The Spectrum - MNA® Elderly - Overview · MNA® in clinical practice. The MNA® agreed with...

INSIDE: HA ELECTION WINNERS • SOCIAL NETWORKING • HA CALENDAR

Linking Evidence Based Medicine toGeriatric Nutrition Screening –The Mini Nutritional Assessment (MNA®)

The Nutrition-Focused Physical Examination:One Dietitian’sPerspective

SPRING 2009

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The SpectrumIntroductionWith the number of persons 65 years and older expected to double in coming decades, there is growing interest in the United States on containing healthcare costs for the older adults by increasing support to maintain them in community settings. The success of this shift in care depends on elders being able to maintain functional status. This occurs at a time when many older persons face failing health or other physiological or psychosocial changes that can lead to undernutrition. If undetected and untreated, progressive undernutrition can lead to malnutrition and cause loss of independence, lower quality of life, increased institutionalization, and death. This scenario presents opportunities for Registered Dietitians (RD) to demonstrate their value by designing effective nutrition programs that can help older Americans maintain or restore their nutrition status and maximize independent function. The first step is effective nutrition screening that quickly and accurately identifies those elders who are at risk for malnutrition so they can receive intervention early, when it is most effective.

The causes of malnutrition in the aging population vary from physical reasons to social and psychological reasons that affect functionality (Table 1). Because each cause has a different treatment, screening tools should use multiple measures to detect specific causes of malnutrition. This article discusses the Mini Nutrition Assessment (MNA®), a nutrition screening tool developed specifically for persons 65 years and older, that helps the RD to target nutrition interventions to specific causes of malnutrition identified by specific questions in the MNA®. Pinpointing the causes of malnutrition helps the RD make accurate nutrition diagnoses and implement early intervention, without wasting resources on those who need no intervention.

Description and Use There are two parts to the MNA® – the short form (MNA-SF) and the full MNA®

(see the Nutrition Aid on page 14). The full MNA® includes 18 total questions and takes less than 15 minutes to complete. The maximum combined total score for the full MNA® is 30; a total score from 24 to 30 indicates adequate nutritional status, scores between 17 and 23.5 indicate risk for malnutrition, and scores less than 17 indicates malnutrition. However, for many older adults, one only needs to complete the short form, which was developed and validated to save time and facilitate more widespread use. The MNA® Short Form (SF)

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A nutrition assessment is encompassing of all the data from the client or patient or setting that is available. The areas of data collection include the client history, their food history, anthropometric measurements, and available biochemical data as well as medical test and procedure data. After review of this information, nutritional insult or risk may be flagged. A health care professional would further examine the patient for nutrition-focused physical findings and possibly more in-depth subjective information. The practitioner may decide to do a full or a focused nutrition physical exam depending on the data collected, the symptoms and diseases of the client and the referrals of other health care providers. If a person has blood work that suggests an iron deficiency (low hemoglobin and hematacrit with a high red blood cell distribution width and a low mean cell volume) the practitioner could look for signs and symptoms of iron deficiency anemia. These might include pale nails, pale everted lower eyelids or a pale tongue or koilynchcia. On the other hand, if a person is a known, longstanding alcoholic who eats poorly, the practitioner may suspect general undernutrition or malnutrition

THE SPECTRUM • Spring 2009 2

Chair’s MessageAdele Huls, PhD, RD, LMNT


As Healthy Aging Chair I would like to welcome you to our first electronic issue of The Spectrum. Healthy Aging hopes you enjoy the instantaneous access to the newsletter articles. One great thing about electronic issues is you can file them for easy access by topic – no more wondering in which issue you saw that article. Healthy Aging has issues available on our website which will work for that purpose also as most of our newsletters are still “in ink”.

A couple issues back I encouraged you to think about getting involved in the Healthy Aging DPG. I would like to introduce to you two HA members who have done just that. These ladies stepped forward and accepted Director positions that will begin with the new fiscal year June 1, 2009. The Director positions are two year commitments. Many Directors go on to run for an office or assist the DPG in a leadership role in another way. The Directors really are the “backbone” of the HA Executive Committee with the officers tending to the “business” of running the DPG – financial accountability, keeping minutes, planning and carrying out Executive Committee meetings, following the guiding principles, providing DPG history and brainstorming for future DPG projects, member benefits, etc.

Sandra Bastin, PhD, RD, LD, CLE will be Healthy Aging’s Director in the area of Professional Development. Dr. Sandra Bastin is an Associate Extension Professor in the Department of Nutrition and Food Science at the University of Kentucky. She is a Registered Dietitian and Certified Culinary Educator. Dr. Bastin works as an Extension Food and Nutrition Specialist providing leadership, technical expertise, program development, research, and grant writing support in nutrition, diet, and health; food safety; food preservation; and entrepreneurial food manufacturing for Cooperative Extension Agents and fellow Kentuckians.

Dr. Bastin’s research and educational interests include food systems from farm to table. Presently she works with farmers markets in Kentucky and other states to train interested farmers how to safely prepare and sell home-based value-added products. In addition, she works with commercial food manufacturers to develop their recipes and assist in the many steps required to successfully market their products. She has also done environmental studies and nutrition education at Superfund sites in Kentucky. Dr. Bastin recently developed the Super Star Chef series to encourage all ages to get back into the kitchen to prepare safe, nutritious meals. Globally and under more primitive conditions, Dr. Bastin helps set up feeding centers in Paraguay, Guatemala, and Mexico. She looks forward to working with the Healthy Aging DPG to provide exciting professional development opportunities and to further our profession.

Maria C. Mahar, MA, RD, CDN has stepped forward to be Healthy Aging’s Communication Director. This Directorship involves coordinating the website

Healthy Aging Dietetic Practice Group

Our MissionLeading the future of dietetics

in healthy aging.

Our VisionHealthy Aging DPG membersare the most valued source

of food, nutrition and wellness information and services

for older adults.

EAL® Guideline Presentations now Available

The EAL® Guideline Powerpoint Presentations are perfect for the busy practitioner looking for user-friendly slides to assist them in implementing the ADA Evidence Based Nutrition Practice Guidelines. Ideal for use in meetings, in-service presentations and classes, these slides include all recommendations and ratings!

Guideline Presentations Available:• Adult Weight Management• Critical Illness• Chronic Obstructive Pulmonary• Disease• Disorders of Lipid Metabolism• Diabetes I & 2• Heart Failure• Hypertension• Oncology• Pediatric Weight Management

To order visitwww.adaevidencelibrary.comand click on Store.ADA Member Price: $8.00 each


SPRING / SUMMER 2009 • HA CALENDAR April 29-May 2, 2009AMERICAN GERIATRICS SOCIETy ANNUAL SCIENTIFIC MEETINGChicago, ILwww.americangeriatrics.org/

May 5-7, 2009ASSISTED LIvING FEDERATION OF AMERICA CONFERENCE & ExPOPhiladelphia, PAwww.alfa.org

May 15-19, 2009AMERICAN COLLEGE OF HEALTH CARE ADMINISTRATORS ANNUAL CONvOCATION & ExPOProvidence, RI http://www.achca.org/joomla/

June 16-18, 2009NATIONAL SOCIETy FOR HEALTHCARE FOOD SERvICE ADMINISTRATORS NATIONAL CONFERENCEClearwater Beach, FLhttp://www.ashfsa.org/displayconvention.cfm

June 23-26, 2009NATIONAL ASSOCIATION OF NUTRITION AND AGING SERvICES PROGRAMS JOINTLy WITH THE ASSOCIATION OF NUTRITION SERvICE PROvIDERS ANNUAL TRAINING CONFERENCEAtlanta, GAwww.nanasp.org

July 11-15, 2009SOCIETy FOR NUTRITION EDUCATION ANNUAL CONFERENCENew Orleans, LAwww.sne.org

July 19-22, 2009NATIONAL ASSOCIATION OF AREA AGENCIES ON AGING ANNUAL CONFERENCE & TRADESHOWMinneapolis, MNwww.n4a.org/training-events/

August 9-13, 2009DIETARy MANAGERS ASSOCIATION ANNUAL MEETING & ExPO ATLANTA, GAhttp://www.dmaonline.org/events/main.html

September 2-4, 2009MEALS ON WHEELS ASSOCIATION OF AMERICA ANNUAL CONFERENCESan Diego, CAwww.mowaa.org

October 17-20, 2009AMERICAN DIETETIC ASSOCIATION FOOD & NUTRITION CONFERENCE & ExPODenver, COwww.eatright.org

November 7-11, 2009AMERICAN PUBLIC HEALTH ASSOCIATION ANNUAL MEETING & ExPOPhiladelphia, PA http://www.apha.org/meetings/

November 8-11, 2009AMERICAN ASSOCIATION OF HOMES AND SERvICES FOR THE AGING ANNUAL MEETING & ExPOChicago, ILwww.aahsa.org

November 18-22, 2009GERONTOLOGICAL SOCIETy OF AMERICA ANNUAL SCIENTIFIC MEETINGAtlanta, GAhttp://www.aghe.org/site/aghewebsite/

December 2-5, 2009INTERNATIONAL COUNCIL ON ACTIvE AGING ANNUAL CONFERENCEOrlando, FL

http://www.icaa.cc/convention.htm

Access to other events calendars:Events Calendar from the DHHS Administration on Aginghttp://www.aoa.gov/press/main_news/events/events.aspx

Events in Aging from the American Society on Aginghttp://www.asaging.org/calendar/home.cfm

American Dietetic Associationhttp://www.eatright.org/cps/rde/xchg/ada/hs.xsl/events.html

Commission on Dietetic Registrationwww.cdrnet.org

Calendar ServiceAvailableDietetics Professionals can call, fax, or write the Commission on Dietetic Registration Office for information on prior approved continuing professional education activities by topic, program provider, location, and/or date.

Call: (800) 877-1600, ext. 5500Fax: (312) 899-4772

Or visit the searchable database at: www.cdrnet.org

Write attention: Commission onDietetic Registration,120 South Riverside Plaza, Suite 2000Chicago, IL 60606-6995


uses the 6 most strongly correlated items of the full MNA® and takes less than 5 minutes to complete. The short form preserves the accuracy and validity of the full MNA®. The maximum score is 14, and a score <11 indicates a person is malnourished or at risk for malnutrition and the need to complete the full MNA®.

Development and Validation of the MNA® The MNA® was developed to assess nutrition status in persons age 65 and older and was validated in large representative samples of older persons worldwide. The tool was comprised of the items listed in Figure 1 plus biochemical markers and was compared with two criteria – clinical status and a battery of anthropometric, dietary, and biochemical indices (Table 2). Clinical status, as defined by a physician, was considered to be the gold standard to define malnutrition risk.1

The development study showed the MNA® correlated strongly with conventional nutrition assessment

Mini Nutritional Assessmentcontinued from page 1

(biochemical data, dietary intake, and anthropometric parameters) and also with clinical status. The final MNA® does not include laboratory data as exclusion of this information did not change the strength of the tool and thus makes it a more practical tool. The sensitivity, specificity, and positive predictive value according to clinical status were 96%, 98%, and 97% respectively.2

Additional validation studies among both frail and healthy older persons confirmed the usefulness of the MNA® in clinical practice. The MNA® agreed with physicians’ ratings of clinical status nearly 90% of the time. Even without laboratory data, the MNA® correctly classified between 70% and 75% of all healthy and frail participants as normal or malnourished. The remaining 25% - 30% could not be definitely classified as either normal or malnourished; but were identified as at risk for malnutrition even before they lost weight or had changes in their serum albumin levels.3 This ability of the MNA to predict malnutrition before marked changes in weight or albumin level occur has proven to be a key benefit in clinical practice.

The Ideal Screening Tool – How Does the MNA® Measure Up?The ideal nutrition screen may vary according to the targeted population, the care setting, and the purpose of the screening. While nutrition screening in a hospital is designed to identify patients who may benefit from nutritional support, screening tools in the community setting should be more focused on identifying individuals who are malnourished or nutritionally at risk. To be effective, the ideal screening tool should meet the criteria in Table 3.

The MNA® is well validated and is supported by more than 400 published studies.4 In contrast, most nutrition screening tools in practice have not been validated. Why is validity important when selecting the best tool for screening a given population? validated tools have proven they actually measure what they claim to measure in a specific population. By using validated tools, clinicians are more likely to correctly identify clients who truly need help, avoid missing those who need intervention, and begin intervention earlier when the potential for recovery is greater. They are less likely to waste resources on those who do not need intervention. validated nutrition screening tools support evidence-based dietetics practice and facilitate decision-making based on the best available, valid, and relevant evidence.

validity is measured by sensitivity and specificity and by predictive value, which range from 0 - 100%. Sensitivity is the effectiveness of a test in detecting a disease in those who have the disease. The higher the sensitivity of a nutrition screening tool, the fewer true cases of nutrition risk go undetected. Specificity is the

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Table 1. Effects of Aging on Nutrition

→Possible Changes with Aging Effect on Nutrition

Sensory Impairment

• Decreased sense of taste

• Decreased sense of smell

• Loss of vision and hearing

• Oral health/dental problems

Change in energy needs

Decreased physical activity

Muscle loss (sarcopenia)

Isolation/depression

Financial constraints

Reduced appetite

Reduced appetite

Decreased ability to purchase and prepare food

Difficulty chewing, inflammation, poor quality diet

Diet lacking in essential nutrients

Progressive depletion of lean body mass

and loss of appetite

Decreased functional ability, help needed with ADLs

Decreased appetite

Limited access to food; poor quality diet

→→→→→→

→→→→Cumulative Effect Progressive Undernutrition

Reprinted with permission from the MNA Web site (www.mna-elderly.com)



extent to which a test gives negative results in those that are free of the disease. The higher the specificity of a nutrition screening tool, the fewer well-nourished people are labeled as at nutrition risk.9 Positive predictive value is how many of the subjects who test positive truly have the disease. Negative predictive value is how many of the subjects who test negative truly do not have the disease. Ideally, a screening test should be highly sensitive and highly specific and have both positive predictive value and negative predictive value.

Reliability is an important measure in assessing the accuracy of a nutritional screening tool. The tool should give the same results every time it is used. Inter-rater reliability measures the agreement between the results when more than one user applies it to the same subject. The MNA® consistently demonstrates a high level of reliability.5

A nutrition screening tool should also provide an acceptable measurement of the condition being studied. A key determinant of reported prevalence

of malnutrition is the cut-off level for body mass index (BMI) that defines malnutrition. The MNA®’s cut-point to define risk for malnutrition is BMI <22kg/m2 and agrees with the most current recommendation for defining malnutrition in older persons. Other tools have higher cut points, which are more reflective of the general population and not specifically geriatrics. This geriatric specific cut off may account for higher reported prevalence of malnutrition with the MNA®, which is consistent with a higher prevalence of nutrition issues in the geriatric vs. the general adult population.

The ideal screening tool should be specific for the population that the tool is targeting. The MNA® was specifically designed for the elderly and has been studied more than any other screening tool for older people.5

Screening tests should have clearly defined thresholds. Cross tabulation of the MNA® score and serum albumin concentration in individuals without inflammation established thresholds that clearly distinguish those with adequate nutrition status vs. malnutrition vs. risk for malnutrition.

Using albumin levels to establish the thresholds was appropriate as they are highly prognostic for morbidity and mortality in the elderly.

In today’s environment, screening tests have to be quick and easy to use to be routinely incorporated into busy practice settings. The MNA® is quick and requires no special skills or calculations, so nurses, dietitians, technicians, and other staff can easily complete the MNA® screen. A convenient table allows users to rapidly determine body mass index (BMI), eliminating the need to perform any calculations. Easy-to-follow directions for performing anthropometric measures, even in challenging patients such as those with amputations or who are bed-bound, are available in the user-friendly guidelines which are downloaded from the MNA® Web site (www.mna-elderly.com).

The MNA® is free to use and widely available for all practice settings. Because it does not rely on laboratory data, the MNA® is ideal for community and ambulatory care settings, such as assisted living facilities and senior feeding programs, where resources for blood sampling may be limited or cost prohibitive.

The ideal screening tool must be effective. Compared with other nutrition screening tools, the MNA® is more likely to identify risk of developing undernutrition at an early stage so intervention can be started early when it is most effective.6 It is useful for follow-up and for monitoring the effectiveness of nutrition intervention. In recent studies, MNA® scores improved in patients who received nutrition intervention after being identified by the MNA® to have early malnutrition.7

Table 2. Principal Criteria Used to Validate the MNA

Anthropometry Weight, height, body mass index (BMI), mid-arm circumference (MAC), calf circumference (CC), mid-arm muscle circumference (MAMC), triceps skinfold (TSF), subscapular skin fold (SSF)

Functional evaluation

Dietary evaluation

Clinicalevaluation

Biochemicalmarkers

Mini-Mental State Examination (MMSE), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL)

Dietary history, 3-day food record, food-frequency questionnaire, calculation of daily energy, fluid, macro- and micronutrient intake

Clinical status including review of patients’ medical records

Hematocrit, hemoglobin, full blood cell count and blood cell differentiation, total protein, albumin, prealbumin (transthyretin), transferrin, ceruloplasmin, retinol-binding protein, C-reactive protein, α1-acid-glycoprotein, creatinine, cholesterol, triglycerides, γ-glutamyl transferase, vitamins A, B1, B2, B6, B12, D, E, folate, copper, zinc. Activation coefficients for vitamins B1, B2, and B6

continued on page 6Adapted from: Guigoz y, vellas B, Garry PJ. Mini nutritional assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 1994;(Suppl 2):15-59



The MNA® predicts not only nutritional risk, but also outcomes of nutrition risk - functional problems, hospitalization, and mortality. Low MNA® scores correlate with decline in functional ability, cognitive impairment, and increased frailty in older persons.8 In hospitalized patients, low MNA® scores are predictive of adverse outcomes, including prolonged lengths of stay, increased frequency of discharges to a nursing home, and a nearly three-fold increase in mortality.9

Challenges in PracticeBecause the MNA® was specifically developed for use in persons over 65 years of age, it is not suitable as a universal screen for all ages and disease states. The MNA® may not be suitable for cognitively impaired patients who cannot provide reliable answers to the subjective questions about personal nutrition and general health. However, if a caregiver can provide accurate input and all questions on the form are answered, the MNA® is considered the best tool to use for geriatric patients. In addition, the MNA® was not designed for persons receiving enteral tube feedings; these high-risk patients should receive on-going full nutrition assessment and follow-up by a RD.

New Opportunities for Using the MNA®

Although the MNA® has been widely studied in research settings around the world, it has not been used extensively in clinical practice in the U.S. It could be an essential component of every comprehensive geriatric assessment, along with the Mini Mental State Evaluation (MMSE), Geriatric Depression Scale (GDS), and Activities of Daily Living (ADLs). There is growing interest in using the MNA® in long term residential care and sub-acute care facilities where malnutrition is extremely common and contributes to longer lengths of stays and more frequent readmissions to acute care.10 Likewise, the phenomenal growth of the assisted living industry presents an unprecedented opportunity for using the MNA® to screen for malnutrition. Unlike long term care and sub-acute care, the assisted living industry is largely unregulated and does not have mandated nutrition screening in place.

More widespread use of the MNA®

would seemingly be welcomed in this setting where high value is placed on maintaining residents’ functional status to prevent transfer to more costly nursing home care.

Perhaps the MNA’s greatest potential is in screening and assessment of community-living older individuals. Its proven ability to identity risk of developing undernutrition at an early stage fits well with the increased

emphasis being given to prevention under Medicare and federal initiatives such as the Administration on Aging’s Choices for Independence that are designed to address the projected staggering increases in health care spending for aging boomers. Helping high-risk older adults avoid unnecessary placement in nursing homes by identifying and treating malnutrition risk early is consistent with the strategies of the “Community Living Incentive” grants. These give high risk elders more choices, and with efforts to build prevention into community living.

SummaryMalnutrition is a serious problem in many older adults that negatively impacts quality of life, functionality, and the ability to live independently. Many times malnutrition is reversible, and this calls for valid, effective screening tools to detect malnutrition. The MNA® fulfills many criteria for an ideal screening tool for the elderly and is recommended by international organizations.11 It provides a simple, non-invasive, inexpensive, easy-to-use nutrition screening tool that is highly specific, reliable, and well validated. The MNA® can quickly and easily identify older adults (over 65 years of age) who are at risk for malnutrition. Among the nutrition screening and assessment tools available to the Registered Dietitian, the MNA® must be regarded as the most established nutrition screening tool for the older population. n

By: Janet Skates, MS, RD, LND, FADA, Nutrition Consulting Services, Kingsport, TN,[email protected]

Patricia Anthony, MS, RD, Nestlé Nutrition, Gland, Switzerland, [email protected]

Table 3. Characteristics of Ideal Nutrition Screening Tool

• valid and reliable scale in the intended population

• Minimal bias due to the data collector

• Accurate

• Clear definition of thresholds

• Easy to use and adminster by available staff

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Adapted from: Thomas DR. Nutrition assessment in long-term care. Nutr Clin Pract. 2008;23:383-387, and Gans KM, et al. Rate your plate: A dietary assessment and educational tool for blood cholesterol control. Nutrition in Clinical Care 2000;3:153-169.

• Low associated cost

• Relevant to outcomes

• Acceptable to patients

• Sensitive to change in score

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CORNERSOCIAL NETWORKINGLately there has been a lot of talk in the news media about politi-cians, celebrities and millions of Americans tweeting. No, they are not singing like birds. Tweeting is an interface, provided by social networking services, that allows users to post instant short blogs.

What is a Social Networking Service?Social networking services focus on building online communities of people with shared interests. Most social networking services are web based and provide a variety of ways for users to interact, such as e-mail, instant messaging, as well as posting photos and streaming video. These services have created new ways to communicate and share information. The main types of social networking services are those that contain directories of categories (such as former classmates) and ways to connect with others (usually with self-description pages). MySpace, Facebook, and Twitter are widely used social networking Web sites in the US.A business networking website, LinkedIn, is also available. This site is geared toward connecting professionals to accelerate business success.

Why use a social networking Web site?Social networking Web sites allow internet users to communicate with each other and make connections – whether romantic, personal or professional. These services can help users reconnect with old friends and make new ones. Although the main focus is social, these Web sites can have a professional application.

Are there professional reasons to join? yes! ADA has a Facebook account. This is an easy to access forum to reach and communicate with other RDs, DTR, and dietetic students.

Should you join?Since most of the major social networking sites are free, why not? Try it and if you do not like it; delete your profile.

How do you join?Joining is simple. Go to any of the sites listed below and follow their directions. If you choose to join Facebook, look for the Healthy Aging DPG page.

Twitter and tweetingSimple definition of Twitter is “micro-blogging/social networking platform that places a 140-character limit on each individual post or tweet.” What does this mean? Twitter is a social networking site that, like other sites, focuses on connecting people with like interests through the exchange of short questions and answers. The chief difference is that Twitter is in real time. This makes it a perfect application for mobile web users.


The MNA Web site resources include MNA forms in more than 20 languages, interactive MNA forms, access to literature, guides to interpret the MNA, and suggested guidelines for intervention using the Nutrition Care Process.www.mna-elderly.com.

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Selected References (Endnotes)1. Guigoz y, vellas B, Garry PJ. Mini

Nutritional Assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 1994;(suppl 2):15-59.

2. vellas B, Guigoz y, Garry PH, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116-122.

3. Guigoz y, vellas B, Garry PJ. Assessing the nutritional status of the elderly: the Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996;54:S59-S65.

4. Guigoz y. The Mini Nutritional Assessment (MNA®): review of the literature – what does it tell us? J Nutr Health Aging. 2006;6:466-487.

5. Bauer JM, Kaiser MJ, Anthony P, Guigoz y, Sieber CC. The Mini Nutritional Assessment –Its History, Today’s Practice, and Future Perspectives. Nutr Clin Pract 2008;23:388-396.

6. Weekes CE, Elia M, Emery PW. The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN). Clin Nutr. 2004;23:1104-1112.

7. Persson MD, Hytter-Landahl A, Brismar K, Cederholm TE. Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition. Clin Nutr 2007;26:216-224.

8. Donini LM, Savina C, Rosano A, et al. MNA predictive value in the follow-up of elderly patients. J Nutr Health Aging 2003;7:282-293.


Nutrition 101: Student Author Contribution

Friend or Foe: Exploring the Dandelion

AS SPRING arrives, it brings the unanimous groan as people watch their lawn enemy, the dandelion, appear once again. With its jagged, hairless leaves, and bright yellow flower, many people immediately start to consider all of the options for eradicating this pest. The dandelion’s stigma can be changed from foe to friend, because this weed provides many nutrients, can increase food security, and provide physical activity benefits from gathering the leaves. This simple weed needs another chance to prove its worth, and show why it can be helpful to add to the diets of older adults.

Dandelions have been used for thousands of years for medicinal purposes to treat liver and kidney problems. The leaves of the plant act as a natural diuretic to help cleanse and detoxify the body. Dandelion leaves can also be used to ease digestion if eaten before a meal because the bitterness of the leaves helps to stimulate the release of gastric juices from the stomach. Dandelion greens also contain large amounts of many important nutrients and antioxidants. One cup of dandelion greens provides 112% of the RDA (for a male adult) vitamin A, 32% for vitamin C, 9% for iron, 10% for calcium, 535% for vitamin K, and 6% for potassium.

In addition to providing valuable nutrients, dandelions are free, and this may help to provide an additional food source for many older adults. For people with limited food security, the addition of dandelion greens to their diets can increase the nutrient density of an otherwise limited diet. It is important that dietitians talk with their clients about collecting

dandelion greens, and why this can be a good food to eat. If the client lives in an urban setting then it will be more difficult to collect dandelion greens from their lawns, but they are available for purchase at many grocery stores, co-ops and famer’s markets at affordable prices.

Collecting dandelion greens can be a form of physical activity for older adults. Being outside will increase sun exposure, and help to increase vitamin D levels in a population whose levels are often low. Informing clients of benefits makes a convincing argument for why dandelion greens are a great addition to their diets.

In order to start collecting dandelion greens, clients will need information on how to find and use the greens. It is important to correctly identify the greens before they are collected. This can be done by showing pictures or sharing the description of the plant. In addition to collecting leaves from the correct plant, it is also important to talk about collecting dandelion greens from lawns that are free of pesticides or weed killers. After leaves are collected, the small young leaves can be washed and eaten raw in salads, and the mature larger greens can be cooked up like any other dark green to reduce the bitterness. It might be a good idea to have a handout for clients with dandelion recipes, since they may not know how to prepare them. These recipes can easily be found online. Some older adults may have a difficult time chewing the raw dandelion greens; for these clients, cooking the greens or eating them in soups will make texture a little softer. Spreading the good news about dandelions to older adults is important because in addition to the

nutritional benefits, the traditional knowledge of edible wild foods such as the dandelion is diminishing. Share this message with clients, patients in the hospital, and even as a public health message. Posters can be hung at community centers, food shelves, churches and schools to inform the public. This will help to inform everyone about the benefits of collecting and eating dandelion greens.

Dandelions are nutrition powerhouses and gathering them can provide an opportunity for older adults to get physical activity, increase food security and increase vitamin D levels from sun exposure. In these difficult economic times, it is important for older adults to learn about this free and wonderful source of nutrients. Spreading the message to eat more dandelions may encourage people to welcome its arrival in the spring. n

By: Leslie LangevinMs. Langevin is pursuing her Master of Science in Dieteticsat the University of Vermont


Legislative Update


THE AMERICAN DIETETIC ASSOCIATION’S Public Policy Workshop (PPW) was held in Washington DC last year with about 500 nutrition “activists” discussing issues, providing information and receiving grassroots training. However, this year the leadership expanded the opportunity by using a new “online format” which attracted approximately 71 percent of the 5,000 registered members for their first exposure to ADA advocacy. The online opening session was matched with a series of get together parties taking place across the nation. Talk about “grassroots” participation. These events, which were held in homes, schools, community centers and health facilities, brought ADA members together to plan how the association could meet its goal that every member of Congress hear about the importance of nutrition as the cornerstone of policies that make and keep Americans healthy. PPW 2009 continues with additional online webinars throughout the remainder of the year. As for the outcome of this meeting, a survey of members revealed that 88 percent liked viewing PPW online, more than 90 percent understood ADA’s policy messages and could deliver them, more than 60 percent would visit and deliver ADA’s messages to federal lawmakers by the end of summer, and 70 percent of the participants stated that PPW 2009 gave them a better understanding of legislative and regulatory processes including how ADA’s Political Action Committee works. PPW sessions can still be viewed at: http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/10988_19461_ENU_HTML.htm Health care reform is the second major issue before Americans, second only to the financial crisis.

The Health Care Reform ADA Report, December 2008 provides us with excellent information about this issue, “Even though America spends more than $2 trillion a year on health care, many Americans suffer every day from preventable diseases like type 2 diabetes, heart disease, and many forms of cancer that deny patients both quantity and quality of life. These chronic and preventable diseases represent both a challenge and opportunity for our nation. The dramatic growth rates and costs for servicing these chronic diseases are multiplying like compound interest and in a short time will overwhelm state and federal budgets.” In anticipation of the challenge for our nation, ADA has developed a set of tenets focusing on preventive and interventional health promotion and care and the role of the Registered Dietitian in maintaining health and wellness; preventing disease; and managing chronic conditions throughout the continuum of life – preconception to end of life care.

The following tenets will be used by ADA to analyze and critique any health care reform package presented to Congress. 1. The health of all Americans should

improve as sufficient resources are made available to ensure optimal health.

2. Access to quality health care is an option of choice that must be extended to all Americans.

3. Nutrition services, from pre-conception through end of life, are an essential component of comprehensive health care.

4. Stable, sufficient and reliable funding is necessary to provide everyone access to a core package of benefits.

5. Health care must be patient-centered.

For detailed information on these five issues, refer to the December 2008 ADA Report. President Obama is sponsoring five regional health care reform forums for citizens to comment. The Detroit Free Press, which attended the first forum held in Michigan reported that about 250 people convened along with Congressional leaders and White House staff members the first week of March at the Michigan Regional Forum on Health Reform. About 30 attendees spoke about their own experiences as patients and providers in the health care system, or suggested ways to improve health care delivery in the United States. “We spend far more in the U.S. for health care than any other country and we have lower outcomes,” Michigan Governor Jennifer Granholm said. “Health care is an issue that we must address if we want to compete globally.” She and Wisconsin Governor Jim Doyle hosted the event – one of five planned for March and April around the country with the others being held in California, Iowa, North Carolina and vermont. In summary, the general public is actively participating in these forums and perhaps each state should conduct their own citizen’s forum in order to broaden the circle of information. One dietitian has suggested that the states should add a few simple questions to state election ballots that citizens could understand, about “how they wanted to have their choices and control over the type and quality of care that they were going to receive. After all, they are the ones



2009-2010 HA DieteticPractice Group

Election of OfficersResults

Congratulations to all the winners!

Chair-Elect • Dian Weddle, PhD, RDSecretary • Barbara Estrada, MS, RD

Nominating Committee Chair-Elect • Sharon Leppert, RD, LDNominating Committee Member-at-Large • Kelly Morrison, RD, CSG, LDN

and look for signs of malnutrition in general as well as those specific to alcoholism. The nutrition-focused physical exam is a great time to spend visiting with the client and asking about possible symptoms, about an unusual finding, about their appetite or foods that most appeal to them. A good way to start a conversation is to lead in with, “Tell me about . . . . . “ or “How long have you had . . . . “. Most people appreciate your spending time with them regarding their concerns. On the other hand the whole process may be new to most clients so it is best to ask them if it would be okay to check them for signs of nutritional concern. Most people don’t object to a “check up” and will agree. I think I have only had one person in my years of dietetics who refused and his wishes were granted. That said, most people are more than happy to cooperate with a nutrition physical examination. During this

time you are looking for lesions that aren’t normally there, for things that are missing that should be there and for any negative situations that would influence nutrition. Let me give you some examples. We’ll start with lesions that are there that aren’t “normal”, things that shouldn’t be there. Examples might be a goiter, ecchymosis, or pitting edema. They can all be caused by nutrient deficiency or be nutrition related. What you are doing is gathering pieces of the puzzle. Proceed to nutrition-related or nutrient deficiency-caused things that are missing. Missing affect, missing color (pale nails or tongue), or patches of hair that are missing would all be examples of things that should be there but aren’t. Once discovered missing, finding the etiology of the problem is the next challenge. It may take asking questions, further tests, a referral or nutrient treatment with follow up and monitoring. Going on to negative situations, some examples might be dental debris that clearly shouts “lack of oral care” or missing teeth that prevent proper

chewing and therefore limit the variety of foods a client can or will eat. Whatever the case, the challenge is “fixing what can be fixed” or, in other words, looking for the solution to the problem with the most important person on the health care team, the client. The nutrition physical exam is like a mystery, you as the health care practitioner are the investigator. Are you up to the challenge?

The Basics of Performing a Nutrition-focused Physical Examination Part 1:A Look at the Mouth & Eyes When learning to do a nutrition-focused physical exam it is good to start from the top down. This is what I call the Head to Toe approach. For one thing, your equipment, including your gloves, are clean so it makes sense to start with the client’s mouth and eyes. My routine is to start with the mouth, eyes, the facial skin and the rest of the head. Actually, the visual scan starts when I approach the client to ask them for permission to do a nutrition physical exam. (This is a good time to get out

Nutrition Focused Examcontinued from page 1



Nutrition Focused Exam continued from page 10Glossitis

your Key Terms chart or other resources you may have to refer to what each of the terms you may not be familiar with are.) Look at areas around the mouth for angular stomatitis (often B vitamin, folate or vitamin B12 deficiency) and/or undifferentiated mucocutaneous border (usually riboflavin deficiency). Also eye the skin on their face and the appearance of their eyes. After obtaining the client’s verbal consent to perform a nutrition physical exam, I proceed by asking them if “it hurts” any place in their mouth. Then I ask them to open their mouth while I examine for oral hygiene, skin lesions, inflammed gums, etc. I ask them to stick out their tongue for me. I often demonstrate this to take any tenseness out of the situation and to give them direction. (several of my older clients have expressed that they have learned long ago that sticking out their tongue is disrespectful). They follow suit and I can easily examine their tongue for glossitis (often niacin, riboflavin B12 or folate deficiency) or whatever is present or not present and observe the color of the tongue. The color of the tongue can be indicative of a deficiency, usually iron, folate, B12 or another B vitamin.

you may observe a lobulated tongue or a geographic tongue which are not typically of nutritional concern. Look at a lobulated tongue for some areas of balding or glossitis or filiform atrophy that IS likely to be of nutritional concern. Then I look at the eyes, observing for brightness. I look for corneal arcus (usually dyslipidemia related), and other visual abnormalities like the “Thiamine Stare“ (seen in some cases of Thiamin deficiency, especially related to alcohol abuse) and pterygium which is nonnutritional. It is important to ask questions about abnormalities you see, especially if it can be explained by the client – history may point to the cause. I had a man who had lye splash up into his eye causing scarring and blinding in one eye. I could have investigated all day and not been able to figure out what caused his eye to appear white like it did.

Get proficient at looking up lesions in a medical dictionary with lesion pictures or other lesions resources. Looking at pictures of lesions is a great way to get these visions “pasted” into your memory. More information and a clinical terms handout is available at my Web site www.nutritionfocusedexam.com. n

By: Adele Huls, PhD, RD

Geographic Tongue

“Thiamine Stare”


Technology Cornercontinued from page 7

Despite the fact that all social networking sounds totally ridiculous – once you start using it, you realize how much fun it is.

http://www.facebook.com/http://www.linkedin.com/http://www.myspace.com/http://twitter.com/ n

By: Barbara Kamp, MS, RDHA Editor-In-Chief

Legislative Update continued from page 9

who will be the “receivers of the healthcare product” and they are paying for it. That’s why it is an “option choice” relationship...fee paid for a service “received” and not a “citizen’s right” as in the US constitution. With all this activity and interest in overhauling the health care system, Americans are in for some exciting and life changing times. Today there are many potential opportunities for RDs in the health care arena. NOW is a great time for RDs to step up to the plate and get involved with health care advocacy. Look for more in the next issue. n

Submitted by: Charlotte vincent, PhD, RD Public Policy Chair

Chair’s Message continued from page 2

and the newsletters with the help of other very talented Healthy Aging volunteers. Maria currently works as the Nutrition Services Coordinator for the Onondaga County Department of Aging and youth in Syracuse, Ny. She graduated from Syracuse University with a Masters Degree in Nutritional Science. She serves on the board of the Central New york Regional Market Authority and is the 2007-2009 Secretary for the New york State Dietetic Association (NySDA); she has co-chaired the NySDA Annual Meeting for 2007, 2008, and 2009.

Currently Maria is an instructor at the Caregivers Institute; she teaches a series of classes for men who are caregivers and for seniors with diabetes. These programs were listed in the 2008 NyS Best Practices report for senior nutrition programs.

She was instrumental in coordinating community leaders to implement the Farm Fresh Mobile Market Program. The Mobile Market sells locally grown fruits and vegetables (from area farmers) to low income, minority neighborhoods and senior housing sites; the mobile market operates all year round. Customers can also purchase fruits and vegetables with their Electronic Benefit Transfer (EBT) cards, senior nutrition and WIC farmers’ market coupons. The Mobile Market also provides information on how to connect to county health screening services, Food Stamps and Home Energy Assistance Program (HEAP). The program was featured in the New york state governor’s monthly media program detailing how various area agencies on aging are helping seniors deal with the current economic crises. Her professional experiences also include clinical nutrition, food service management and information technology.

This article was written just before results of the election for officers were made available to the DPG. In the next Healthy Aging newsletter we will have two more members that have stepped forward to get involved to introduce to you. It is not too early to consider contacting our Nominating Committee Chair for 2009-2010, Martha Peppones, MS, RD, CD ([email protected]) to inquire about positions available to see what fits into your interest area. Getting involved in a DPG is a wonderful opportunity waiting to be seized. The people you meet make it that way!

Eat for the Health of It, Your Health. n


9. Kagansky N, Berner y, Doren-Morag N, et al. Poor nutritional habits are predictors of poor outcomes in very old hospitalized patients. Am J Clin Nutri 2005;82:784-791.

10. Thomas DR, et al. Malnutrition in sub-acute care. Am J Clin Nutri 2002;75:308-318

11. Kondrup J, Allison SP, Elia M, vellas B, Plauth M. ESPEN guidelines for nutrition screening. Clin Nutr. 2002;22:415-421.

Acknowledgement: The MNA® was developed by the Nestlé Research Center, in collaboration with hospital clinicians, and is the property of Nestlé S.A.

Reprinted with permission from the MNA® Web site (www.mna-elderly.com). The MNA® form is protected by copyright laws and MNA is also a registered trademark of Société des Produits Nestlé S.A. You are not entitled to modify at all the external appearance of the form nor the order of the questions. In addition, all references and logos may not be altered in any way nor removed. In case of a doubt concerning your planned use of the MNA® form, please contact Nestlé directly.


Dandelioncontinued from page 8

References:1. USDA, National Nutrient Database for

Standard Reference. Dandelion greens. Available at: http://www.nal.usda.gov/fnic/foodcomp/cgi-bin/list_nut_edit.pl. Accessed November 8, 2008.

2. University of Maryland Medical Center. Dandelion. Available at: http://www.umm.edu/altmed/articles/dandelion-000236.htm. Accessed November 8, 2008.

3. Greives M. Dandelion, 2008. Available at: http://www.botanical.com/botanical/mgmh/d/dandel08.html. Accessed November 8, 2008.

4. Topel A. Dandelion greens: packed with flavor and nutrition. National Geographic (serial online). 2003: 96. Available at: http://www.thegreenguide.com/doc.96/dandelion. Accessed November 8, 2008.

New England Diet Manual for Extended Care2008 Edition

All pricing includes shipping and handling.

To download an order form, please visit:http://eatrightma.org/diet-manual

Less than 25 copies: $52.95 each25 - 49 copies: $50.95 each50+ copies: $47.95 each

Depression and Hardiness and their Association with Appetitein Older Adults

Healthy Aging Student Research Award 2007

POOR appetite leads to increased morbidity in older adults, and can be influenced by many factors, including chronic disease and depression. However, the direction of influence of depression on appetite is unclear in this population. Hardiness is believed to be another risk factor that may influence appetite in older adults, and is defined as an ability to manage stress and having a positive outlook on life.

The aim of this research is to examine the associations of hardiness, depression, and emotional well-being with appetite in older adults. A survey evaluating hardiness, depression and appetite was administered to

292 adults (≥ 60 years), residing in assisted-living facilities or attending senior centers in the Washington D.C. area.

In univariate models, depression, hardiness, and emotional well-being are associated with appetite. Fair/poor emotional well-being increases risk for poor appetite (Odds Ratio “OR”=5.13, 95% Confidence Interval “CI”:2.47-10.67) whereas commitment (a dimension of hardiness – which indicates an individual’s involvement in life) is associated with decreased risk of poor appetite (OR=0.81, 95% CI: 0.68-0.95). Both variables emerged as the strongest predictors of appetite

in multivariate models. These strong associations may further elucidate the components of mental health which contribute to poor appetite in this population. n

By: Julia Engel; Nadine Sahyoun, PhD, RD; Robert Jackson, PhD, RD; andFrank Siewerdt, PhDUniversity of Maryland,College Park, MD 20742

Julia Engel is a winner of the 2007 Healthy Aging Student Research Award. She is a Masters of Science in Nutrition candidate at the University of Maryland.


Chair:Adele Huls, PhD, RD, LMNT, LN16614 Highway 385Chadron, NE 69337(h) [email protected]

Chair-Elect:Willa Thomas, MS, RD, LD142 Stout Avenueversailles, Ky 40383(w) [email protected]

Past Chair:Cheryl Meskus, RD72H Foote RoadCharlton, MA 01507(h) [email protected]

Secretary:Mary Herrstrom, RD, LDN414 Franklin CourtTrappe, PA 19426(cell) [email protected]

Treasurer:Elaine Smith, MS, RD1816 Evanrude PlaceSandston, vA [email protected]

Public Policy Chair:Charlotte vincent, PhD, RDP.O. Box 9443Salt Lake City, UT 84109(w) [email protected]

Nominating Committee Chair:Becky Snyder, RD3270 Rustic Lodge RoadIndiana, PA 15701(w) [email protected]

Awards Chair: Gail Schechter, RD, CDN6 Burns Street, Apt. 310Forest Hills, Ny 11375(w) [email protected]

External RelationsCarlene Russell, MS, RD, LD, FADAIowa Department of Elder Affairs510 E. 12th StreetDes Moines, IA 50319(w) [email protected]

MembershipAmy Nickerson, MS, RD, CDUniversity of vermont, 305 Terrill HallBurlington, vT 05405-0148(w) [email protected]

HA DIRECTORSHA EXECUTIVE COMMITTEE

Professional DevelopmentEleanor Schlenker, PhD, RD304 Hearthstone DriveBlacksburg, vA 24060-7213(w) [email protected]

CommunicationsBarbara Kamp, MS, RD7850 SW 86th Street, #18Miami, FL 33143(h) [email protected]

Nutrition Education AidThe Nutrition Education Aid on page 14 was created by:

the Nestlé Nutrition Institute

HA members are urged to share nutrition education mastersfor this section in future newsletters.

Send a copy (on white background) to:Michelle Hunter, Coordinating Editor,

at El Dorado County Area Agency on Aging,937 Spring Street, Placerville, CA 95667.

E-mail: [email protected] permission from author to reprint.

Awards and Stipends AvailableDid you know that the Healthy Aging Dietetic Practice Group offers awards and stipends to its members? Well we do!

We have student research awards, best practice awards, service awards, speaker awards, and more.

visit our web site at: http://www.healthyagingdpg.org and go to the “awards and stipends” link for award descriptions, criteria, deadlines, and applications.

Complete all information and submit to HA Awards Chair:Gail Schechter, RD, CDN6 Burns Street, Apt. 310, Forest Hills, Ny 11375fax: 718-298-8441 • email: [email protected]

(electronic applications preferred). n

ADA Practice Team ManagerLisa Sands, MSAmerican Dietetic Association120 South Riverside Plaza, Suite 2000 Chicago, IL 60606-69951-800-877-1600 ext. 4813(fax) [email protected]

Healthy AgingA Dietetic Practice Group ofAmerican Dietetic Association120 South Riverside • Suite 2000Chicago, IL 60606-6995

The Spectrum newsletterPublication of Healthy Aging –A Dietetic Practice Group of American Dietetic Association.Subscription for individuals not eligible for ADA membership:Send $20 payable to ADA/HA per year’s subscription directly toHA Treasurer. (see address on page 15)

Coordinating Editor: Michelle Hunter, RD El Dorado County Area Agency on Aging 937 Spring Street, Placerville, California 95667 (w) 530-621-6161 [email protected]

Editor-in-Chief: Barbara Kamp, MS, RD 7850 SW 86th Street, #18, Miami, FL 33143 (w) 305-275-7330 [email protected]

Review Board: Adele Huls, PhD, RD, LMNT, LN Cheryl Meskus, RD Amy Nickerson, MS, RD, CD Martha Peppones, MS, RD, CD Lisa Sands, MS

Schedule: Issue Deadline Spring December 15 Summer March 15 Fall June 15 Winter September 15

Change of Address: Please notify ADA headquarters, which sends monthly updates to HA. Change-of-address card is in the Journal of the American Dietetic Association or email: [email protected]

HA Web site: www.healthyagingdpg.org

HA Electronic [email protected] List Address: We invite you to join this HA communication forum. Please send your name via email to: [email protected]

© Copyright 2009 by Healthy Aging – A Dietetic Practice Group of American Dietetic Association.viewpoints and statements in this Newsletter do not necessarily reflect policies and/or positions of American Dietetic Association. Mention of product names in this publication does not constitute endorsement by the authors or American Dietetic Association.

In this issue ...

Linking Evidence Based 1Medicine to Geriatric NutritionScreening – The MiniNutritional Assessment (MNA®)

The Nutrition-Focused 1Physical ExaminationWhat is a NutritionFocused Exam?

Chair’s Message 2

Mark your Calendar 3

Technology Corner: 7Social Networking

Student Author Contribution 8Friend or Foe:Exploring the Dandelion

Legislative Update 9

2009-2010 HA Dietetic 10Practice Group Electionof Officers Results

Healthy Aging Student 13Research Award 2007Depression and Hardinessand their Association withAppetite in Older Adults

Nutrition Aid: 14Mini Nutritional Assessment

Awards and Stipends 15Available

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