Duration: 10/01/2004 to 09/30/2009

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

Fruit, vegetables and whole grains contain numerous bioactive compounds that are involved in reducing oxidative damage in tissues, improving gastrointestinal function, and other physiological processes. A large body of evidence suggests that diets rich in fruit, vegetables and whole grains are associated with a lower incidence of coronary heart disease, hypertension, and some cancers (1-4). Furthermore, low intakes are associated with obesity, an independent risk factor for coronary heart disease, type 2 diabetes, and other chronic diseases. Conversely, improving consumption may also lower the risk of certain functionally debilitating diseases associated with aging, such as those that impair vision (age-related macular degeneration or cataracts), or negatively impact the digestive system (diverticular disease) (5,6). Thus, the habitual consumption of fruit, vegetables, and whole grains may be a means of extending the number of healthy and productive years for older adults and enhancing their overall quality of life.

Although older Americans are the most rapidly growing segment of the U.S. population, data are limited with respect to dietary and other lifestyle factors involved in achieving or optimizing their health status. Poor physical health also exacts an economic toll, as older adults who are disabled by or hospitalized for largely preventable, diet-related diseases represent a disproportionate amount of national health care costs (7,8). Many of these seniors burden the already stretched resources of social service and community-based agencies such as congregate and home delivered meal programs, and the adult day care system. For example, it has been estimated that for each line of vision lost, use of social services increases by 12% in this population.

Despite the importance of fruit, vegetable and whole grain intake in maintaining health and functional status, older adults are not meeting minimum dietary recommendations. Healthy People 2010: Objectives for Improving Health (HP2010) has set specific goals for Americans relative to fruit, vegetable and whole grain intake based on a broad scientific consensus (9). However, the Continuing Survey of Food Intakes by Individuals (CSFII) found that only about one-third of adults over the age of 60 consumed the recommended number of servings of fruit per day, half consumed the minimum daily number of vegetable servings, and about 40% consumed the minimum recommended servings of grains, including whole grains. Furthermore, only a fraction of those seniors surveyed selected vegetables and grain-based foods considered to be good sources of protective food constituents such as fiber and antioxidants. In addition and perhaps as a consequence, obesity is extremely high in the older adult population. One major concern facing nutrition educators related to this sub-optimal intake is that aging consumers are confused by conflicting media reports and advertisements related to the properties of fruit, vegetables and whole grains, making apparent the need for clearer informational messages. Disease prevention in the older population with the goal of fostering independent living and a high quality of life has been set as a national priority within federal health policy (HP2010) (9). Toward this goal, considerable integrated research needs to be conducted in order to improve fruit, vegetable and whole grain intake to reduce diet-related disability, obesity and chronic disease rates among rapidly growing numbers of older Americans.

Related, Current and Previous Work

IMPACTS / RESULTS OF THE CURRENT PROJECT (NE-172)

1. Modifiable factors (diet and weight) appear to influence macular pigment optical density (MPOD), however, changes in macular pigment may not be uniform across the retina as established through longitudinal supplementation studies. These findings could have significant public health implications if MP is determined to protect the retina from age-realetd eye disease.

2. Establishment of factors (BMI, glucose tolerance, diet/ n-6 to n-3 fatty acid ratios, docosahexanoic acid, and fish consumption) that underlie fatty acid status in vulnerable populations.

3. Daily consumption of blueberries (1 cup) for 1 month led to increased antioxidant status (oxygen radical absorbance capacity) in older women; evidence of an antiinflammatory effect (anti-platelet aggregation) related to blueberries in this population.

4. Dietary patterns that feature fruit, vegetables and grains (and their biomarkers) were associated with a more optimal weight status and other physiological markers of health in older adults.

5. A screening tool to estimate carotenoid intake, complete with a program that calculates actual carotenoid values, was developed, tested and validated against 3-day food records and food frequency methodologies in an older, low-income population.

6. Evaluation of knowledge, attitudes and barriers related to the intake of fruit and vegetables reveals the need to educate older consumers in the areas of lutein/antioxidant food sources and the association between the intake of carotenoid rich foods and prevention of age-related macular degeneration (AMD).

7. Developed strategies and training to improve environmental availability of fruit and vegetables through community emergency food systems and to improve the availability and quality of relevant nutrition information to older food pantry participants using train the trainer techniques.

8. Testing of qualitative interviewing techniques to gather dietary and food behavior data from older African American men.

The results of the NE-172 work set the stage for new and continued intervention studies as outlined in this proposal. An historical review and a collection of papers representing some of this work will be published in the journal "Topics in Clinical Nutrition," Volume 19:3, 2004.

NE-172 investigators have shown that blood and tissue concentrations of antioxidants found in fruit and vegetables may serve as biomarkers of dietary intakes of these foods. For example, the ORAC (oxygen radical absorbance capacity) value increases significantly with the consumption of blueberries, a source of flavonoids. MPOD (macular pigment optical density) is associated with intake of fruit and vegetables, dietary sources of carotenoids. More needs to be known related to the detection of these dietary components in whole grains and the evaluation of their physiological effects. Further refinement and testing of dietary intake methodology to document intake of fruit, vegetables and whole grains will serve to enhance the quantification of intake of protective food components, and to assess the value of increasing the intake of these foods in the older person's diet. The association of biomarkers with functional endpoints (obesity, glucose tolerance, hypertension) in an older population will be investigated within the context of dietary intake patterns of fruit, vegetables and whole grains.

NE-172 researchers have also studied carotenoids and n-3 long-chain fatty acids, nutrients for which there is compelling evidence for a role in the prevention of age-related macular degeneration (AMD). The importance of this research lies in the fact that cataracts and AMD are the leading causes of visual impairment in the US. The incidence of these diseases is increasing with the aging population, exacting a serious economic toll. Cataract extraction represents the largest single line item on the national Medicare bill. Delaying or preventing the onset of age-related eye disease will have a significant impact on the quality of life for seniors and will significantly reduce associated healthcare costs (www.nei.nih.gov/news).

NE-172 researchers have found that the carotenoids lutein (L) and zeaxanthin (Z) are selectively sequestered in the macular region of the human retina where they are collectively known as macular pigment (MP). (L) is also found lining the lens capsule. Since humans do not synthesize carotenoids de novo, the origin of the pigment must be the diet. Previously, we and others have shown a significant relationship between diet and MP; ie. diets rich in vegetables and fruit are associated with increased MP (5,10,11). Meanwhile, other research indicates that diets rich in fruit and vegetables are associated with decreased risk for AMD and cataract (12,13).

In green plants, (L) and (Z) are associated with chlorophyll where they serve as accessory pigments in the process of photosynthesis. According to our work and in agreement with the USDA food composition tables, the most concentrated dietary sources of (L) include the green leafy vegetables, spinach and kale (14). The goal of the proposed research is to determine if increased daily consumption of spinach by a single serving will increase MP and alter other physiological markers of oxidative stress associated with AMD. There is also growing evidence for the involvement of n-3 long chain fatty acids (eicosopentanoic acid, EPA, 20:5n-3; and docosahexaenoic acid, DHA, 22:6n-3) in retinal health, specfically decreasing risk for AMD (15,16). The proposed study will build on the current work as plasma and plasma phospholipid fatty acids will be evaluated as they relate to MP, diet and other physiological assessments.

Carotenoids are a group of fat soluble compounds formed by plants and
photosynthetic microbes. Dietary carotenoids are absorbed from the small intestine, and are transported via lipoprotein carriers in the blood or serum. Concentrations of carotenoids in human serum and tissues are extremely variable, and reflect not only diet and supplement use, but also factors including food matrix, fat intake, cholesterol and lipoprotein status and body composition (16-19). Typically, as BMI approaches or exceeds clinically defined obesity (> 30.0) there are lower circulating levels of carotenoids. Increased BMI is also associated with decreased glucose tolerance, increased
insulin resistance and altered lipoprotein status (20, 21). NE-172 researchers have found that intake of the carotenoids (L) and (Z) and serum carotenoid concentrations are positively associated with MP status; there are conflicting research results reported for the influence of age and BMI on MP (21-23). As BMI is inversely related to carotenoid intake and circulating concentrations, and plasma phospholipid DHA, it may also be inversely related to macular pigment.

One aim of the proposed research is to investigate factors that influence MP density and health status as related to dietary intake and intervention in an older population. To our knowledge no study has evaluated the relationship of physiological status, including a plant-based diet intervention on lipid profiles, oxidative stress markers (when blood may be drawn), BMI, diabetes risk parameters and MP in an older cohort. If diet or lifestyle practices can enhance or alter the health risk profile including increased MP, delaying or preventing decline in health status (specifically ocular health), enhanced quality of life may be realized.

Arterial thrombosis can result in heart attack and stroke, the two most common causes of mortality in developed countries. Platelets, with fibrin, are prominent components of the clots that occlude arteries, but platelets may also participate in the development and progression of the atherosclerotic plaque. Most acute coronary syndromes are caused by platelet adhesion, aggregation and thrombus formation in the area of ruptured atheromatous plaques. Decreased platelet aggregation at low agonist (collagen) concentrations has been observed in human subjects. In the current work, preliminary data from 7 human subjects who consumed 1 cup of blueberries in their normal diet for 2 weeks indicate that at low collagen concentrations platelet aggregation was decreased relative to the sampling period after no consumption of blueberries. Inhibition of platelet aggregation with low collagen concentrations has also been seen with aspirin, which is one of the most widely used inhibitors of platelet function and is the standard against which other agents are judged (24,25). The response in platelet aggregation with aspirin is dose dependent, but inhibition up to 48% has been observed with collagen as an agonist (25). Blueberry is the only fruit or berry other than purple grapes(juice) that has been shown to have inhibitory effects on platelet aggregation (26-30). Grape juice consumption led to a 12.8% decrease in platelet aggregation (30). In vitro/in vivo studies have demonstrated that purple grape juice inhibits platelet aggregation and production of superoxide anion and increases platelet formation of nitric oxide (28-32). In animals and humans, Folts et al have shown that 5-10 ml/kg of purple grape juice inhibits platelet activity, and protects against epinephrine activation of platelets (29,31). Grape juice enhances platelet and endothelial production of nitric oxide (27,33,34). However, no studies have been conducted on specific components within Concord grape or blueberry on platelet aggregation.

Both the study of dietary behavior and use of behavior change interventions in older adults should be approached differently than in a younger cohort. The NE-172 project has worked over the past five years to develop age-appropriate dietary and related assessment tools that are both valid and reliable. Valid and reliable dietary intake measures are needed to establish the association of food intake with physiological and biochemical measures of nutrition risk. Several new approaches and instruments have been under development, including a 'Carotenoid Food Screener/Calculator' (35). Lessons learned from the development and testing of this instrument will be applied to develop a new prototype 'Whole Grains Food Screener/Calculator.' Both of these instuments will be tested with vulnerable aging groups such as those with limited incomes, those living in isolated, rural areas, and older adults of diverse backgrounds, including African Americans and Latinos (non-Mexican).

Using the Logic Model as a framework for planning, implementing and evaluating the proposed project, the dietary, health risk and functional outcomes related to low fruit, vegetable and whole grain intake by older adults will drive new educational strategies (see appendix for a sample whole grain application of the model)(www.uwex.edu/ces/pdande/). The overall goal of these strategies will be to increase the likelihood that older adults will improve their intake of fruit, vegetable and whole grains, consistent with the most recent dietary advice reflected in the Dietary Guidelines for Americans, and the Food Guide Pyramid. Desired changes may also be qualitative (e.g. substituting antioxidant rich fruit, vegetables,or whole grains for foods with lower or no significant antioxidant capacity). These nutrition education interventions will be developed collaboratively and will be tested by participating stations in their respective states/regions. At the individual/household level, these interventions will be evaluated based on short and medium term outcomes, and the subsequent, potential impact on the long-term health/quality of life for older participants (improvements of health risk factors or functional outcomes). At the community/institutional level, assessment of outcomes will be based on increased awareness by agencies of relevant nutrition issues for the older adults they serve, participation in the development of plans to address issues, and in the long term, evidence of improved conditions that will enhance or positively affect clients' fruit, vegetable or whole grain intake and nutritional status. A variety of educational techniques will be required to reach diverse, hard-to-reach elders (rural, low-income, multi-ethnic).

The food provisioning process is an important framework for examining the processes food undergoes from purchase through disposal. There are five stages of the food provisioning process:acquisition, preparation, cooking, eating, and disposal (36). Although each stage is important, it is the acquisition stage that is pivotal to determining which foods are available for in-home consumption. Identifying the complexity of food choice factors, or 'why' consumers select the foods they do (37) , will enable nutrition educators to design behavior change interventions based on what influences the food choices of the target audience. General food choice factors have been identified for a number of target groups, including older adults (38). However, few studies have examined food choice factors related to fruit, vegetables or whole grains.

Further, nutrition educators need information on how the complex array of food choice factors is translated into food-related practices (behaviors) or the 'how' of food selection. Understanding the target's food cognitions and classification systems will help researchers to frame interventions that are compatible with how the target audience thinks about, simplifies, and implements factors throughout the food provisioning process. Cognitive interviewing or 'think aloud' techniques are used extensively to enhance survey development (39,40). Building on previous food intake assessments by the NE-172,these techniques will also be used clarify food choice factors in older adults (41).

Despite the scientific evidence linking fruit, vegetables and whole grains to health, most older adults do not consume the recommended number of fruit and vegetables (42), or include sufficient fiber in their diets. Several factors that are related to intake in older adults may inform interventions to increase consumption. Gender may play a role, but its effects on fruit and vegetable consumption have been inconsistently reported (43,44). Some research has reported that men had higher intakes of fruit and vegetables (5.7 servings) than women (4.8 servings), while the oposite has also been found. Male elders generally are less able to cook meals than women, and age has been associated with reduced vegetable intakes among the oldest of respondents (aged 75 years and older) (44,45). Living arrangements have been shown to affect fruit and vegetable intakes of older men; some research has found that the presence of a woman in the household has a significant positive effect on fruit and vegetable intake (44). Marital status may also influence intake of plant foods: single men consume fruit and vegetables less often than single women or married men and women; single men also eat a less varied selection of vegetables than others in thier age cohort. Psychological factors affecting fruit and vegetable intake in older adults include social support and attitudes toward personal connectivity and community involvement (45). Work conducted by NE-172 researchers and others associate fruit and vegetable intake with income, social class and education among older adults (43-46).

The most recent edition of the Dietary Guidelines (DGs) for Americans (USDA/DHHS 2000) emphasizes the importance of whole grain foods: 'Choose a variety of grains daily, especially whole grains.' This underscores emerging research suggesting that whole grains contribute significantly to the foundation of a nutritious diet, having important implications in reducing the risk of diabetes, stroke, coronary heart disease, and other chronic diseases (47-49).

Whole grains are grains that have not been refined to remove any of their nutrient-rich layers (bran, germ or endosperm). A whole grain food is a food that contains as its main ingredient the entire grain kernel. Compared to foods made with refined grains, whole grain foods generally have higher amounts of fiber, antioxidants, and other phytonutrients, which may act synergistically to produce multiple health benefits (50,51). The Dietary Guidelines advise consumers to eat 'several' servings per day of whole grain foods (whole wheat breads and crackers, oatmeal, brown rice, corn tortillas, barley soup, tabouli salad). However, there is minimal concensus as to what 'several" means, adding to consumer confusion. In addition, whole grain foods may be non-traditional or unfamiliar to many older people. Moreover, most people are unable to identify a whole grain food from information provided on the product label (52). Although the DGs also suggests that consumers use whole grains in mixed dishes, this practice is unlikely because consumers lack adequate cooking skills and have little time to prepare meals from scratch. Consequently, whole grain intake in the overall population, as well as seniors, is low (53,54). Considering the scientific evidence documenting the importance of whole grains, it is critical that researchers learn more about barriers to the consumption of whole grains, that consumers learn more about what these foods are, how to incorporate them into their snacks and meals, and how to read labels to determine whether or not a food product actually is a whole grain food (55).

Innovative methods are needed to increase fruit, vegetable and whole grain consumption in elders, especially those who are single, with lower incomes/ educational levels, and less socially engaged. Multifaceted approaches will be required to bring the message of increasing fruit, vegetable and whole grain intake. The information needs of individuals will need to be met, as well as creating system and environmental changes through the use of current health behavior theories to effect desired dietary modifications of older people (56). Efforts to increase fruit and vegetable availability in homes and other sites where elders obtain food, such as elder meal programs, adult day health programs, and food pantries, are needed. Models such as the Logic Model are useful in examining the system of agency-based services offered to elders and to identify inputs (such as staff, funds, and time), outputs (such as workshops, curricula, and other services), and outcomes (such as behavior or social change). Staff training can also be an important way to reach elders in need, as many staff in adult day health facilities as well as food pantries are interested in receiving additional nutritional training (42). Few studies have examined the effectiveness of agency-based nutrition education to increase intake of fruit, vegetables, or whole grains in older adults, or have documented changes in outputs or outcomes as a result.

RESULTS OF CRIS SEARCH

A CRIS Search initially revealed 60 matches when the key words, "Elderly; Aging; Fruit, Vegetable, Whole Grain Intake; Antioxidants and Nutrition Risk" were submitted. Nine studies were redundant with each other, leaving 51 matches. Twelve of those were NE-172 research projects (current work), leaving 39 non-NE-172 matches. The proposed project does not appear to duplicate any of the other 39 CRIS generated studies. In fact, no studies were revealed that addressed whole grain intake in older people.

PLANS TO SECURE ADDITIONAL FUNDING

PA: Improving Diet and Physical Activity Assessment/Screening for Diet Quality in Rural Older Adults (NIH)

MA: Massachusetts Family Nutrition Program (USDA/FNS); Care Giver Nutrition Education ( MA Dept. of Education)

MD: Nutrition and Aging (FDA/UMD Joint Institute for Food Safety and Applied Nutrition)

RI: Rhode Island Family Nutrition Program (USDA/FNS); URI Food, Hunger and Nutrition Partnership (President's Initiative, URI)

Objectives

1. Improve methods of measuring intake of fruit, vegetables and whole grains to include biomarkers, dietary assessment and associations with obesity, other biomarkers and functional endpoints in older adults.
   
2. Develop effective assessment techniques and intervention strategies to improve intake of fruit, vegetables and whole grains by older adults.
   

Methods

OBJECTIVE 1: Improve methods of measuring intake of fruit, vegetables and whole grains to include biomarkers, dietary assessment and associations with obesity, other biomarkers and functional endpoints in older adults. Experiment 1A: Hypothesis: Increasing dietary intake of lutein rich vegetables by one serving per day will increase retinal carotenoids and alter the physiological markers in such a way as to reduce risk of Age-related Macular Degeneration (AMD) and cataract (NH Lead). Methods: Healthy, non-smoking adults ages 25-65 (n=50) will be recruited by poster and advertisement in local papers (NH). Subjects will be screened for visual acuity and will complete a fruit and vegetable screener and a food frequency questionnaire. Macular pigment density will be determined by heterochromatic flicker photometry resulting in a macular pigment optical density (MPOD) and distribution. A fasting blood sample will be collected to analyze serum carotenoids, lipid profiles, plasma fatty acids, and ORAC. Weight, height, and waist circumference will be measured; BMI will be calculated. Initially, all subjects will receive an inert 'nutritional' supplement, and will be measured for one month (baseline) by diet, serum and MPOD measurements. Subjects will then be randomly assigned to continue with the placebo or the intervention. The lutein intervention consists of a one-half cup serving of frozen spinach or spinach entree (grown, analyzed and prepared at UNH) to be consumed daily for 4 months. Subjects will return biweekly for MPOD evaluation and monthly for serum measurement. Anthropometric and dietary data will be collected monthly. Experiment 1B: Hypothesis: Dietary intake of fruit and vegetables will positively correlate with MPOD and inversely correlate with BMI, serum cholesterol, fasting blood glucose and triglycerides. Following the interventions (improving nutrient density or increasing number of servings), the relationships will be strengthened (NH Lead). Methods: URI will identify and screen aging subjects meeting the visual criteria for inclusion in this study (through grass root partnerships, senior centers, community action programs). URI and UNH will collect relevant dietary, anthropometric and biochemical data. Physiological data will be collected from subjects prior to and following participation in interventions and assessments described under Objective 2, Experiments 1 and 2. Samples will be collected in RI and distributed to the appropriate stations for analysis. Macular pigment optical density will be measured using a Macular Metrics heterochromatic flicker photometry unit. Cholesterol, fasting blood glucose and triglycerides will be measured using a finger stick sample and will be processed using a Cholestech autoanalyzer. Dietary and anthropometric measures will be collected as described in Objective 2. Experiment 2: Hypothesis: Dietary patterns with higher proportions of fruit, vegetables and whole grain will be associated with indexes of dietary quality, quality of life, with weight status, and with selected biomarkers (PA Lead). Diets are complex with multiple components including nutrients, other natural compounds, additives, and foods and potentials for interaction (57-59). Studies of dietary patterns generally focus on food groups rather than on individual foods. Recent food pattern analyses have focused on multiple food groups using several analytic techniques including factor and cluster analyses(60-61). The purpose of this experiment is to identify food patterns and to determine the relationships between patterns and indicators of nutritional/health status in rural, older, primarily white adults and a sample of minority urban adults. Methods: The rural study sample (n=200, PA) will be selected from participants in the Geisinger Rural Aging Study (GRAS, 21,000 seniors). At the time of initial enrollment, participants were 65 years or older and split evenly by gender. Random samples of 100 persons will be recruited until 225 persons are identified. The urban sample (n=100, CT) will be minority older adults residing in metropolitan Hartford, CT. Random samples of 100 persons will be generated to recruit 110 persons for the final sample. Data collection will take place during a baseline visit (PA: primary care clinic; CT: FSNEP offices), and by telephone for 24-hr diet recalls (four recalls, total). Food group analyses will be based on established procedures (62). Mean Adequacy Ratio (MAR), a Healthy Eating Index (HEI) score and energy density (ED)will be determined. Multivariate techniques, including cluster analysis, will be used by PA, CT and the USDA/HNRCA to describe dietary patterns. The diet quality and pattern procedures have been selected because of association with biomarkers or weight status in previous research. Baseline demographic and health-related data will also be collected and used for descriptive purposes. Height, weight and waist circumference will be measured; Body Mass Index (BMI) will be calculated. Standardized procedures developed on the basis of the NHANES will be followed (63). A venous blood sample will be obtained from participants after a 12-hour fast(analysis of folate, cobalamin, MMA, homocystein, C-reactive protein, glucose, blood lipids, ORAC and carotenoids). Experiment 3: Anticoagulation Study with Blueberry Consumption (ME/AR Leads) Methods: A study of 36 adult females will be carried out in ME. Three groups of 12 each (half non-smokers, half smokers), will be formed. One group will consume 1 cup of wild blueberries per day for four weeks, another group 1/2 cup of wild blueberries per day for four weeks, and a control group will consume no blueberries. Fasting blood and urine samples will be taken at baseline, two and four weeks. A full dietary profile will be examined utilizing food frequency and recall/record data. Blood and urine samples will be sent to USDA/ARS and UConn for specific analyses; dietary data will be analyzed by Maine. Maine researchers will be trained in platelet aggregation analysis at the USDA/ARS Arkansas Center; the equipment for analyzing platelet aggregation will be released on loan to ME so information can be recorded at the time of the blood draws. Raw data will be forwarded to AK for final analysis. Platelet aggregation studies will be performed using a whole-blood aggregometer using impedance measurements. Collagen will be used as an agonist. Determination of Antioxidants and Oxidative Damage Products: Ascorbic acid, uric acid and a-tocopherol in plasma will be analyzed. Malondialdehyde, a lipid peroxidation product of polyunsaturated fatty acids, will be measured by HPLC with fluorescence detection using published methods (64) and ESA Application Note on Malondialdehyde determination. Baseline diene conjugation as a direct measure of in vivo LDL oxidation will be measured (65-67). 8-OxodG will be measured in urine by using the commercially available monoclonal antibody ELISA kit. (USDA ARS). C-Reactive Protein will be determined using the high sensitivity CRP test system (68). Fatty Acids and Lipids: Plasma and plasma phospholipid fatty acids will be assessed using procedures established at UConn. Plasma cholesterol, HDL cholesterol and triglycerides will be determined. Antioxidant Capacity: The automated ORACFL assay will be carried out on a BMG Fluorescence Microplate Reader. In the final assay mixture (0.4 ml total volume), fluorescein will be used as a target of free radical attack, with 2,2'-azobis(2-amidinopropane) dihydrochloride (AAPH) (4 mmol/L) as a peroxyl radical generator. Trolox (6 Hydroxy 2,5,7,8-tetramethylchroman 2 carboxylic acid) will be used as a control standard. The analyzer will be programmed to record the fluorescence every 2 minutes after AAPH addition. All fluorescent measurements will be expressed relative to the initial reading. Final results will be calculated using the differences of areas under the fluorescence decay curves between the blank and a sample, and expressed as 5mole Trolox equivalents. OBJECTIVE 2: Develop effective assessment techniques and intervention strategies to improve intake of fruit, vegetables and whole grains by older adults. Experiment 1: The effect of improving intake of deeply colored fruit and vegetables on overall diet quality and anthropometric and biochemical measures of nutrition risk in older adults (RI Lead). Many health education initiatives promote increasing the number of fruit, vegetables and whole grain products in the diet. Given the nationwide problem of obesity and the lower caloric needs of the elderly, a better approach might be to promote switching to more nutrient dense food sources, rather than increasing the number of servings. The purpose of this experiment is to evaluate if a nutrition education intervention promoting an improvement in intake of nutrient dense food sources will affect overall dietary quality, serum cholesterol, serum glucose, and BMI, and further, to determine if improving the nutrient density of fruit and vegetables alone, whole grains alone, or the two groups in combination is the most effective in improving these parameters overall for the target population. The nutrient dense food sources being studied include 1) deep-colored fruit and vegetables only, 2) whole grains only, and 3) both deep-colored fruit and vegetables and whole grains. Methods: Nutrition education interventions will consist of face-to-face, interactive workshops that will include information related to nutrient dense food choices, recipes, and taste testing of promoted foods. Workshops will be presented to low-income elderly populations residing in community senior housing sites in RI and through other cooperating states/stations. Materials will be pre-tested in a parallel population. Workshop presenters will be trained graduate students from URI and other cooperating stations. Three different housing sites will be used, one for each of the experimental conditions, to ensure no contamination across subjects. Prior to the workshops, subjects will complete multiple dietary records in person and by telephone, have serum values taken, and be weighed and measured using standardized protocols. Demographic data will be used for descriptive purposes. BMI will be calculated. The community based workshop series will be presented over a 1 year time period with an anticipated sample of 10-15 older adults per group (approximately 30-45 subjects per station). A minimum of 4 workshops will comprise a series. Repeated measures will be collected at the end of one year (dietary, serum, and anthropometric measures/BMI). All data will be collated at the URI station for analysis. Experiment 2: Identification of food choice factors associated with fruit, vegetables and whole grains using cognitive interviewing techniques with older adults (NH Lead). Methods: This experiment will utilize a qualitative methodology to assess the cognitions and food shopping practices utilized by older adults related to the purchase of fruit, vegetables and whole grain foods. A semi-structured interview protocol will be developed based on cognitive interviewing ('thinking aloud') techniques. Interview questions will probe how older adults think about factors that influence purchase of these foods. In addition to food choice factors, food shopping practices or how these foods are purchased will also be explored. Interviews will be conducted with a broadly representative sample of older adults through participating research stations. Researchers will be convened to identify discrepancies between what is known about this target group and what information is needed to complement or expand the knowledge base. For example, interview questions may support Experiments 1 and 3 and complement Experiment 4. Based on these, the interview protocol, questions, and coding procedures will be developed, pre-tested, and revised. Participating states will conduct approximately 10 to 15 interviews for a total sample of 50 to 75 older adults. Interviews will be audio-recorded and transcribed verbatim. Transcripts for field notes and interviews will be checked for accuracy by each interviewer. Content analysis of the transcripts will be conducted by participating researchers. Inter-rater reliability of transcript coding will also be completed by the research group. Emerging themes and trends will be identified. Use of confirmatory statistical analysis will be explored. Experiment 3: Assessing Impact of a 'Farm-to-Table' Approach to Improving Diets of Older Adults (ME/RI Leads). The overall aim of this effort will be to assess the availability and accessibility of farm to table initiatives for seniors (such as the Senior Farmers' Market Nutrition Program (SFMNP) and to promote the purchase of locally grown produce as a way to increase fruit and vegetable intake in a variety of senior populations (69). Participating stations will, using new and existing systems as educational vehicles in their states, create educational/promotional materials (fact sheets, resource listings, recipes) and/or programs to increase senior purchases of locally grown foods. Methods: Maine Senior Farm Share (MSFS) is a unique Seniors Farmers' Market Nutrition Program (SFMNP) that provides low income seniors with the opportunity to purchase fresh fruit and vegetables from local farmers. MSFS does not require participating elders to use coupons to purchase fruit and vegetables from farmers' markets; Maine is the only state that is able to currently provide each senior with a $100 share, whereas seniors in other states receive only $50 in vouchers. Maine also permits seniors to use their shares at farmers' markets and farms stands. One study will involve a comparison of the variety of fruit and vegetables that low income seniors of Maine receive when they participate in the MSFS program. Some seniors receive their fruit and vegetables by delivery from farmers; others pick up their fruit and vegetables at farms or farm stands, making their own selections. However, fruit and vegetables available at any one time may vary. Data on the type and amounts of fruit and vegetables obtained will be tracked. One objective is to see if seniors who have fruit and vegetables delivered are accessing a wider variety compared to the seniors who are picking out their own fruit and vegetables, and to determine impact on diet quality. In addition, we propose to analyze the overall effect of the MSFSP on increasing consumption of fruit and vegetables by participants. Intakes will be assessed during the growing season and will be compared to intakes at other times of the year. Assessments will occur in the months following the end of the program, and before the program begins a new cycle (Do seniors continue to buy fruit/vegetables in the off-season; Develop new preferences for fruit/vegetables; Positively alter their overall diet?) In RI, CT, MA and DC, researchers will work with SFMNPs to assess the level of participation of low income seniors, to assess factors influencing participation (cognitive interviewing techniques will be folded into this effort), and to evaluate purchases and the impact of these purchases on diet quality and longer term behaviors related to sustained or improved overall intake of fruit/vegetables. Nutrition education materials related to the purchase, preparation, storage and nutrient/phytochemical content of a variety of foods available through SFMNPs will be identified, or developed and tested. These materials will be distributed through community based workshops provided through cooperating stations and through existing SFMNP networks. This work will be coordinated with the Maine station. Experiment 4: Awareness, knowledge, attitudes, and behavior of elderly individuals with respect to whole grain foods (MD Lead). Methods: A survey instrument to assess awareness, knowledge, attitudes, and behaviors associated with whole grain foods will be developed and validated, including pre-testing and cognitive testing. The instrument will address knowledge of the health benefits of whole grains, awareness of the FDA-authorized health claim ('Diets rich in whole grain foods and other plant foods, that are low in total fat, saturated fat, and cholesterol, may reduce the risk of heart disease and certain cancers'), ability to recognize whole grain foods and ingredients from product labels, misinformation or misconceptions, frequency of consumption, attitudes and beliefs including barriers to purchasing and consuming whole grain foods, and self-efficacy. The latter issues will be addressed in the context of the stages of change model of behavioral theory (70). In addition, a new Whole Grains Screener, based on the previously developed Carotenoid Screener (35), will be tested for use in this population. The survey will be administered in-person to through participating stations, or when able, subjects will complete the survey on their own and will return it to the researchers. Data will be collected at each participating station and collated and analyzed at UMD. Results will be used to identify gaps in knowledge, to develop strategies to help consumers identify whole grains at the point of purchase, and to develop appropriate educational interventions aimed at increasing the intake of whole grain foods. The effectiveness of the intervention to positively change attitudes and behavior will be evaluated in conjunction with Experiment 5. Experiment 5: Evaluation of the effectiveness of staff and consumer training on changes in outputs and outcomes related to fruit, vegetables and whole grains using the Logic Model in agencies serving elders (MA Lead). Methods: Staff training guides and consumer fact sheets developed by investigators in this project as well as others will be reviewed for dissemination through this study. A core set of materials to increase fruit, vegetable and whole grain consumption in elders who participate in community-based programs will be identified. Other materials, such as Powerpoint slides that can be used by sites to teach others, and materials targeted specifically to the psychosocial needs of participants, will also be developed. Participating stations will identify common outputs (workshops, staff use of materials to teach others, number of participants, etc.) and outcomes, including dietary change, increased knowledge, and improved ratings on measures of health and quality of life. Staff in adult day health programs, elder nutrition programs (congregate/home-delivered meals), food banks/pantries and other community service sites will participate in nutrition trainings and will provide nutrition training and information to other staff and consumers using project materials. A comparison group of non-participating staff/consumers will also be identified. A core of pretest-posttest questions will be developed based on prior work and pilot-tested to identify changes in outputs and outcomes as a result of interventions. All data will be collated at UMass for analysis.

Measurement of Progress and Results

Outputs

• Develop and validate survey instruments and develop interview protocols; recruit subjects; administer surveys and conduct interviews; manage and analyze data.

Outcomes or Projected Impacts

• Participants/clientele/subjects will gain skills, awareness, and knowledge, and will demonstrate positive changes in attitudes, regarding the importance of choosing more nutrient dense fruit and vegetables and more whole grains; reading food labels; comparing prices at the grocery store; understanding portion size; and planning meals using the Food Guide Pyramid.
• Participants/clientele/subjects will change their behavior and improve their nutrition by consuming more nutrient dense fruit and vegetables and more whole grains; choosing healthy snacks, convenience foods, and fast foods; and paying closer attention to food labels when shopping.
• The incidence of functionally debilitating diseases associated with aging, such as AMD, cataracts, coronary heart disease, and other diet-related chronic diseases, will gradually decrease.
• Personal and systems social service and health care costs will be reduced.

Milestones

(2005): Identification of existing nutrition education materials; Collection and analysis of dietary records; Development, pre-testing, and validation of survey instruments, cognitive interviewing questions, and new educational materials; Development of community partnerships, interventions and nutrition education programs; Implementation of interviews and workshops

(2006): Review and revision of existing nutrition education materials; Collection and analysis of dietary records; Review and revision of survey instruments, cognitive interviewing questions, and new educational materials; Maintenance of existing and development of new community partnerships, interventions and nutrition education programs; On-going implementation of interviews and workshops; Development of publications (if aspects of data collection and analysis are complete)

(2007): Review and revision of existing nutrition education materials; Collection and analysis of dietary records; Review and revision of survey instruments, cognitive interviewing questions, and new educational materials; Maintenance of existing and development of new community partnerships, interventions and nutrition education programs; On-going implementation of interviews and workshops; Development of publications (if aspects of data collection and analysis are complete)

(2008): Data analysis and information dissemination; Development of Refereed Publications (by experiment and collectively by project)

(2009): Publications (by experiment and collectively by 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:
Chairperson, Vice-Chairperson, Secretary, Regional Administrative Advisor

EXECUTIVE COMMITTEE:
Chairperson, Vice-Chairperson, Secretary, Member(s) at Large (1 or more), 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 aad 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 by experiment and collectively will be proposed and/or reviewed at this meeting, when appropriate.

STUDY DESIGN and STATISTICAL SUPPORT FOR THE PROJECT

The Executive Committee will critique overall study design as well as annual work plans for each Objective and supporting Experiments. Four lead stations have identified statisticians that will work with the project as technical support (PA: F. Lawrence, Methodology Center, PSU; MA: Statistical Consulting Unit, UMASS School of Public Health; MD: N. Sahyoun, Nutritional Epidemiologist, UMD; RI: L. Gonzalez, Professor of Statistics and Computer Science, URI).

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Attachments

Land Grant Participating States/Institutions

DC, LA, MA, MD, ME, MN, NH, PA, RI

Non Land Grant Participating States/Institutions

Food and Drug Administration, Purina, University of Connecticut, USDA/ARS