Barriers to Nutrition Education for Older Adults, and Nutrition and Aging Training Opportunities for...

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Barriers to Nutrition Education for Older Adults,and Nutrition and Aging Training Opportunities forEducators, Healthcare Providers, Volunteers andCaregiversMary Meck Higgins PhD, RD, LD, CDE a & Mary Clarke Barkley PhD, RD, LD aa Department of Human Nutrition , Kansas State University , Manhattan, KS, USAPublished online: 05 Oct 2008.

To cite this article: Mary Meck Higgins PhD, RD, LD, CDE & Mary Clarke Barkley PhD, RD, LD (2004) Barriers to NutritionEducation for Older Adults, and Nutrition and Aging Training Opportunities for Educators, Healthcare Providers, Volunteersand Caregivers, Journal of Nutrition For the Elderly, 23:4, 99-121

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Barriers to Nutrition Educationfor Older Adults, and Nutrition

and Aging Training Opportunitiesfor Educators, Healthcare Providers,

Volunteers and Caregivers

Mary Meck Higgins, PhD, RD, LD, CDEMary Clarke Barkley, PhD, RD, LD

ABSTRACT. Literature citations of barriers to nutrition education foundin those who teach and care for older adults, as well as within older adultsthemselves, are discussed. No attempt was made to compare educationalbarriers for learners of varying ages. These obstacles need to be addressedin order for nutrition to be taught or learned effectively so that nutritionpractices and health improve. Barriers for healthcare professionals toproviding nutrition education include misconceptions and stereotypesabout older adults and about their nutritional concerns; lack of attentionto and lack of funding for older adult educational programs; and difficul-ties recruiting older learners. Hindrances for older adults in respondingto nutrition education can be categorized as attitudinal, motivational, en-vironmental, and related to low literacy and poverty. Published examplesof opportunities for education and training about nutrition and aging that

Mary Meck Higgins is Assistant Professor and Cooperative Extension Human Nu-trition Specialist, and Mary Clarke Barkley is Professor Emeritus and Cooperative Ex-tension Human Nutrition Specialist, Department of Human Nutrition, Kansas State Univer-sity, Manhattan, KS.

Address correspondence to: Mary Meck Higgins, Assistant Professor, Department ofHuman Nutrition, 202 Justin Hall, Manhattan, KS 66506 (E-mail: [email protected]).

Journal of Nutrition for the Elderly, Vol. 23(4) 2004http://www.haworthpress.com/web/JNE

2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J052v23n04_07 99

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are in place for health educators, healthcare providers, volunteers and care-givers regarding nutrition and aging are discussed. Suggestions are pre-sented regarding future efforts to minimize educational barriers and toprovide training for healthcare professionals, volunteers and caregivers.New research is needed in this field of study in order to realize the poten-tial quality of life benefits and reduced healthcare costs associated withproviding effective nutrition education to older adults. This is one of aseries of reviews of recent literature on nutrition education for olderadults. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-HAWORTH. E-mail address: <[email protected]>Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. Allrights reserved.]

KEYWORDS. Nutrition education, health educators, healthcare provider,caregiver, older adults, ethnic groups, training, minority, barriers

INTRODUCTION

Assisting older adults and caregivers in obtaining accurate information andthen applying it to their own nutrition practices holds many benefits for im-proving their quality of life and has the potential for decreasing healthcarecosts. Through case studies of the American Dietetic Association on medicalnutrition therapy (Gallagher-Allred et al., 1996) and studies such as those ofHeaney et al. (1999) on dietary changes and bone remodeling, there is a grow-ing body of evidence of the value of nutrition interventions for seniors. Nutri-tion-related chronic diseases occur in 80-86% of adults age 70 years and older,and the elderly, whose numbers are expected to grow to 20% of the populationby 2030, consume health care dollars at a rate four times that of younger adults(Silver and Wellman, 2002).

While various barriers exist that hinder the provision of nutrition educationto people of all ages, in this article, we focus on adults ages 60 years and older.Obstacles for educators and healthcare providers to effectively teach nutritionto older adults exist, along with both psychological and external factors thathinder older adults in responding to nutrition education. We believe that in-creasing nutrition educators’ awareness of common hindrances can help thembe more proactive in overcoming them.

Many different kinds of health professionals (i.e., health educators and health-care providers) and paraprofessionals interact with older adults. All of these in-dividuals need to know how to apply the fundamentals of good nutrition as it

100 JOURNAL OF NUTRITION FOR THE ELDERLY

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relates to their areas of interest or scope of practice, and also to be able to pro-vide the understanding and environmental support that older adults need tomaintain or improve food habits. Opportunities to obtain such training currentlyare limited. Because of the high consumer interest in all kinds of diets and regi-mens and the commercialism in dietary supplements, it is especially importantthat older adults receive accurate and useful information. The designers of andtrainers for suitable educational resources and programs should be well pre-pared themselves. Such professionals include dietitians, college and universitynutrition faculty, clinical and public health nutritionists, and others trained innutrition and gerontology, along with health educators and practitioners whohave completed nutrition training, such as some physicians, physician assis-tants, registered nurses and cooperative extension service faculty.

This article focuses on published research studies along with reports thatdescribe barriers to teaching nutrition to older adults, barriers that hinder olderadults from responding to nutrition education, and reports on the training ofhealth educators, healthcare providers, volunteers and caregivers. To be in-cluded, papers had to be published in the past decade, i.e., since 1993. This datewas chosen because of the review by Contento et al. (1995) that summarizedearlier research on nutrition education, including a chapter on older adults. Acomputer-assisted literature search was conducted for reports that examinednutrition education programs that targeted older adult participants living inde-pendently in the U.S. No attempt was made to find unpublished papers or doc-uments such as dissertations due to their inaccessibility. In addition, articlesthat focused on intensive individual nutrition counseling by various healthcareproviders were excluded, as were reports of mass media campaigns broadcast-ing health messages to older adults and reports of nutrition screening tech-niques for senior adults. Search methods are reported more fully elsewhere(Higgins and Clarke Barkley, 2003b).

No similar review was found in the literature. Current published research onthis topic is limited. We found 30 articles reporting research findings that ad-dressed barriers to education or training opportunities, or both. Although re-search papers showed inconsistencies in study designs used, sample sizes, andmethods of data collection and evaluation, we did not set exclusion criteria forpapers on this basis. The remaining articles that we cited were descriptive of pub-lished literature and of authors’ experiences related to the topic. Some of the ar-ticles we reveiwed had a different focus than to provide information regardingour topic, but nevertheless, portions of them were appropriate in providingsupporting information.

This article is one of a series of reviews of recent literature on topics relatedto various aspects of nutrition education for older adults (Higgins and ClarkeBarkley, 2003a, b, c, d, and 2004). The purpose of this series is to assist nutri-

Nutrition Education for Older Adults 101

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tion educators, researchers and healthcare practitioners in familiarizing them-selves with more effective strategies pertaining to nutrition education for olderadults. Specifically, the purposes of this article are:

1. To discuss recent literature regarding barriers to effectively teach nutri-tion to older adults, as well as barriers for older adults to respond to nu-trition education.

2. To review recent reports of nutrition and aging programs for the educa-tion and training of nutrition educators and healthcare providers, volun-teers and lay leaders, and caregivers.

3. To discuss areas for future program and research efforts for minimizingbarriers and for training educators and healthcare providers, volunteersand caregivers.

BARRIERS TO TEACHING NUTRITIONEFFECTIVELY TO OLDER ADULTS

In the following subsections, reports citing barriers for educators and health-care providers are reviewed, including ten studies reporting research data. Bar-riers fell into three main categories, including perceptions that health profes-sionals have regarding older adults, little attention being given to older adultnutrition education programs and their funding, and issues involved with recruit-ing older learners. These barriers need to be understood and then addressed in or-der for health professionals to overcome them and teach nutrition effectively.

Health Professionals’ Perceptions of Older Adults

A major hindrance to education among the older population is the poor atti-tude of health professionals regarding this type of education’s value and feasi-bility (Sprague et al., 1999; Schuster, 1995; Kaempfer et al., 2002). Many donot understand theories of human development and the nature of aging and be-havior change in older adults. Those who assume that all older adults have cog-nitive deficits and are unable to learn or are unwilling to care for themselvesare guilty of ageism (Ahroni, 1996). The misperception lingers that providingeducation for the older population is difficult and that elders are unproductiveand therefore unworthy of health education dollars. Dietetics students, for ex-ample, have limited knowledge about aging and ranked working with olderadults as their least preferred choice (Kaempfer et al., 2002). Kaempfer et al.noted that their results were similar to those obtained for nursing, medical andsocial work students, who often hold negative attitudes about aging and havemisconceptions such as that older people are institutionalized, have low in-


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comes, and are bored, angry and isolated. Misconceptions about aging and theirimpact on health professionals who worked with older adults were discussedby Schuster (1995). The author reported that professionals commonly believethat beyond a certain age, a positive behavior change, e.g., smoking cessation,will not improve health status; that older adults are too set in their ways; and theyassume that older adults are generally frail and in poor health. All of these arefalse for most elders (Sahyoun, 2002). Contrary to the perceptions of some peo-ple, the position statement of the American Association of Diabetes Educators(2000) states that the capacity to learn remains intact during aging but educa-tors need to account for changes that affect processing of information, e.g., hear-ing loss and mental status.

Prejudice and stereotyping by health professionals should be acknowledgedand then dealt with and replaced with respect. Most older adults are lifelonglearners. They also make many lifestyle/behavior changes during their ad-vanced years, often as a result of geographical relocation, health conditions,changes in their financial situation, retirement, death of loved ones, etc. Addi-tionally, more older adults are enjoying good health, volunteering, traveling andgenerally staying engaged in life. They are interested in good nutrition and inmaintaining/improving their physical and mental health. At times, however,professionals’ views about models for productive or successful aging conflict(Kerschner and Pegues, 1998; Scheidt et al., 1999).

Helping educators and care providers improve their collaborative skills maybe vitally important for improving their ability to work with senior adults. Healthprofessionals should plan for an open exchange of communication, with empa-thy and mutual respect, as discussed in the published literature reviewed byHiggins and Clarke Barkley (2003c). One reason that elderly participants werehighly satisfied with an educational program was because the group’s facilita-tors treated them as “regular adult people,” according to Hendricks et al. (1999).

Nutrition educators for the most part have assumed that the major barriers tonutritional adequacy for older adults are lack of knowledge and misconcep-tions about nutrition, according to Contento et al. (1995). This assumption is inline with federal programs such as the Older Americans Act of 1965 and itsamendments. But studies have shown that the elderly possess a great deal of nu-trition information; however, they do not necessarily put it into practice (Contentoet al., 1995).

Another barrier to effective elderly nutrition education efforts stems fromhealth professionals’ incomplete understanding of their audiences’ nutrition con-cerns (Pierce et al., 2002). This lack of understanding can result in inadequateor misguided educational efforts. On the other hand, professionals who canidentify concerns from an older adult perspective are positioned to develop ed-ucational interventions with appropriate goals and objectives that consider mul-


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tiple needs simultaneously. Mayo and Rainy (2001) investigated nonphysicianhealth professionals’ and low-income elderly women’s views of nutritionalbeliefs and practices. While there was some variance between the two groupsregarding their perceptions of older adult barriers to eating a good diet, the rea-sons for their food choices and eating patterns, and the nutrition informationaltopics they were most interested in, there was also much agreement. Profes-sionals’ perceptions of nutrition information needs stressed the importance ofreading food labels, grocery shopping, and cooking, while older adults per-ceived the need to learn about nutrition and chronic diseases. Knowing whendivergence of perceptions occurs is an important factor for nutrition educatorsto bear in mind so that they can tailor their teaching approaches more effec-tively.

Attention to and Funding of Older Adult Programs

Health educators have focused primarily on children, youth and young adults.Scant attention has been paid to nutrition education needs of older adults and tothe potential healthcare cost benefits as well as quality of life improvementspossible from educating the elderly (Sahyoun, 2002; American Dietetic Asso-ciation, 2000). Blumberg (1997) concluded his review of nutritional needs ofseniors with the exhortation to provide “new efforts in consumer educationsensitive to the needs and beliefs of older people.” The scarcity of publishedreferences about varying aspects of nutrition education of older adults hasbeen noted repeatedly in our series of literature reviews. The lack of attentiondirected to this expanding cohort of our population is historical; Schuster(1995) also reported that three health education journals in a six-year period,1989-1994, contained only 21 health-related program reports pertaining toolder adults. Similarly, Ahroni (1996) concluded that older adults with diabe-tes also are an overlooked population when it comes to diabetes education:They received the least instruction, yet they had the highest level of motivationcompared to other age groups. Nevertheless, we found that nutrition educationof older adults with diabetes mellitus has received more attention in the litera-ture than the education of seniors affected by other chronic diseases. We be-lieve that it is likely that many published findings by professional diabeteseducators could apply to older adults with other diseases where nutrition edu-cation plays an important role in its prevention, treatment, and/or management.

Likewise, much of the attention of funding agencies, policy makers and gov-ernment agencies has been focused on children, youth and young adults, andthey have omitted older adults in their priorities. For example, the U.S. Depart-ment of Agriculture’s (USDA) strategic goal of promoting health by providing


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access to safe, affordable and nutritious food does not specifically mention olderadults, but makes repeated references to children (USDA, 2002).

Exceptions have occurred. In September 2000, USDA’s Center for NutritionPolicy and Promotion sponsored millennium conferences, one of which focusedon nutrition and aging, with the objectives of increasing awareness of the is-sues and providing professionals with the latest available scientific informa-tion on the subject (USDA, 2000). In addition, the USDA Food and NutritionService includes older adults in their guidelines for food stamp nutrition edu-cation programs that began in the early 1990s. Another exception is the OlderAmerican’s Act, which was reauthorized in 2000. This thirty-year-old pro-gram is the source of funding for the congregate and home-delivered elderlynutrition program (ENP), whose main purpose has been to feed older adults,but an additional purpose is to provide other nutrition, health and social ser-vices or referrals. Its guidelines provide for some nutrition education and othernutrition services (Wellman et al., 2002; American Dietetic Association, 2000),but nutrition expertise and additional nutrition services are not consistentlyprovided (American Dietetic Association, 2000). An evaluation of effective-ness of the ENP was mandated by Congress in 1992. Results of that study werepublished by Mathematica Policy Research, Inc. (1996) and in a summary byMillen et al. (2002). Eighty-seven percent of local ENP projects provided somenutrition education, but its extent was not described.

Even when nutrition educators are committed to elderly nutrition education,funding is still limited (Wellman et al., 2002). For example, it is more difficultfor local and state educators to provide the necessary “match” for USDA nutri-tion education funds provided by the food stamp program when teaching olderadults versus school children, and therefore, there is less money available foreducating older audiences. Private funding agencies have not made nutritioneducation for elderly a priority. Increased commitment and resources for help-ing older adults remain healthy and independent have been called for (Sahyoun,2002; Wellman et al., 2002).

Older Learner Recruitment

In contrast to children who attend school-based programs and adults partici-pating in work-site projects, older adults do not necessarily attend a specificplace regularly. The amount of time and costs to recruit older adults to partici-pate in a home-based nutrition education study were reported by Taylor-Daviset al. (1998). These researchers’ recruitment source was the patient database ofa large, rural tertiary-care hospital. They used introductory letters and fol-low-up telephone calls to contact their random selection of 1,300 individualsaged 60 to 74 years. Of those reached by telephone (1,077), only 45 percent


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agreed to participate. The total cost of recruitment was $8.56 per subject or atotal of approximately $5,000. This high cost and large time commitment to re-cruit elders would be beyond the resources of many nutrition educators. Diffi-culties with reaching older adults via telephone were also reported by ClarkeBarkley et al. (2003).

Recruiting older adults from already-established groups, such as congre-gate nutrition sites and senior centers, was more successful than through ad-vertising and word-of-mouth according to one study (Clarke Barkley et al.,2003). Participants in this study were individuals who showed a high level ofinterest in practicing healthy eating habits, believed in the importance of nutri-tion to good health, and appeared presently to be eating a good diet. Recruitingat-risk older adult participants with poor food habits who would not normallyvolunteer to join a nutrition class would be logical, but how to accomplish sucha recruitment process is a matter for more research. Recruiting elderly partici-pants at congregate nutrition sites was “surprisingly easy,” however, accord-ing to McClelland et al. (2001). Other possible recruitment or teaching sites, assuggested by Xaverius et al. (1999), include low-income housing complexes,doctors’ offices, congregate meal facilities, senior centers, adult day programs,and senior housing communities.

BARRIERS FOR OLDER ADULTSTO RESPOND TO NUTRITION EDUCATION

Like people of all ages, older adults are not always receptive to nutrition ed-ucation, and for many reasons. It was not our aim in this review to discern dif-ferences in educational barriers, if any, between older and younger learners.Barriers discussed in the following subsections have been divided into catego-ries, including psychological determinants, such as attitudes and motivators ofthe older adult, and external determinants, such as factors involving their envi-ronment, physical facilities, poverty and limited literacy. We found nine re-search reports providing data on psychological determinants, but only fivestudies reporting research findings regarding external determinants. Very fewauthors have reported on why older adults did not participate in health educa-tion programs (Chapman et al., 1995; Sprague et al., 1999).

Psychological Determinants

Older adults may not respond to nutrition education messages at times be-cause of their beliefs and attitudes. Some older adults believe that nutrition ed-ucation takes too much time and effort. Nutrition messages must compete for


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older adults’ attention against much other advice and life events, both health re-lated and otherwise (McNutt, 1995). Practicing–or not practicing–healthfuleating patterns on the basis of nutrition knowledge may result from psycholog-ical determinants, including attitudes toward dietary recommendations, a de-sire to enjoy certain foods, and not wanting to appear “different” from peers(Chapman et al., 1995). If older adults perceive a nutrition education opportu-nity to be unimportant; requiring too much time, money or energy; or have hadprevious unpleasant experiences with it, they are unlikely to engage in the pro-gram (Sprague et al., 1999; Ralston and Cohen, 1999). Older adults who feltthat a specific nutrition education program “would not be good for seniors”perceived that barriers would include limited incomes, types of foods used inthe program, and elders’ resistance to change at their age (Mayeda and Ander-son, 1993).

Seniors who do not respond to nutrition education messages may believe thatthey are already eating a good diet. Often there is a disconnection, however,between nutrition knowledge and beliefs. For example, Ryan (1997) looked atnutrition knowledge and beliefs of caregivers who were spouses, relatives andothers who assumed that role, usually involuntarily, because of need. Eighty-eight percent (n = 78) were responsible for their elder’s food consumption, and90% of them believed that their care recipient received proper nutrition on adaily basis. However, their average score on a nutrition knowledge test wasonly 58%, so it is not clear that they could judge accurately. Similarly, a recentcomparison of a self-assessment of diet quality to an objective measure of thediets of Americans of all ages found that about 40% overrated their diets, rat-ing them as excellent or good, when they were actually poor or needed im-provement (Shim et al., 2000). Respondents over the age of 70 years had themost accurate sense of the healthfulness of their diets, yet still 30% overratedtheir diet quality. These overraters need special attention from nutrition educa-tors because they perceive their diets to be more healthful than they are.

Additionally, a growing problem for older adults is the vast array of confus-ing nutrition messages, and at times even fraudulent nutrition misinformation,products and services that they encounter. Older adults are susceptible to mis-information and are confused by contradictory messages (Rainey et al., 2000;Mayo and Rainey, 2001). It seems likely that this is exacerbated by their lackof nutrition expertise, declining cognitive abilities, reliance on advertising fortheir nutrition information, and increasing vulnerability to chronic diseases.Some, not knowing how much is too much, may take massive doses of dietarysupplements, but behavior-based, health-promoting nutrition education pro-grams can be one way to deal with such threats to health and economic well-being (Sahyoun, 2002).


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Skepticism about nutrition education or the findings of research also hin-ders some older adults’ ability to respond. Such skepticism is justified in manyinstances because the “instructor” is primarily interested in selling them some-thing or has sensationalized research findings. Some older adults do not takeresponsibility for their behaviors because they expect that the actions of theirhealthcare providers, not their own initiative and actions, will primarily deter-mine their health outcomes.

Minority elders have a strong sense of autonomy and may be unresponsiveto suggestions about changes in cooking or eating habits, so it may be more ef-fective to promote gradual and individualized changes for them than to imposerapid generic dietary modifications (Buchowski and Sun, 1996). Barriers tonutrition education programming for Black elderly include suspicion of out-siders (Ralston and Cohen, 1999). Since minority elders may have experiencedyears of racial discrimination, they, therefore, may be less trusting of all aspectsof the healthcare system (Haber, 1996).

The intention to perform or not perform a behavior includes attitude towarddietary adherence, such as whether the behavior is seen as good or bad, benefi-cial or harmful, etc., according to Chapman et al. (1995). Furthermore, the sub-jective norm, which is the person’s perception of the expectations of importantothers, affects intentions. This research team suggested that attitude toward di-etary adherence is important, and it needs to be addressed by instructors orcounselors, at least for elderly patients with diabetes. Helping older adults dis-cover their own attitudes by asking them specific questions sometimes causesthem to change certain behaviors. The authors also proposed more research.

Certainly, older adults vary widely in their attitudes and ability regarding nu-trition education. Important motivators for older adults that can be used in nu-trition intervention include interest in maintaining health, how to modify dietsfor chronic disease, opportunities for social interaction and social support, en-hanced self-efficacy, and desire for ease of food preparation and tasty foods,according to published literature reviewed by Higgins and Clarke Barkley(2003c). Similarly, rural elderly southern women shared their attitudes and be-liefs regarding food and nutrition practices and nutrition information needsduring six focus groups (Rainey et al., 2000). Participants described selectingfoods based on taste and childhood familiarity, beliefs about its benefits anddetriments, the influence of health conditions, and their perceived barriers topurchasing, preparing and consuming certain foods. Their supplement use wasinfluenced by media advertisements and their doctor’s advice. They expresseda desire for nutrition education about nutrition and chronic disease, and nutri-tional values of altered cooking methods for traditional foods.

In contrast to opinions that elderly have difficulty coping with dietary changeand food choice restrictions, Plaisted et al. (1995) found that their 15 subjects,


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mean age 66 years, easily coped with severe dietary food-choice restrictionsduring a 21-day group feeding study. The authors concluded that older adultsshould not be overlooked for nutrition interventions solely because of age. Inanother study that contrasts with traditional beliefs, women ages 50 to 75 yearswere more concerned about their health and nutrition than they were abouttheir weight and appearance (Lahmann and Kumanyika, 1999). The authors con-cluded that a high awareness or knowledge of health and nutrition improvedthe dietary quality of these older women, but there was no clear connection be-tween concern with appearance and weight to dietary quality. They noted thatolder adults might be more receptive to nutrition education messages that stressfoods that they should include in their diets rather than foods to avoid.

External Determinants

Various external determinants, such as factors in the environment, can pre-sent obstacles to elders’ response to nutrition education programs. These vari-ables can hinder older adults from establishing healthful nutrition practices,and have as much or perhaps more influence than their nutrition knowledgehas. For example, sources of nutrition stress from the perspective of low-in-come elderly women centered on food acquisition, including such items as therising cost of foods and their inability to drive to the store, as well as food prep-aration issues, including lack of motivation to eat right and physical disabili-ties that impaired shopping and cooking skills (Pierce et al., 2002). Lack oftransportation is a factor for many (Misra et al., 1999; Ralston and Cohen,1999; Taylor et al., 2000). The popularity of a program offered at congregatenutrition sites was partly due to seniors having transportation to the educationalsite, along with having comfort factors such as appropriate seating, lighting,ambient noise, and room temperature (McClelland et al., 2001). Barriers to prac-ticing health behaviors can include inadequate grocery stores and no places forphysical activity, such as sidewalks (Misra et al., 1999). Lack of availablecooking facilities and access to appropriate foods are other barriers to adoptinghealth behaviors (Jack Jr. et al., 1999). While health professionals cited trans-portation as a barrier to nutritious diets, the low-income rural elderly southernwomen that Rainey et al. (2000) and Mayo and Rainey (2001) interviewedmentioned barriers such as their inability to wash and cut up vegetables andopen jars because of arthritis, diabetes and lack of strength, but indicated thatgetting to the grocery store was not a problem.

Poverty and low literacy interfere with positive responses and often arelinked with nutritional problems in the elderly (U.S. Department of Health andHuman Services Surgeon General’s Report, 1988). Almost one in five olderadults has a household income at or below 130% of the federal poverty level,


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the level at which elderly may become eligible for food stamp assistance. Olderadult households are the population group least likely to enroll in the foodstamp program, with only about one in three of those eligible receiving assis-tance (Guthrie and Lin, 2002). Older adults with low reading ability find nutri-tion education print materials to be too complex, or they may be unfamiliar withconcepts of percentages and measurement abbreviations, according to Mayedaand Anderson (1993). Numerous published examples of strategies to considerin order to adjust nutrition education intervention programs to meet needs andinterests of older adults, such as accommodating physical handicaps like poorvision and hearing, were reviewed by Higgins and Clarke Barkley (2003c).For example, printed handouts and evaluation forms in easy to read, large14-point type help compensate for low literacy and poor vision.

EXAMPLES OF EDUCATING AND TRAINING HEALTHEDUCATORS AND HEALTHCARE PROVIDERS, VOLUNTEERS,

AND CAREGIVERS ABOUT NUTRITION AND AGING

Articles describing the need for–and opportunities to provide–training aboutnutrition and aging are cited in the following subsections. They are divided ac-cording to the audience to be educated, i.e., health educators and care provid-ers, volunteers and lay leaders, and caregivers. Thirteen reports provided re-search findings on the topic, while the remaining articles were descriptive ofeducators’ experiences or reviewed published literature.

The Need

Several papers have been published in the last few years about healthcareproviders and their need for training in nutrition and aging. For example, moreinstruction about aging and more positive experiences with older adults throughfieldwork for healthcare practitioner students was recommended by Kaempferet al. (2002). Dental, physician assistant, nurse practitioner and nurse midwiferyprogram directors agreed that their graduates needed a level of competence inproviding a variety of nutrition services, including nutrition education, and rec-ommended use of computer-based programs to enhance their students’ nutri-tion education options (Touger-Decker et al., 2001). Shawver and Cox (2000)surveyed 209 physicians, of whom 61% perceived themselves as well pre-pared or fairly well prepared to counsel patients on diet for diet-related chronicdiseases, while 38% believed that they were either not prepared or were some-what prepared. However, older food-stamp-eligible chronic disease patients in


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the same community perceived that their primary care physician should beproviding more nutrition education. More than half, 57%, of the physicianswere unfamiliar with available sources of nutrition counseling/education otherthan registered dietitians. Only 23% sometimes referred patients to a commu-nity nutrition program, while 72% never or rarely did. The most common toleast common community nutrition program referrals, respectively, were tohome health agencies; Weight WatchersTM and other private organizations; healthdepartments; social services and food stamps; free clinics; food pantries; andcooperative extension.

Training Health Educators and Care Providers

The education and training of family practice residents and practicing phy-sicians in nutrition has not fully matured, according to Kolasa (1999). The au-thor noted that physicians do not get adequate preparation in nutrition counsel-ing skills and clinical nutrition practice in their education and training programsor through their continuing medical education program options. Training cur-rently available to healthcare practitioners, including physicians, about nutri-tion of older adults is limited (Levkoff et al., 1996). More extensive geriatrictraining for health professionals is needed for health promotion issues overall.In response, Levkoff’s team developed geriatric education modules, includingone on nutrition, for use by primary care health professionals in office-basedpractices and outpatient facilities. The evaluation plan for the training modulesalso was described, but no data were presented as to their effectiveness.

Other progress is being made. For example, continuing education in diabe-tes via clinical fellowships at the East Carolina School of Medicine includesnurses, dietitians, pharmacists, physician assistants, nurse practitioners, exer-cise physiologists, health educators and psychologists (Bell et al., 2000). Di-etitians in home care expect growth and role expansion and feel competent toprovide services in caregiver education (Arensberg and Schiller, 1996). TheAmerican Dietetic Association (1996) described the synergy between oral healthand nutrition and proposed that appropriate education be promoted in not onlydietetics and dental professions, but in other allied health education programsas well. Some geriatric education centers associated with veterans administra-tion hospitals and university medical teaching facilities provide opportunitiesfor educating geriatric health professionals, including nutritionists.

Gerontological nutritionists’ standards of professional practice, which aredirected to dietetics professionals working with older adults, recommended thathealthcare professionals collaborate with each other, caregivers and older adultsto promote quality health and nutrition services (Shoaf et al., 1999). Similarly,the position statement of the American Dietetic Association on nutrition, aging


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and the continuum of care (American Dietetic Association, 2000) suggests thatdietetics professionals collaborate with other health professionals to developinterventions that improve care of elders and maintain or enhance quality oflife. In the community setting, the statement mentions assisting caregivers withimplementation of nutritional interventions (such as education) and undertak-ing nutrition and health education activities in collaboration with industry andnonprofit organizations. In the academic setting, it recommends developingmultidisciplinary continuing education/distance learning courses for healthprofessionals so that they are able to disseminate current information about ed-ucation programs targeted to older adults. There is much work to be done inraising awareness to the need and to plan programs and their implementationand evaluation for the benefit of the expanding numbers of older adults.

A two-hour attitudinal intervention with occupational therapy students dur-ing their training influenced their perceptions of and practices with older peo-ple nine years later (Gardner, 1994). The author’s approach successfully addressedmyths and misconceptions of upcoming health professionals. He also sug-gested that students need role models in their classrooms, laboratories, clinicsand practice settings–i.e., role models who are committed to the importance ofolder people as patients, clients and individuals.

Accrediting organizations, such as the Joint Commission on Accreditationof Healthcare Organizations (JCAHO), require nutrition education training fornursing home staff, but the rigor and frequency is highly variable from one or-ganization to another. McCue (1998) very briefly described mandatory in-ser-vice education classes taught by her facility’s dietitian; classes covered theimportance of liquids and techniques for feeding assistance to prevent weightloss. We found no other examples of nursing home educational training ses-sions with the literature search protocol used.

Diabetes educators and researchers, who seem to be leaders in education forthose with chronic disease, have published a research agenda for determiningsuccessful diabetes education outcomes (American Association of DiabetesEducators, 2001). Among the issues needing more study are provider and pro-gram characteristics that affect outcomes. One of the top six priority issues ontheir research agenda is identifying educator characteristics, such as training,personality and approach or orientation, that affect outcomes.

Home health aides can have a positive impact on nutrient intake of urbanblack elders through their selection and preparation of nutrient-dense foodsand by providing guidance in healthy food practices (Ralston and Cohen, 1999).Awareness of their clients’ food consumption patterns should be included intraining protocols. The authors also recommended that home health aidesshould be taught to help informal supports, such as family and friends, andshould be more sensitive to and encouraging of healthy eating habits of elders.


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Training Volunteers and Lay Leaders

Healthcare professionals and policy makers have been seeking new, cost-ef-fective ways to educate the expanding number of older adults. One of the meth-ods for meeting this need is through trained volunteers. This approach cannotonly cut health and home care costs as healthcare dollars become more scarce,but also can improve effectiveness of programs by increasing peer interactionsand can provide motivation to the volunteer educators to improve their healthbehaviors (Moore and Mengel, 2002). However, as McClelland et al. (2002)pointed out, training lay personnel carries limitations and needs to be furtherstudied and monitored to learn the benefits and the drawbacks for both the re-cipients and the providers.

Enlarging health education teams by training community volunteers, or layhealth workers, to participate in a diabetes education program was proposed byMoore and Mengel (2002). Quinn and McNabb (2001) concluded that if layhealth educators, who were ages 35 to 68 years old, were given training appro-priate to the structure of the program and specific to the targeted health behav-ior, they could reliably and effectively administer even rather complex pro-grams. In this case, it was a weight loss program in a church setting for minor-ity women of all ages. The lay volunteers were closely supervised, and the pro-gram was very detailed in how it was to be presented.

The feasibility of a Train-the-Trainer approach at congregate nutrition sites(CNS) was reported by McClelland et al. (2002). Trained CNS managers, whowere supported by ongoing information from cooperative extension staff, de-livered scripted nutrition education modules to groups of elderly site partici-pants over eight weeks. Both the trainers and the participants in this smallstudy of four managers and 53 participants indicated approval of receiving ed-ucation in this manner. The authors concluded that this method of stretchingresources deserves further study.

Young Hispanic grandmothers, 78 percent of whom were 31 to 60 years ofage, were trained to be nutrition educators in a model described by Serrano etal. (2000) and Taylor et al. (2000). Their training program used techniques pre-ferred by adult learners, such as small groups and hands-on activities, as wellas bilingual, culturally appropriate educational materials that were developedfor low literacy. Written materials were kept to a minimum, while visual re-sources and useful kitchen items were emphasized as teaching aids.

Training Caregivers

Policy makers have shifted care of incapacitated elders to the home ratherthan to the hospital or other community settings. Unpaid family caregivers pro-


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vide 80% of this vital service, according to Silver and Wellman (2002). Theseauthors argue that healthcare providers have directed most of their attention toproviding for the nutrition needs and services for the ill recipients and offervery little attention to caregivers and the physical and mental stresses that im-pact their health and well-being. Nutrition educators need to perceive the po-tential malnutrition risk that these caregivers experience and recognize that keepingthem well, in part through meeting their nutrition education needs, would havemany benefits in helping caregivers help both themselves and their elderly carerecipients. As mentioned previously, nutrition knowledge of caregivers may bepoor, as evidenced in one study by their low (58%) average score on a nutritionknowledge test (Ryan, 1997).

The resource Home Health Nutrition: Patient Education Manual (AspenReference Group, 1998) is an example of a partial solution to providing educa-tion to caregivers in home health settings. It includes handouts in a large-print,ready-to-copy and easy-to-read format for those providing services for homehealth clients. Other sources of information for reaching and teaching physi-cally and mentally impaired individuals are available from specific organiza-tions for those with disabilities, some of which are referenced in a directory ofnutrition and aging Websites (Gaston and Munroe, 2002).

Nutrition education was successfully provided to rural caregivers of peoplewith Alzheimer’s disease using distance education technology in the form ofsatellite teleconferencing (Paul et al., 2000). The authors described rural homecaregivers as often elderly themselves, female, having chronic disease, lesslikely to seek out information about their problems, and receiving less emo-tional support from their family and friends than urban dwellers. Participantsreported that they appreciated the information and recognized the convenienceof the educational program that was offered locally through simultaneous broad-casting and, thus, saved them travel time, decreased their need for longer respitecare, and reduced their travel expenses. The program also could be watched onvideotape later.

DISCUSSION AND SUGGESTIONS FOR RESEARCHON MINIMIZING EDUCATIONAL BARRIERS

AND FOR TRAINING HEALTH PROFESSIONALS,VOLUNTEERS AND CAREGIVERS

Published literature that addresses older adult nutrition education barriersand/or nutrition and aging training opportunities is scattered. Major inconsis-tencies exist in objectives, research designs, participants and outcomes mea-sured among the 30 published research studies that we located. Written surveys


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were used by 11 research teams, while 10 studies used face-to-face or telephoneinterviews or focus groups to gather participant information. Group meetingsor print information were used in 11 studies to teach older adults or to trainvolunteers to teach older adults. Some researchers used a combination of ap-proaches. Sample sizes ranged from four subjects to more than eight thousandcontacts. Few reports were based on theory. They had no common measuredoutcomes among them. Reported findings cannot be generalized. Nevertheless,they are valuable as a starting point for designing and reporting future researchstudies.

Future research in education should include determining how best to marketit to increase the awareness of patients, physicians and other healthcare profes-sionals of its benefits and importance, according to Sprague et al. (1999).While this research team was referring to diabetes education, we believe this tobe true for nutrition education as well. Well-designed nutrition education pro-grams for the vulnerable older adult population are needed not only to treat ormanage disease, but also to prevent its occurrence.

The wide and diverse potential of benefits that would accrue to the commu-nity as a result of the provision of nutrition education to older adults suggeststhe need for well-trained professionals. Because of the complexity of and thebarriers to changing attitudes and behavior in both professionals and older adultclients, nutrition educators and researchers need expertise from numerous dis-ciplines, such as older adult nutrition, adult education, program evaluation, chronicdisease, research methodology, behavior change techniques, cultural under-standing of the target audiences and gerontology. At present, very few individ-uals have this background. Even fewer have this background plus work experi-ence. In lieu of specialized training for individuals in each kind of expertiseneeded, teams of interested professionals could collaborate to pool their col-lective knowledge. Strengths and weaknesses of collaborative teams were dis-cussed by Dutram et al. (2002), Clarke Barkley et al. (2003) and McClelland etal. (2001).

In order to better understand and, thus, minimize barriers in providing nutri-tion or aging education/training to older adults, health professionals, volun-teers and caregivers, we suggest the following for future program and researchefforts:

1. Explore and document the rank order importance of different educa-tional barriers–such as attitudes, beliefs, motivations, physical environ-ment and facilities, physical and learning disabilities, and poverty–thathandicap various ethnic/racial and age groups from effectively recruit-ing, teaching or responding to nutrition education.

2. Test methods for modifying negative attitudes and beliefs held byhealthcare professionals, lay volunteer educators and caregivers, and


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encourage them to participate in teaching healthy nutrition practices toolder adults.

3. Train and fund collaborative teams that seek to overcome educationalbarriers and to demonstrate effective program outcomes.

4. Determine ways to promote healthful nutrition habits in volunteer care-givers to improve their care recipient’s health status and to reduce theirpersonal risk for malnutrition, disease and burnout.

5. Develop instruments to calculate quality of life and economic benefits tobe gained from enabling older adults to overcome barriers to healthy eat-ing behaviors.

SUMMARY

Various barriers to older adult nutrition education for health professionalsand older learners cited in the literature are discussed in this article in order toraise awareness of educators who wish to be proactive in overcoming commonobstacles. These barriers need to be understood and then addressed in order fornutrition to be taught or learned effectively and so that nutrition practices andhealth improve.

Perhaps one of the most important obstacles is skepticism by some healthprofessionals that changing food behaviors among the elderly is possible orworth the effort. Health professionals frequently stereotype or have miscon-ceptions of older adults, may not interact with them on a collaborative basis,and often do not understand their nutritional concerns. Other barriers for edu-cators to teaching nutrition to older adults include inadequate attention to andfunding for programming and difficulties recruiting older learners since, un-like school children and employed adults, they do not necessarily frequent aspecific place regularly.

As is true for people of all ages, older adults experience a number of attitu-dinal and motivational barriers that can hinder their response to nutrition edu-cation. These may include negative factors such as competing interests fortheir attention, previous unpleasant experiences with it, beliefs that they al-ready are eating nutritiously, misunderstanding or confusion over the plethoraof nutrition information, distrust and others. Likewise, older adult caregivers,often themselves elderly spouses or relatives susceptible to malnutrition, maybelieve that they are doing a good job of providing adequate nutrition for theirpatients, but their knowledge is often limited and their efforts can fall short.External barriers that may influence nutrition and health practices includeproblems such as lack of or poor physical facilities, reduced transportation op-tions, physical disabilities, limited literacy and poverty.


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Few healthcare provider associations and health education professionalshave paid attention to the nutrition needs of older adults, and some have had lit-tle or no training in gerontology or geriatrics. Examples are cited regarding ed-ucation and training opportunities that are in place for health professionals,volunteers and caregivers, but more programs are needed.

Recent literature suggests some good possibilities for addressing needs andminimizing barriers. We found 30 articles reporting research that addressedbarriers to education and/or training opportunities. The remaining articles that wecited were descriptive of published literature and of authors’ experiences re-lated to the topic. The surface has barely been scratched for how to train health-care providers and educators, volunteers, lay leaders and caregivers in provid-ing nutrition education for older learners. New research is needed. Severalsuggestions for future programs and research efforts are made. This importantarea needs attention from practitioners, educators, researchers, funders andpolicy makers in order to realize quality of life benefits and healthcare costcontrol possibilities through effective nutrition education for older adults.

Received: November 2002Revised: September 2003Accepted: October 2003

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