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Native Americans, African Americans, Hispanics, Asians, and Pacific Islanders

are at increased risk of diabetes (International Diabetes Center, 2003).

Breast Cancer Although recommendations vary somewhat for screening for

breast cancer, it is well documented that regular mammography reduces death

from breast cancer by approximately 30% in women between the ages of 50 and

69. After years of encouraging breast self-exam, the empirical evidence support-

ing this intervention is not so strong as to justify a continued recommendation

one way or the other. Regular (every 1 to 2 years) mammography, which is a cov-

ered Medicare service, continues to be the recommended screening. However, the

importance of such screening for women 70 years and older is less clear. Al-

though older women experience a higher rate of getting and dying from breast

cancer, they are simultaneously subject to higher risks of other causes of death as

well. “Women with comorbid conditions that limit their life expectancy are un-

likely to benefit from screening” (National Guideline Clearinghouse, 2005a).

Colorectal Cancer Screening for colorectal cancer should be offered to men and

women 50 years of age and older. The options for such screening vary widely and

include home fecal occult blood testing, sigmoidoscopy, a combination of these

two, colonoscopy, and double-contrast barium enema. Because each of these dif-

ferent screening methods carries different advantages and disadvantages—as

well as costs and risks—providers should review the options with older adults

and incorporate personal preferences of the consumer into the selection of a spe-

cific screen. The fecal occult blood testing (with samples collected at home) is rec-

ommended by the U.S. Preventive Services Task Force (2002a) annually, and the

more invasive sigmoidoscopy is recommended on a 5-year schedule. When posi-

tive screening results are detected, further screening with a colonoscopy is rec-

ommended. Initial screening with a colonoscopy generally obviates the need for

other screening procedures; however, both the inconvenience and the cost weigh

against an automatic turn to colonoscopy as the screening procedure of choice

(National Guideline Clearinghouse, 2005b).

Prostate Cancer Although it has been recommended that all men age 50 and above

receive annual screening for prostate cancer using either a prostate-specific anti-

gen (PSA) test or a digital rectal exam, the U.S. Preventive Services Task Force

(2002b) found inconclusive evidence that early detection actually improves health

outcomes. In part, the difficulty arises from the proportion of false testing results.

The PSA test is more sensitive than a digital rectal exam, but 10% to 20% of these

tests yield false negatives. Naturally, as the threshold for assessment is made more

stringent, an increased number of false-positive results occur. Negative factors as-

sociated with screening, including a high number of false positives, raise further

questions about the benefits of population screening. African American men and

men with a first-degree relative with a history of prostate cancer face an increased

risk and therefore will derive greater benefit from routine screening, but even

among this target population the benefits of biennial screening are likely to equal

those of annual screening (National Guideline Clearinghouse, 2005c).

Osteoporosis Osteoporosis is a disease characterized by reduced bone density. Al-

though it occurs in both men and women, it predominates among women. The most

Health Promotion 177

serious effects of osteoporosis are spontaneous compression fractures of the spine

and broken bones resulting from falls or other injury. Older women should receive

regular screenings for osteoporosis. In fact, it would be ideal if women younger than

60 received a baseline screening for bone density against which to assess subsequent

potential change. Risk factors for osteoporotic fractures include low body weight

(<150 pounds), smoking, weight loss, a family history of osteoporosis, low calcium

vitamin intake (either supplementary or dietary), and low physical activity.

ROPER

SE OF

HARMACEUTICALS

“Take two aspirin and get plenty of rest.” It seems like a simple enough instruc-

tion. But the reality of contemporary pharmacotherapy is not nearly so simple.

Older adults take far more prescribed medications and OTC drugs daily than do

younger adults. In 2001, Medicare beneficiaries accounted for about 14% of the

community-residing population but consumed over 40% of the cost of prescribed

drugs (Goulding, 2005). Add OTC medications to these prescriptions and the

complexities of appropriately following administration guidelines increase expo-

nentially. Some drugs are to be appropriately taken on any empty stomach, oth-

ers with a meal; some should be taken specifically with milk, others with juice,

but perhaps not a citrus juice. Following all of the directions to the letter can be

daunting. Beyond the administration guidelines for multiple drugs, the potential

interaction effects among multiple drugs are almost limitless. The effect of one

drug might be potentiated, whereas another may be negated. Entirely new and

often unanticipated interactive side effects occur. It is just not the simple world of

two aspirin and plenty of rest.

Almost two-thirds of older adults take their prescriptions improperly, and of

these about 140,000 die each year as a result of this medication mismanagement

(American Public Health Association, 2005). The clear paradox here is that some-

thing with the power to have such a positive influence on health promotion, as

well as treatment of acute and chronic conditions, can simultaneously create a

health threat of such significant proportion. With perhaps 20 million older adults

mismanaging their medications, the opportunity for health promotion through

education and management is huge.

Practice Guidelines for Medicine Management The practice guidelines for promot-

ing good health by minimizing mismanagement of prescriptions and other drugs

essentially entail creating avenues of clear communication and developing sys-

tems of support that provide cues for proper medicine administration. The book-

let Your Medicine: Play It Safe (Agency for Healthcare Research and Quality, 2003)

offers several steps aimed at older adults to reduce the likelihood of using med-

ications inappropriately. These include the following:

• Give your health care team important information. Beyond the obvious benefit of

providing other health-related information to providers, this step draws the

older adult’s attention to the fact that he or she is working with and is a part

of a team. Different providers are not independent providers with regard to

the individual client. They are intimately related through the interactive ef-

fects of their individual interventions in a shared client. Further, the client

must work with these providers, not passively be worked on. To facilitate this

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information exchange, the client should be prepared with a list of all medi-

cines and supplements that are being taken.

• Get the facts about your medicine. Older adults must be educated to seek all the

relevant information about drugs that have been prescribed. Questions

about the name and purpose of the drug, dosage level and administration

schedule, side effects, interactions, and anticipated results should be pre-

pared in writing and answered in full. Clients should feel comfortable in

taking notes while meeting with providers and should bring a friend or

family member to assist in recording this information if necessary. It is also

very beneficial to use a single pharmacy to fill prescriptions so that a single

record of all prescriptions can be maintained.

•

Stay with your treatment plan. If the preceding steps have been followed, the re-

quired regimen should be clear; now it must be followed. Depending on indi-

vidual needs, clearly understanding the requirements of administration may

be adequate. However, many people need assistance in managing their multi-

ple medications on multiple schedules. At the very lowest level, a schedule list

may provide the structure that will support some people in meeting their

medication requirements. A variety of pill dispensers (with and without

timers) may address some needs; others may be better managed by friendly

reminder telephone calls. Still others will require explicit monitoring.

• Keep a record of your medicines. This final step serves to bring the list that

should have been presented to the health team in Step 1 up to date. Keeping

track of a range of different medications, each with its own schedule and set

of concerns, can be a daunting task. Mismanaging them can be fatal. Unfor-

tunately, modern pharmaceutical miracles come packaged with a tremen-

dous potential for mistakes, misapplication, and misery. The goals of health

promotion are served when a social worker or other supportive person can

provide the older adult with procedures, mental or mechanical, that mini-

mize the opportunity for confusion and error.

UMMARY OF

REVENTIVE

EALTH

Opportunities abound to exercise a preventive attitude toward the goal of health

promotion. Among these opportunities, keeping vaccinations up to date, attend-

ing to periodic and regular screenings for the common disease conditions of older

adulthood, and appropriately managing the multiple pharmaceuticals that are in-

tended to bring the benefits of medical science without creating the quagmire of

drug interactive possibilities can do tremendous service in advancing good

health. But in each of these areas, the older adult or a responsible caregiver must

be proactively engaged in intentionally pursuing these preventive opportunities.

As with all efforts at primary prevention, the tendency is ever present to ignore

preventive opportunities in the absence of forceful personal evidence of need.

Alas, by the time that personal evidence is available to us, the opportunity for

prevention has often passed. Only through the good practice of intentional living

with an eye to prevention do we harvest these rich benefits.

EXERCISE

The health promotion activity that is widely believed to have the single greatest

impact on a person’s overall health and well-being is physical activity. When

Health Promotion 179

older adults increase their level of physical activity they significantly lower their

risk of chronic diseases and conditions that often lead to premature death, while

simultaneously improving their physical health, mental health, cognitive func-

tioning, and quality of life.

COPE OF THE

ROBLEM

Older adults are disproportionately affected by an array of chronic conditions

and diseases that collectively account for more than 75% of deaths (CDC, 2005).

The top three chronic diseases among Americans age 65 and older are heart dis-

ease, cancer, and stroke, accounting for 60% of all deaths in this age group (CDC,

2004b). Regular physical activity reduces one’s risk for coronary heart disease,

high blood pressure, colon cancer, diabetes, and overall risk of dying prematurely

(CDC, 2004b; DHHS, 1996; Levkoff, Chee, & Noguchi, 2001; Rowe & Kahn, 1998).

Regular physical activity can even negate the adverse effects of other risk factors

associated with chronic disease, such as smoking, obesity, and high blood sugar

(Rowe & Kahn, 1998). Adopting healthier behaviors, including regular physical

activity, can dramatically reduce a person’s risk for most chronic diseases.

The presence of chronic diseases in older adults is not only life-threatening,

but also negatively impacts quality of life and functional status. “Chronic condi-

tions limit activities for 12 million elderly individuals living in community set-

tings; 25% of these affected individuals are unable to perform basic activities of

daily living, such as bathing, shopping, dressing, or eating. Nearly one-third of

adults over age 65 are disabled, compared to 18% of all Americans” (Center for

the Advancement of Health, 2006, p. 9). By adopting healthier lifestyles, older

adults can reduce and compress disability into a shorter period toward the end of

life (Hubert, Bloch, Oehlert, & Fries, 2002)—the essence of health promotion.

In the surgeon’s general report Bone Health and Osteoporosis (DHHS, 2004), it is

suggested that the greatest benefit of physical activity for older adults is reduc-

tion in the risk of falling, discussed elsewhere in this chapter. “Physical activity

is the only single therapy that can simultaneously improve muscle mass, muscle

strength, balance, and bone strength. As a result, it may decrease the risk of frac-

tures, in part by reducing the risk of falling” (p. 20). Approximately 20% of sen-

iors who suffer a hip fracture die within a year of the fracture, and another 20%

end up being placed in a nursing home within a year of the fracture. Maintaining

bone health is critically important to the overall health and quality of life for all

older adults, and regular exercise is the key to doing so.

Regular physical activity aids in weight control and is a key part of any weight

loss effort. Maintaining a healthy weight improves one’s overall mortality, as

studies show that extra pounds can literally change DNA and accelerate the aging

process (Yeager, 2005). In the ongoing 32-year research project at the Tulane

School of Public Health (Yeager, 2005), researchers found that as people gained

weight they became more insulin-resistant and their telomeres (strands of DNA

on the tip of each chromosome that typically shorten with age) shrank, a clear

sign that the aging process was accelerating in the overweight study volunteers.

In addition to the physical health benefits associated with regular physical ac-

tivity, there are a number of mental health benefits. Moderate amounts of physical

activity can help reduce depression, anxiety, and stress, while increasing feelings

of self-confidence and self-esteem (CDC, 2004b; DHHS, 2000; Rowe & Kahn, 1998;

Williams & Lord, 1995). People who get moderate amounts of exercise also report

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sleeping better and show lowered blood pressure reactivity to stress tests (DHHS,

2003). Those who participate in regular physical activity often report higher levels

of social support, as well as higher levels of satisfaction with social relationships.

Beingphysicallyactiveallowsolderadultstomaintaintheirinvolvementinthe

community, thereby maintaining and building their social networks.

Despite the proven benefits of exercise and regular physical activity, 60% of

the American public remains sedentary (Pescatello, 2001). Only 15% of adults

participate in the recommended amount of regular physical activity. One third

of adults age 65 and older do not engage in any leisure-time physical activities

(CDC, 2004b). By age 75, 1 in 3 men and 1 in 2 women engage in no regular phys-

ical activity (DHHS, 2000).

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The surgeon general’s report Physical Activity and Health (DHHS, 1996) concludes

that people of all ages benefit from regular physical activity. It is recommended

that people engage in moderate amounts of physical activity (e.g., 30 minutes of

brisk walking or raking leaves, 15 minutes of running, or 45 minutes of playing

volleyball) on most, if not all, days of the week. Traditionally it was recommended

that the 30 minutes of moderate exercise be consecutive, but recent research con-

cludes that accumulating several 5- to 10-minute bursts of physical activity over

the course of the day provides the same beneficial effects as consecutive routines

(Haber, 1999; Rowe & Kahn, 1998).

Physical activity is often thought to be synonymous with exercise, but exercise

is really a subset of physical activity. The term physical activity is defined simply

as the physical movements we participate in every day. Any body movement pro-

duced by the use of skeletal muscles that results in energy expenditure is consid-

ered physical activity. Rising from a seated position, standing, walking, bending

to pick up the newspaper—these are all forms of physical activity and they all ex-

pend energy. Exercise is defined as planned, structured, repetitive body move-

ments that use major muscle groups. The most beneficial physical activity is

planned exercise that uses certain sets of muscles for certain periods of time,

which provides maximum health benefits and minimal health risks for the least

effort possible (Klein & Bloom, 1997).

Exercise is generally broken down into two classifications: aerobic and

strength training. Aerobic activities are those that increase the flow of oxygen

and improve cardiovascular functioning. Some examples of aerobic activities are

walking briskly, jogging, dancing, hiking, cycling, and swimming. Aerobic exer-

cises increase flexibility and overall endurance, but they generally do not sig-

nificantly increase strength. Strength-training exercises involve resistance

training (isometrics) or the use of weights; these exercises increase physical

strength, muscle mass, muscle tone, balance, and bone density. Resistance train-

ing focuses on contracting muscles without moving joints, such as pushing

against a wall and holding that pose. Weight training involves the use of free

weights or machine weights.

The amount of exercise needed to produce health benefits is considerably less

than the amount needed to improve physical fitness (Pescatello, 2001). The pro-

tective factors associated with moderate exercise are almost as significant as the

protective factors associated with high levels of exercise. In an 8-year study of

Health Promotion 181

more than 13,000 people, walking for 30 to 60 minutes every day was almost as

beneficial in reducing the overall death rate as jogging up to 40 miles per week

(Blair et al., 1989).

The model of physical activity traditionally recommended by professionals was

structured exercise routines, but the emphasis is slowly being shifted to models

focused on increasing physical activity as part of one’s everyday life. Over the

past decade, research has begun to show that there are significant health benefits

from engaging in low to moderate physical activity, and from this research the

concept of “lifestyle physical activity” has emerged. “Lifestyle physical activity

has deviated from traditional methods of exercise prescription by advocating ac-

cumulated, unstructured activities of daily living according to individual prefer-

ences and convenience” (Pescatello, 2001, p. 115). An increase in lifestyle physical

activity is often an ideal fit for older adults who are predominantly sedentary and

likely unable or unwilling to engaged in exercise programs.

There are potential risks involved in physical activity programs, but they are

usually minor and can often be avoided by seeking advice from qualified medical

professionals. Every older adult who is initiating an exercise program after being

sedentary should receive a checkup by a physician to ensure that he or she is free

from cardiac problems that may cause difficulty. Generally, it is advisable to start

with a low-intensity exercise program and slowly build capacity and endurance

for more vigorous exercise. Low-intensity exercises include balance exercise, tai

chi, walking, gait training, and leg strength training. Instruction in the proper ex-

ecution of any exercise is essential, and exercise should be initially supervised to

ensure safety (Gill, DiPietro, & Krumholz, 2000).

Most older adults acknowledge that they understand what they should be

doing to stay healthy and fit, yet fewer than half achieve even the minimum

amount of recommended physical activity. From 1999 to 2003, the American As-

sociation of Retired Persons (AARP, 2004) conducted surveys and focus groups

with some 15,000 Americans age 50 and over about attitudes and knowledge

about exercise. Their research showed that lack of knowledge was not the primary

challenge in addressing low levels of physical activity in older adults, but other

barriers, both real and perceived, were deterring people from action. Some com-

monly noted excuses for not exercising are fatigue, fear of heart attack, trouble

catching breath, need to relax, too old, bad back, and arthritis (Haber, 1999).

The AARP (2004) research found that imagery and tone of presentation were

very important in motivating older adults to be physically active, but that photos

of elite senior athletes made them feel discouraged or overwhelmed. “Some peo-

ple discussed openly that images of very fit and toned people contributed to their

discomfort and embarrassment about being physically active” (p. 6). The “no

pain, no gain” message that is often used to motivate younger audiences to exer-

cise is not motivating to seniors. The critical role of health care professionals was

also noted, with the majority of research participants reporting that their doctor

is their primary and most trusted source of health information. Focus group re-

spondents who were most physically active consistently reported that they were

following the recommendations of their doctor to exercise.

The transition from a sedentary lifestyle to one that involves regular physical

activity is a struggle that requires both motivation and support. Research shows

that older adults who are supported by friends and family are more likely to suc-

ceed in increasing their level of physical activity and in maintaining those lifestyle

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changes (AARP, 2004). In surveys conducted by the AARP, respondents suggested

that motivational messages that encouraged lifestyle changes, while recognizing

how difficult change can be, were most encouraging to older adults.

One of the barriers to regular physical activity that is often noted by older

adults is the perception that exercise is painful and difficult, involves some level

of skill that they do not currently possess, and is not enjoyable. Older adults seem

more comfortable with the term and concept of physical activity rather than exer-

cise, and can often provide several examples of physical activities that they find

enjoyable, such as gardening and walking. Professionals working with older

adults should carefully consider the language they are using when discussing rec-

ommended lifestyle changes, using realistic examples that are tailored to the in-

dividual’s situation, needs, and desires.

For older adults to participate in exercise programs, they must have regular ac-

cess to equipment, classes, and safe places to exercise. Many communities offer

safe walking trails and parks, community centers with exercise groups specifi-

cally designed for older adults, community swimming pools, and some trans-

portation services to and from these sites. Other communities offer very little in

community resources; in those cases, opportunities for exercise within the home

need to be available to older adults. Professionals supporting older adults should

be aware of the resources in their community and be knowledgeable about home-

based programs.

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UIDELINES

In 2001, the National Blueprint: Increasing Physical Activity among Adults Age 50 and

Older was released as a joint effort of many organizations interested in health

promotion for older adults (Robert Wood Johnson Foundation, 2001). As part of

the Blueprint project, a variety of national-level activities were initiated to iden-

tify programs that successfully increase seniors’ level of physical activity. A few

of those programs are highlighted next, with additional information available on-

line at www.healthyagingprograms.org and www.agingblueprint.org.

The Lifetime Fitness program is a physical activity program that provides sen-

iors with low-cost fitness classes taught by certified fitness instructors. The 1-hour

classes meet three times per week in ongoing, 5-week sessions. The classes in-

clude strength training with wrist and ankle weights, as well as aerobics, stretch-

ing, and balancing exercises. The program is designed to be safe and effective for

seniors with a wide range of physical abilities. Participants have shown a marked

improvement in physical and social functioning, as well as a decline in areas such

as pain, fatigue, and depression. Information about this program can be found at

www.seniorservices.org/wellness/replication.htm.

The People with Arthritis Can Exercise (PACE) program was developed by the

Arthritis Foundation specifically for older adults with arthritis. This program

uses gentle activities to help increase joint flexibility and range of motion to

maintain muscle strength. Two levels of PACE are available, basic and advanced,

to address the varying levels of fitness and limitation among those with arthritis.

Participants have experienced such benefits as increased functional ability, in-

creased self-care behaviors, decreased pain, and decreased depression. Trained

leaders are required to implement this course. More information about this pro-

gram can be found at www.arthritis.org.

Health Promotion 183

The National Institute on Aging has developed a manual and companion video

that guides older adults through safe and effective exercises for increased en-

durance, strength training, balance, and flexibility. The program can be con-

ducted in a group setting or individually. The manual is available online at no

cost, and the video can be ordered for a cost of $7.00 (also available in Spanish).

More information can be obtained at www.nia.nih.gov/exercisebook/index.htm.

In addition to community-based physical activity programs, a variety of exer-

cise programs are designed to be done in the home on an individual basis. The

Strong-for-Life program consists of a 35-minute videotaped program of 11 exer-

cise routines performed by a trained leader (Jette et al., 1999). The program is de-

veloped specifically for older adults with some degree of physical disability.

Additionally, there are literally hundreds of physical activity videos available at

local retailers that provide video instruction of a variety of physical activities

and exercises.

In addition to engaging older adults in specific physical activity programs,

other strategies are recommended to help encourage older adults to maintain

lifestyle changes. It has been estimated that between 22% and 76% of those who

start exercise programs drop out within 6 months (Center for the Advancement of

Health, 2006). Strategies proven to maintain or increase levels of physical activity

in older adults include cognitive-behavioral approaches such as face-to-face meet-

ings with health counselors, regular follow-up calls to check progress, group

meetings, group exercise opportunities, and self-documentation of progress

(Lachman & Jette, 1997; Williams & Lord, 1995).

Physicians are in a unique position to influence the potential lifestyle habits of

older adults. More than 60% of older adults say that their primary care physician

is their most trusted source of information about health care-related issues. When

physicians have recommended lifestyle changes to their patients that include

more regular physical activity, more than 50% of those patients followed those

recommendations and increased their activity level. When physicians took the

practice a step further and actually wrote a prescription for exercise, patients

were even more likely to increase their level of exercise (Pfeiffer, Clay, &

Conatser, 2001).

NUTRITION

It is essential to consider the role of nutrition when thinking about health promo-

tion. Eating a healthy and well-balanced diet, along with taking supplemental vi-

tamins and minerals as recommended by a physician, helps to ensure

maintenance of a healthy body weight and good bone health while reducing one’s

risk of several nutrition-related problems, such as obesity, Type 2 diabetes, osteo-

porosis, and malnutrition.

COPE OF THE

ROBLEM

Approximately 65% of adults in the United States are overweight, and 30% are

obese (Booth & Winder, 2005). The prevalence of obesity among adults age 65 and

older is 19%, an increase from 12% in 1990 (CDC, 2004b; Rhoades, 2005). Being

overweight or obese substantially raises one’s risk of illness from high blood

pressure, high cholesterol, Type 2 diabetes, heart disease and stroke, gallbladder

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disease, arthritis, sleep disturbances and problems breathing, and certain types

of cancer. Obese individuals also often suffer from social stigmatization, discrim-

ination, and lower self-esteem (DHHS, 2000). The effect of obesity on longevity

has led many experts to believe that the steady rise in life expectancy during the

past two centuries may soon come to an end (Olshanksy et al., 2005).

Type 2 diabetes is the fifth leading cause of death among adults in the United

States, and 85% of all people with diabetes are overweight or obese (National In-

stitute on Aging, 2000). Research shows that the majority of cases of Type 2 dia-

betes could be prevented by the adoption of a healthier lifestyle (Hu et al., 2001).

The American Diabetes Association (n.d.) reports that having Type 2 diabetes in-

creases your risk for many serious complications, including heart disease, blind-

ness, nerve damage, and kidney damage. Several studies have also linked Type 2

diabetes to mild cognitive dysfunction in older adults (Hewer, Mussell, Rist,

Kulzer, & Bergis, 2003).

The surgeon general’s report on bone health and osteoporosis estimates that 10

million Americans over the age of 50 have osteoporosis, and another 34 million

are at risk of developing osteoporosis (DHHS, 2004). Osteoporosis is often consid-

ered a “silent” condition, because so many people are unaware that their bone

health is in jeopardy. “In fact, four times as many men and nearly three times as

many women have osteoporosis than report having the condition” (p. 2). Each

year, nearly 1.5 million people suffer a bone fracture related to osteoporosis. Hip

fractures are the most serious type of fracture experienced by older adults. Hip

fractures are the leading cause of death, disability, and a reduced quality of life in

older adults (CDC, 2004b). Up to 25% of hip fracture patients die within a year,

and those who survive often experience a reduced ability to remain independent.

Older adults are at greater risk for malnutrition than the general population,

especially older adults who are hospitalized or institutionalized. Surveys con-

ducted in nursing homes found malnutrition to be as high as 52% to 85% for all

residents (Levkoff et al., 2001). Chandra’s (1997) research found that almost one

third of analyzed elderly were deficient in vitamins and trace elements. The Insti-

tute of Medicine (2000) reports that older adults are not getting adequate

amounts of key nutrients such as calcium, vitamin D, magnesium, and phospho-

rus, which are nutrients associated with structural and muscular function, mus-

cle metabolism, and bone health.

Eating healthfully has been shown to help lower people’s risk for many chronic

diseases, including heart disease, stroke, some cancers, diabetes, and osteoporo-

sis. However, a large gap exists between recommended dietary habits and what

Americans actually eat. An assessment by the U.S. Department of Agriculture

(USDA) found that 74% of American diets need improvement (Center for the Ad-

vancement of Health, 2006). In 2003, only about 1 in 4 adults ate the recommended

five or more servings of fruits and vegetables each day (CDC, 2005). Approxi-

mately 30% of Americans age 65 and older are underweight or malnourished

(Haber, 1999).

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The Dietary Guidelines for Americans 2005 (DHHS, 2005) recommends that people

choose a healthful assortment of foods that includes vegetables, fruits, grains (es-

pecially whole grains), low-fat milk products, and fish, lean meat, poultry, or

Health Promotion 185

beans. A key recommendation is that people consume a variety of nutrient-dense

foods and beverages within and among the basic food groups while choosing

foods that are low in saturated fats and transfats, cholesterol, added sugars, salt,

and alcohol.

The USDA developed the well-known Food Guide Pyramid to help people make

healthy food choices. There are five major food groups, with specific recommen-

dations on the amount of servings one should strive to eat from each food group

on a daily basis: grains, 6 to 11 servings; vegetables, 3 to 5 servings; fruits, 2 to 4

servings; milk, yogurt, and cheese, 2 to 3 servings; and meat, poultry, fish, dry

beans, eggs, and nuts, 2 to 3 servings. It is recommended that people limit their

intake of fats, oils, and sweets. Consumers should note that the recommended

pyramid servings are typically smaller than the serving sizes listed on nutri-

tional labels of food products.

Although eating a wide variety of healthy foods is considered to be the ideal

way to achieve nutritional goals, there is growing concern that the level of nutri-

ents in the highly processed foods that many Americans eat may not be sufficient

to ensure adequate nutrition.

Many physicians now recommend that older adults take a multivitamin con-

taining modest amounts of vitamins and minerals (Haber, 1999). Older adults

should always consult their doctor or a registered dietitian before taking any di-

etary supplements. Just like any other medication, there are potential side effects

and drug interactions from taking dietary supplements, so patients should be en-

couraged to make their health care professional aware of all medications they are

taking, as well as any medical conditions they may have.

Some vitamins and minerals are of significant concern to older adults in main-

taining their health. Calcium is known to strengthen bones and decrease the risk

of fracture in older adults, and vitamin D is essential to the absorption of cal-

cium. The U.S. surgeon general recommends that the average adult consume

about 1,000 mg of calcium and 200 IU of vitamin D per day (DHHS, 2004). The

usual diet of most older adults includes only 700 to 800 mg of calcium daily, which

means that older adults need to adjust their diet or consider taking a supplement

(Rowe & Kahn, 1998). The surgeon general has identified other nutrients that may

be potentially beneficial to bone health, including vitamins C and K, zinc, man-

ganese, phosphorus, potassium, magnesium, and iron.

Older adults who are diagnosed with certain chronic diseases will often be re-

quired to follow specialized dietary guidelines specific to their diagnosis. For ex-

ample, a person diagnosed with Type 2 diabetes will need to follow a dietary plan

that limits intake of raw sugars and simple carbohydrates to maintain appropri-

ate blood glucose levels. For overweight people diagnosed with Type 2 diabetes, a

weight loss plan is a must for proper blood glucose control. When detected early,

many older adults with Type 2 diabetes can keep their blood glucose levels near

normal by controlling their weight, exercising, and following a sensible diet,

sometimes making it possible for them to avoid taking medications (National In-

stitute on Aging, 2000).

It is important for professionals to consider not only the specific nutritional

needs of older adults, as assessed by their doctor or a registered dietician, but

also environmental barriers that might prevent older adults from implementing

dietary recommendations. Households with lower incomes are at greater risk

for malnutrition, given the high costs of purchasing healthy food choices such as