work by this team of scientists. This proposal includes interventions to increase physical activity in combination with interventions to increase consumption of fruits, vegetables and whole grains and a determination of lifestyle choices (including number of pregnancies and breast feeding earlier in life) as factors related to the incidence of chronic conditions, including macular degeneration or blindness in later years. There is clearly a need for additional research that will lead to improvements in both diet and exercise behaviors in older Americans, and that will address health disparities that exist among the elderly, particularly those from minority groups and of lower socioeconomic status.

• The importance of the work, and what the consequences are if it is not done

A large body of evidence suggests that regular exercise and a diet rich in fruit, vegetables and whole grains are associated with a lower incidence of age-related diseases such as cardiovascular disease, eye disease, and certain cancers as well as obesity. The importance of both endurance and strength-type exercises in older adults is increasingly being recognized for lowering the risk of sarcopenia, the age-related loss of muscle mass which can lead to disabilities and loss of independence. The proposed research is important because it will (1) increase our knowledge of effective intervention strategies to help lower the risk of chronic diseases and age-related disabilities in older adults and (2) enhance our ability to identify appropriate biomarkers and our understanding of how biomarkers may be used as a tool for assessing improvements in diet and physical activity status in older adults. The proposed research supports the USDA strategic goal of improving the nation's health and nutrition. If the trajectory of health is not changed, we can anticipate ever-increasing health care costs as the baby boom generation enters into the expanding population of older adults.

• The technical feasibility of the research

Our multistate team has a successful record of research focused on the health and nutrition of older adults, addressing their dietary needs with respect to fruit, vegetable and grain intake, and the affect of diet on biomarkers. We propose herein protocols that integrate nutrition with physical activity and expand the types of interventions needed to increase fruit, vegetable and whole grain consumption. Additionally, we will add to the past research exploring determinants of macular pigment (MP) density as a biomarker of retinal health with two novel approaches. First, we propose to monitor how lifestyle modifications (weight loss and increased physical activity) influence changes in MP and second, we will test the hypothesis that life style factors earlier in life are risk factors for eye health in later years. The research team is comprised of experts in both nutrition and physical activity and with accomplishments in the applied and basic research which will be necessary to conduct the proposed work. Collectively this team brings experience in assessing the nutritional status of older adults and in developing, implementing, and evaluating nutrition and physical activity intervention and education programs. The team has the expertise with respect to state-of-the-art approaches and methodologies, as well as the requisite understanding of the theoretical underpinnings of the proposed project, to implement and carry out the proposed studies, assuring the success of the research.

• The advantages for doing the work as a multistate effort

There are numerous advantages to performing this work as a multistate effort. The members of the proposed project have a history of successful collaborative research in the area of nutrition and older adults (Fey-Yensan et al., 2004; Lammi-Keefe and Contois, 2004; Contois et al., 2004). By bringing together different experts in the region to solve common problems, the multistate project can be highly effective. For example, Dr. Curran-Celentano brings expertise in the assessment of macular pigment density and lutein/zeaxanthin (carotenoids that function as antioxidants and that are associated with a reduced risk of age related macular degeneration), and Dr. Lammi-Keefe has expertise in the assessment of fatty acid status (Loosemore, Judge and Lammi-Keefe, 2004; Judge, Harel, and Lammi-Keefe, 2007). As the macular pigment of the eye is a complex of carotenoids and omega-3 fatty acids, the partners comprising our team can assess the importance of these nutrients with respect to MP density and the risk of age related macular degeneration. Similarly, the multistate researchers in the proposed project bring in complementary expertise in physical activity interventions (Drs. Delmonico and Lofgren), extension education (Drs. Kantor, Violette, and Cohen), and dietary studies (all members ). Through pairing complementary expertise and sharing the responsibilities for planning and implementing studies, this regional research project can fulfill an innovative research agenda at an efficient cost.

Efficiencies occur when different researchers work individually or in teams to be responsible for different aspects of the project, pool resources to compensate for budget restrictions or limitations that may exist in individual states, or implement the same protocols in different states, thus dramatically increasing the sample size and diversity of subjects. One example of this is from our previous work in the NE1023 project. The protocol for this qualitative research experiment utilized cognitive interviewing principles in a semi-structured interview to assess how older adults identify whole grain foods. Five research stations participated in the experiment (NH, MA, MD, MN, DC). The participating researchers shared their expertise to develop the protocol and assessment instruments as a group. Each research station participated in recruiting subjects and conducting interviews. As a result, the multistate approach increased both the number and diversity of subjects participating in the experiments compared to what could be assessed if only one or two stations participated. In addition, many members of this research team previously have worked together effectively on other multistate projects which will facilitate communications and cooperation in meeting deadlines.

• What the likely impacts will be from successfully completing the work

Information gathered from the results of these research projects will assist nutrition and exercise professionals in designing effective physical activity and nutrition interventions for older adults emphasizing the need for fruits, vegetables and whole grains in the diet and based on factors relevant to them. Results will also be used to design community-wide food and environmental policies to promote improved plant food intake and physical activity among older adults. By improving the assessment of food, nutrient, and health status through biomarker indicators, nutritionists can increase their ability to measure intervention outcomes and disease risks. Together, these efforts can result in improved interventions and nutrition-related health outcomes in the growing and diverse population of older Americans.

Related, Current and Previous Work

The nation's population is aging. The U.S. Census Bureau projects that the older adult population will comprise 20% of the U.S. population by 2030, up from 12.4% in 2006 (He et al., 2006). Older adults are more likely to have a chronic health condition with 80% having at least one condition and 50% having at least two (He et al., 2006). Lifestyle factors such as diet will become increasingly important in maintaining and enhancing health and overall quality of life as the nation's population ages.

Good nutrition and moderate physical activity can promote health and delay disability in older adults. Yet, most older adults do not follow dietary recommendations, and fruit, vegetable and whole grain consumption remain low. The U.S. Dietary Guidelines for Americans recommends increased consumption of fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products as these foods have important health benefits (U.S. Department of Health and Human Services, U.S. Department of Agriculture, 2005). Whole grains are an important source of nutrients and fiber. Consuming at least 3 ounce-equivalents of whole grain foods each day can help to reduce the risk of several chronic diseases as well as support weight maintenance (U.S. Department of Health and Human Services, U.S. Department of Agriculture, 2005).

In examining the Healthy Eating Index (HEI) of adults aged 60 and over, Ervin (2008) noted that only about 18%, 27% and 32% meet the dietary recommendations for grains, fruits, and vegetables, respectively. Data from the 2001-2004 NHANES surveys support this finding, and indicate that the mean intake of fruits is 1.3 cups in women over age 70 and 1.4 cups in men over age 70, below the recommended 1.5 cups. Similarly, mean vegetable intake was below recommended levels in older adults.

Several studies have indicated that older adults can increase fruit and vegetable intakes through nutrition education. Researchers from this regional project found that the effectiveness of a manual, newsletters, and coaching calls to increase fruit and vegetable consumption in older adults was related to stage of change (Greene et al., 2008). Shaikh et al. (2008) have also found that communication style, self-efficacy, knowledge, and social support are important to increase fruit and vegetable intake in general populations of adults. Additional and innovative efforts are needed, however, to make progress toward achieving national guidelines for fruits and vegetables in diverse populations of older adults.

Survey data indicate that American adults typically consume slightly less than one serving of whole grain food each day (Slavin et al., 2001). Mean whole grain intake in women over age 70 was only 0.8 oz per day, while men consumed 1.1 oz per day, well below the 3 ounces recommended (National Cancer Institute, 2008). Since the publication of the 2005 U.S. Dietary Guidelines, the media and the food industry have extensively promoted the importance of eating whole grains. As a result, awareness of the benefits of eating whole grains is high but few studies have explored how best to increase consumption, especially for older adults. One of the few studies reported in the literature is by Ellis and colleagues who examined the impact of a whole grain nutrition education program on intake in 84 older adults recruited through congregate meal sites (Ellis et al., 2005). The intervention resulted in a high awareness of the health benefits of whole grains among the participants and a significant increase in the consumption of whole grain bread, cereal and crackers per week. However, despite the increased consumption in some food categories, total consumption of whole grains remained low. These authors call for additional interventions to increase whole grain food consumption to recommended levels.

Our work from the NE1023 project has indicated that while many older adults are aware of whole grains, some had misinformation about the meaning of this term. When asked what foods they think of when we use the term 'whole grain', about half the subjects mentioned breads and cereals in general. While many participants mentioned whole wheat or whole grain bread, only some respondents listed particular grains such as barley or oats. In contrast, some subjects considered fruits, vegetables, beans, peas and nuts when thinking about the term 'whole grain.' Many older adults in our previous study were aware of the health benefits of eating whole grains and were interested in including more in their diet. To determine if a food is whole grain, many older adults used information provided on the product package. The food product ingredient list was used most frequently but other sources of information, such as the Nutrition Facts panel and nutrient content claims, were used as well. Some older adults interpreted this information accurately to conclude whether or not the food was whole grain, while others were unsure or did not know how to use the information to determine if selected foods were whole grain. To extend these results, the next step will be to develop and pre-test an education curriculum designed to help older adults accurately identify whole grain foods.

In addition to improvements in diet, the need for increased physical activity in older adults is well recognized. Only 10% of adults aged 64-74, and 7% of those above age 75 engage in physical activities to enhance or maintain strength or endurance two or more times per week. The rates of obesity have increased in the 60-69 and over 70 year old age groups by 56% and 36%, respectively (Villareal et al., 2005). Moreover, the increased prevalence of obesity-related disability is expected to increase by 17.7% and 21.8% in men and women, respectively, by the year 2020 (Sturm et al., 2004). Because of these rising obesity and obesity-related disability rates in older adults, interventions that define the role of weight loss and exercise are especially needed in this high risk group.

Although National Heart, Lung, and Blood Institute guidelines recommend weight loss for obese adults to prevent morbidity and mortality, specific methods for how best to improve function, preserve lean mass, and improve coronary heart disease (CHD) risk factors in obese older adults are needed (Expert Panel, 1998). Geriatric research has helped to define the individual contributions of obesity, loss of muscle mass, and low physical activity to physical function and health-related outcomes in older adults (Nair, 2005). However, an emerging line of research is to determine the most effective treatment for improving physical functioning, reducing CHD risk, and optimizing body and muscle composition in older adults, particularly among those who are obese and therefore at greater risk of disability. Consequently, interventions that combine different strategies need to be investigated (Ferrucci et al., 2004).

Increasingly, the community environment is recognized as an important factor in facilitating improved dietary intakes and physical activity. Studies of the 'built environment' show that sidewalks, bike paths, parks, safe neighborhoods and other environmental facilitators of physical activity may be useful in promoting increased walking and other activities in youth and adults (Lee et al., 2008). Similarly, a food environment with availability of affordable and healthful foods in grocery stores, schools, worksites, farmer's markets, gardens, and other community venues may also promote improved dietary behaviors in diverse adults (Lee et al., 2008). It is unclear, however, if these same recommendations would promote healthful eating and physical activities in older adults. Little work has been done to consider whether the type of physical environment needed to promote improved physical activity and dietary behaviors including increased fruits, vegetables and whole grains in families and children will also be effective in older adults, or if modified recommendations are needed.

In recent years, foods recognized as being highly nutritious, such as vegetables and fruits, have been related to large outbreaks of foodborne illness (Beuchat, 2002). For example, a 2006 outbreak of E. coli O157:H7 associated with raw baby spinach resulted in 205 confirmed illnesses and three deaths (FDA, 2007). Cantaloupes, tomatoes, and jalapeño peppers also have been linked to recent foodborne illness outbreaks.

Older adults are particularly vulnerable to foodborne illnesses and more likely to suffer severe symptoms compared to younger people because the immune system generally declines with aging. Aging may also result in a diminished sense of taste, smell and vision, so spoiled food, which at times is contaminated with pathogenic bacteria, may escape detection. In order to encourage the consumption of fruits, vegetables, and other nutrient dense foods, it is important that older adults have confidence that these foods are safe, and that foods made available to them are handled, prepared, and stored safely.

Older adults who are homebound and vulnerable may participate in the home delivered meals (HDM) program, a service offered through the Elderly Nutrition Programs of the Federal Older Americans Act. Nationwide, about 1.5% of adults >60 years of age rely on the HDM program to provide them with a daily nutritious meal, five days a week.

Agencies that deliver meals to the homes of elderly residents face a whole host of food safety challenges related to preparation, handling, transportation, and storage of the food, but food safety is not consistently addressed by state agencies on aging. Food that is delivered to homebound individuals is typically handled by many different people and is susceptible to contamination with pathogenic organisms. Although meat and poultry products have traditionally been considered highly perishable and potentially hazardous foods, it is important that older individuals recognize that fresh fruits and vegetables also may become contaminated with pathogenic organisms and that these foods may be implicated in foodborne illnesses.

There have been reports linking the HDM program to undesirable food safety practices, such as temperature abuse during transportation and delivery, meals being left outside the home or on counter tops in clients' homes, and poor sanitary practices during transport. Moreover, older adults may inadvertently engage in unsafe food safety practices stemming from their limited budget, unwillingness to waste food, and an impaired memory or dementia (Roseman, 2007; Mathieu, 2002; Almanza et al., 2007).

For example, a significant proportion (between 44%-88%) of HDM participants did not consume their entire meal upon delivery, but rather saved their meal for later consumption (Fey-Yensan et al., 2001, Lau et al., 1994). Refrigerators operating at improper temperatures are also a problem (Anderson et al., 2000). Therefore, there is a critical need to learn more about the food safety practices of older adults, and to develop a practical, science-based food safety educational program to address the specific challenges faced by the HDM program.

While developing interventions to increase physical activity and the intake of fruits, vegetables and whole grains is critical, measurement of health outcomes and mediating biomarkers as a result of these interventions is also important. Improving consumption of some foods such as fruits and vegetables has been documented to improve health and to lower risk for many diseases, including cardiovascular disease, blindness and low vision. While cardiovascular disease is a leading cause of mortality in older adults, macular degeneration (decrease in macular pigment) is the leading cause of severe vision loss among the elderly in the U.S. Every year, approximately 200,000 new cases of macular degeneration are diagnosed (Eye Disease Research Group, 2004). Treatments for age-related macular degeneration are accompanied by risks and thus primary prevention is the preferred primary public health approach to this disease.

Lutein is a plant carotenoid and pigment present in certain fruits and vegetables that has been documented to be both positively related to macular pigment (Burke, Curran-Celentano and Wenzel, 2005) and to lower the risk for age-related macular degeneration and cataracts. For this reason, it is added to vitamin and mineral supplements that are marketed to the over-50 sector. The other constituent of the eye's rod outer segments is the n-3 fatty acid prevalent in marine species, i.e., docosahexaenoic acid (DHA, 22:6n-3). DHA is intimately associated with the lutein of the rods and it is constantly being renewed. Intake of marine lipids is relatively unexplored but available evidence points to very low consumption in the U.S. population, and in particular, among pregnant women and women of child-bearing age. Furthermore, during pregnancy there is an increased need for this fatty acid as it is integral to brain and eye development of the fetus and is therefore preferentially transferred across the placenta resulting in depleted status for the mother (Lammi-Keefe, 2000). If the association between lutein and DHA, depletion of DHA and decreased macular pigment in pregnant women can be demonstrated, strategies to increase the consumption of lutein rich fruits and vegetables and DHA rich fish for this population can be evaluated.

As far as we know, there have been no studies to date to assess the impact of pregnancy on macular pigment of the eye or incidence of macular degeneration as it relates to multiple pregnancies. This segment of the population deserves close scrutiny as fish advisories target pregnant women and the advisories, while well-intentioned, continue to be misinterpreted and misunderstood by women and health care professionals alike. As a result, fish is very often excluded from the diets of pregnant women. Women also tend to have lower concentrations of macular pigment compared to men, which raises the question: Could pregnancy be a risk factor for this lower concentration? There is no evidence that this has previously been explored. In partnership with local physicians, we propose to assess retrospectively the incidence of macular degeneration as it relates to number of full or near full-term pregnancies.

A systematic review and meta-analysis of the evidence on dietary n-3 fatty acid and fish intake in primary prevention of age-related macular degeneration was published in Archives of Ophthalmology in June 2008 (Chong et al., 2008). The authors conclude: 'this meta-analysis suggests fish and foods rich in n-3 fatty acids may be associated with lower risk of AMD ... [but] few prospective studies and no randomized clinical trials [have been conducted]'

In the proposed study, we will build on our previous NE1023 work on age-related macular degeneration (AMD), macular pigment density, dietary lutein and dietary DHA. As women, compared to men, are at higher risk for AMD we propose to explore if life events and choices that are specific to women diagnosed with AMD are related to number of pregnancies or breastfeeding choices. Additionally we will examine how both pregnancy and breast feeding impact macular pigment density in women. These data will help establish if pregnancy and breast feeding women should be consuming more lutein and DHA compared to non-pregnant and non-breast feeding women, in order to protect the retina with aging. In addition we will look at how lifestyle changes influence the uptake and distribution of serum and retinal carotenoids.

Results of CRIS search

A CRIS search with key words 'elderly' and 'nutrition' and 'fruits' and 'vegetables' and 'grains' revealed 5 projects, not including the projects of our research team. There are no similar regional projects, as these other projects appear to be focusing mainly on bone health. A project that has the potential for overlap with our efforts is entitled 'Epidemiology applied to problems of aging and nutrition' (Jacques P, Wilhelm KR, and Tucker K, ARS, Boston). However, an important difference is that this other project appears to use a number of existing data sets to investigate diet/disease relationships. A CRIS search with the key words 'food' and 'safety' and 'elderly' and 'nutrition' yielded 10 hits with no similar projects or overlap.

Objectives

1. To examine novel interventions to increase fruit, vegetable and whole grain intake and physical activity in older adults.
   
2. To identify effective biomarkers and other indicators that reflect improvement in diet (fruit, vegetables, and whole grains) and physical activity and chronic disease risk in older adults.
   

Methods

Objective 1, Experiment 1
Environmental changes to increase fruits, vegetables, and whole grain intakes and physical activity in older adults. (UMass, lead; RI, MD participating stations)

Purpose. To determine recommended environmental changes related to dietary and physical activity behaviors specific to older adults, and pilot test food environment changes adopted by a local food policy council.

Methods. Increasingly, strategies and tools are available to assess whether environments are supportive of positive dietary and physical activity behaviors (CDC, 2008; Glanz et al., 2007; Lee et al., 2008). However, few tools address increasing whole grain consumption in populations or strategies specific to older adults, such as through senior gardening programs, Senior Farmers Market Coupon Program, or senior centers. A survey to identify perceived and desired environments that would promote fruit, vegetable and whole grain consumption and physical activity in older adults of diverse racial/ethnic and socioeconomic backgrounds will be developed in collaboration with participating stations and administered to elder service agency staff, nutrition professionals and community members of a food policy council in western Massachusetts. The survey will include perceived dietary intake and access issues in older adults, perceived availability of healthful foods and access to physical activity in the community, and recommendations for improving the local environment related to fruits, vegetables, whole grains and physical activity. As a result, a food environment tool tailored to the needs of older adults will be developed to assess the local community, and findings will be reported to local elder service agencies and food policy councils. Short-term environmental changes in food availability will be piloted as a result of selected food policy actions based on assessed needs. The tool developed as part of this experiment will also be disseminated to other states for wider community usage.

Objective 1, Experiment 2
Pre-testing a whole grain foods education program (UNH lead; MA, MD participating stations)

Purpose. Research results from the NE1023 project (2004-2009) indicate that older adults utilize the ingredient list, Nutrition Facts panel, and other package information to determine if a food is whole grain. Based on these results, a draft whole grain foods education curriculum was designed collaboratively with a group of older adult volunteers in Manchester NH. The curriculum design selected by the older adult volunteers was a series of three face-to-face meetings. This experiment will pre-test this curriculum and explore expanding content and design to other food groups such as fruits and vegetables. Further, this study will explore alternative delivery methods such as web-based programming that might extend the reach of the program to older adults who might not attend meetings. The websites will be geared for use by older adults and service providers and will be appropriately publicized. This study will address the research question: Can an education program increase whole grain food consumption in older adults?

Methods. Researchers from participating stations will contribute to the development of the whole grain foods curriculum and the development and pretesting of the diet assessment and program evaluation tools for inclusion in the curriculum.

Cooperative Extension specialists from participating and non-participating states in the region will be contacted to solicit their participation in the pre-testing phase of the whole grain foods curriculum. Each specialist will identify and recruit staff in their state to participate. Educators who will implement the program will be trained on all aspects of the curriculum, including overview of whole grain research, curriculum content, delivery, promotion and recruiting, and assessment and evaluation.

Implementation of the curriculum will utilize a pre/post design. Educators will implement the program with approximately 50-75 older adults 65 years of age or older. The convenience sample of independent-living older adults will be recruited from senior centers, congregate meal sites, subsidized housing facilities, and through agencies reaching older adults. Efforts will be made to recruit a varied (for example; age, income, ethnicity, rural/urban) older adult audience to participate in the program. Cognitive interviews with older adults will be used to design and pre-test assessment questionnaires. The draft questionnaires will be sent to selected nutrition and/or aging experts to determine face and content validity. Test-retest reliability will also be determined in a small sample of program participants. Program assessment and evaluation data will be analyzed and results used to revise the program. Additional funding to support a larger scale experimental/control group design will be explored to test the effectiveness of the revised curriculum.

Objective 1, Experiment 3
Design and evaluation of a motivational curriculum and modified recipes to increase fruits and vegetables in a multicultural population of older adults (UDC lead station).

Purpose. To motivate elderly Washington, D.C. residents to increase their consumption of fruits and vegetables through the development and evaluation of unique, fun filled games, and to identify the determinants of food choices by designing a new Food Choice Questionnaire. The specific objectives of this experiment are: (1) To investigate and compare the priorities of high fruit and vegetable consumers with low fruit and vegetable consumers; (2) to design new and innovative fun filled games and activities through which nutrition education can be effectively rendered; and (3) to collect traditional recipes from the elderly, modify the ingredients and method of cooking to improve the vegetable content and nutrient density, and publish a recipe book containing both the original and the modified recipes.

Methods. The subjects for this study will be drawn from the District of Columbia congregate sites. Between 120-150 eligible free-living participants (age >60 years) will be recruited from the registered congregate site participants. The congregate sites are direct services provided by the D.C. Office on Aging through a senior service network. Tasty and nutritious noon meals are served in group settings at all congregate sites around the city. The congregate sites also provide social and recreational activities and information on staying well, including advice on nutrition. Volunteers for this experiment will be asked to sign a consent form after the study is explained. In order to investigate and compare the priorities of high fruit and vegetable consumers with the low fruit and vegetable consumers, a new food questionnaire will be designed and implemented prior to and after completion of the study, to identify the portion sizes and quantity of fruits and vegetables. The questionnaire will also include items to assess socio-economic, medical and other demographic data, dietary supplement intake, knowledge of fruits and vegetables, and determinants of consuming high or low amounts of fruits and vegetables. A 4-day food diary will be used to assess the number of portions of fruits and vegetables consumed. Participants will be provided with a camera for photographing each meal consumed to provide an accurate record of fruit and vegetable intake, and to serve as an incentive for participating in the study. Using a camera reduces the respondents burden, provides qualitative and quantitative information, serves as a validation tool, and can be used by individuals who cannot write.

Based on the data obtained from the 4-day food records, the participants will be divided into Groups A and B based on their fruits and vegetable consumption. Group A will be comprised of participants who are high consumers of fruits and vegetables i.e., consume more than 5 servings of fruits and vegetables/day. Group B will be comprised of participants who are low consumers of fruits and vegetables (less than 5 servings/day). Group A will meet once/month and will be provided with nutrition education based on MyPyramid and will be asked to provide 4 days of dietary data through pictures taken from the camera. Group A will be given a questionnaire for use in identifying the determinants of high consumption of fruits and vegetables.

Group B will meet once every two weeks. Group B will initially be divided into four groups for the purpose of conducting focus group sessions to identify the determinants of low consumption of fruits and vegetables. These participants will be informed about collecting their favorite recipes which may be subsequently modified to improve nutritional composition. Participants will be interviewed by the researchers or student interns to translate recipes or if the participant is not capable of writing the recipe. Participants will also be informed about the rationale of collecting recipes: (1) to use familiar and cultural recipes; (2) to modify the method or the ingredients for better nutritional content and density; (3) to publish a recipe book that is culturally sensitive and appropriate to meet the needs of the elderly population.

Based on the feedback from focus group sessions and the pre-test, a series of educational classes will be completed at each facility. The classes will be designed to bring interesting and relevant information to the participants in a fun, interactive way. Each class will include easy-to-read handouts and will involve participation. The Types of participation may include group discussion and individual volunteering. Appropriate and culturally sensitive fun games will be designed to be implemented. The series of educational classes may include the following components: Memory game, food demo, recipe collection, international cuisine, seasonal fruits and vegetables, farmers market food demo, bingo, Jeopardy. The games will be designed to educate participants about the quantity of fruits and vegetables recommended to be consumed and its nutritional benefits. These fun filled activities will be implemented to ensure full participation of all participants.

In order to assess the effect of the nutrition education, a pre-test and identical post-test will be created and administered at the various senior centers. The test will assess basic knowledge of nutrition, focusing on fruits and vegetables and the vitamins and minerals contained in them. The post test will be given at the end of 6 months. The post-test will reveal the success of the intervention and behavioral change.

Statistical methods and analysis: Using the 4-day dietary data the numbers and portion of fruits and vegetables consumed per person will be calculated and averaged over the four day period. A nutrition analysis software will be used to analyze the nutrient content and serving sizes of the dietary data obtained from the participants. Analysis will be carried out by using statistical package for the Social Sciences. The food questionnaire will be designed with scores ranging from 1-5. One(1), being very important to five (5) being not important. Scores for each dimension which include knowledge, attitude and perceptions will be added and divided by the number of questions related to particular dimension to provide an average score of 1-5 per person for each dimension. The subjects will be split into tertiles of fruit and vegetable consumption. A linear regression model will be used to determine the food choice factors that are strongest predictors of fruit and vegetable consumption. After using the proper questioner to collect the data, the variables for experiment will be identified. As it is stated in the proposal, there will be independent and dependent variables. It is important to manage the data properly as well. Management will consists of the inferences with graphs, estimation, hypothesis testing, and model assessment. Study suggests that the multivariate regression analysis and the applications of empirical Bayes will be appropriate to do the analysis. Having collected, summarized and analyzed the data, the results will be presented to reflect the findings. This will be repeated and stated for age and education levels. Descriptive analysis will also be used to compare the results of the control group with the interventional group. Analysis for group A will be based on their demographic information, knowledge and motivational factors for high consumption as compared with Group B.

Objective 1, Experiment 4
Maximizing the benefits of fruits, vegetables, and whole grains by keeping foods safe among recipients of home delivered meals (UMD lead; MA, NH participating stations)

Purpose. To investigate food safety practices of older adults and develop, implement, and evaluate a food safety education program targeted to older adults who are recipients of the home delivered meal (HDM) program.

Methods. To identify food safety and food handling practices at the national level, the 2006 FDA Food Safety Survey will be analyzed to obtain background information and trends over time on food handling and food safety in the home of older adults. This dataset has not been previously examined for the age group >60 years of age. Some of the relevant FDA survey questions will also be administered to convenience samples of HDM recipients residing in our participating states, and these results will be compared to the national sample. The sections of this survey of interest to this proposal are: perception of the risk from foodborne illnesses; knowledge and habits regarding food safety practices; awareness of different microorganisms and the foods that harbor them; thermometer usage; unsafe food consumption; and knowledge of food advisories. Analysis will include testing for predictors of hand washing during meal preparation, food storage practices, food thermometer usage, risky food consumption (such as raw or undercooked hamburger, eggs, sprouts, and seafood), proper cutting board usage (avoiding cross-contamination), and fruit and vegetable washing. Independent variables will include knowledge of common pathogens, awareness of food safety advisories, perception of personal vulnerability, perceptions of risk, health status, and demographics such as income, education, race, and sex. A SAS software program will be used to develop the regression models.

Based on the information obtained, educational materials and an evaluation tool will be developed in cooperation with participating states to encourage older individuals to practice safe food handling behaviors. The materials will be disseminated to older individuals in the participating states as an educational intervention, with a particular emphasis on reaching recipients of home delivered meals.

Objective 2, Experiment 1
The effect of combined physical activity and dietary interventions on body composition, physical performance, and CHD risk factors in overweight and obese older adults. (URI lead; UNH participating)

Purpose. To develop effective intervention strategies to improve physical performance and reduce CHD risk factors in overweight and obese older adults.

Methods. Several different modes of exercise interventions focusing on reversing the negative effects of sarcopenia will be investigated in older adults over the age of 60 years who are overweight or obese. All participants will receive medical clearance from their primary care physician prior to joining the study to ensure that weight loss and structured physical activity is appropriate for them. These older men and women will be randomized (n = 25 per group, based on our 400 meter walk change pilot data) to a different exercise training or control group for ~ 24 weeks. All subjects will attend weekly nutrition education sessions that will consist of small group sessions that will focus on implementation of the modified DASH diet by increasing whole grain, fruit and vegetable, mono- and polyunsaturated fat intake while decreasing total caloric intake for 5-10% weight loss. Exercise intervention groups will include yoga, Tai Chi, and resistance exercise (muscle power) training. Each of these interventions will be based on previously published methods that have proven to be successful in improving physical function in older adults who are at risk of functional limitations but have not been applied during dietary weight loss. These exercise interventions will follow standardized formats but will also be individualized based on each subjects current condition and rate of progression. These various exercise intervention modes will be done three times per week and will be conducted at the URI station. Trained exercise physiologists and graduate students will administer the exercise portion of the study, while a registered dietitian will oversee the nutrition education intervention component, which will include providing calcium and vitamin D supplements. The control group will consist of a usual care, dietary weight loss only encouragement to increase physical activity. Outcome measures will include changes in leg extensor muscle strength and power, physical function (400 meter walk, short physical performance battery), fasting lipids and glucose, body and muscle composition (DXA, computed tomography/MRI of mid-thigh and mid-abdomen), bone density (DXA), BMI, and food frequency and physical activity questionnaires. Additional demographic information will also be collected for descriptive purposes for each group. All data will be collected at the URI station for analysis. In addition, subjects will be tested for macular pigment in Objective 2, Experiment 3b (below).

Objective 2, Experiment 2
Investigating determinants of macular pigment density as a biomarker of carotenoid status and eye disease risk in the elderly.

2a. Purpose. To determine the impact of pregnancy and lactation on lutein status, retinal health and MPOD; Does number of pregnancies impact lutein/n-3 FA status and health risk with aging. (UNH lead; LSU participating)

We will build on our previous work on age-related macular degeneration (AMD), macular pigment density, dietary lutein and dietary DHA. As women, compared to men, are at higher risk for AMD we propose to explore if life events and choices that are specific to women (number of pregnancies and breast feeding versus formula feeding) diagnosed with AMD are related to incidence for AMD. This will be done by retrospective examination of medical records; this will be carried out in partnership with clinicians in ophthalmology and pediatrics at LSU Medical School. Additionally we will examine how both pregnancy and breast feeding impact macular pigment density in women. These data will help establish if pregnancy and breast feeding women should be consuming more lutein and DHA compared to non-pregnant and non-breast feeding women to protect their retina with aging.

2b. Purpose. To assess the impact of exercise and weight loss on carotenoid status and macular pigment optical density (MPOD); to characterize the transport of lutein and MPOD as impacted by exercise and/or weight loss. (UNH lead and RI participating)

This study is an expansion of our current research looking at transport of lutein following supplementation for 120 days. The methodology for evaluating carotenoid status and MPOD will be coordinated with the exercise study of URI (Objective 2, experiment 2). RI will identify and screen subjects for inclusion in Objective 2, Experiment 2 and collect relevant dietary, anthropometric and biochemical data. MPOD will be measured using a Macular Metrics heterochromatic flicker photometry unit set-up at the laboratory at URI. Subject MPOD will be established at baseline and measured every 4 weeks for the duration of the 16 week intervention. At the time of each retinal measurement, blood samples will be collected for carotenoid analysis by HPLC at NH. Changes in MPOD and carotenoids will be assessed along with changes in serum cholesterol, lipid profiles, dietary and anthropometric measures.

Conceptual model
A conceptual model of this proposal is presented in Figure 1, showing relationships between the different issues being addressed in this proposal.

Measurement of Progress and Results

Outputs

• Development and pre-testing of an educational curriculum designed to increase whole grain food consumption in older adults.
• Analyzed results of dietary change in conjunction with three different exercise regimes to determine which has a greater impact on physical functioning and reduced coronary heart disease risk.
• A Food and Physical Activity Environment tool will be developed for communities to use to assess local environments supportive of increasing fruits, vegetables, whole grains, and physical activities in older adults.
• A culturally sensitive recipe book with traditional recipes collected from participants to motivate participants to use familiar recipes with healthier modifications.
• Data indicating how dietary intake of folic acid affects plasma levels of homocysteine, cholesterol (total, LDL, and HDL), triglycerides, glucose, and CRP, and cognitive indicators of memory.
• Assessment of macular pigment density data as it relates to dietary and plasma lutein; plasma or RBC DHA levels; and the ratio of plasma lutein to plasma/RBC DHA levels.
• Analyzed data on the association of number of births and/or the length of breastfeeding early in life (during the childbearing years) with the incidence of age related macular degeneration or blindness later in life (postmenopausal years).
• Analyzed results of the FDA Food Safety Survey focusing on trends related to food handling and food safety practices among older adults >60 years of age.

Outcomes or Projected Impacts

• 50% of older adults participating in the whole grain foods education program will increase their whole grain food consumption.
• Older adults who were at risk for obesity related disabilities and co-morbidities will have improved health indicators.
• Using the tool developed as part of this project, food policy councils of local communities will assess their local environments and develop action plans for improving the eating and exercise habits of older adults.
• Older adults will have an increased awareness of how lutein and DHA may affect their risk of developing AMD.
• 50% of older adults participating in the Washington, D.C. congregate meal sites will improve their diet with respect to increasing their intake of fruits, vegetables, and whole grains.
• 50% of older adults receiving home delivered meals will initiate changes in their home food safety practices that will reduce their risk of developing a foodborne illness.

Milestones

(2009): Obtain IRB approval for all studies requiring human subjects, and recruit subjects and collect baseline data. For the whole grain education curriculum, a draft document will be developed, comments and suggestions will be obtained. Diet assessment tools and evaluation tools will be selected or developed, and the curriculum will be pre-tested. For the diet and exercise experiment, data will be collected on the first cohort of 40-50 participants.

(2010): A final draft will be developed of the whole grain education program, and extension educators and specialists will be trained to deliver this program. For the diet and exercise experiment, data will be collected on the second cohort of 40-50 participants, and the follow-up on the first cohort of 40-50 participants will be completed. For the community environment study, a survey will be administered to elder service staff and community members on food availability and environments supporting healthy eating and physical activity in older adults. Experiments will be conducted to investigate the effects of lutein and DHA on macular pigment density (MPD). For the social activity experiment, baseline information will be collected, focus groups will be conducted, and the nutrition games will be developed. Begin analysis of data collected from elderly subjects who participated in the FDA Food Safety Survey.

(2011): The whole grain education curriculum will be implemented. The follow-up on the second cohort of 40-50 participants in the exercise study will be completed. A food and physical activity environmental tool will be developed and pilot tested for use in the community environment study. Nutrition education classes incorporating the nutrition games will be conducted as part of the social activity experiment. Complete analysis of food safety data and begin development of outreach educational materials.

(2012): Results of the whole grain education program will be evaluated. Data collected during the diet and exercise study will be compiled and analyzed, and work will begin on publishing the data. Depending on the results of the previous experiments, studies will begin on testing the effects of lutein and/or DHA dietary supplements on macular pigment density. For the social activity experiment, family/traditional recipes will be modified, education classes will continue, and the post test will be conducted. Complete development of food safety educational materials and disseminate materials.

(2013): The whole grain curriculum will be revised as needed according to the results of the evaluation. In the diet and exercise study, work will continue on publishing the results and on developing grant proposals. In the community environment study, the local food policy council will use the tool that was previously developed to assess the environment for meeting the food and physical activity needs of older adults. Information will be disseminated to the public on decreasing the risk of age related macular degeneration through the increased consumption of either lutein and/or DHA. Food safety educational materials will be evaluated. For all studies, continue data analysis and submit publications.

(2014): Alternative formats for education programs pertaining to the benefits of whole grains, fruits, and vegetables will be developed, and additional sources of funding will be pursued to continue these investigations. Continue to work on publications for all aspects of the project.

Projected Participation

View Appendix E: Participation

Outreach Plan

Publications in peer-reviewed journals; distribution of nutrition education materials to grassroots agencies, senior service and community based health service agencies (particularly those serving ethnic-minorities and low income older adults); presentations at local, regional and national professional meetings; posting of nutrition updates, consumer fact sheets, and research summaries on Departmental and College web sites (as relate to outreach or research).

Organization/Governance

Offices of the Technical Committee include Chairperson, Vice-Chairperson, Secretary, and Regional Administrative Advisor. The Executive Committee includes the Chairperson, Vice-Chairperson, Secretary, Member(s) at Large (1 or more), and Regional Administrative Advisor.

All voting members of the Technical Committee are eligible for office, regardless of sponsoring agency affiliation. Officers will be elected at the Annual Meeting of the Technical Committee (June), with the expectation that the Vice Chair moves to Chairperson. The Chairperson, in consultation with the administrative advisor, notifies the TC members of the time and place of meetings by mail, prepares the agenda, presides at meetings of the Technical Committee and Executive Committee, and initiates the formulation of ad hoc committees (ie. Nominating committee, publications committee, rewrite committee, etc.). The Chair is responsible for coordination of the preparation of annual reports and project revisions. The Secretary records the minutes and performs other duties assigned by the Chair, the Technical Committee or the Administrative Advisor. A Lead Research Station will coordinate all aspects of each study area (experiments) included under the objectives outlined in the research proposal. Publications related to the project will be proposed and/or reviewed as appropriate by the publications committee.

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Attachments

Land Grant Participating States/Institutions

DC, IA, LA, MA, MO, NH, NJ, RI, WV

Non Land Grant Participating States/Institutions