This article was downloaded by: [Case Western Reserve University]On: 14 October 2014, At: 15:29Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Journal of Nutrition For the ElderlyPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/wjne20

Group Nutrition Education Classes for Older AdultsMary 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) Group Nutrition EducationClasses for Older Adults, Journal of Nutrition For the Elderly, 23:4, 67-98

To link to this article: http://dx.doi.org/10.1300/J052v23n04_06

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Group Nutrition Education Classesfor Older Adults

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

ABSTRACT. A thorough search of the literature revealed only nine ar-ticles published since 1993 that focused on nutrition education for olderadults attending group classes and that measured outcomes. A table sum-marizes the reports, including the theoretical bases, descriptions of inter-ventions, participants and comparison groups, program outcomes, meth-ods of verification, and follow-up after interventions. Only three of thestudies explicitly indicated that elements of a stated behavioral changetheory had been incorporated. All of the educators employed a variety ofolder adult educational strategies to enhance learning. Six research teamsreported on classes where nearly half or more of the participants repre-sented minority groups. Six studies included comparison groups. Typesof outcomes included measurements of change in knowledge, attitudes/beliefs, behaviors, and/or physiological measures, but the actual vari-ables examined differed among reports. No consistent patterns were de-tected among reported outcomes. The longest follow-up after interven-tions ceased was seven months. The review addresses issues raised froman analysis of the quantity, quality and findings of the articles and makes

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 StateUniversity, Manhattan, KS.

Address correspondence to: Mary Meck Higgins, Assistant Professor, Departmentof Human Nutrition, 202 Justin Hall, Manhattan, KS 66506 (E-mail: mhiggins@humec.ksu.edu).

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_06 67

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

suggestions for future research and offers preliminary ideas for develop-ing group nutrition education classes for older adults. This is one of a se-ries of reviews of recent literature on nutrition education for older adults.[Article copies available for a fee from The Haworth Document Delivery Ser-vice: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com>Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. Allrights reserved.]

KEYWORDS. Nutrition education, older adults, ethnic groups, groupclasses, education strategies, nutrition behavior change, nutrition outcomes,nutrition interventions, minority groups

INTRODUCTION

Like people of all ages living in the U.S., older adults, i.e., those ages 55 yearsand older, are exposed to nutrition messages in a wide variety of ways. Exam-ples are television and radio, newsprint and magazine articles, the Internet,friends and family, health care providers and salespersons of nutrient supple-ments. All of this information, which varies widely in its scope and reliability,leaves many older adults confused and often misguided. And even when theyhave science-based valid guidance, they quickly learn that modifying nutritionpractices is difficult. The nutrition educators’ role is to help these older con-sumers sort out what is relevant and useful, often by providing a collaborative,open exchange of information with empathy and mutual respect. Educatorsmust facilitate the application of knowledge to daily nutrition behaviors, therebyprotecting or improving an older adult’s personal health and well-being. Healthbenefits and reduced costs are likely if the rapidly expanding cohort of olderadults receive effective nutrition education. Many would benefit from health-ful diets by avoiding or minimizing the effects of major chronic diseases andco-morbidities, such as heart disease, some cancers, stroke and hypertension,diabetes and obesity (Sahyoun, 2002).

Providing group classes, i.e., offering topical education to groups of peoplein a series of sessions, is a frequently used nutrition education method. Twohistorical sources of group nutrition education for senior adults have been edu-cators working with cooperative extension services based in counties or areasand at each state’s land-grant university, in cooperation with the U.S. Depart-ment of Agriculture; and the Elderly Nutrition Program (ENP), funded throughthe Older Americans Act to provide congregate and home-delivered meals.About 87% of ENPs include nutrition education (Mathematica Policy Re-

68 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

search, Inc., 1996), although quantity and quality vary. Millen et al. (2002) notedthat the ENP offers preventive nutrition and other health-related services, in-cluding nutrition education. More recently, USDA Food and Nutrition ServiceFood Stamp Program funds have become available in most states for nutritioneducation programs targeting low-income older adults through food stamp mon-ies.

A paucity of published research suggests that little attention has been paidto investigating the possibilities of improving or maintaining health in olderadults through nutrition education. In particular, we found no review of groupnutrition education classes for older adults. Only nine articles were found aftera thorough computer-assisted literature search for reports published in the pastdecade, i.e., since 1993, on group classes that included nutrition education as asubstantial component and that targeted, or at least separately reported on,adults ages 50 years and preferably older living independently in the U.S. Tobe considered for review, articles had to include information about the nutri-tion education component of the program and the classes had to be offered in aseries, i.e., as more than one session. No attempt was made to find unpublishedpapers or documents such as dissertations, or studies that were reviewed byContento et al. (1995), who summarized older research on nutrition education,including a chapter on older adults. Search methods are reported more fullyelsewhere (Higgins and Clarke Barkley, 2003b).

This article is one of a series of literature reviews on topics related to nutri-tion education for older adults. Published findings on older adult nutrition edu-cation issues are discussed in the review series, including difficulties in evaluat-ing outcomes and impact (Higgins and Clarke Barkley, 2003a), cost benefitsof nutrition education for older adults (Higgins and Clarke Barkley, 2003b);methods for determining nutrition education needs and interests, and experi-ences tailoring education intervention programs to different populations ofolder learners (Higgins and Clarke Barkley, 2003c); older adult learning andbehavioral change theories, nutrition education/behavioral strategies, and nu-trition education program design components (Higgins and Clarke Barkley,2003d); and ways to improve effectiveness of nutrition education resources forolder adults (Higgins and Clarke Barkley, 2004). The purpose of this series isto assist nutrition educators, researchers and health practitioners in familiariz-ing themselves with recently published methods and to discern more effectivestrategies and their evaluation. It also suggests the need for a greater quantityand an improved quality in the published research. Specifically, the purposesof this article are: (1) To describe the interventions, participants and outcomesof recent studies using group nutrition education classes that targeted olderadults; and (2) To discuss how the studies presented point to the need for re-

Nutrition Education for Older Adults 69

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

search of improved quantity and quality, and to make preliminary suggestions fordeveloping group nutrition education classes for older adults.

POTENTIAL ADVANTAGES OF GROUP CLASSES

Group classes can benefit both health professionals and older adults. Moreand new research is needed to determine whether group nutrition education classesare more effective than are other educational interventions with older learners.Most of the advantages of group classes described below have yet to be sup-ported by definitive research, but preliminary findings indicate that group ses-sions have potential for eliciting certain outcomes as compared to other typesof educational intervention.

One advantage is that group nutrition education classes may be cost- and timeefficient for the educator. More people can be reached in less time with groupclasses versus individual counseling. Group sessions were believed to be “themost efficient method” for teaching the large number of clients with diet-re-lated problems among participants at congregate meal sites in a Florida study(Weddle et al., 1997). While not part of their study design, Weddle et al. (1997)very briefly described their multiple group sessions, which emphasized car-diovascular risk reduction along with diabetes, basic healthy eating, and drug-nutrient interactions, which were topics that they had identified as being ofgreatest need among their participants. They also emphasized appropriate foodchoices using the Food Guide Pyramid, reading food labels, shopping and foodsubstitutions.

Messages presented to a group class can be tailored more readily to the needsand interests of the specific members than with mass media methods.

A potential advantage of group classes as compared to individual nutritioncounseling sessions or mass media educational channels is that they may en-hance older learners’ adoption of new behaviors as participants share ideas andexperiences and solicit the support of classmates. The wisdom of older adultscan be utilized in the teaching/learning interaction that is intrinsic in groupclasses. The group’s dynamics may enhance effective communication and ed-ucational strategies that benefit older participants. Characteristics of olderlearners and older adult nutrition education and behavioral change strategieswere reviewed recently by Higgins and Clarke Barkley (2003d).

Few reports have compared effectiveness of group classes to other educa-tional interventions. Agurs-Collins et al. (1997) compared a group who partic-ipated in nutrition education classes to a comparison group who participated ina single-session group class and received two sets of mailed written nutrition

70 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

information and copies of their laboratory blood test results. The interventiongroup attended one individual diet counseling session and twelve weekly, thensix biweekly 90-minute group classes with eight to ten people per group. Theweekly sessions featured 60 minutes of lecture and discussion, goal setting,recipes, and take-home activities, followed by 30 minutes of aerobic exercise,while the biweekly sessions emphasized sharing and problem solving. Thestudy’s class sessions emphasized weight loss and general nutrition. Bothgroups were overweight older adults with type 2 diabetes. Agurs-Collins et al.found that the multiple sessions of nutrition classes for small groups of olderlearners provided an advantage to the intervention group by increasing theirknowledge and improving their dietary intake but that these gains did not per-sist after the group intervention ceased. Modest weight loss and improvedblood glucose (hbA1c) control were sustained, however, among their partici-pants versus their comparison group.

In a review of diabetes education literature that compared interventions foradults of all ages, group education was noted to be more effective at increasingknowledge than was the provision of written instructions alone (Brown, 1999).Diabetes self-management group instruction has benefits greater than just po-tential program cost savings, including effective behavioral outcomes, accord-ing to Walker (1999). Walker reported on diabetes self-management educationfor adults, including but not limited to older adults, that involved knowledge,skills and problem-solving abilities needed for managing the disease. In part,the report looked at three sample studies comparing group learning versus indi-vidual learning, which overall indicated that more favorable diabetes controlwas found for subjects exposed to the group learning situations. Walker in-cluded a table of unanswered questions and concluded that more research isneeded regarding optimal class size, frequency and number of classes, and thecharacteristics of those adults most likely to benefit from groups.

Using adults, including older adults, as peer educators for group nutritionclasses benefits them and presents a possible method for educating hard-to-reachaudiences. In one case, actual and “figurative” Hispanic grandmothers (thosewhose advice, opinion and authority are honored in the Hispanic community,and who are called abuelas) were provided nutrition education in two day-longsessions (Serrano et al., 2000; and Taylor et al., 2000). In this instance, thegroup was quite young, with more than half of the 36 abuelas being ages 31 to50 years and just 14% being 60 years or older. The group was taught how toimprove their own nutrition and to be community nutrition educators. Teachingkept the grandmothers’ knowledge and skills sharp. The six who had not taughthad decreased nutrition knowledge and skill scores six months after their train-ing, as compared to the 30 abuelas who did teach who showed no declines (Tay-lor et al., 2000). Similarly, the nine African American lay health educators de-

Nutrition Education for Older Adults 71

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

scribed by Quinn and McNabb (2001) were ages 35 to 68 years, with the averageage being 50 years, and, in this case, they provided weight loss education to mi-nority women of all ages. Thus, peer educators may benefit from both theirown training and the teaching of classes on various nutrition topics. We believethat training a higher percentage of older individuals to be community educa-tors would have many positive effects, especially since an important socialrole for older adults is to be involved in guiding the next generation.

CHARACTERISTICS OF REPORTED GROUPNUTRITION EDUCATION CLASSES FOR OLDER ADULTS

Figure 1 shows the specific type of information included in correspondingcolumns of the subsequent table. Table 1 summarizes nine studies’ interventions,participants and comparison groups, and outcomes.

These were the only nine articles that were found in literature published since1993 that offered a series of classes that included nutrition education messagesto older adults living independently in the U.S. Additional reports of groupclasses that did not include much nutrition education or that did not primarilyfocus on older adults were excluded from the table but are discussed in the text.In the next three subsections, aspects of all of these studies’ interventions, par-ticipants and outcomes are reviewed.

Interventions

Intervention methods were not standard among the nine studies. Few of thestudies were based on theory. Older adult learning strategies were incorpo-rated into all of the studies. Class frequency was generally weekly, but groupsize and class duration varied greatly. All of the classes had educational topicsthat included nutrition because, otherwise, the reports were not included in thisreview. A diversity of nutrition and other health topics, however, were cov-ered. Cultural adaptations to meet the needs and interests of minority partici-pants were prominent in three of the reports.

Use of Theory

Nutrition educators should select educational and behavioral change strate-gies according to the characteristics of the intended audience, and they shouldrely on appropriate theory or theories (Higgins and Clarke Barkley, 2003d.)Admittedly, however, research is needed to validate educational approachesand especially behavior change theories that are applicable for use with older

72 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

FIG

UR

E1.

Spe

cific

info

rmat

ion

abou

teac

hst

udy’

sin

terv

entio

ns,p

artic

ipan

tsan

dou

tcom

esth

atis

show

nin

Tab

le1,

and

the

lege

ndfo

rco

lum

nhe

adin

gs.

AB

CD

EF

GH

INT

ER

VE

NT

ION

SP

AR

TIC

IPA

NT

SO

UT

CO

ME

S

Dur

atio

nof

clas

sse

ssio

ns;

educ

atio

nals

trat

egie

sus

ed

Gro

upsi

ze

Num

ber

&fr

eque

ncy

ofcl

asse

s

Cla

ssto

pics

Num

ber

inin

terv

entio

ngr

oup

who

com

plet

ed;

%co

mpl

etio

nra

te%

atte

ndan

cera

te

Age

;%

fem

ales

;et

hnic

ity/r

ace;

Oth

erin

form

atio

n

Rec

ruitm

ent

proc

ess

ofpa

rtic

ipan

tsan

dco

mpa

rison

grou

pm

embe

rs

Num

ber

inco

mpa

rison

grou

pw

hoco

mpl

eted

;%

com

plet

ion

rate

Age

;%

fem

ales

;et

hnic

ity/r

ace

Oth

erin

form

atio

n

Com

paris

ongr

oup

trea

tmen

t

Ver

ifica

tion

met

hods

Tim

ing

ofev

alua

tion

and

leng

thof

follo

w-u

p

Sta

tistic

alan

alys

esre

port

ed

Sta

tistic

ally

sign

ifica

nt(p

<.0

5)ch

ange

sin

-Kno

wle

dge;

-Atti

tude

s/be

liefs

;-B

ehav

iors

-Phy

siol

ogic

mea

sure

s

Wer

ech

ange

s,if

any,

sust

aine

daf

ter

inte

rven

tion

beca

me

less

freq

uent

orce

ased

?

Author&Year

Statedorimpliededucationorbehaviorchangetheoryused

Wereculturaladaptationsmadetotheinterventions?

73

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

TA

BLE

1.S

umm

ary

ofpu

blis

hed

stud

ies

ofgr

oup

nutr

ition

educ

atio

ncl

asse

sfo

rol

der

adul

ts(s

eeF

igur

e1

for

colu

mn

lege

nd).

AB

CD

EF

GH

90m

inut

es:

60m

inut

esle

ctur

e/di

scus

sion

,goa

lset

ting,

reci

pes,

and

take

-hom

eac

tiviti

es,f

ollo

wed

by30

min

utes

ofae

robi

cex

erci

se;b

iwee

kly

sess

ions

emph

a-si

zed

shar

ing

and

prob

lem

solv

ing.

8-10

/gro

up+

1in

divi

dual

diet

coun

selin

gse

ssio

n

12w

eekl

y,th

en6

biw

eekl

y

Wei

ghtl

oss,

gene

ral

nutr

ition

32pa

rtic

ipan

tsin

itial

ly;3

0(9

4%)

com

plet

edth

epr

ogra

m;a

vera

geat

tend

ance

was

63%

.

Ave

rage

:62

year

s;ra

nge

55-7

9ye

ars;

66%

fem

ale;

100%

Afr

ican

Am

eric

an

Par

ticip

ants

and

cont

rols

who

wer

eov

erw

eigh

t,w

ithty

pe2

diab

etes

and

hbA

lcle

vels

>8%

,w

ere

recr

uite

dfr

omW

ashi

ngto

n,D

C,

clin

ics

and

phys

icia

nof

fices

,and

from

the

com

mun

ity.

32co

ntro

lsin

itial

ly;2

5(7

8%)

com

plet

edth

epr

ogra

m.

Ave

rage

:61

year

s;ra

nge:

55-

79ye

ars;

88%

fem

ales

;10

0%A

fric

anA

mer

ican

s

Com

paris

ongr

oup

rece

ived

usua

lcar

e,i.e

.,1

grou

pcl

ass

&2

nutr

ition

info

rmat

ion

mai

lings

at3

and

6m

onth

s;&

copi

esof

thei

rla

bora

tory

valu

es

Sel

f-re

port

edqu

estio

nnai

res

rega

rdin

gnu

triti

onkn

owle

dge,

self-

effic

acy

and

attit

udes

,he

alth

beha

vior

s,ph

ysic

alac

tivity

,1-

wee

kfo

odfr

eque

ncy

inta

kes.

Blo

odpr

essu

re,h

bAlc

and

chol

este

roll

evel

s.B

MIa

ndw

aist

-to-

hip

ratio

.

Mea

sure

dpr

e-in

terv

entio

n;at

3m

onth

sw

hen

the

wee

kly

sess

ions

wer

eco

mpl

eted

;and

agai

nat

6m

onth

sw

hen

the

biw

eekl

yse

ssio

nsw

ere

com

plet

ed.

Sta

tistic

alan

alys

esin

clud

edt-

test

san

dlin

ear

orlo

gist

icre

gres

sion

.

Sta

tistic

ally

sign

ifica

ntat

3m

onth

s:Im

prov

edam

ount

ofnu

triti

onkn

owle

dge

(p<

.05)

,ph

ysic

alac

tivity

(p<

.01)

.Im

prov

edca

loric

(p<

.05)

,fat

(p<

.01)

carb

ohyd

rate

(p<

.05)

and

satu

rate

dfa

t(p

<.0

5)in

take

.Im

prov

edgl

ycem

icco

ntro

l(p

<.0

1).L

ost2

-3kg

mor

eth

anco

mpa

rison

grou

p(p

<.0

1).

Not

stat

istic

ally

sign

ifica

nt:C

hang

esin

bloo

dch

oles

tero

l.W

aist

-to-

hip

ratio

.D

ieta

ryin

take

offib

er,

prot

ein,

sodi

um,

pota

ssiu

m,a

ndch

oles

tero

l.

Cha

nges

nots

usta

ined

afte

rin

terv

entio

nbe

cam

ele

ssfr

eque

nt,

exce

ptfo

rw

eigh

tlos

san

dhb

Alc

leve

ls(p

<.0

1).

Agurs-Collinsetal.,1997

Educationprinciplesappropriateforolderlearners;

StateduseofSocialActionTheory

Yes

74

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

AB

CD

EF

GH

21/

2ho

urs:

lect

ure/

disc

ussi

onno

naer

obic

exer

cise

,sn

ack

20-2

5/gr

oup

8w

eekl

y

Hea

lth,w

ithem

phas

ison

exer

cise

,nut

ritio

n,st

ress

man

agem

ent,

and

rela

xatio

n

96pa

rtic

ipan

tsin

itial

ly;7

0(7

3%)

com

plet

edth

est

udy.

Ave

rage

:69

year

s;ra

nge:

55-8

3ye

ars;

81%

fem

ale;

“Nea

rlyex

clus

ivel

y”w

hite

By

self-

repo

rt,8

9%ha

d“g

ood”

to“e

xcel

lent

”he

alth

;85

%w

ere

high

scho

olgr

adua

tes.

Par

ticip

ants

and

cont

rols

recr

uite

dfr

omus

ers

of8

seni

orce

nter

sin

Wes

tern

New

Yor

k.

50co

ntro

lsin

itial

ly;3

2(6

4%)

com

plet

edth

est

udy.

Tra

itssi

mila

rto

trea

tmen

tgro

up.

Com

paris

ongr

oup

mem

bers

wer

epa

rtic

ipan

tsat

4of

the

seni

orce

nter

sw

hoco

mpl

eted

the

stud

yqu

estio

nnai

res

and

wer

epu

ton

acl

ass

wai

ting

list.

Sel

f-re

port

edqu

estio

nnai

res:

heal

thbe

lief(

self-

effic

acy)

,he

alth

ybe

havi

ors,

use

ofm

edic

atio

ns,

and

heal

thst

atus

.

Mea

sure

dpr

e-in

terv

entio

n;an

dag

ain

9m

onth

saf

ter

the

star

toft

hepr

ogra

m,w

hich

was

7m

onth

saf

ter

com

plet

ion

ofth

ein

terv

entio

n.

Sta

tistic

alan

alys

esin

clud

edan

alys

isof

varia

nce,

anal

ysis

ofco

varia

nce

and

effe

ctsi

ze.

Sta

tistic

ally

sig

nifi

can

t:In

crea

sed

num

bers

(2x)

had

very

stro

ngbe

lief

that

thei

rbeh

avio

r(i.

e.,

eatin

gfru

itsan

dve

geta

bles

,not

smok

ing,

and

4ot

her

heal

thy

beha

vior

s)is

rela

ted

toth

eirh

ealth

(p<

.05)

.Inc

reas

ein

repo

rted

prac

tices

ofhe

alth

ybe

havi

ors

(p<

.05)

.Dec

reas

edav

erag

eus

eof

num

bero

fove

rth

eco

unte

rand

pres

crib

edm

edic

atio

ns(p

<.0

5).P

erce

ived

heal

thst

atus

impr

oved

(p<

.05)

.

Cha

nges

wer

esu

stai

ned

afte

rth

ein

terv

entio

nce

ased

.Ind

icat

ors

wer

eon

lym

easu

red

prio

rto

inte

rven

tion,

and

agai

nat

9m

onth

saf

ter

prog

ram

bega

n,an

dw

ere

notm

easu

red

imm

edia

tely

afte

rco

mpl

etio

nof

the

2m

onth

inte

rven

tion.

Briceetal.,1996

Educationprinciplesappropriateforolderlearners;

Implicit,notexplicitlystateduseofhealthbelieftheory

Notapplicable

75

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

Leng

thno

tind

icat

ed:

lect

ure/

disc

ussi

on,v

i-su

als,

take

-hom

eac

tiv-

ities

,han

dout

s,re

cipe

s,fo

odde

mon

stra

tions

&ta

ste

test

ing.

10-1

5/gr

oup

6to

18w

eekl

y

Nut

ritio

n,em

phas

ison

Foo

dG

uide

Pyr

amid

,D

ieta

ryG

uide

lines

,N

utrit

ion

Fac

tsla

bels

78pa

rtic

ipan

tsco

mpl

eted

;co

mpl

etio

nra

teof

eval

uatio

nda

taw

as“p

oor”

–spe

cific

data

wer

eno

tpr

esen

ted;

“ver

yhi

gh”

atte

ndan

cera

tes,

butn

otsp

ecifi

ed.

94%

wer

e60

-89

year

s;91

%fe

mal

e;87

%C

auca

sian

,8%

Afr

ican

Am

eric

an

Sub

ject

ssc

ored

98%

onpo

sitiv

enu

triti

onat

titud

es,

87%

onse

lf-es

teem

and

85%

self-

repo

rted

heal

thas

good

toex

celle

nt.

Tau

ghtt

hrou

ghco

oper

ativ

eex

tens

ion

serv

ices

.

Par

ticip

ants

and

cont

rols

wer

em

ostly

recr

uite

dat

seni

orce

nter

sin

Kan

sas,

Nor

thC

arol

ina

&O

hio.

40co

ntro

lsco

mpl

eted

;co

mpl

etio

nra

teof

eval

uatio

nda

taw

aspo

or,b

utsp

ecifi

cda

taw

ere

not

pres

ente

d.

Con

trol

san

dtr

eatm

entg

roup

wer

ede

scrib

edto

geth

er.

Com

paris

ongr

oup

had

notr

eatm

ent;

they

com

plet

edth

equ

estio

nnai

res

and

inte

rvie

w.

Sel

f-re

port

edqu

estio

nnai

res:

Inte

ntio

nsor

read

ines

sto

chan

ge,

alon

gw

ithac

tual

eatin

gpr

actic

es(fo

odfre

quen

cy-ty

pequ

estio

ns).

At6

mon

ths,

via

tele

phon

ein

terv

iew

s.

Mea

sure

dpr

e-in

terv

entio

n;at

the

com

plet

ion

ofw

eekl

ycl

ass

sess

ions

;and

for

half

ofth

epa

rtic

ipan

ts,a

gain

appr

ox.6

mon

ths

afte

rth

ein

terv

entio

nw

asco

mpl

eted

.

Sta

tistic

alan

alys

esin

clud

edt-

test

,an

alys

isof

varia

nce,

and

Kru

skal

-Wal

lisno

npar

amet

rican

alys

is.

Sta

tistic

ally

sign

ifica

ntch

ange

s:no

ne.

Not

stat

istic

ally

sign

ifica

nt:C

hang

esin

read

ines

s/in

tent

ions

toch

ange

orin

curr

ent

food

prac

tice

beha

vior

s.(M

ostr

epor

ted

eatin

ghe

alth

ydi

ets.

For

inst

ance

,27%

cons

umed

reco

mm

ende

dle

vels

offru

its&

vege

tabl

esw

hile

mor

eth

an50

%be

lieve

dth

eyat

eth

erig

htam

ount

.)

Mai

nten

ance

ofch

ange

sno

tapp

licab

le,

sinc

eno

stat

istic

ally

sign

ifican

tcha

nges

wer

efo

und

initia

lly.

ClarkeBarkleyetal.,2003

Educationprinciplesappropriateforolderlearners;

StateduseofSocialLearning,ReasonedAction&PlannedBehavior,andTranstheoretical

Notmentioned

76

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

AB

CD

EF

GH

Leng

thno

tind

icat

ed:

lect

ure/

disc

ussi

on,

cook

ing

dem

onst

ratio

ns,

follo

wed

by30

-40

min

utes

ofex

erci

se

Not

spec

ified

exac

tly,

butp

roba

bly

31/g

roup

5bi

wee

kly

Fitn

ess

trai

ning

and

nutr

ition

,em

phas

ison

redu

cing

bloo

dch

oles

tero

llev

els,

incl

udin

gho

wto

low

erfa

t,sa

ltan

dca

loric

inta

ke.

31pa

rtic

ipan

tsco

mpl

eted

;at

tend

ance

and

com

plet

ion

rate

sno

tmen

tione

d.

Ave

rage

:72

year

s;ra

nge:

55-8

8ye

ars;

87%

fem

ale;

97%

blac

k

Tau

ghti

na

chur

chto

incr

ease

prog

ram

acce

ssib

ility

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

anur

ban

Ohi

oco

mm

unity

.

No

com

paris

ongr

oup.

Sel

f-re

port

edqu

estio

nnai

res

rega

rdin

g:24

-hou

rfo

odre

call,

food

prac

tices

,and

exer

cise

hist

ory.

Wai

st-t

o-hi

pra

tio,

body

wei

ght,

skin

fold

thic

knes

ses,

bloo

dlip

ids

leve

ls.

Mea

sure

dpr

e-in

terv

entio

ns;a

ndat

10w

eeks

,whi

chis

whe

nth

ebi

wee

kly

sess

ions

wer

eco

mpl

eted

.

Sta

tistic

alan

alys

isin

clud

edt-

test

.

Sta

tistic

ally

sign

ifican

t:D

ecre

ase

inw

aist

circ

umfe

renc

e(p

<.0

4)Lo

wer

bloo

dto

tal

chol

este

rol(

p<

.03)

&lo

wde

nsity

lipop

rote

inch

oles

tero

lleve

ls(p

<.0

1).

No

tst

ati

stic

ally

sign

ifica

nt:I

ntak

eof

calo

ries,

carb

ohyd

rate

,pr

otei

n,fa

t,ch

oles

tero

lor

satu

rate

dfa

t.B

ody

wei

ght,

skin

fold

thic

knes

s,hi

pci

rcum

fere

nce.

Hig

hde

nsity

lipop

rote

inch

oles

tero

land

trigl

ycer

ide

leve

ls.

Rep

orte

dea

ting

rela

tivel

yhe

alth

ydi

ets.

Mai

nten

ance

ofch

ange

notm

easu

red.

Doshietal.,1994

Educationprinciplesappropriateforolderlearners;

Nostateduseofbehaviorchangetheory

Yes

77

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

2ho

urs:

shor

tvid

eota

pes,

disc

ussi

on

8-10

/gro

up

8w

eekl

y

Dia

bete

s,w

ithnu

triti

onas

focu

sof

1se

ssio

n&

apa

rtof

allo

ther

s,em

phas

ison

wei

ght

loss

,eat

ing

frui

ts,

vege

tabl

esan

dw

hole

grai

ns,a

ndde

crea

sing

satu

rate

dfa

tand

chol

este

roli

ntak

e.

58(7

4%)

part

icip

ants

com

plet

edth

est

udy.

Atte

ndan

cera

tes

not

men

tione

d.

Ave

rage

:60-

63ye

ars;

rang

e:ov

er50

year

s;69

%fe

mal

e;10

0%M

exic

an-

Am

eric

an

Som

esp

oke

only

Spa

nish

;ov

erw

eigh

t

Par

ticip

ants

and

cont

rols

with

type

2di

abet

esw

ere

recr

uite

dfr

om2

low

-inco

me

com

mun

ities

inso

uthe

rnT

exas

usin

gra

dio

mes

sage

s,po

ster

s,et

c.,a

ndra

ndom

lyas

sign

edto

trea

tmen

tor

cont

rol

grou

ps.

46(6

2%)

cont

rols

com

plet

edth

est

udy.

Con

trol

san

dtr

eatm

entg

roup

wer

ede

scrib

edto

geth

er.

Com

paris

ongr

oup

rece

ived

notr

eatm

ent;

they

com

plet

edfo

odre

calls

and

body

wei

ght

mea

sure

men

ts.

Sel

f-rep

orte

d24

-hou

rfo

odre

calls

,BM

I.

Mea

sure

dpr

e-in

terv

entio

n;an

dag

ain

10&

14w

eeks

afte

rcom

ple-

tion

ofth

ein

terv

en-

tion

Sta

tistic

alan

alys

isin

clud

edt-

test

s.

Sta

tistic

ally

sign

ifica

ntat

10w

eeks

:In

terv

entio

nm

ales

incr

ease

dvi

tam

inC

inta

ke(p

<.0

4)In

terv

entio

nm

ales

&m

ale

and

fem

ale

cont

rols

lost

1-2

kg(p

<.0

5)

Not

stat

istic

ally

sign

ifica

nt:

For

allg

roup

s,th

ete

nden

cyw

asto

decr

ease

calo

riein

take

.F

orin

terv

entio

nfe

mal

es,t

hete

nden

cyw

asto

war

dsim

prov

edca

loric

dist

ribut

ion

ofm

ore

carb

ohyd

rate

and

less

fat,

and

redu

ced

chol

este

roli

ntak

e.C

hang

ein

inta

keof

vita

min

A,c

alci

umfo

ral

lgro

ups,

and

vita

min

Cfo

rw

omen

.For

inte

rven

tion

fem

ales

,w

eigh

tlos

s.

Mal

esdi

dno

tmai

ntai

nin

crea

sed

vita

min

Cin

take

.Wei

ghtl

ostw

asm

aint

aine

dam

ong

mal

es,b

utno

tam

ong

cont

rolf

emal

es.

Elshawetal.,1994

Educationprinciplesappropriateforolderlearners;

Nostateduseofbehaviorchangetheory

Yes

78

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

AB

CD

EF

GH

Leng

thno

tind

icat

ed:

lect

ure/

disc

ussi

on,

visu

als,

in-c

lass

activ

ities

,han

dout

s,re

cipe

s,fo

odde

mon

stra

tions

&ta

ste

test

ing.

Gro

upsi

zeno

tspe

cifie

d

8w

eekl

y

Nut

ritio

n,em

phas

ison

food

sele

ctio

n,pr

epar

atio

nan

dsa

fety

.

76pa

rtic

ipan

tsco

mpl

eted

;co

mpl

etio

nan

dat

tend

ance

rate

sno

tm

entio

ned.

Ave

rage

:69

year

s;ra

nge:

over

55ye

ars;

sex

&ra

ceno

tgi

ven

Tau

ghtt

hrou

ghco

oper

ativ

eex

tens

ion

serv

ices

.

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

the

publ

icus

ing

mul

ti-m

edia

mes

sage

san

dpo

ster

s,et

c.,i

n10

Okl

ahom

aco

untie

s.

No

com

paris

ongr

oup.

Sel

f-re

port

edfo

odan

dnu

triti

onbe

havi

orqu

estio

nnai

re,2

4-ho

urre

calls

,BM

I,bl

ood

chol

este

rol

leve

ls.

Mea

sure

dpr

e-in

terv

entio

n;an

dat

the

com

plet

ion

ofth

ew

eekl

yse

ssio

ns.

Sta

tistic

alan

alys

esin

clud

edre

peat

edm

easu

res

proc

edur

e.

Sta

tistic

ally

sign

ifica

nt(p

<.0

5):I

mpr

oved

food

and

nutr

ition

beha

vior

s:fo

odse

lect

ion

and

prep

arat

ion

and

food

safe

ty,a

nddi

etar

yin

take

ofbr

eads

,ve

geta

bles

,dai

ry,a

ndfa

ts/s

wee

tsfo

odgr

oups

.Dec

reas

edbl

ood

chol

este

rol

leve

ls.

Not

stat

istic

ally

sign

ifica

nt:

4po

unds

aver

age

wei

ghtl

oss,

and

chan

gein

inta

kefo

rfr

uits

and

mea

tsfo

odgr

oups

.

Mai

nten

ance

ofch

ange

notm

easu

red.

Hermannetal.,2000

Authorsstatedthey“usedseveralnutritioneducationtheoriesincluding

nutritioninformation,nutritionpromotion,andbehaviorchange

strategies,”butauthorsdidnotdescribehowtheyincorporatedthese

intothestudy

Possiblynotapplicable

79

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

30m

inut

es:

lect

ure/

disc

ussi

on,i

n-cl

ass

and

take

-hom

eac

tiviti

es,m

eals

itech

ange

s,fo

odde

mon

stra

tions

,foo

dta

stin

g,w

ritte

npe

rson

alpl

ans.

18-4

5/gr

oup

4to

16w

eekl

y

Mal

nutr

ition

risk

redu

ctio

n

780

part

icip

ants

wer

esc

reen

ed(6

32co

mpl

eted

both

dem

ogra

phic

and

mal

nutr

ition

risk

data

);co

mpl

etio

nan

dat

tend

ance

rate

sno

tm

entio

ned.

Ave

rage

:76

year

s;9%

unde

rag

e65

year

s;75

%fe

mal

e;53

%W

hite

&47

%B

lack

Rur

al,l

owin

com

e;ta

ught

thro

ugh

coop

erat

ive

exte

nsio

nse

rvic

es.

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

user

sof

26co

ngre

gate

nutr

ition

site

part

icip

ants

in10

Nor

thC

arol

ina

coun

ties.

No

com

paris

ongr

oup.

Sel

f-re

port

edqu

estio

nnai

res

rega

rdin

gkn

owle

dge

and

nutri

tion

beha

vior

s.*

Mea

sure

dpr

e-in

terv

entio

ns,a

ndag

ain

atco

mpl

etio

nof

the

wee

kly

sess

ions

.*

*Per

sona

lco

mm

unic

atio

n,A

ugus

t200

0.

Sta

tistic

ally

sign

ifica

nt(p

<.0

5):

70%

incr

ease

dkn

owle

dge.

*D

ecre

ased

risk

ofm

alnu

tritio

nba

sed

onfo

odpr

actic

es.*

Main

tena

nce

ofch

ange

notm

easu

red.

*Per

sona

lco

mm

unic

atio

n,A

ugus

t20

00.

McClellandetal.,2001a

McClellandetal.,2002

Educationprinciplesappropriateforolderlearners;

Stateduseofhealthbelief,socio-ecological,andsocialmarketingmodels

Notspecificallyadaptedforculture

80

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

AB

CD

EF

GH

1ho

ur:

15-m

in.l

ectu

re,2

5m

in.d

iscu

ssio

n,&

15m

in.g

oals

ettin

g.

6/gr

oup

12w

eekl

y

App

rox.

half

ofth

ese

ssio

nsem

phas

ized

diet

,in

rela

tion

todi

abet

esco

ntro

l.

12pa

rtic

ipan

tsco

mpl

eted

;co

mpl

etio

nan

dat

tend

ance

rate

sno

tm

entio

ned.

Ave

rage

:74

year

s;ra

nge:

68-8

2ye

ars;

100%

fem

ale;

50%

Cau

casi

an&

50%

Afr

ican

-A

mer

ican

Six

ofth

epa

rtic

ipan

tsliv

edin

“nur

sing

hom

esan

dw

ere

rece

ivin

gin

term

edia

teca

re.”

Par

ticip

ants

and

cont

rols

with

diab

etes

wer

ere

crui

ted

usin

gne

wsp

aper

ads

and

phys

icia

nre

ferr

als

inur

ban

Indi

ana.

6co

ntro

ls

Com

paris

ongr

oup

was

one

ofth

etw

oin

terv

entio

ngr

oups

,but

thei

rin

terv

entio

nw

asde

laye

dby

12w

eeks

.

Sel

f-re

port

edfo

odin

take

ques

tionn

aire

,de

sign

edto

mea

sure

“die

tvio

latio

nfr

eque

ncie

s.”

Blo

odgl

ucos

ele

vels

.

Mea

sure

d3

times

wee

kly

for

48w

eeks

:du

ring

12w

eeks

pre-

inte

rven

tion;

atth

een

dof

the

wee

kly

sess

ions

;and

agai

nat

12or

24m

ore

wee

ksaf

tert

heco

mpl

etio

nof

the

inte

rven

tion.

Sta

tistic

alan

alys

esin

clud

edm

ultiv

aria

tean

alys

isof

varia

nce

and

Tuk

ey’s

test

.

Sta

tistic

ally

sign

ifica

nt(p

<.0

5):R

educ

edbl

ood

gluc

ose

leve

ls.

Few

erde

viat

ions

from

diet

plan

s.

Sta

tistic

ally

sign

ifica

ntim

prov

emen

tsw

ere

mai

ntai

ned

afte

rin

terv

entio

nce

ased

.

Robison,1993

Educationprinciplesappropriateforolderlearners;

Nostateduseofbehaviorchangetheory

Nonementioned

81

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

1-ho

urle

ctur

e/di

scus

sion

,vi

sual

s,fo

odm

odel

s,fo

odta

stin

g,fo

odde

mon

stra

tions

,re

cipe

s,ha

ndou

ts

Gro

upsi

zeno

tspe

cifie

d

Six

,dur

ing

3m

onth

s

Gen

eral

nutr

ition

,em

phas

ison

Foo

dG

uide

Pyr

amid

,Die

tary

Gui

delin

es,f

ood

shop

ping

/saf

ety/

stor

age

53(7

0%)

part

icip

ants

com

plet

edth

est

udy;

clas

sat

tend

ance

rate

was

43%

to60

%

Ave

rage

:74

year

s;ra

nge:

58-9

1ye

ars;

91%

fem

ale;

79%

Afr

ican

-A

mer

ican

,21

%w

hite

Low

inco

me

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

at7

cong

rega

tem

eal

site

sin

Sou

thC

arol

ina.

39(7

0%)

cont

rols

com

plet

edth

est

udy.

aver

age:

73ye

ars;

rang

e:62

-85

year

s;87

%fe

mal

e;95

%A

fric

an-

Am

eric

an,

5%w

hite

Low

inco

me

Com

paris

ongr

oup

mem

bers

wer

epa

rtic

ipan

tsat

3of

the

cong

rega

tem

eal

site

sw

hoco

mpl

eted

the

stud

y’s

inte

rvie

ws

and

wer

epr

ovid

edth

ecl

ass

afte

rth

est

udy.

Fac

e-to

-fac

ein

terv

iew

sre

gard

ing:

nutr

ition

know

ledg

e,nu

triti

onat

titud

es,

and

food

frequ

enci

es.

Mea

sure

dpr

e-in

terv

entio

n,an

dag

ain

with

in2

mon

ths

afte

rea

chsi

te’s

final

clas

s.

Sta

tistic

alan

alys

esin

clud

edt-

test

,chi

-sq

uare

test

and

anal

ysis

ofva

rianc

e.

Sta

tistic

ally

sign

ifica

nt:

Par

ticip

ants

gain

ednu

tritio

nkn

owle

dge

rega

rdin

gfru

itan

dve

geta

ble

inta

kere

com

men

datio

ns(p

<.0

2)an

dlo

wnu

trien

tde

nsity

ofce

rtain

food

s(p

<.0

4).I

mpr

oved

1of

8fo

odbe

havi

ors

stud

ied,

frequ

ency

ofea

ting

fruit

(p<

.02)

.

Not

stat

istic

ally

sign

ifica

nt:

No

impr

ovem

enti

n7

of8

food

beha

vior

sst

udie

d.N

och

ange

inat

titud

esab

outd

iet&

dise

ase

links

.

Mai

nten

ance

ofch

ange

notm

easu

red.

Sharpeetal.,1996

Educationprinciplesappropriateforolderlearners;

Nostateduseofbehaviorchangetheory

Nonementioned

82

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

adult populations. Only three of the nine studies reviewed here and summa-rized in Table 1 stated their behavioral theoretical framework and included adescription of how their theory or theories influenced the intervention ele-ments used in class, while a fourth study implied using such theory. Theories andmodels used were Health Belief, Social Action, Social Learning, Socio-Eco-logical, and Transtheoretical (Stages of Change). Likewise, only seven of the16 older adult nutrition intervention studies reviewed by Higgins and ClarkeBarkley (2003a) stated which theoretical framework(s) was used to predict be-havior change, and Bowen and Beresford (2002) also noted that few authors ofthe 80 studies that they reviewed regarding dietary interventions mentioned atheoretical basis or model of intervention. Similarly, a review of diabetes edu-cation programs for African American women revealed that few were theorybased, with an implied use of the Health Belief model, Extended Parallel Pro-cess model, theory of Reasoned Action, Social Cognitive theory, Transtheo-retical model and Social Marketing theory being the most common (Hugheset al., 2001).

All of the authors employed a variety of educational techniques besides justlectures. All used adult learning theory and older adult educational strategiesto enhance learning. For instance, they combined lecture with discussions andhands-on class activities, such as exercise, food preparation/cooking demon-strations, recipes and food tasting. Some showed and discussed videotapes,and/or provided easy-to-read visuals or handouts, and take-home activities andchallenges. Educators encouraged changes in attitudes and behaviors by usingstrategies such as problem solving, goal setting, making personal plans, takingpersonal responsibility and increasing self-efficacy among the participants.Some noted the need for low literacy and/or bilingual print materials, and forreading materials for those with physical disabilities such as vision problems.

Class Size and Sessions

Group classes varied greatly in size. One author limited group size to sixpeople. Three reports indicated that classes were kept to 8 to 15 people, whilethree others grouped 18 to 45 older learners together. The remaining two stud-ies did not specify what size classes they offered. Some of the groups werestructured to be a specific size, while others used already-established groups–such as those conducted at congregate meal sites–that determined how manyolder subjects participated.

Class sessions most commonly were held weekly (in 7 of 9 cases), but in onestudy they occurred biweekly, and one study group was even without a set sched-ule (Sharpe et al., 1996). Locations in which classes were held varied. An ac-cessible convenient location or having transportation provided is important

Nutrition Education for Older Adults 83

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

(Doshi et al., 1994; Williams et al., 1996; and McClelland et al., 2001a). Thenumber of sessions ranged from 4 to 18 for all nine studies, while the durationof each was from 30 minutes to 2 1/2 hours, of those six research groups whoreported this latter statistic. Three authors did not indicate how long each ses-sion usually lasted. Thus, educators attempted to change nutrition behaviorsover one or more months, and usually with a class total time of just 2 to 6 hoursof nutrition information, discussions and activities. A notable exception wasthe study by Agurs-Collins et al. (1997), whose participants were offered 18hours of in-class weight loss and general nutrition information, discussionsand activities.

In two studies (Robison, 1993; Sharpe et al., 1996), multiple groups weretaught by one person. Other studies (Agurs-Collins et al., 1997; Doshi et al., 1994)formed one group but involved two or more instructors from two or more sci-entific disciplines. In yet other studies (Clarke Barkley et al., 2003; Elshaw etal., 1994; Hermann et al., 2000; McClelland et al., 2001a), multiple instructorswere recruited–sometimes from different agencies or to teach in Spanish ratherthan in English–to lead groups in multiple locales. Some reports (Brice et al.,1996) did not clarify whether the same instructor taught the groups at differentsites or if different people led groups at the multiple locales.

Educational Topics

Topics addressed by the group classes likewise were varied. Some includedsessions of mixed topics, but they had to have a nutrition education componentto be considered for this review. Three of the studies focused on nutrition forpeople with diabetes (Agurs-Collins et al., 1997; Elshaw et al., 1994; andRobison, 1993). Some taught about physical fitness and exercise, and othersincluded information about how to lose weight. Other topics covered includedstress management and relaxation. Those devoted entirely to nutrition educa-tion included such topics as the Food Guide Pyramid, Dietary Guidelines andNutrition Facts food labels. Other groups emphasized two or more of the fol-lowing: lowering salt, carbohydrate, fat and cholesterol intakes. Still others em-phasized guidelines such as eating more fruits, vegetables and whole grains,and ways to reduce risk for food-borne illness and malnutrition.

A study with older adult groups that reported on nutrition outcomes but pro-vided only cursory nutrition education to support their participants in attaininggoals was reported by both Mayer et al. (1994) and Williams et al. (1996).Their study was not included in Table 1 because their nutrition messages werenot a substantial portion of their classes. These researchers held just one two-hour nutrition lecture/discussion session out of eight classes, even though 32%of their older adult participants’ stated goals regarded changing nutrition prac-

84 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

tices, such as increasing cruciferous vegetable intake and reducing dietary fat(Mayer et al., 1994). Not surprisingly, it would seem, they reported no changesin nutritional pattern or in objectively reported (versus self-reported) nutritionoutcomes. Nutrition was also a limited part of the sessions in a study by Arnoldet al. (1996) using older adult subjects, where just three nutrition education ses-sions over 18 months of a diabetes education support group were reported. Nev-ertheless, nutrition outcomes were studied. At the end of the study, the 45 olderadult participants reported that they perceived that they had changed their eat-ing habits, including eating fewer snacks, sweets and fats, but the authors couldnot identify statistically significant changes in BMI, caloric intake, or percentintake of carbohydrate, fat or protein.

Cultural Adaptations

Three of those educators whose reports are summarized in Table 1 and whoworked with minority groups stated that they tailored their program for cul-tural appropriateness (Agurs-Collins et al., 1997; Doshi et al., 1994; and Elshawet al., 1994), while four other groups did not, despite having minority elderscomprising 8 to 79 percent of their participants. One of the nine groups did nothave minority audiences, and Hermann et al. (2000) possibly did not.

Participants

All but one of the nine studies included in Table 1 had an intervention sam-ple of less than 100 people. Only four of the nine research teams reported classcompletion rates, while just two of the nine reported class attendance rates. Sim-ilarly, basic demographic descriptions (age, sex and race/ethnicity) of the par-ticipants were missing from some reports. These studies varied in recruitmentprocesses, and some were not designed to include comparison groups.

Sample Size, Class Completion and Attendance Rates

In eight of the nine studies, the number of intervention participants was small,i.e., 12 to 78. In the notable exception, McClelland et al. (2001a) taught 780congregate nutrition site participants in 26 locations in 10 rural southern coun-ties in North Carolina. Demographic data were presented for 632 elders of thisgroup in another report (McClelland et al., 2002).

In Table 1, we report the number of older participants who began each study,if available, in addition to how many completed. Studies varied in the percent ofparticipants who dropped out, with completion rates ranging from 70% to 94%;and five authors did not report on this statistic at all. Those participants who

Nutrition Education for Older Adults 85

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

completed the studies ranged in their actual attendance rate of sessions, froman average of 43% to 63%, according to the only two authors who specificallyreported on these data (Agurs-Collins et al., 1997; and Sharpe et al., 1996).

Demographics

Participants’ ages ranged from 50 to 91 years, with most being in their sixthor seventh decade of life. Not all reports indicated the range of ages and the av-erage ages of participants. Hahn and Gordon (1998), for example, reported astudy that was not summarized in Table 1 because they did not specify ages ofthe participants in their group diabetes classes. The authors implied that their120 African-Americans subjects were ages 65 years and over. Their study fea-tured four, two-hour sessions consisting of games, giveaways and cookingdemonstrations, taught in part by community members. Six months after theeducational intervention, glycohemoglobin levels were decreased among the25 participants who had pre- and post-blood work measured, while there wasno change in blood lipids. Results may have been influenced by other factors,such as changes in diabetes medication, which were not controlled for duringthe study. Participants showed high levels of enthusiasm and interest in theprogram, which continued even after the series ended.

A large percentage of study participants were females, i.e., 66-100%. Thisis a reflection of the population, since most older adults are female. In 2000,71% of those ages 85 and older were women (Rogers, 2002). When comparingparticipation in group classes, females tend to be more health conscious, moreinclined to use health care and more willing to participate in health interven-tion programs than are males, according to Doshi et al. (1994) who cited anearlier study.

Six studies reported on classes where nearly half or more of the participantsrepresented minority groups. Five mentioned teaching African-Americans(Agurs-Collins et al., 1997; Doshi et al., 1994; McClelland et al., 2001a and 2002;Robison, 1993; and Sharpe et al., 1996), while Elshaw et al. (1994) taught Mexi-can-Americans. Two of the remaining reports enrolled mostly Whites, andHermann et al. (2000) did not report the ethnicity/race of their participants nordid they identify the percentage of females.

Recruitment Procedures

The participant selection process varied among studies. Many participantswere recruited from already-established groups, such as congregate nutritionsites and senior centers (Brice et al., 1996; Clarke Barkley et al., 2003; Mc-Clelland et al., 2001a and 2002; and Sharpe et al., 1996). In other cases, group

86 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

classes were held in neighborhood clinics and churches (Agurs-Collins et al.,1997; Doshi et al., 1994; and Elshaw et al., 1994). A number of educatorsworked with low-income senior adults. Three of the studies focused on peoplewith diabetes (Agurs-Collins et al., 1997; Elshaw et al., 1994; and Robison, 1993).Some of the groups were taught through county cooperative extension services(Clarke Barkley et al., 2003; Hermann et al., 2000; and McClelland et al.,2001a and 2002).

The degree of independence among noninstitutionalized older adults varies,since some live with family members and in other arrangements that varywidely in the number of choices they can make regarding their nutrition prac-tices (food shopping, selection, preparation, accessibility, etc.). Robison (1993)stated that some of his group class participants lived in area nursing homes andwere receiving intermediate care, which we believe may be similar to today’sassisted living facilities, although it was not described. We included the au-thor’s report in this review of literature, since his participants may be very sim-ilar to adults who rely on family, friends or community programs to delivergroceries or prepared meals to their homes.

Comparison Group Treatment

Six of the nine studies reviewed had some kind of a comparison group en-rolled. In five of the studies, the older adults in the comparison group did notreceive any kind of intervention during the comparison period, except for par-ticipating in pre- and post-intervention data collection activities. Those en-rolled in the study by Agurs-Collins et al. (1997) received “usual care” activities,i.e., one group class, two nutrition information mailings at three and six months,and copies of their laboratory values. Numbers in comparison groups were alsosmall. In the study by Robison (1993), for instance, six of the intervention par-ticipants served as the comparison group prior to their participating in the edu-cational sessions themselves. Brice et al. (1996) and Sharpe et al. (1996) alsoemployed this tactic, but with larger sample sizes.

Outcomes

No single outcome was measured by all nine research groups. Some authorsmeasured outcomes immediately after their group classes were completed,while others waited up to seven months to do so. Reported results and the abil-ity of older learners to sustain changes varied among studies.

Verification Methods

Educational outcomes can be verified in a number of ways. Comparison ofany result among all of the studies was not possible since no single standard

Nutrition Education for Older Adults 87

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

outcome was reported. The usual outcomes in these studies measured changesin knowledge, attitudes and beliefs, behaviors or intentions to change behav-iors, and physiological measures such as BMI, blood glucose or glycated he-moglobin levels, blood pressures, and blood cholesterol levels. Higgins andClarke Barkley (2003a) described various evaluation methods and how theyhave been used in studies with older adults.

In this review, all of the studies summarized in Table 1 indicated that infor-mation (i.e., a goal to change knowledge) was part of the program. The out-comes desired, however, were not limited to class members acquiring informa-tion or increasing their understanding of nutrition. In fact, in many cases, changesin knowledge were not even assessed. When nutrition knowledge was as-sessed, questionnaires were used to capture improvements, except for the face-to-face interviews used by Sharpe et al. (1996) and telephone follow-up inter-views conducted by Clarke Barkley et al. (2003). Three of the studies sought tomodify nutrition attitudes and beliefs (Agurs-Collins et al., 1997; Brice et al.,1996; and Sharpe et al., 1996). Using the Transtheoretical model, Clarke Barkleyet al. (2003) wanted to document increases in intentions to improve eating be-havior.

Several methods were used to evaluate the amount of behavior change. Allnine studies compared pre- and post-intervention self-reported nutrition prac-tices, using food frequency, food recall, and/or other types of questionnaires.Instruments such as food records and food frequencies are better able to verifyfood and nutrition practices, compared to more subjective questionnaires ask-ing participants whether they have perceived changes in their food habits.Three studies asked for 24-hour recalls (Doshi et al., 1994; Elshaw et al., 1994;and Hermann et al., 2000), while three used food frequencies (Agurs-Collins etal, 1997; Clarke Barkley et al., 2003; Sharpe et al., 1996). Questionnaires alsowere used to gauge changes in other health practices, such as physical activity.Several studies employed physiological measures to verify group nutrition ed-ucation class outcomes. These included BMI/weight measurements (Agurs-Collins et al., 1997; Doshi et al., 1994; Elshaw et al., 1994; and Hermann et al.,2000); waist circumference (Agurs-Collins et al., 1997; and Doshi et al.,1994); blood glucose and/or glycated hemoglobin levels (Agurs-Collins et al.,1997; and Robison, 1993); blood cholesterol levels (Agurs-Collins et al., 1997;Doshi et al., 1994; and Hermann et al., 2000); and one measured blood pres-sures (Agurs-Collins et al., 1997). One study (Doshi et al., 1994) looked at skinfold thicknesses, while McClelland et al. (2002) studied malnutrition risk.

Length of Follow-Up

Length of follow-up after interventions ceased varied from none for fourstudies (Agurs-Collins et al., 1997; Doshi et al., 1994; Hermann et al., 2000;

88 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

and McClelland et al., 2001a and 2002) to 2 months (Sharpe et al., 1996), 2 1/2and 3 1/2 months (Elshaw et al., 1994), 3 and 6 months (Robison, 1993), 6 months(Clarke Barkley et al., 2003), and 7 months (Brice et al., 1996).

Reported Outcomes

No consistent patterns were detected in outcomes–whether knowledge, atti-tude, behavior or physiologic–among the studies. Rather, the efforts met withvarying success (statistical significance equals p � .05). Outcomes data forparticipants in the study by McClelland et al. (2001a; 2002) were not includedin the published articles, but were obtained by personal communication.

Improved knowledge scores were reported by Agurs-Collins et al. (1997),McClelland et al. (personal communication; August, 2000), and Sharpe et al.(1996). Nutrition beliefs and attitudes improved in the study reported by Briceet al. (1996), but not in that of Sharpe et al. (1996).

Readiness or intentions to change nutrition practices did not increase amongparticipants in the study by Clarke Barkley et al. (2003), but their diets weregenerally already good before the intervention. Improvements of certain aspectsof perceived dietary practices and intake were noted by some authors (Brice etal., 1996; Hermann et al., 2000; and McClelland et al., personal communica-tion, August, 2000). In other reports, verified dietary intake of certain food groupsor nutrients improved, while intake of other food groups or nutrients did notchange (Agurs-Collins et al., 1997; Elshaw et al., 1994; Hermann et al., 2000;and Sharpe et al., 1996). Robison (1993) found improvement in the only nutri-tion behavior variable that he studied, i.e., compliance to diet plans as mea-sured by diet violation frequencies. In contrast, verified dietary intake did notchange for any food groups or nutrients in other studies (Clarke Barkley et al.,2003; and Doshi et al., 1994).

Similarly, physiologic measures improved for some variables, but not forothers in four studies (Agurs-Collins et al., 1997; Doshi et al., 1994; Elshaw etal., 1994; and Hermann et al., 2000). Robison (1993) found improvements inthe physiologic indicator that he measured, blood glucose. There was no uni-formity, however, among studies: Measures that improved in some studies, forexample blood cholesterol, waist circumference and body weight, did not changein other studies.

Maintenance of Reported Changes

Some of the improvements in nutrition practices and physiological mea-sures were sustained after the group classes ceased or became less frequent. Inthe only study where indicators of change were measured immediately after

Nutrition Education for Older Adults 89

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

the classes had ceased, and again 3 and 6 months later (Robison, 1993), diabeticglycemic control and adherence to a prescribed diet were improved even at sixmonths post-intervention. In the one study (Agurs-Collins et al., 1997) whereoutcomes were measured again after group classes were held less frequently,two improvements persisted, weight loss and diabetic glycemic control. In astudy where changes were measured 2 1/2 months after group classes hadceased (Elshaw et al., 1994), improved intake for just one nutrient (vitamin Cfrom increased fruits and vegetables consumption) was found among men butnot women, but this change did not persist by 3 1/2 months, while weight lossfor the men enrolled in the classes did persist. In only one study were changesmeasured for as long as 7 months after the group classes had ceased (Brice etal., 1996). Compared to the nonintervention group, class participants more fre-quently held strong beliefs that their nutrition and other healthy behaviorswere related to their health.

DISCUSSION AND SUGGESTIONS FOR FUTURE RESEARCHAND FOR DEVELOPING GROUP NUTRITION EDUCATION

CLASSES FOR OLDER ADULTS

Major inconsistencies in interventions, participants and outcomes exist amongthe only nine articles located through a thorough computer-assisted literaturesearch that were published since 1993 on group classes that included nutritioneducation as a substantial component and that targeted, or at least separatelyreported on, adults ages 50 years and older living independently in the U.S.The studies vary from those that were conducted by an individual workingalone to those where the team was multidisciplinary. Reported study interven-tions varied by whether and which theoretical model or models of behaviorchange were used; number, frequency and duration of class sessions; educa-tional techniques; class topics; group size; recruitment procedures; and whetherthe information was adapted to the culture of the target audience. The studies gen-erally included small numbers of intervention participants, and even smallernumbers in comparison groups. Authors did not consistently report their popu-lation’s demographic characteristics, nor class attendance and completion rates.

Additionally, types of program outcomes varied widely in these reports, andincluded measurements of change in knowledge, attitudes/beliefs, behaviors,and/or physiological measures. The actual variables examined, such as bodymass index (BMI), blood glucose or glycated hemoglobin (hbA1c) or lipid con-centrations, nutrient intakes, etc., also varied among reports, and there were nocommon indicators used that could be adopted as a benchmark for compari-sons. No consistent patterns were detected among reported outcomes. Studies

90 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

did not necessarily include follow-up after the intervention ceased to determineif statistically significant outcomes identified were sustained. With such a smallsample, inconsistencies in goals, designs and interventions, and differing par-ticipant characteristics and verification methodologies, findings based on thisgroup of studies are not conclusive.

The discussion of the need for future research and the suggestions for devel-oping group nutrition education classes for older adults that follow are basedon issues raised by our review of the publications in the preceding sections. Weemphasize that research is needed to determine the appropriateness of thesepreliminary suggestions for various populations. We hope that this discussionwill encourage new research–reflecting increased quantity and improved qual-ity–which is needed before conclusive recommendations regarding groupclasses for older adults can be provided to nutrition educators.

Regarding Educational and Behavioral Strategies

The educational and behavioral strategies used varied among studies. We com-mend the educators for using adult learning theory and multiple educationaltechniques that appeal to different senses such as taste, smell, touch, and vision.Discussion often was emphasized during the group sessions. Some classes fea-tured goal setting, making personal plans, and increasing self-efficacy. A fewstudies featured take-home activities to practice a new behavior between classes.Additionally, about half of the educators used resource materials and topicsthat were judged to be culturally relevant and at the appropriate literacy level.A recent review, while not focusing on group education specifically, describedhow to tailor the subject matter content and more effectively deliver messagesto meet the diverse needs and interests of older adults engaged in nutrition edu-cation programs (Higgins and Clarke Barkley, 2003c), while another articlesuggested ways to improve effectiveness of nutrition education resources forolder adults (Higgins and Clarke Barkley, 2004), and a third review describedsteps to consider in designing an older adult educational program, includingthe incorporation of adult education and behavioral change theories (Higgins andClarke Barkley, 2003d). Four of the nine studies reported here employed oneor more types of behavioral theories.

We suggest that all future reports of studies name and describe their use ofbehavioral change theory-based strategies in their design and implementation.More research is needed to determine appropriate teaching styles that suitolder adult learners. We also suggest that nutrition educators seek out partnerswith varying kinds of expertise to plan programs for senior adults, as well aslearn the needs and interests of their prospective groups and tailor classes ac-

Nutrition Education for Older Adults 91

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

cordingly. And as mentioned near the beginning of this article, we suggest train-ing more older adults to be lay community educators.

Regarding Scheduling Group Education Sessions

The amount of time spent on nutrition education varied considerably amongstudies. In the six studies where the total class time spent could be estimated, therange was 2 to 18 hours. Sometimes nutrition was just a part of the whole pro-gram, such as the diabetes education or the nutrition and exercise programs;sometimes nutrition classes were short, being thirty minutes or less; sometimesthey were only a few weeks while other times they lasted several months. Groupswere sometimes a gathering of six participants, while in other studies up to 45people formed a single group. Like Walker (1999), whom we cited earlier asreporting on different types of educational interventions for diabetes self-man-agement, we, too, conclude that there are many unanswered questions.

We suggest that research be designed to test for appropriate/optimal frequencyof sessions, length of each session, number of participants per group, locationheld, and number of sessions in a class series, using varying audiences. Researchis needed to determine how much learning time is needed before any long-last-ing behavior change can be expected from older adults.

Regarding Educational Topics

All studies included in Table 1 indicated multiple sessions on various as-pects of nutrition. The reproducibility of and control over teaching varied con-siderably, from studies where there was one instructor teaching one group tostudies with multiple sites across one or more states. The attendance rate of anygiven session was just 43% to 63%, based on data from two studies. With suchlow attendance rates, many participants did not gain exposure to the nutritioninformation provided in any single class session. These data can help informeducators how their information should be presented. For instance, if informa-tion about consumption of a particular food group was presented during justone session during a series of classes on healthy eating, more than half of classparticipants who completed the series would have missed the information aboutthat food group because they did not attend that single session. On the otherhand, if half of the information about two different food groups were presentedduring each of two sessions, the likelihood that a participant would hear at leasta partial message about both food groups would increase. These attendance sta-tistics also indicate that the time spent engaged in nutrition education activities,rather than being 2 to 18 hours as indicated in the preceding paragraph, wascloser to just 1 to 11 hours.

92 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

We suggest that each class topic be repeated in different ways across severalsessions. This not only would introduce all concepts to more members of thegroups, but it also would reinforce them to those who attend sessions more fre-quently, which would likely enhance the possibility that they would imple-ment nutritional behavior changes. We also suggest that nutrition educatorsfocus on a few main points, given the limited time that any one group memberlikely spends in class. Additionally, when several different instructors teach aclass, researchers need to control for or at least report on differences amongteachers in what (and how) information was presented.

Regarding Class Participants

For comparing results and understanding factors impacted by diversity, au-thors need to describe the experimental and control or comparison groups thor-oughly. In this review, all studies provided information about the number ofpeople studied. They usually reported the average age and age range of the par-ticipants, while some reported the percentage of those within age categories.(Those who did not report enough information to determine participants’ ageswere excluded from the table.) Just one study omitted the sex of the participantsand their ethnicity or race. Information about health status and chronic diseases,socioeconomic status, and educational background was sometimes provided inthe descriptions. Recruitment methods were sometimes, but not always, fullydescribed. Comparison groups were used in six of the studies cited, but onlyone provided interventions for the older adults who served as their control group.

We suggest that authors describe their participants more fully and includecontrols or comparison groups in the experimental design of the study.

Regarding Program Evaluation and Follow-Up

In each of the nine studies summarized in Table 1, more than one type ofoutcome was measured, but there was no single standard outcome among stud-ies. The group educational programs reviewed here were fairly short-term, i.e.,one to six months. The group classes in some cases induced no measurablechanges, while, in the other cases, change for similar variables was inconsistentamong studies. For example, blood cholesterol improved in some studies, butnot in others; dietary intakes improved for certain nutrients in some studies,but not in others. Weight loss and improved diabetic glycemic control were thetwo changes most likely to persist, but more data are needed to establish the re-liability of such findings. Difficulties in evaluating outcomes and impact ofnutrition education programs designed for older adults were recently reviewedby Higgins and Clarke Barkley (2003a), while similar difficulties with pro-

Nutrition Education for Older Adults 93

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

grams for low-income audiences were reviewed by McClelland et al. (2001b),and evaluation difficulties with educational programs for individuals with dia-betes were reviewed by Mulcahy et al. (2000).

We suggest that researchers develop more sensitive indicators of change innutrition knowledge, attitudes and behaviors among older adults, and includelonger follow-up after interventions cease to assess permanency of changes.We also suggest including at least one and, preferably, a variety of physiologicmeasures to document change. More research is needed to determine the typesof changes that can be expected as a result of more intensive group nutritioneducation classes for older adults. We encourage educators to report their find-ings in peer-reviewed journals.

Regarding Comparisons of Group Classes to Other Educational Interventions

As mentioned earlier in the article, few reports have compared effectivenessof group classes to other interventions. Agurs-Collins et al. (1997) was the onlyresearch group of the nine studies summarized in Table 1 to do so. Another as-pect of the published research that is lacking describes what specific programswill attract different subgroups of older adults. Completion rates of the fourstudies that reported them were 70% to 94%. These values seem high and indi-cate that many older adults indeed do enjoy and are encouraged by participat-ing in classes, at least among those who opt to enroll in a series. Of course,those people who volunteer to participate in a class may not be representativeof the population, and, because of their interest, they may have above-averagenutrition knowledge and practices. In at least one study (Clarke Barkley et al.,2003) where group education classes were not associated with changes in nu-trition practices among participants, this was the case; the volunteers’ dietswere generally already good before the intervention. As noted by Walker (1999),however, many people will not participate in group classes. Williams et al.(1996) posed a question regarding what at-risk groups of non-attendees desirein order to be attracted to health-promotion behaviors. This research team com-pared who benefited the most from eight mental and physical health promotiongroup sessions, one of which included nutrition education, that were offered toMedicare recipients. The impact was least on those 75 years and older, smok-ers, and those who did not read health articles. This finding is intriguing be-cause these particular populations of older adults are among those whose healthis most in need of improvement.

We suggest that more research be conducted to elucidate which older learn-ers are better suited to group classes versus other types of educational interven-tions. A combination of intervention approaches may be the most effective,but new research is needed to determine recommendations for educators.

94 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

Regarding Planning a Research Agenda

Nutrition educators of older adults need a wide variety of information abouthow to program effectively for this diverse population. These articles demon-strate the scarcity of information about older learners who attend group classes,topics to teach, educational techniques to employ, outcomes and evaluationmethods to use, and reporting protocols. No two programs were similar. Whatlevel and type of intervention contact is needed for which groups of olderadults in order to establish and sustain improvement remains to be determined.Facing similar problems regarding effective diabetes education, diabetes edu-cators held research summit conferences and then published a research agenda(American Association of Diabetes Educators, 1999; and American Associa-tion of Diabetes Educators, 2001). Additionally, a short description of problemsassociated with diabetes education research and recommendations for improv-ing its quality and meaningfulness were published by Wheeler et al. (2001).

We suggest that an organization or an interested group working in coopera-tion with complementary professionals such as nutrition educators, adult edu-cators, gerontologists and evaluators hold a similar conference to discussissues and develop a research agenda for effective methods of providing nutri-tion education to older adults.

SUMMARY

While group nutrition education classes for older adults are frequently used,educators and researchers encounter many difficulties in planning, designing,implementing, evaluating and reporting on them. This review covers the sur-prisingly little recently published research data about teaching nutrition toolder adults in group settings. Few studies published over the last ten years werelocated after a thorough computer-assisted literature search. The number ofstudies and the quality of the research fall short in one or more aspects. Wecommend the authors who reported what they have done, however, and urgemore educators to do the same. Participants in the group classes reviewed showedsome improvement in nutrition knowledge, beliefs/attitudes, food and nutri-tion practices and physiological health, but no consistent patterns were de-tected among reported outcomes. Also, the studies were usually short-term, andfew data showed that improvements were maintained. Certainly, findings fromthese studies cannot be generalized to all older audiences. We conclude thatthere are many unknowns regarding characteristics of effective group classesfor older adults receiving nutrition education. And while group classes arepopular with some audiences, little comparative research has been conducted

Nutrition Education for Older Adults 95

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

to determine if they are one of the most appropriate educational approaches touse to teach healthy nutrition practices to this age group.

We recommend that researchers and educators conduct studies to explore allaspects of older adult group education. Published research is needed describ-ing advantages and disadvantages of group classes versus other educational in-terventions versus combination approaches. Reports of these studies shouldinclude detailed descriptions of the theory-based educational and behavioralstrategies selected by the partners in the planning team; the sessions provided;the topics taught and their instructors; a complete description of the older adultparticipants and control or comparison groups; and the evaluation and fol-low-up methods used. A team of nutrition educators and affiliated profession-als should hold a research planning conference to discuss issues and developan agenda for future studies for this largely ignored population, many of whomneed and are interested in nutrition and health. Nutrition education for olderadults is in its infancy, but such education holds high promise in promotinghealthier, high quality lives.

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

REFERENCES

Agurs-Collins, T.D., Kumanyika, S.K., TenHave, T.R. & Adams-Campbell, L.L.(1997). A randomized controlled trial of weight reduction and exercise for diabetesmanagement in older African-American subjects. Diabetes Care, 20, 1503-1511.

American Association of Diabetes Educators (1999). Diabetes educational and behav-ioral research summit. The Diabetes Educator, 25(suppl.), 2-88.

American Association of Diabetes Educators (2001). Toward a research agenda for theAmerican Association of Diabetes Educators. The Diabetes Educator, 27, 899-907.

Arnold, M.S., Funnell, M.M., Herman, W.H., Brown, M.B., Merritt, J.H., Fogler, J.M.& Halter, J.B. (1996). Discrepancies between perceived dietary changes and 4-dayfood records in older adults with diabetes. Journal of the American Dietetic Associ-ation, 96, 705-707.

Bowen, D.J. & Beresford, S.A.A. (2002). Dietary interventions to prevent disease. An-nual Reviews of Public Health, 23, 255-286.

Brice, G.C., Gorey, K.M., Hall, R.M. & Angelino, S. (1996). The STAYWELL Pro-gram–maximizing elders’ capacity for independent living through health promo-tion and disease prevention activities. Research on Aging, 18, 202-218.

Brown, S. (1999). Interventions to promote diabetes self-management: State of the sci-ence. The Diabetes Educator, 25(suppl.), 52-61.

Clarke Barkley, M., Higgins, M. Meck, Hart, W.D., McClelland, J.W. & Saddam, A.(2003). Development and evaluation of a multi-state older adult nutrition educationpilot program. Journal of Nutrition for the Elderly, 22(4), 55-68.

96 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

Contento, I., Balch, G.I., Bronner, Y.L., Lytle, L.A., Maloney, S.K., Olson, C.M. &Swandener, S.S. (1995). The effectiveness of nutrition education and implicationsfor nutrition education policy, programs, and research: A review of research. Jour-nal of Nutrition Education, 27, 339-346, 374-375.

Doshi, N.J., Hurley, R.S., Garrison, M.E., Stombaugh, I.S., Rebovich, E.J., Wodarski,L.A. & Farris, L. (1994). Effectiveness of a nutrition education and physical fitnesstraining program in lowering lipid levels in the black elderly. Journal of Nutritionfor the Elderly, 13(3), 23-33.

Elshaw, E.B., Young, E.A., Saunders, M.J., McGurn, W.C. & Lopez, L.C. (1994). Uti-lizing a 24-hour dietary recall and culturally specific diabetes education in MexicanAmericans with diabetes. The Diabetes Educator, 20, 228-235.

Hahn, J.M. & Gordon, D.H. (1998). “Learn, Taste, and Share”: A diabetes nutrition ed-ucation program developed, marketed, and presented by the community. The Dia-betes Educator, 24, 153-161.

Hermann, J., Brown, B. & Heintz, S. (2000). Impact of a nutrition promotion programon dietary behaviors, dietary intake, and health measures in adults over fifty-fiveyears of age. Journal of Nutrition for the Elderly, 19(3), 1-14.

Higgins, M. Meck & Clarke Barkley, M. (2003a). Evaluating outcomes and impact ofnutrition education programs designed for older adults. Journal of Nutrition for theElderly, 22(4), 69-81.

Higgins, M. Meck & Clarke Barkley, M. (2003b). Important nutrition education issuesand recommendations related to a review of the literature on older adults. Journal ofNutrition for the Elderly, 22(3), 65-78.

Higgins, M. Meck & Clarke Barkley, M. (2003c). Tailoring nutrition education inter-vention programs to meet needs and interests of older adults. Journal of Nutritionfor the Elderly, 23(1), 59-79.

Higgins, M. Meck & Clarke Barkley, M. (2003d). Concepts, theories and design com-ponents for nutrition education programs aimed at older adults. Journal of Nutritionfor the Elderly, 23(2), 57-75.

Higgins, M. Meck & Clarke Barkley, M. (2004). Improving effectiveness of nutritioneducation resources for older adults. Journal of Nutrition for the Elderly, 23(3),19-54.

Hughes, H.E., Love, A., Peabody, K. & Kardong-Edgren, S. (2001). Diabetes educa-tion programs for African American women: What works? The Diabetes Educator,27, 46-54.

Mathematica Policy Research Inc. (1996). Executive summary: Serving elders at risk;The Older Americans Act nutrition programs–National evaluation of the ElderlyNutrition Program, 1993-1995. U.S. Department of Health and Human Services,Washington, D.C. <www.aoa.dhhs.gov/aoa/nutreval/execsum.html> Date accessed:12-01-02.

Mayer, J.A., Jermanovich, A., Wright, B.L., Elder, J.P., Drew, J.A. & Williams, S.J.(1994). Changes in health behaviors of older adults: The San Diego Medicare pre-ventive health project. Preventive Medicine, 23, 127-133.

McClelland, J.W., Bearon, L.B., Fraser, A.M., Mustian, R.D. & Velazquez, S. (2001a).Reaching older adults with nutrition education: Lessons learned during the Partnersin Wellness pilot project. Journal of Nutrition for the Elderly, 21(2), 59-72.

Nutrition Education for Older Adults 97

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014

McClelland, J.W., Keenan, D. Palmer, Lewis, J., Foerster, S., Sugerman, S., Mara, P.,Wu, S., Lee, S., Keller, K., Hersey, J. & Lindquist, C. (2001b). Review of evalua-tion tools used to assess the impact of nutrition education on dietary intake and qual-ity, weight management practices, and physical activity of low-income audiences.Journal of Nutrition Education, 22(suppl.1), S35-S48.

McClelland, J.W., Bearon, L.B., Velazquez, S., Fraser, A.M., Maier, E.H. & Mustian,R.D. (2002). Profiling rural southern congregate nutrition site participants: Implica-tions for designing effective nutrition education programs. Journal of Nutrition forthe Elderly, 22(2), 57-70.

Millen, B.E., Ohls, J.C., Ponza, M. & McCool, A.C. (2002). The Elderly Nutrition Pro-gram: An effective national framework for preventive nutrition interventions. Jour-nal of the American Dietetic Association, 102, 234-240.

Mulcahy, K., Peeples, M., Tomky, D. & Weaver, T. (2000). National Diabetes Educa-tion Outcomes System: Application to practice. The Diabetes Educator, 26,957-964.

Quinn, M.T. & McNabb, W.L. (2001). Training lay health educators to conduct achurch-based weight-loss program for African American women. The Diabetes Ed-ucator, 27, 231-238.

Robison, F.F. (1993). A training and support group for elderly diabetics: Descriptionand evaluation. The Journal for Specialists in Group Work, 18(3), 127-136.

Rogers, C.C. (2002). America’s older population. Food Review, 25(2), 2-7.Sahyoun, N.R. (2002). Nutrition education for the healthy elderly population: Isn’t it

time? Journal of Nutrition Education and Behavior, 34(Supp.1), S42-S47.Serrano, E., Taylor, T., Kendall, P. & Anderson, J. (2000). Training program preparing

abuelas as nutrition educators. Journal of Nutrition Education, 32, 225-232.Sharpe, P.A., Vaca, V.L., Sargent, R.G., White, C., Gu, J. & Corwin, S.J. (1996). A nu-

trition education program for older adults at congregate nutrition sites. Journal ofNutrition for the Elderly, 16(2), 19-31.

Taylor, T., Serrano, E., Anderson, J. & Kendall, P. (2000). Knowledge, skills, and be-havior improvements of peer educators and low income Hispanic participants aftera Stage of Change-based bilingual nutrition education program. Journal of Commu-nity Health, 25(3), 241-262.

Walker, E.A. (1999). Characteristics of the adult learner. The Diabetes Educator,25(suppl.), 16-24.

Weddle, D.O., Wellman, N.S. & Bates, G.M. (1997). Incorporating nutrition screeninginto three Older Americans Act Elderly Nutrition Programs. Journal of Nutritionfor the Elderly, 17(1), 19-37.

Wheeler, M.L., Wylie-Rosett, J. & Pichert, J.W. (2001). Diabetes education research.Diabetes Care, 24, 421-422.

Williams, S.J., Drew, J., Wright, B., Seidman, R., McGann, M. & Boulan, T. (1996).Health promotion workshops for seniors: Predictors of attendance and behavioraloutcomes. Journal of Health Education, 27(1), 13-20.

98 JOURNAL OF NUTRITION FOR THE ELDERLY

Dow

nloa

ded

by [

Cas

e W

este

rn R

eser

ve U

nive

rsity

] at

15:

29 1

4 O

ctob

er 2

014