Practice paper of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities

It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. The Association advocates the use of qualified registered dietitians (RDs) to assess and evaluate the need for nutrition care according to each person's individual medical condition, needs, desires, and rights. Dietetic technicians, registered, provide support to RDs in the assessment and implementation of individualized nutrition care. Individual rights and freedom of choice are important components of the assessment process. An RD must assess each older adult's risks vs benefits for therapeutic diets. Older adults select housing options that provide a range of services from minimal assistance to 24-hour skilled nursing care. Food is an important part of any living arrangement and an essential component for quality of life. A therapeutic diet that limits seasoning options and food choices can lead to poor food and fluid intake, resulting in undernutrition and negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. The expansion of health care communities creates a multitude of options for RDs and dietetic technicians, registered, to promote the role of good food and nutrition in the overall quality of life for the older adults they serve.     

Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care,Post-Acute Care,and Other Settings

It is the position of the Academy of Nutrition and Dietetics that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered dietitian nutritionists assess, evaluate, and recommend appropriate nutrition interventions according to each individual’s medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered dietitian nutritionists in the implementation of individualized nutrition care, including the use of least restrictive diets. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.     

Position of the American Dietetic Association: liberalized diets for older adults in long-term care

It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet. The Association advocates the use of qualified dietetics professionals to assess and evaluate the need for medical nutrition therapy according to each person's individual medical condition, needs, desires, and rights. One of the major determinants among the predictive factors of successful aging is nutrition. Long-term care includes a continuum of health services ranging from rehabilitation to supportive care. Nutrition care for older adults in long-term settings must meet two goals: maintenance of health through medical care and maintenance of quality of life. However, these goals often seem to compete, resulting in the need for a unique approach to medical nutrition therapy (MNT). Typically, MNT includes assessment of nutritional status and development of an individualized nutrition intervention plan that frequently features a theraperutic diet appropriate for managing a disease or condition. MNT must always address medical needs and individual desires, yet for older adults in long-term care this balance is especially critical because of the focus on maintaining quality of life. Dietetics professionals must help residents and health care team members assess the risks versus the benefits of therapeutic diets. For frail older adults, overall health goals may not warrant the use of a therapeutic diet because of its possible negative effect on quality of life. A diet that is not palatable or acceptable to the individual can lead to poor food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. Often, a more liberalized nutrition intervention that allows an older adult to participate in his or her diet-related decisions can provide for the person's nutrient needs and allow alterations contingent on medical conditions while simultaneously increasing the desire to eat and enjoyment of food. This ultimately decreases the risks of weight loss, undernutrition, and other potential negative effects of poor nutrition and hydration.     

Practitioners' opinions on Food and Nutrition Care Indicators in assisted living facilities for older adults

This study assessed the utility of the 57-indicator Food and Nutrition Care Indicators Checklist for assessing food and nutrition services in assisted-living facilities for older adults among registered dietitians (RDs). They were members of two American Dietetic Association practice groups focusing on aging and long-term care and were also employed in assisted-living facilities. The 1,281 respondents rated the importance of each checklist item and provided their views on the role of assisted-living facilities and their level of agreement with statements regarding the importance of residents' autonomy for making food choices and their ability to make wise dietary choices. Registered dietitians practicing in assisted-living facilities considered all of the domains on food and nutrition quality indicators on the Food and Nutrition Care Indicators Checklist to be highly important (92% of dining room environment items, 83% of foodservice operations, 92% of general nutrition, and 89% of therapeutic nutrition items). They preferred a service style that included both health and amenities, as did national health and aging experts. Registered dietitians should work with other professionals to further validate the checklist, promote its use, and establish optimal service models for food and nutrition services in assisted-living facilities for older adults.     

Position of the American Dietetic Association: benchmarks for nutrition in child care

It is the position of the American Dietetic Association that child-care programs should achieve recommended benchmarks for meeting children's nutrition needs in a safe, sanitary, and supportive environment that promotes optimal growth and development. Use of child care has become increasingly common and is now the norm for the majority of families in the United States. Therefore, it is essential that registered dietitians; dietetic technicians, registered; and other food and nutrition practitioners work in partnership with child-care providers and families of children in child care to meet children's nutrition needs and provide them with models of healthful eating and active lifestyles. This Position Paper provides guidance for food and nutrition practitioners, health professionals, and child-care providers regarding recommendations for nutritional quality of foods and beverages served; menus, meal patterns, and portion sizes; food preparation and service; physical and social environment; nutrition training; nutrition consultation; physical activity and active play; and working with families. This Position Paper targets children aged 2 to 5 years attending child-care programs and highlights opportunities for food and nutrition practitioners to promote healthful eating in child care through both intervention and policy-based initiatives.     

Attitudes, knowledge, and problem-solving approach of Michigan dietitians about aging

Dietitians' attitudes and knowledge about aging are important because of the potential influence on quality and quantity of nutrition services provided to older adults. Four instruments were used to survey active members of The American Dietetic Association (ADA) in Michigan. The survey was mailed to 1,408 dietitians; 738 responded (52.4%). The responding dietitians were predominantly under 40, well educated, and female, which was consistent with the 1986 national census of ADA members. The results indicated that dietitians hold positive attitudes toward older adults in most areas. An exception was that a majority of the dietitians perceived older adults as resistant to treatment. Although dietitians' knowledge about aging generally was adequate, the questionnaire revealed that dietitians lacked knowledge in the areas of economic and health status; dietitians answered that older adults have a lower income and are sicker and more institutionalized than is in fact true. These are critical areas of deficiency in knowledge by dietitians, since food and nutrition issues often involve money and health. In the problem-solving section of the study, the dietitians usually focused on one specific environment or area of concern. Neither the full range of all possible environments for older adults nor the diversity of older adults' needs was usually considered. Continuing education as well as comprehensive undergraduate courses on aging would have a positive influence on Michigan dietitians' attitudes and knowledge about aging.     

Position of the American Dietetic Association: nutrition, aging, and the continuum of care

Scientific evidence increasingly supports that good nutrition is essential to the health, self-sufficiency, and quality of life of older adults. With the population of the United States living longer than ever before, the older adult population will be more diverse and heterogeneous in the 21st century. The oldest-old and minority populations will grow more quickly than the young-old and non-Hispanic white populations, respectively. For the current 34 million adults 65 years of age and older living in the United States, there are about 12 million caregivers who provide formal or informal care. A broad array of culturally appropriate food and nutrition services, physical activities, and health and supportive care customized to accommodate the variations within this expanding population of older adults is needed. With changes and lack of coordination in heath care and social-support systems, dietetics professionals need to be proactive and collaborate with aging-services and other health care professionals to improve policies, interventions, and programs that service older adults throughout the continuum of care to ensure nutritional well-being and quality of life. The American Dietetic Association supports both the provision of comprehensive food and nutrition services and the continuation and expansion of research to identify the most effective food and nutrition interventions for older adults over the continuum of care. J Am Diet Assoc. 2000;100:580-595.     

Position of the American Dietetic Association: Nutrition Intervention and Human Immunodeficiency Virus Infection

It is the position of the American Dietetic Association that efforts to optimize nutritional status through individualized medical nutrition therapy, assurance of food and nutrition security, and nutrition education are essential to the total system of health care available to people with human immunodeficiency virus (HIV) infection throughout the continuum of care. Broad-based efforts to improve health care access and treatment have stabilized HIV prevalence levels in many parts of the world and led to longer survival for people living with HIV infection. Confounding clinical and social issues, such as medication interactions, comorbidities, wasting, lipodystrophy, food insecurity, aging, and other related conditions further complicate disease management. With greater understanding of the mechanisms of HIV disease and its impact on body function, development of new treatments, and wider ranges of populations affected, the management of chronic HIV infection continues to become more complex and demanding. Achievement of food and nutrition security and management of nutrition-related complications of HIV infection remain significant challenges for clients with HIV infection and health care professionals. Registered dietitians and dietetic technicians, registered, should integrate their efforts into the overall health care strategies to optimize their clinical and social influence for people living with HIV infection.     

Position paper of the American Dietetic Association: nutrition across the spectrum of aging

It is the position of the American Dietetic Association that older Americans receive appropriate care; have broadened access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies across the spectrum of aging. Food and water and nutritional well-being are essential to the health, self-sufficiency, and quality of life for the fast growing, heterogeneous, multiracial, and ethnic populations of older adults. Many people, as they age, remain fully independent and actively engaged in their communities; however, others fare less well and need more support. A broad array of appropriate, culturally sensitive food and nutrition services, physical activities, and health and supportive care customized to the population of older adults are necessary. National, state, and local policies that promote coordination and integration of food and nutrition services into health and supportive systems are needed to maintain independence, functional ability, chronic disease management, and quality of life. Dietetics professionals can take the lead by researching and developing national, state, and local collaborative networks to incorporate effectively the food and nutrition services across the spectrum of aging.     

Position of the American Dietetic Association: Providing Nutrition Services for People with Developmental Disabilities and Special Health Care Needs

It is the position of the American Dietetic Association that nutrition services provided by registered dietitians (RDs) and dietetic technicians, registered (DTRs), are essential components of comprehensive care for all people with developmental disabilities and special health care needs. Nutrition services should be provided throughout life in a manner that is interdisciplinary, family-centered, community-based, and culturally competent. People with developmental disabilities and special health care needs frequently have nutrition concerns, including growth alterations (failure to thrive, obesity, or growth retardation), metabolic disorders, poor feeding skills, medication-nutrient interactions, and sometimes partial or total dependence on enteral or parenteral nutrition. Individuals with special needs are also more likely to develop comorbid conditions such as obesity or endocrine disorders that require nutrition interventions. Poor health habits, limited access to services, and long-term use of multiple medications are considered health risk factors. Health maintenance and avoidance of complications can be promoted by timely and cost-effective nutrition interventions. Public policy for individuals with special needs has evolved over time, resulting in a transition from institutional facilities and programs to community living. The expansion of public access to technology and health information on the Internet challenges RDs and DTRs to provide accurate scientific information for those with developmental disabilities and special health care needs. Nationally credentialed RDs and DTRs are best prepared to provide appropriate nutrition information for wellness and quality of life.     

Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness

It is the position of the Academy of Nutrition and Dietetics that all Americans aged 60 years and older receive appropriate nutrition care; have access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies. Health, physiologic, and functional changes associated with the aging process can influence nutrition needs and nutrient intake. The practice of nutrition for older adults is no longer limited to those who are frail, malnourished, and ill. The population of adults older than age 60 years includes many individuals who are living healthy, vital lives with a variety of nutrition-related circumstances and environments. Access and availability of wholesome, nutritious food is essential to ensure successful aging and well-being for the rapidly growing, heterogeneous, multiracial, and ethnic population of older adults. To ensure successful aging and minimize the effects of disease and disability, a wide range of flexible dietary recommendations, culturally sensitive food and nutrition services, physical activities, and supportive care tailored to older adults are necessary. National, state, and local strategies that promote access to coordinated food and nutrition services are essential to maintain independence, functional ability, disease management, and quality of life. Those working with older adults must be proactive in demonstrating the value of comprehensive food and nutrition services. To meet the needs of all older adults, registered dietitians and dietetic technicians, registered, must widen their scope of practice to include prevention, treatment, and maintenance of health and quality of life into old age.     

Position of the American Dietetic Association: ethical and legal issues in nutrition,hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitian's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.     

Position of the American Dietetic Association, American Society for Nutrition, and Society for Nutrition Education: Food and Nutrition Programs for Community-Residing Older Adults

Given the federal cost-containment policy to rebalance long-term care away from nursing homes to home- and community-based services, it is the position of the American Dietetic Association, the American Society for Nutrition, and the Society for Nutrition Education that all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutritional status. Appropriate food and nutrition programs include adequately funded food assistance and meal programs, nutrition education, screening, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to ensure more healthful aging. The growing number of older adults, the health care focus on prevention, and the global economic situation accentuate the fundamental need for these programs. Yet far too often food and nutrition programs are disregarded or taken for granted. Growing older generally increases nutritional risk. Illnesses and chronic diseases; physical, cognitive, and social challenges; racial, ethnic, and linguistic differences; and low socioeconomic status can further complicate a situation. The beneficial effects of nutrition for health promotion, risk reduction, and disease management need emphasis. Although many older adults are enjoying longer and more healthful lives in their own homes, others, especially those with health disparities and poor nutritional status, would benefit from greater access to food and nutrition programs and services. Food and nutrition practitioners can play a major role in promoting universal access and integrating food and nutrition programs and nutrition services into home- and community-based services.     

Position of the American Dietetic Association,American Society for Nutrition,and Society for Nutrition Education: Food and Nutrition Programs for Community-Residing Older Adults

Given the federal cost-containment policy to rebalance long-term care away from nursing homes to home- and community-based services, it is the position of the American Dietetic Association, the American Society for Nutrition, and the Society for Nutrition Education that all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutritional status. Appropriate food and nutrition programs include adequately funded food assistance and meal programs, nutrition education, screening, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to ensure more healthful aging. The growing number of older adults, the health care focus on prevention, and the global economic situation accentuate the fundamental need for these programs. Yet far too often food and nutrition programs are disregarded or taken for granted. Growing older generally increases nutritional risk. Illnesses and chronic diseases; physical, cognitive, and social challenges; racial, ethnic, and linguistic differences; and low socioeconomic status can further complicate a situation. The beneficial effects of nutrition for health promotion, risk reduction, and disease management need emphasis. Although many older adults are enjoying longer and more healthful lives in their own homes, others, especially those with health disparities and poor nutritional status, would benefit from greater access to food and nutrition programs and services. Food and nutrition practitioners can play a major role in promoting universal access and integrating food and nutrition programs and nutrition services into home- and community-based services.     

Position of the American Dietetic Association: oral health and nutrition

It is the position of the American Dietetic Association that nutrition is an integral component of oral health. The American Dietetic Association supports the integration of oral health with nutrition services, education, and research. Collaboration between dietetics and dental professionals is recommended for oral health promotion and disease prevention and intervention. Scientific and epidemiological data suggest a lifelong synergy between nutrition and the integrity of the oral cavity in health and disease. Oral health and nutrition have a synergistic bidirectional relationship. Oral infectious diseases, as well as acute, chronic, and terminal systemic diseases with oral manifestations, impact the functional ability to eat as well as diet and nutrition status. Likewise, nutrition and diet may affect the development and integrity of the oral cavity as well as the progression of oral diseases. As we advance in our discoveries of the links between oral and nutrition health, practitioners of both disciplines must learn to provide screening, baseline education, and referral to each other as part of comprehensive client/patient care. Dietetics practice requires registered dietitians to provide medical nutrition therapy that incorporates a person's total health needs, including oral health. Inclusion of both didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in both dental and dietetic education programs. Collaborative endeavors between dietetics and dentistry in research, education, and delineation of health provider practice roles are needed to ensure comprehensive health care. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit continued, detailed delineation.     

What Food and Nutrition Services Should Be Regulated in Assisted-Living Facilities for Older Adults?

The opinions of both national aging and health experts and practicing registered dietitians (RDs) were surveyed on which key quality indicators from the Food And Nutrition Care Indicators checklist should be regulated in assisted-living facilities (ALFs) for older adults. The extent to which the practices on which the indicators were based should be regulated, and which were in fact included in the current regulations of the 50 states was also studied. One hundred fifty-three national aging and health experts were surveyed in 2005 and 882 practicing RDs who were members of two American Dietetic Association dietetic practice groups employed in ALFs were surveyed in 2006. Both the experts and the RDs believed that the need for regulations in ALF food and nutrition services was vital for about a third of the indicators, (eg, 18 items on the 57 item checklist), particularly those involving facilities and staffing. For seven out of the 18 indicators, there was substantial consensus between experts and RDs. Only three of the seven indicators were addressed by regulations in more than half of the states. Consensus exists among experts and RDs that a small but significant number of food and nutrition service indicators need to be regulated.     

Model for multicultural nutrition counseling competencies

A model for multicultural nutrition counseling competencies for registered dietitians was developed and tested. Six hundred four registered dietitians who were members of The American Dietetic Association Public Health Nutrition Practice Group or directors of dietetic internships and didactic programs in dietetics were selected by a stratified random sample method and were mailed a survey. Respondents rated each of 46 competencies using a Likert scale to delineate how essential each competency will be for entry-level dietitians in the next 10 years. Of the 60% who responded (n=363), 94.4% met the study selection criteria. Most were white (85.7%), spoke English as their primary language (96.8%), and had a master's degree (64.4%). Many (37.9%) worked in community/public health facilities or organizations, and 50.4% provided nutrition counseling or education to clients culturally different from themselves. Exploratory principal components analysis extracted 3 factors with 28 competencies loading on them: multicultural nutrition counseling skills, multicultural awareness, and multicultural food and nutrition knowledge. Subjects responded similarly whether or not they provided nutrition counseling to culturally different clients. Secondary analysis revealed no significant interaction or differences between how bilingual dietitians and those of color scored items in the 3 factors. The resulting model is a guideline that can be used by educators to enhance dietetics education and training and by public health nutritionists as a basis for self-evaluation and selection of continuing education opportunities to enhance their multicultural nutrition counseling competence.     

Adolescent nutrition: self-perceived deficiencies and needs of practitioners working with youth

Sixty-three percent of a random sample of 866 members within three practice groups of The American Dietetic Association responded to a survey designed to assess (a) perceived competency of nutrition management in 20 major areas of adolescent health, (b) desire to increase skill level in each area, and (c) preferred approaches for continuing education activities. Of the 549 respondents, 92% were registered dietitians (R.D.s), 5% were registration-eligible, and more than half (51%) had advanced degrees. Twenty-five percent or more of all practitioners reported deficiencies in 17 of the 20 categories. The five top areas in which respondents believed that they had insufficient skills were psychosomatic problems (87%), handicapping conditions (82%), sports nutrition (81%), alcohol/drug abuse-related nutrition concerns (80%), and anorexia nervosa/bulimia nervosa (72%). The strongest desires to improve skills were in the areas of obesity, poor dietary patterns, sports nutrition, food fads, supplement misuse, alternative diets, and eating disorders. There was low interest in strengthening skills in family planning, psychosomatic problems, and handicapping conditions. The implications of the results are discussed. Continuing education methods respondents believed to be most beneficial for learning were small conferences, lectures with ample discussion, and "hands-on" workshops.     

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care–related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services.Position StatementIt is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs.