The Growing Demand of Nutrition Services and Nutrition

Professionals for Low-Income, Community-Dwelling, Older Adults

Taelin Lanier, Keene State College Dietetic Internship
July 2017

Keywords: older adults, nutrition professionals, registered dietitian, senior centers

Background
Introduction
The term nutrition professional encompasses a broad range of individuals interested in
learning, teaching, and applying nutrition concepts. Since there is no universal definition of this position,
it may include both the selfproclaimed and formally educated. Nutrition professionals may be thought
of by the public as nurses, doctors, personal trainers, chefs, athletes, models, bloggers, nutritionists and
Registered Dietitian Nutritionists (RDN). It is important to note that RDNs have received the highest level
of educational preparation in nutrition and are uniquely qualified to administer high quality nutrition
care.1 In most states, only a practitioner with the RDN credential is legally qualified to call themselves a
nutritionist.2 Their rigorous academic courses and breadth and depth of hands-on experience make them
the most apt at managing complex nutrition-related problems. 1
Nutrition services are provided by various organizations and institutions in effective manners. 3
They offer services such as increased access to food, nutrition screening, education, and care. Many
organizations that offer nutrition services do not employ RNDs. Nationally, the federal government
administers the majority of nutrition services through programs such as the Supplemental Nutrition and
Food Program (SNAP), Womans Infants and Children Nutrition (WIC), Child and Adults Care Food
Program (CACFP), and the Older Americans Act Nutrition Program (OAA), the largest nutrition program
for seniors.4,5 These programs are targeted to our most vulnerable populations who would otherwise face
health complications as a result of inadequate nutrition. Low income pregnant and nursing woman and
children, racial and ethnic minorities, those facing physical and mental disabilities, and adults ages 65-
years and older are all considered vulnerable. 6
The demand for comprehensive nutrition services are rising with a growing populace. With older
adults being the quickest growing demographic, special attention should be on senior wellness. It is
estimated that by 2030, the senior population will grow from 40 to 91 million. This exponential growth
has been coined the Silver Tsunami. 7 The impact of this growth is significant. As adults age, they face
obstacles that place them at high nutrition risk, such as decreased appetite, limited mobility, and fixed
income.8 Poor nutrition decreases quality of life, and independence. Seniors who cannot maintain this

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independence have more hospital visits and lengthier hospital stays- placing them at risk of
institutionalization.9 About 93% of non-institutionalized people rely on federal aid such as Medicaid. Yet
Medicaid only covers 100 days of long-term care. 10 A loss of this independence and limited medical
coverage will have dramatic effects on the nations health care system 11 Nutrition services have been
shown to slow this unfortunate transition and RDNs who focus on prevention are able to reduce health
care expenditures.12,13 Decreasing our community-dwelling seniors need for care facilities can play a vital
role in not only senior wellness but also long-term economy.

Since RDNs can provide the highest level of nutrition care for this population, their inclusion in
nutrition services is imperative. The purpose of this paper is to assess the demand for continued
federally funded nutrition services and the inclusion of RDNs in those services for low-income,
community-dwelling, seniors.

The Silver Tsunami

Healthy living is essential to ones wellbeing, and nutrition is a core health-concept. In older
adults, limited food intake, poor quality diet, and chronic diseases can rapidly decline health, placing
them at risk of costly complications.7 One of the greatest complications is malnutrition. Malnutrition is a
result of undernutrition in calories, protein and micronutrients and leads to muscle wasting, fat loss, and
poor function.9 It contributes to decreased quality of life, and increases risk of infection, falls, food-borne
illness, hospital remittance, and extended hospital length of stay. 14 It also exacerbates chronic conditions
such as congestive heart failure, kidney disease, osteoporosis, and cancer. Chronic diseases,
polypharmacy, mental decline and illness, living alone, and food insecurity further exacerbate
complications, completing the pernicious cycle. In America, malnutrition is astonishingly prevalent with a
literature review of the Mini Nutritional Assessment showing between 2-38% of institutionalized patients
alone.14 Disease-associated malnutrition in older adults is estimated to cost the US $51.3 billion
annually.15 This places a financial burden on both the patient and the nation. Early identification of
undernutrition using nutrition screening tools can slow down the diagnosis of malnutrition by providing
opportunities for early intervention.14 In the U.S., dietitians use validated screening tools verified by the
Academy and the American Society for Parenteral and Enteral Nutrition to identify and document
malnutrition in routine clinical settings.9 Currently, the literature is being reviewed on best practices for
catching this in community dwelling seniors. 14
With fixed incomes and increased health costs, many seniors face poverty. The federal poverty
level was created in 1964 as a one size fits all number that does not account for regional cost of living
differences. UCLAs Center for Health Policy Research developed a better measurement that uses region

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specific data to calculate basic needs. This measurement is called the Elder Index.7 The current federal
poverty level is set at $931/month or $11,170/year as recommended income for average Americans for
food, housing, healthcare, and transportation. Today, this is not even enough for rent alone. 16 Senior
poverty is one of the main reasons nutrition services need to remain bountiful, adequately staffed, and
increasingly funded in the years moving forward.

Nutrition Services
Overview
The bipartisan Older Americans Act of 1965 is administered through Agency for Community
Living division of the U.S. Department of Health and Human Services. Title III State and Community
Programs on Aging receive the largest part of OAA funding (71% or 833 million for FY 2017). 4,5 Programs
include nutrition, supportive services, family caregivers, and health promotion activities. The main
nutrition services are home-delivered meals, often referred to as Meals on Wheels (MOW), and
congregate meals and are in all 50 states and US territories. Its highest reach was in 2011 with 25.4
million people served. Most recent data shows a low of only 2.4 million people served. 17 Programs such
as Commodity Supplemental Foods Program (CSFP) and senior farmers markets are also making its way
throughout the country, however its nutritional impact is not yet known. 11
Program funds are allocated to states with demonstrated need. From there, 56 state agencies
distribute funds to over 200 tribal organizations, two native Hawaiian organizations, more than 600 area
agencies on aging and 20,000 local service providers. 18 Several studies have demonstrated the
association between nutrition-based programs and positive health outcomes in community residing
seniors.3 This ranges from nutrition screenings, food services, education intervention, and food tastings
and demos.3, 10, 12, 19-22 Organizations then carry out the work through senior volunteers and paid
employees at community centers, schools, churches, or senior housing complexes. 4 That being said,
nutrition services offer more than meals to vulnerable people, they offer opportunities for active older
adults to contribute to the local economy, engage in social interactions, and give back to their
community. Over 1 million adults ages 65 and older have been employed through this act. 4

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Nutrition Problems Are National Problems
As shown in the image above, funding for senior-focused nutrition services have not kept pace
with population growth. The impact of limited access to adequate and comprehensive care is a costly
one. Nutrition services have the ability to both help improve nutritional and save federal dollars. In a
survey, 82% of seniors were reported having unhealthy diets. 10 Given that home-delivered and
congregate meals provide 1/3 of all essential nutrients, it often the most nutrient dense meal they
consume.17 The problem of unhealthy diets is significant. Lack of funding for such programs can place a
strain on the economy when viewed from a long term perspective. As health declines, many are forced
to move into long-term care facilities where expenses escalate to approximately $88,000 per year for a
private room in a nursing home.23 This equates to a years-worth of meals for 52 seniors. Given the high
reliance of federal aid, a transition into long-term care can increase Medicare expenses. 10 It is estimated
that for every one person Medicare covers in a nursing home, three adults can be assisted in their own
home.23 Similarly, Brown University found that states who invested in community services such as home-
delivered meals, had fewer low care residents in nursing home, that is, residents with low levels of
acuity.23 This saves federal dollars. Medicare and Medicaid make up the largest portion of overlay
expenses, and in 2010 the country spent $136 billion in Medicare for long-term care alone. This is an
unnecessarily high expense given the preventative solutions that exist.
Furthermore, the imperative programs that many seniors rely on for health and survival have
received funding cuts or have been eliminated completely. In May 2017, the executive branch cut
Medicaid by $62 billion and eliminated the State Health Insurance Assistance Program. 24 OAA is also at

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risk since funding has remained stagnant over the years. For FY12, OAA received $1.913 billion.4 In 2014,
they received $1.88 billion- only a .04% increase from 2004. 23 A review of the OAA by AARP states that,
if the OAA programs had kept up with inflation over the past decade, funding would have been $2.23
billion in FY14 just to maintain the same buying power as in FY04. Although its 2016 reauthorization was
unanimous, funding for fiscal year 2018 was approved for only $1.9 billion- a decrease of 135 million
from 2017.25 In 2010, 3 million were served by these programs on daily basis and 8 million on a less-
than-regular basis. [23] The 2018 budget covers only 2.3 million seniors. At this rate, funding is unable to
keep up with inflation rates and the growing population. 23 As our country ages and their resources
dwindle, the nation carries an increasing heavier weight. Inadequate resources place pressure on
infrastructure, housing, transportation, and healthcare. 7 We have the opportunity to plan for this shift
now.

The Demand of Dietitians

Role of an RDN
Dietitians play important roles in community sites. Using the Nutrition Care Process, a frame
work which provides RDNs with a, systematic decision-making/problem-solving method to manage
nutrition care activities in multiple practice environments they can assess the health of their clients at a
community level and identify gaps in their nutrition status and knowledge. 26 Using a high level of
awareness to various community resources and programs, they select interventions to meet the clients
needs and connect them to adequate services. They are qualified to conduct personalized one-on-one
nutrition counseling and in-home nutrition assessments. 13 Community RDNs serve both individuals and
groups. The Academy of Nutrition and Dietetics (Academy) recommends a staffing ratio of one RDN for
every 50,000 people yielding a demanding 113% increase in the work force. 13 High demand of RDNs with
an increasing senior population suggests dietitian services will be significantly needed in senior wellness.
Few studies have measured the effectiveness of RDNs in nutrition services of low-income
community-dwelling seniors. The studies that have, found dietary treatments to be more promising
when administered by RDNs compared to other health professionals. 21, 27 Endevelt states that this holds
especially true for serving populations that face chronic disease such as diabetes and kidneys disease.
While more research is needed, a short review of the current literature describes the need for nutrition
services in senior wellness settings. Dietitians are equipped to lead the those services and offer
interventions that will address complex issues such as malnutrition and help to improve overall health
among seniors.
To assess if a nutrition education intervention aimed at caregivers could affect the risk of
malnutrition in seniors ages 65 and older, Barres-Fernandez et al. conducted a randomized controlled

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trial.19 Nurses with previous exposure to formal nutrition education were trained to give a one-hour
nutrition education session. Topics included general information of food, macronutrients and
micronutrients, how to design a healthy diet, dietary adaptation to address common nutrition problems
and cooking techniques. Patient-oriented objectives were established between caregivers and nurses. To
assess nutritional status over six months, the following values were monitored: results from the Mini
Nutritional Assessment (MNA), anthropometric measurements, biochemical markers, consumption of
food, degree of dependency, cognitive function and mood. Results showed a significant increase in
consumption of protein, egg, folate, vitamin E, and polyunsaturated fats compared to the control. The
intervention also significantly improved MNA scores at 12 months by 27% compared to 0% in the
control. Only 9% of the intervention group were assessed as malnourished compared to 22.6% of the
control group. Researchers concluded that educating caregivers may be effective in reducing risk of
malnutrition in vulnerable seniors by improving dietary habits and risk of malnutrition. 19 This type of
intervention provides an example of the work that RDNs are qualified to lead. Having an RDN carry out a
similar program would save money and time on trainings given the level of nutrition education that an
RDN must possess prior to credentialing. Interventions led by RDNs can be personalized to the patient.
The study mentioned a limitation using biochemical markers such as albumin. This is an old standard that
many health care professional continue to use due to limited or outdated training in medical nutrition
therapy. Since dietitians complete continuous educational credits to obtain their credentials, they remain
up to date on current nutrition tools and research.
A randomized control trial in a Canadian senior center compared changes in nutrition knowledge
and risk-behavior of 44 older adults after nutrition education interventions following a nutrition-risk
screening. [9] Seniors were randomly assigned to one of two interventions: A) received a personalized
letter and nutrition education booklet or B) a personalized letter. Dietitians crafted the personalized
letters that included positive reinforcement for healthy eating and obtained a generic educational packet
called Food for Eating Well. The packet was created to accompany the screening tool used for nutrition
risk assessments. Outcomes revealed that group A had significantly greater gains in knowledge points
from pre to post-test then group B. While those in group A did improve nutritional risk behavior scores
more than group B, this was not significant. The researchers concluded that screenings raise awareness
of behaviors and may serve as a starting point for implementing education. Dietitians prove to be
valuable in this model. Simple educational tools like letters and written standardized nutrition materials
may be useful for initiating the process of change. Administration of nutrition materials promptly after
screening may reinforce corrective behaviors for identified risks. Thus RDNs have an opportunity to take

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advantage of this intervention. The researchers also mentioned that many seniors may have not been
ready to make a change. Here, the RDN can work with patients to assess readiness and use motivational
interviewing to help overcome barriers to change and begin making healthier choices.
A partially randomized clinical trial studied whether RDN-led nutrition interventions would result
in different outcomes compared to standard physician care among community-dwelling seniors at
nutritional risk.27 Sixty-eight seniors were screened for nutrition risk using the Mini Nutritional
Assessment and assigned to either the dietary intensive treatment led by the RDN (DIT) or the physician
intervention (MT). Fifty-nine seniors were in a control group and received no intervention. Those in DIT
had a total of four RDN visits which used a validated protocol and clinical judgement to assess and
diagnose nutrition problems, select an appropriate intervention, and monitor and evaluate the change in
dietary habits overtime. The MT group received standard physician care which did not include nutrition
focused intervention but did include a senior nutrition booklet. The researchers found that there was a
significant improvement in depression scores and cognitive function scores of the DIT group. They also
discovered that seniors in the DIT group increased their intake of b-vitamins, protein, and carbohydrate
significantly compared to the MT group. While their intake of zinc and iron also increased, these values
were not significant. In addition to health improvements, there was a lower cost of primary care
physician appointments for DIT intervention than the MT intervention. Researchers concluded that
intensive dietary interventions led by RDNs deliver significant improvements in mental status, dietary
habits, and health care economy. This study demonstrates the utility of dietitians in nutrition service
settings. Often times in home care programs such as MOW, a nutrition risk screen is conducted. Having
RDNs on staff to expand on this work would improve the lives of the recipients as well as decrease health
care costs.
Results from a six-week pilot study in Canada evaluated whether using the Elderly Nutrition
Screening Tool (ENS) was a reliable tool for older adult volunteers on home-bound clients at risk of
malnutrition.21 The intervention included appropriately screening nutrition risk screening, delivering
education, selecting correct interventions, and evaluating subjects. Implementation of the intervention
by senior pairs were compared to a pair of one older volunteer and one RDN. Volunteers were trained by
RDNs in two three-hour sessions on how to administer ENS, educate clients on healthy eating, select
appropriate interventions addressing nutrition risk needs and following up. Results indicated that test
subjects assigned to volunteers did not feel significantly different about their care than those assigned to
an RDN. However, 27% of nutrition screenings by the volunteer pairs were false positives and 13% were
false negatives. This raises concerns since false negatives result in excess use of resources and false
negatives place our elderly clients at greater risk of unrecognized malnutrition. Moreover, 73% of

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volunteers expressed low comfort levels with selecting nutrition interventions without an RDN present.
Similarly, 66% of case managers (those who implemented the intervention selected) felt uncomfortable
with sole volunteer intervention selections. The researchers concluded that older adult volunteers when
trained by an RDN can reliably administer a nutrition screening tool to home-bound seniors at nutrition
risk. However, intervention selection should be left to the RDN. Clearly, dietitians play an important role
in training volunteers in a consistent and reliable manner to carry out complex screenings. None-the-
less, they should remain integrated in the screening as well as interventions to lessen false responses
and select optimal nutrition interventions. They can also contribute to the strengthening processes by
monitoring health outcomes for longer durations and evaluating program outcomes.
As described previously, the nutrition systems in place face many obstacles such as securing
additional funding. Using various case studies to examine methods of overcoming barriers the Riverside
County Foundation on Aging identified additional problems nutrition programs commonly face. 28 They
include lack of or non-standardized screening for nutritional risk, barriers to participation, and culturally
sensitive nutrition education. They found that to overcome these barriers organization included
expanding transportation accesses, changing the image of nutrition programs, using voucher programs,
implementing validated behavior change and adult learning theories into lesson plans, and expanding
partnerships. Dietitians can conduct similar analysis at their local nutrition program sites to identify and
eliminate relevant barriers.28

Local Examples of Application

One prime example of RDN expansion in nutrition services on a local level is demonstrated by
Community Action Programs of Belknap and Merrimack Counties Incorporated (CAP). Covering two
counties, CAP served 2,544 people with MOW and CM programs from January to June of 2017. 29
Currently they employ 100 people and have 360 volunteers given 24,547 hours of their time. Many of
these paid and in-kind work is completed by adults 60 and older. Similar to many other nutrition service
agencies, they do not have an RDN on staff. Having just a part-time dietitian offers substantial benefits to
the program and the programs clients. The breadth and depth of RDN knowledge and the large scope of
practice make them an asset for filling program gaps and improving senior quality of life. This includes
responsibilities such as grant writing, nutrition screening for high risk patients, one-on-one client
counseling and specific nutrition interventions, education, collaboration with physicians and other health
care professionals regarding patient care, evaluating effectiveness of programs, collecting and analyzing
surveys, assisting the kitchen director with menu development and recipe modification, and advocating

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for seniors services at state and federal levels. 13 Like many state agencies, funding is a barrier in further
program development.
To begin making moves in addressing some of these needs, a collaborative agreement between CAP
and Keene State College Dietetic Interns has begun. As required by the Accreditation Council for
Education in Nutrition and Dietetics, interns of this program must complete at least 1200 hours of
supervised practice. For Keene State students, several hundreds of these hours are community-based
nutrition endeavors. By working with community organizations, local agencies, and other dietitians, they
identity and fulfill the nutrition needs of their clients and partnerships. This results in an enriching
hands-on experience and examples of potential work as RDNS. Under the supervision of dietetic
internship staff, who are Registered Dietitians and CAP staff, interns can provide nutrition education and
perform public health activities as defined by the AND: Standards of Practice Standards of Professional
Performance for Registered Dietitian Nutritionists in Public Health and Community Nutrition. Examples
include the following.13
Help plan and evaluate public health and community nutrition programs
Conduct research and generate program policies
Provide Kitchen Coordinators with nutrition expertise in diet modification and nutrient analysis
Administer nutrition education training to groups and individuals
Advocate for changes in regulations related to nutrition at a state level
Conduct community needs assessments and help to coordinate nutrition interventions
Collaborate with interdisciplinary teams and community professionals
Identify referrals and resources as needed
Assist with grant writing and research
Create nutrition education display boards and host food tastings
While this is an innovative and useful partnership, it is limited by time constraints, efficiency and
liability. Interns are only available for a certain number of hours per season and on certain days of the
week. Such a short timeline restricts the amount of contributions they can make and the depth at with
they can be involved. Moreover, as each new intern begins their rotation, they complete a training
course- an expense to CAP. They are also limited by geographic region and cannot meet all of the needs
of the nine congregate meal sites that CAP needs coverage for. Given the large reach of the community,
intern responsibilities can be maintained even with the addition of an employed RDN. In, fact the hiring
of an RDN would be significantly useful in addition to hosting interns. For example, as stated within their
ethical scope of practice interns have limited abilities to engage with participants in their plan of care. 26
An identified need of CAP is in-home nutrition education, counseling, and food evaluation. Interns do
not have this opportunity because without an RDN present, it would be out of the interns individual
scope of practice. The addition of a dietitian allows interns to work under the supervision of an RDN.

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Conclusion
To summarize, our senior population is growing at alarming rates and their access to
comprehensive resources are dwindling. Nutrition services are faced with budget cuts and are
inadequately staffed. The demand for RDN expertise and training is thus increasing. The scope of
practice and services an RDN can offer seniors have been shown to increase nutrition knowledge, health
status, dietary behaviors, and decrease risk of malnutrition. Given the impact RDNs can have on senior
wellness, our most vulnerable adults may maintain independence longer and decrease incidences of
hospitalization. If agencies that provide nutrition services are not currently able to hire RDNs they can
begin collaborating with dietetic internships to begin implementing useful services that a competent
entry-level dietitian could perform while also helping the agency seek funding for RDN positions to meet
all of the agencys nutrition service needs

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