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Background Sodium, potassium, and the balance between these 2 nutrients are associated with hypertension and cardiovascular disease, and prevalence of these conditions increases with age. However, limited information is available on these intakes among older adults. Objective Our aim was to explore the socioeconomic and health factors associated with usual sodium and potassium intakes and the sodium to potassium (Na:K) ratio of older adults. Design This was a cross-sectional, secondary analysis of the 2011-2012, 2013-2014, and 2015-2016 National Health and Nutrition Examination Survey. Participants/setting This study included the data of 5,104 adults 50 years and older, with at least one reliable 24-hour dietary recall and an estimated glomerular filtration rate ≥60 mL/min/1.73 m2. Main outcome measures Sodium and potassium intake, as absolute intake, density (per 1,000 kcal) and ratio of Na:K intake. Statistical analyses We used t tests and χ2 tests to examine significant differences in intakes on a given day by characteristics. Linear and logistic regression models were used to assess associations of socioeconomic and health characteristics with usual sodium and potassium intakes, determined using the National Cancer Institute method. Results Only 26.2% of participants consumed Conclusions Participants consumed too much sodium and not enough potassium, based on current recommendations. A higher Na:K ratio was significantly associated with established risk factors for cardiovascular disease. The study findings suggest that more research on cardiovascular health should include both sodium and potassium, as well as balance between these nutrients.

Objectives:(1) To examine total quality of foods consumed on the day a home-delivered meal (HDM) of the Older Americans Act Nutrition Program (OAANSP) was served, and when a HDM was not served; and (2) to estimate proportion of HDM participants and non-participants meeting the daily average recommendations for guidance-based foods and nutrients.Design:Cross-sectional study.Setting:Data were obtained from the national 2015–2017 Outcomes Evaluation Study of HDM participants in the USA.Participants:Adults aged 67 years and older (n 1227), 620 HDM recipients and 607 matching non-participants examined in three groups: (1) meal recipients who received a HDM on the day of the 24-h dietary recall; (2) no-meal recipients who did not receive a HDM on the day of the recall and (3) matching HDM non-participants.Results:Healthy Eating Index (HEI)-2010 scores of HDM participants were significantly lower on the day the meal was not received compared with when a meal was received (52·5 v. 63·4, P < 0·0001). There was no significant difference in the total HEI-2010 scores of HDM meal recipients and HDM non-participants. Despite the meal, less than 20 % of HDM participants and non-participants met the 2010-Diet Guidelines for Americans recommended average daily intake for fruit, vegetables, dairy, protein foods and solid fats.Conclusion:HDM participants’ diet quality is poorer when they do not receive a meal putting them at increased risk of malnutrition. Expanding the OAANSP to offer meals on weekends and/or to include more than one meal/d is recommended to improve the diet of this vulnerable population.

This cross-sectional study examined how the COVID-19 pandemic impacted the food practices, physical activity (PA) levels, and stress levels of aging adults ages 40 years and older from seven states. It also explored to what extent the COVID-19 outcomes were affected by the social determinants of health (SDH).Respondents (Respondents were mostly White (75.9%), married (58.7%), age 60 years and older (61.8%), with a high school education or higher (97.4%). Most of the respondents (85.8%) live in areas that respondents perceived as supportive of health and well-being opportunities for older adults. Nearly one-half of the respondents reported maintaining their pre-pandemic grocery shopping/food buying frequency (44.7%) and PA levels (48.1%). However, 48.6% reported being "somewhat or very stressed" due to the pandemic. Findings revealed that the COVID-19 impacts on food-buying, PA levels, and stress levels were significantly influenced by age, gender, race, education, location, community, nutritional risk, quality of life, food security, and income (These findings provide valuable information as we continue to confront the impact the COVID-19 pandemic has had on the health and well-being of aging adults. We can use this information to inform future public health programming interventions and opportunities.

Objectives: To examine: (1) diet quality of older adults, using the Healthy Eating Index 2010 (HEI-2010) and self-rated diet quality, (2) characteristics associated with reported awareness and use of nutrition information and (3) factors associated with HEI score and self-rated diet quality. Design: Cross-sectional study. Based on Day 1 and/or Day 2 dietary recalls, the Per-Person method was used to estimate HEI-2010 component and total scores. T-tests and ANOVA were used to compare means. Logistic and linear regressions were used to test for associations with diet quality, controlling for potential confounders. Setting: National Health and Nutrition Examination Survey, 2009–2014. Participants: Three thousand and fifty-six adults, aged 60 years and older, who completed at least one 24-h recall and answered questions on awareness and use of nutrition information. Results: Mean HEI score for men was significantly lower than for women (56·4 ± 0·6 v. 60·2 ± 0·6, P < 0·0001). Compared with men, more women were aware of (44·8 % v. 33·7 %, P < 0·05) and used (13·7 % v. 5·9 %, P < 0·05) nutrition information. In multivariable analyses, awareness and use of nutrition information were significant predictors of both HEI and self-rated diet quality for both women and men. Groups with lower nutrition awareness included men, non-Whites, participants in nutrition assistance programmes and those with lower education and socio-economic status. Conclusions: Nutrition awareness and use of nutrition information are associated with diet quality in adults 60 years and older. Gaps in awareness of dietary guidelines in certain segments of the older adult population suggest that targeted education may improve diet quality for these groups.

Improving care for the older population is a growing clinical need in the United States. Ageism and other attitudes of healthcare professionals can negatively impact care for older adults. This study investigated healthcare professionals’ (N = 140) views towards aging and characterized a confluence of factors influencing ageism perspectives in healthcare workers using path analysis models. These models proposed relationships between aging anxiety, expectations regarding aging, age, ageism, and knowledge. Aging anxiety had a less critical role in the final model than hypothesized and influenced ageism in healthcare workers through its negative effect (β = −0.27) on expectations regarding aging. In contrast, aging knowledge (β = −0.23), age (β = −0.27), and expectations regarding aging (β = −0.48) directly and inversely influenced ageism. Increased knowledge about the aging process could lower ageism amongst healthcare professionals and improve care for older adults. The results put forth in this study help to characterize and understand healthcare workers’ complex views towards the aging population they often encounter. Moreover, these results highlight the need and utility of leveraging practitioner education for combating ageism in the clinical setting.

Economic food insecurity tools are used to detect need for assistance in the general population. However, in older adults, food insecurity can also be due to factors other than economic, such as physical inability to shop or cook.We determined: 1) the proportion of older adults in the United States who experience physical and/or economic food insecurity; 2) differences in characteristics, diet quality, chronic conditions, and depression by economic and/or physical food insecurity; and 3) the relation of physical and economic food insecurity with diet quality and with depression.Data from adults aged ≥60 y of the NHANES (2013-2018) were used. Groups were created based on economic food security [measured using the USDA's Household Food Security Survey Module (HFSSM)] and physical food security (measured using questions evaluating ability to shop and cook). Depression, Healthy Eating Index (HEI-2015) score, and socioeconomic characteristics were compared by food security group. Rao-Scott χ2 tests were used to test for significant differences between categorical variables, and t tests for continuous variables. Associations between food security status, HEI-2015, and depression score were examined using linear regression analysis.One-quarter (25.0%) of older adults had physical difficulty accessing food but were not living in economically food insecure households. Those who lived in economically food insecure households and also had physical difficulties accessing food had the lowest mean HEI-2015 score (51.7) and highest mean depression score (6.9); both were significantly lower than the mean scores of those who lived in food secure households (HEI-2015 = 57.3; depression = 2.1; P 0.01).Considering physical ability to shop for and prepare food when measuring food insecurity in older adults can help identify those who might need dietary and mental health support the most, and those who need food assistance but would otherwise be missed if only measuring economic access.

BACKGROUND Recent studies have shown that children are able to accurately describe their own experiences of food insecurity; however, few studies have quantified this experience. OBJECTIVES We aimed to develop and validate a child food security scale to be used in Arabic-speaking countries. METHODS As part of the Healthy Kitchens Healthy Children study on food security and nutrition in schools, 14 questions were administered to 5-15-y-old children (n = 1433) attending 4 UN Relief and Works Agency for Palestine refugees schools. We used statistical methods based on Item Response Theory to assess the internal validity of a proposed food security scale using these items. Further validation of the scale was conducted by examining associations with sociodemographic, economic, household food security, and diet diversity variables through logistic regression models adjusted for age, sex, and school of the children. RESULTS A total of 1287 children (89.8%) provided complete responses to the questionnaire. Four items were dropped from the scale because of high infit statistics (>1.3) and high residual correlation with other items. The resulting 10-item scale had acceptable reliability (Cronbach α coefficient = 0.89). Children who reported food insecurity were more likely to be from food-insecure households (OR: 2.3; P

Objectives:To examine: (1) diet quality of older adults, using the Healthy Eating Index 2010 (HEI-2010) and self-rated diet quality, (2) characteristics associated with reported awareness and use of nutrition information and (3) factors associated with HEI score and self-rated diet quality.Design:Cross-sectional study. Based on Day 1 and/or Day 2 dietary recalls, the Per-Person method was used to estimate HEI-2010 component and total scores.T-tests and ANOVA were used to compare means. Logistic and linear regressions were used to test for associations with diet quality, controlling for potential confounders.Setting:National Health and Nutrition Examination Survey, 2009–2014.Participants:Three thousand and fifty-six adults, aged 60 years and older, who completed at least one 24-h recall and answered questions on awareness and use of nutrition information.Results:Mean HEI score for men was significantly lower than for women (56·4 ± 0·6v. 60·2 ± 0·6,P< 0·0001). Compared with men, more women were aware of (44·8 %v. 33·7 %,P< 0·05) and used (13·7 %v. 5·9 %,P< 0·05) nutrition information. In multivariable analyses, awareness and use of nutrition information were significant predictors of both HEI and self-rated diet quality for both women and men. Groups with lower nutrition awareness included men, non-Whites, participants in nutrition assistance programmes and those with lower education and socio-economic status.Conclusions:Nutrition awareness and use of nutrition information are associated with diet quality in adults 60 years and older. Gaps in awareness of dietary guidelines in certain segments of the older adult population suggest that targeted education may improve diet quality for these groups.

Background School feeding programs have the potential to supply children with healthy school food, alleviate short-term hunger, and improve children's educational outcomes. Objectives We linked community kitchens to a subsidized school snack intervention and assessed the impact of this intervention on nutritional (diet diversity, hemoglobin, and anthropometry) and educational (attendance and academic performance) outcomes of Palestinian refugee schoolchildren. Methods We collected data from 1362 students (aged 5–15 y) and their parents at baseline, and at an 8-mo follow-up in 2 control and 2 intervention schools. We conducted linear, logistic, and negative binomial regression analyses to assess changes in outcomes of children participating in the intervention schools compared with children in control schools (intention-to-treat). We also assessed the impact of the snack intervention in children who participated ≥50% of the time (HP, high-participation) compared with those who participated, The “Healthy Kitchens, Healthy Children” home-grown school feeding model was associated with a modest but significant improvement in diet diversity and school attendance of Palestinian refugee schoolchildren.

Background The Food Insecurity Experience Scale (FIES) is a UN FAO Voices of the Hungry (FAO-VoH) experiential metric of food insecurity (FI). It was pilot tested in some countries but not in Arab speaking ones and validated using global data. Yet, its psychometric properties may vary in the League of Arab States (LAS) due to cultural and linguistic differences. Objectives 1) assess the validity of FIES for use in the LAS region, 2) determine the prevalence of FI, by gender, age group, and the human development index (HDI), and 3) examine sociodemographic characteristics of severe FI individuals. Methods To assess the psychometric properties of FIES, Rasch modeling was applied to the 2014–2015 Gallop World Poll (GWP) in the LAS. Prevalence and characteristics of severely FI individuals were assessed using the 2014–2017 GWP data of 62,261 respondents. Results Overall, FIES met the Rasch model assumptions of equal discrimination and conditional independence. Infit statistics for FIES items, in most LAS countries, were 1.3. Outfit statistics >2.0, indicating erratic responses, were noted in 26% of the LAS countries. Significant correlations were found (≥0.4) between items in Algeria, Tunisia, and Lebanon. The overall prevalence of severe FI was 15.7%. At highest risk were those aged ≥50 y compared with younger adults (16.5% versus 15.5%, respectively, P

Functional limitations in homebound older adults may cause difficulties with obtaining and preparing adequate healthy food. Services exist to help with these difficulties, however, not all individuals who could benefit receive them. This secondary analysis of observational data, obtained via questionnaires from homebound, recently hospital discharged older adults (n = 566), aimed to identify the prevalence and correlates of unmet need for such services, and to examine the disagreement between self-reported need for a service and functional limitation that could be addressed by that service. One-fifth of respondents reported unmet need for vision services and oral health services, and one-tenth reported unmet need for transportation services and physical therapy. There was a significant association between reported need and functional limitation (p 0.001) for all services, except mental health and grocery delivery. However, for each service there were participants who under-reported need, compared with functional ability indicators. More research is required to determine the best methods for measuring these needs to ensure that nutritional vulnerability is detected and addressed in those returning from hospital.

Evenly distributing daily protein intake at meals has been suggested to improve muscle mass among older adults. The aim of this research is to evaluate protein intake and its distribution across three meal types (breakfast, lunch, and dinner). Nationally representative dietary intake data of adults aged 51 years and older who reported consuming breakfast, lunch, and dinner on the intake day from What We Eat in America, National Health and Nutrition Examination Survey (NHANES) 2011–2012, were analyzed. Total mean daily protein intake and protein intake per meal type were determined. The proportion of individuals consuming ≥25 g protein per meal type and across all three meal types was estimated. Of men and women aged 51 years and over, 64% and 71% consumed three meal types on the intake day, respectively. Men had significantly higher mean daily protein intake than women (84.4 ± 2.33 g vs. 60.9 ± 1.21 g, p

Recent studies show that child-specific instruments to assess food insecurity describe childhood food insecurity more accurately than parent reports. Whether this is true in the Middle Eastern cult...

Older adults are at higher risk of invasive listeriosis compared with the general population. Some foods are more likely than others to be contaminated with or to contain high levels of Listeria monocytogenes. The objectives of this study were to (i) determine dietary consumption patterns among older adults in the United States; (ii) evaluate sociodemographic and economic characteristics of older adults associated with each pattern; (iii) determine intake of foods associated with larger relative risk of listeriosis within these patterns; and (iv) rank these patterns based on risk. Data related to older adults (age 60 and older) participating in the cross-sectional National Health and Nutrition Examination Surveys (NHANES) 2009 to 2010, 2011 to 2012, and 2013 to 2014 (n = 4,967) were included in these analyses. Cluster analysis was used to define dietary patterns based on 24-h dietary recalls from day 1 and day 2. Mean intake of foods associated with higher risk of listeriosis was examined within each pattern, and analysis of variance with Dunnett's method of adjustment was used to evaluate significant differences in mean intake of foods. Patterns were ranked based on relative risk of listeriosis, using outbreak illness attribution data. Five distinct dietary patterns were identified. Patterns ranked at highest relative risk of listeriosis, based on U.S. outbreak illness attribution data, were characterized by relatively higher intakes of fruits, vegetables, and cheeses (∼13% respondents) or cereal, milk, and yogurt (∼14% respondents). Individuals consuming these dietary patterns differed in sex, race, food security, self-rated diet quality, and self-rated health. Cluster analysis, despite methodological limitations, provides new information on consumption, sociodemographic, and economic characteristics of subgroups within susceptible populations, which may be used to target educational messages. HIGHLIGHTS

BackgroundThe aim of this study is to investigate the potential impact of a community-based intervention - the Healthy Kitchens, Healthy Children (HKHC) intervention - on participating women’s household’s economics and food security status, decision making, mental health and social support.MethodsWe established two healthy kitchens in existing community-based organizations in Palestinian camps in Lebanon. These were set up as small business enterprises, using participatory approaches to develop recipes and train women in food preparation, food safety and entrepreneurship. We used a mixed-methods approach to assess the impact of participating in the program on women’s economic, food security, decision making, social and mental health outcomes. A questionnaire was administered to women at baseline and at an 8-month endpoint. The end line survey was complemented by a set of embedded open-ended questions.ResultsThirty-two Palestinian refugee women were employed within the kitchens on a rotating basis. Participating women had a 13% increase in household expenditure. This was translated into a significant increase in food (p p p ConclusionsThis model created a social enterprise using the concept of community kitchens linked to schools and allowed women to significantly contribute to household expenditure and improve their food security.

Objective:Decades of marginalization have led Palestinian refugees living in Lebanon to experience multigenerational poverty and food insecurity. The Healthy Kitchens, Healthy Children programme implemented and examined the impact of a two-pronged intervention that employed women through community kitchens to deliver a subsidized healthy daily school snack to elementary-school children in Palestinian refugee camps in Lebanon. We describe the rationale, study design, theorized impact pathways, and discuss lessons learned.Design:The programme was quasi-experimental. We conducted formative and process evaluation of both components of the intervention to elucidate the pathways to programme impact.Setting:Palestinian refugee camps in Lebanon.Participants:Thirty-three women participated in the kitchens and provided subsidized snacks to 714 children.Results:Snacks were healthy, traditional Palestinian recipes designed by women and a nutritionist. Participation fluctuated but eventually increased after modifying the meals to ensure acceptability by children. The main challenges to sustainability related to the need for subsidization of the meals and the lack of school policies around the regulation of sales of school food, which together led to fluctuations in programme participation.Conclusions:The study provides lessons learned on the potential of this model to improve the human capital of two generations of protracted refugees. The availability of schools as a constant market for these social enterprises offers an opportunity for sustainable livelihood generation and food security gains. Challenges to sustainability remain and could be addressed through social (subsidies to support the programme) and structural (policies to restrict unhealthy food sales) measures.

OBJECTIVES: This study aimed to investigate: 1) the diet quality of older adults, using the Healthy Eating Index 2015 (HEI-2015) and self-rated diet quality, 2) characteristics associated with reported awareness and use of nutrition information, 3) factors associated with HEI-2015 score and self-rated diet quality, including the relationship with awareness and use of nutrition information. METHODS: A cross-sectional analysis of 24-hour recall and questionnaire data from the National Health and Nutrition Examination Survey 2009–2014, including 4493 subjects, aged 60 years and older. The population ratio method was used in SAS 9.4 to calculate mean HEI scores. Data was stratified by gender, then t-tests and ANOVA were used to compare means and chi-squares were used to compare proportions. Logistic and linear regression were used to test for associations with diet quality, controlling for potential covariates. RESULTS: The mean total HEI score for men was significantly lower than for women (63.7 ± 0.8 vs. 66.6 ± 0.8 respectively, P

OBJECTIVES: This study aimed to measure the direct and indirect relationships between food insecurity (FI), dietary intake (DI), social relationships (SR), depressive symptoms (DS) and their impact on healthcare utilization (HU) in older adults receiving home-delivered meals (HDM) using data from the national 2015–17 Outcomes Evaluation Study. METHODS: The 2015–2017 Outcomes Evaluation Study is a multistage, clustered, longitudinal observational study of 641 older adults; 306 HDM recipients, and 335 matching controls. Study participants were homebound older adults aged 67 years and older. Measurements: Demographic, health-related, dietary and hospitalization data were obtained using a Client Outcomes Survey, 24-hour dietary recalls and Medicare files. Structural equation modeling was used to measure the direct and indirect relationships between FI, SR, DS, HU and DI (usual protein intake), estimated using the National Cancer Institute's statistical modeling method. RESULTS: HDM recipients’ mean usual protein intake (34.0 grams) was significantly higher than controls (31.8 grams), but both groups had mean usual protein intakes that were lower than recommendations. FI prevalence in HDM recipients and controls was 25.1% and 16.0%; respectively. Greater severity of FI was associated with lower usual protein intake in both groups. Receiving instrumental social support was directly associated with lesser severity of FI in HDM recipients, and higher FI was associated with more DS only in controls. Eating alone was associated with lower usual protein intake and greater hospitalizations in the controls. CONCLUSIONS: HDM recipients and controls may be at a high risk for protein insufficiency, further underscored by the high prevalence of FI. Received instrumental social support can play an important role among HDM recipients and controls, both vulnerable populations. Findings also highlight the need for validated tools to measure different aspects of social relationships in older adults. FUNDING SOURCES: No funding sources to declare.

OBJECTIVES: This research investigated the experience of household food insecurity among Syrian refugees resettled in the US using the lens of family resilience. The objectives were to understand how refugee families create resilience to food insecurity in the US, how they construct the meaning of food insecurity as a source of stress in comparison to other stressors, and what are the family's capabilities that have played a role in their efforts to reduce food insecurity. METHODS: This qualitative case study was conducted with 9 Syrian refugee families who lived in the Washington metropolitan area for 8 years or less. An Arabic semi-structured interview guide was developed. A maximum of three separate interviews were conducted in each family, one with each of two adults (usually parents) and one with the child. Demographics, information about their network of family and friends in the US, and the Arab Family Food Security Scale were collected. Arabic data from 17 in-depth interviews were analyzed using the family adaptation and adjustment response model. RESULTS: All 9 families were using food assistance programs (SNAP and/or WIC), and 3 of them were food insecure at the time of the interviews. Although experiences of food insecurity varied between families and over time, most families reported greater food insecurity immediately after arriving in the US with food security improving as additional resources (e.g., SNAP) were accessed. However, being food insecure was not perceived as a stressor to most families because they had lived a difficult life in the country from which they escaped. Their major stressors were fear of losing their jobs and of being unable to pay their bills and rent. Each family had a unique capability, with their own combination of resources and strategies, for maintaining household income and food availability, but social networks consistently played an important role in families’ efforts to reduce food insecurity. CONCLUSIONS: Food insecurity was not perceived as a major stressor because families experienced a broad range of insecurities including finances, housing, and employment. The social network was one of the most important resources that supported families’ capabilities to improve their food status. FUNDING SOURCES: The research is partially funded by a University of South Carolina doctoral research award.

Objective: Limited research is available examining community-based social support programs (SSPs) for individuals with type 1 diabetes (T1DM). The purpose of this study was to describe SSPs characteristics and the perceived benefits and barriers to attendance from the perspective of SSPs leaders. Research Design and Methods: This study used a qualitative study design. In-depth interviews were conducted with SSPs leaders (n = 9) in the Washington D.C. metro area. Individuals were recruited from community- and college-based programs. Using content analysis, interviews were analyzed for key themes. Results: Programs served different populations, leading to different discussion such as college-based groups discussing alcohol use while community-based groups discussing issues with their child’s diabetes. SSPs leaders described informational support, emotional support, and peer networking as benefits of program attendance while logistics, stigma, and avoidance of diabetes as barriers to program attendance. Conclusions : Exploring the characteristics of SSPs is essential to understanding their utilization and role in self-management and empowering individuals with T1DM. SSPs offer many benefits, and SSP attendance should be encouraged.

The dose-response relationship between folate levels and cognitive impairment among individuals with vitamin B12 deficiency is an essential component of a risk-benefit analysis approach to regulatory and policy recommendations regarding folic acid fortification. Epidemiological studies provide data that are potentially useful for addressing this research question, but the lack of analysis and reporting of data in a manner suitable for dose-response purposes hinders the application of the traditional evidence synthesis process. This study aimed to estimate a quantitative dose-response relationship between folate exposure and the risk of cognitive impairment among older adults with vitamin B12 deficiency using "probabilistic meta-analysis," a novel approach for synthesizing data from observational studies. Second-order multistage regression was identified as the best-fit model for the association between the probability of cognitive impairment and serum folate levels based on data generated by randomly sampling probabilistic distributions with parameters estimated based on summarized information reported in relevant publications. The findings indicate a "J-shape" effect of serum folate levels on the occurrence of cognitive impairment. In particular, an excessive level of folate exposure is predicted to be associated with a higher risk of cognitive impairment, albeit with greater uncertainty than the association between low folate exposure and cognitive impairment. This study directly contributes to the development of a practical solution to synthesize observational evidence for dose-response assessment purposes, which will help strengthen future nutritional risk assessments for the purpose of informing decisions on nutrient fortification in food.

Older adults returning home from the hospital may encounter health issues that cause anxiety about their ability to obtain enough food. Home-delivered meal (HDM) programs support nutritional needs and improve food security of those who cannot provide for themselves. A study conducted in six states examined feelings of anxiety about getting enough food in older adults (aged 60 years and older), comparing three time points: prior to hospitalization, at hospitalization (n = 566) and after receiving HDMs for two months posthospitalization (n = 377). Food anxiety during hospitalization was significantly higher among Hispanic ethnicity, current and former smokers, diabetics, and those who eat alone or have difficulty shopping. Food anxiety was significantly lower from baseline to two months follow-up (P 0.0001), and participants showed improvements in certain coping strategies they used to get their meals. Indicators of food anxiety can help the health care system and community nutrition programs target those at highest risk of negative health outcomes.

Folate is a vitamin that plays a role as a cofactor and coenzyme in many essential reactions. These reactions are interrelated and any change in folate homeostasis could affect other reactions. With food fortified with folic acid, and use of multivitamin, unmetabolized folic acid (UMFA) has been detected in blood circulation, particularly among older adults. This has raised concern about the potential harmful effect of high folic acid intake and UMFA on health conditions such as cognitive dysfunction and cancer. To examine what is known about folate metabolism and the release of circulating UMFA, the Key Events Dose-Response Framework (KEDRF) was used to review each of the major key events, dose-response characteristics and homeostatic mechanisms of folate metabolism. The intestine, liver and kidneys each play essential roles in regulating body folate homeostasis. But the determining event in folate metabolism leading to the release of UMFA in circulation appears to be the saturation of dihydrofolate reductase in the liver. However, at each of the key events in folate metabolism, limited information is available on threshold, homeostatic regulation and intracellular effects of folic acid. More studies are needed to fill in the knowledge gaps for quantitatively characterizing the dose-effect relationship especially in light of the call for extending folate fortification to other foods.

Introduction Distributing daily protein intake evenly across meals (∼25–30g/meal) has been suggested to improve muscle mass. The aim of this research is to examine the association between grip strength, total protein intake and its distribution across day’s meals in older adults. Methods Nationally representative dietary intake data of adults aged 51 years and older (n = 4,123) who participated in What We Eat in America, NHANES 2011–2014 were analyzed. Protein intake per day and per eating occasion (breakfast, lunch, dinner, and snack) were determined. Combined grip strength was calculated and expressed in kilograms. Grip strength of individuals consuming ≥25g protein at 1 eating occasion was compared with those consuming same level of protein at 2 and 3 or more eating occasions. Grip strength of individuals in quartile 1 of daily protein intake was compared to those in the other quartiles. All associations were examined without and with adjustment for age, race/ethnicity, physical activity, health status, and smoking status. The comparison involving eating occasions and protein intake quartiles were further adjusted for daily protein intake and energy intake, respectively. Results Only 33% of men and 19% of women had protein intake of ≥25g at 2 or more eating occasions. These individuals also had higher grip strength and daily protein intake. Grip strength was positively associated with consumption of ≥25g protein at 2 eating occasions as compared to consumption of same level of protein at 1 eating occasion (p

The trend among older adults in the United States is to "age in place" instead of opting for institutionalization. To maintain older adults with chronic conditions in their homes and to improve health after hospitalization, comprehensive social, health, and nutrition services are essential. Quality of dietary intake is crucial and yet often underestimated. Calorie needs decrease with age while nutrient needs remain the same, even increasing for some nutrients. This poses difficulties for individuals with functional disabilities who are unable to shop and cook due to physical or mental limitations or on a limited budget. The Older American Act home-delivered meal (HDM) program offers at least 1 healthy meal per day, 5 or more days per week, and targets individuals homebound due to illness, disability, or social isolation and those with greatest economic or social need. This review summarizes the available literature on the relationship between HDM and health outcomes. The HDM program is difficult to evaluate because of the multifactorial effect on health status. However, national surveys and smaller studies show that it is well targeted, efficient, and well liked; provides quality food to needy individuals; and helps individuals remain living independently. Studies show that HDMs improve dietary intake, with greater health benefits when more meals reach the neediest individuals. HDMs also decrease institutionalization of older adults and resulting healthcare expenditures. However, funding has not kept up with increased demand for this program. More studies with improved designs may provide more information supporting the program's impact on nutrition status and decreased health expenditures.

Iraqi refugees in Lebanon are vulnerable to food insecurity because of their limited rights and fragile livelihoods. The objective of the present study was to assess household food insecurity among Iraqi refugees living in Lebanon, almost 10 years after the invasion of Iraq. A representative survey of 800 UN High Commissioner for Refugees-registered refugee households in Lebanon was conducted using multi-stage cluster random sampling. We measured food insecurity using a modified US Department of Agriculture household food security module. We collected data on household demographic, socio-economic, health, housing and dietary diversity status and analysed these factors by food security status. Hb level was measured in a subset of children below 5 years of age (n 85). Weighted data were used in univariate and multivariate analyses. Among the Iraqi refugee households surveyed (n 630), 20·1 % (95 % CI 17·3, 23·2) were found to be food secure, 35·5 % (95 % CI 32·0, 39·2) moderately food insecure and 44·4 % (95 % CI 40·8, 48·1) severely food insecure. Severe food insecurity was associated with the respondent's good self-reported health (OR 0·3, 95 % CI 0·2, 0·5), length of stay as a refugee (OR 1·1, 95 % CI 1·0, 1·2), very poor housing quality (OR 3·3, 95 % CI 1·6, 6·5) and the number of children in the household (OR 1·2, 95 % CI 1·0, 1·4), and resulted in poor dietary diversity (P

OBJECTIVES: 1) Determine dietary consumption patterns, among older adults in the United States; 2) Evaluate sociodemographic and economic characteristics associated with each pattern; 3) Determine intake of foods associated with larger relative risk of listeriosis within these patterns; and 4) Rank these patterns based on risk. METHODS: The study included older adults, age 60 and older, from What We Eat in America, National Health and Nutrition Examination Surveys 2009–2010, 2011–2012 and 2013–2014 (n = 4967). Cluster analysis based on day 1 24-hour dietary recalls was used to define dietary patterns. ANOVA with Dunnett's method of adjustment used to evaluate significant differences in mean intake of foods associated with higher risk of listeriosis within each pattern. Patterns were ranked based on relative risk of listeriosis using outbreak illness attribution and risk assessment data. RESULTS: Five distinct dietary patterns were identified -Vegetables, Fruits & Oils; Mixed Dishes; RTE (Ready-To-Eat) Cereal, Milk & Yogurt; Meat & Potatoes; and Cured Meats & Cheese. The patterns ranked at highest relative risk of listeriosis, based on 2013 outbreak illness attribution data, were (1) the Vegetables, Fruits & Oils, characterized by relatively higher intakes of fruits, vegetables, and vegetable oils (∼22% respondents), (2) the RTE (Ready-To-Eat) Cereal, Milk & Yogurt, with relatively higher intakes of cereal, milk, and yogurt (16% respondents); and, based on 2003 risk assessment data, (3) the Cured Meats & Cheese with relatively higher intakes of breads, cheese, and cured meats (∼9.6% respondents). Individuals consuming these dietary patterns differed in sex, race/ethnicity, food security, self-rated diet quality, and self-rated health. CONCLUSIONS: Cluster analysis, despite methodological limitations, provides new information on consumption, sociodemographic, and economic characteristics of subgroups within susceptible populations that can be used to target educational messages. FUNDING SOURCES: Agricultural Research Service, US Department of Agriculture; Food and Drug Administration.

OBJECTIVES: Background: Populations in the League of Arab States (LAS) are rapidly growing, along with increase in life expectancy and lower mortality rate, leading to a higher proportion of older adults. It is expected that the percentage of adults aged 60 and older is estimated to increase from 5.3% in 2005 to 18.1% in 2050. There are no studies that have focused on food insecurity (FI) in older adults in this region and gender differences. Women in the LAS tend to have lower educational attainment than men and are under- or un-employed, which might predispose them to higher risk for FI. METHODS: Data on 9156 adults, 50 years and over [5193 men and 3963 women], from the 2014, 2015, and 2016 Gallup World Poll [GWP] were analyzed. Food security status of participants was obtained using the Food Insecurity Experience Scale (FIES). Using country-specific thresholds, participants were classified into food secure/moderately FI versus severely FI (SFI) categories. Prevalence of SFI and characteristics of SFI individuals were estimated from pooled data of 19 countries, by gender. RESULTS: SFI was more prevalent among women than men (17.8% and 15.1%, respectively p-value 0.0045). Significantly more SFI women tended to be unmarried, unemployed, and with lower educational attainment than SFI men. Logistic regression analysis showed that SFI was associated with lower educational attainment in women (OR 5.5, 95% CI 2.7–11.3) more than in men (OR 1.8%, CI 1.1 - 2.7). Being unemployed was significantly associated with a higher risk of being FI in men (OR 1.7, 95% CI 1.3–2.2) but not in women (OR 1.1 95% CI 0.7–1.6). Comparing those in the lowest income quintile to the highest, men and women showed similar association with SFI (OR 7.2 95% CI 4.6–11.2 and OR 7.8 95% CI 5.1–11.7, respectively). CONCLUSIONS: FI is a big concern in the LAS especially in women. Low educational attainment is highly associated with SFI among women. This might be associated with their high unemployment status and low income. A better understanding of the causes of FI in women is essential to inform intervention programs. FUNDING SOURCES: N/A.

OBJECTIVES: The objective of this research was to examine the association between total flavonoid intake and flavonoid sub-classes and CVD mortality among a nationally representative sample of US adults aged 40+ years at baseline and free of CVD. METHODS: A nationally representative sample of adults from the NHANES III data (1988–1994; n = 7900; age > = 40 years) were matched with mortality data reported by the National Death Index through 2015 to examine associations between estimated usual intakes of total flavonoid intake and flavonoid sub-classes and CVD mortality. Cox Proportional Hazards regression models were constructed to estimate hazard ratios and 95% confidence intervals for CVD mortality. Up to four 24-hour recalls were used to estimate total flavonoid intake and flavonoid sub-class intake for participants at baseline. RESULTS: During a median follow-up of 17.9 years, there were 4245 death; 1629 CVD deaths (767 males, 862 females) documented. Mean flavonoid intake was 247.7 mg/day for males and 216 mg/day for males. We did not observe an inverse association between total flavonoid intake and CVD mortality for males (HR: 0.95, 95% CI 0.87, 1.03) or females (HR: 1.03, 95% CI 0.93, 1.14), after adjustments for demographic, lifestyle, clinical and dietary quality variables. We also did not find significant associations between intake of flavonoid sub-classes and CVD mortality. However, for males only, intake of flavanones was inversely associated with CVD mortality after adjustments for demographic variables, lifestyle, clinical variables and diet quality (HR: 0.93, 95% CI 0.87, 0.99, p-value

OBJECTIVES: 1) Examine diet quality of OAANSP meals, 2) examine diet quality of complementary food consumed in addition to the CM/HDM meal, and 3) examine diet quality of daily intake by individuals who did versus did not consume a CM/HDM meal. Background: Older adults are becoming a larger proportion of the US population, a phenomenon that will continue over the next few decades. Congregate (CM) and home-delivered meals (HDM) of the Older Americans Act Nutrition Program (OAANP) have beneficial effects on the lives of older adults. Yet, data demonstrating value remains relatively limited, arguably leading to underfunding. METHODS: Data from the Administration for Community Living (ACL) Outcomes Evaluation Study was collected using a multistage clustered sample design. Data collection tools comprised a survey (including information on respondent's sociodemographics, health status, self-reported weight and height, social relationships, dietary self-reliance, participation in other nutrition assistance programs, and food security) and two 24-hour recalls. HEI-2010 was used to calculate individual and mean scores using the simple HEI scoring algorithm and the population ratio method, respectively. Radar plots were used to visualize HEI comparisons, and multiple logistic regression models were built to examine associations between diet quality and OAANSP. RESULTS: OAANSP participation was associated with HEI (P

OBJECTIVES: Using the social ecological model, the objectives of this study were to examine (1) the associations between proximate factors (food security and physical health) and measures of subjective well-being (SWB), and (2) the associations of distal community and country level risk factors with SWB, independent of food security and physical health. METHODS: Sub-Saharan Africa (SSA) data of 5585 respondents aged 60 years or older included in Gallup World Poll (GWP) 2014 and 2015 were included in these analyses. GWP collected data on several indicators SWB (eudaimonic, hedonic and evaluative), together with data on food security, physical health, social support and social participation, and country level factors such as quality of roads and public transport. We estimated three hierarchical logistic regression models for each index controlling for country and GWP survey year as a fixed effects. RESULTS: In bivariate logistic regression analysis, food security was most associated with higher evaluative well-being (OR 2.80, 95% CI 2.05–3.83) and physical health was most associated with higher eudaimonic well-being (OR 3.30, 95% CI 2.64–4.14). Physical health was also most associated with higher positive experiences (OR 1.83, 95% CI 1.59–2.10), and most inversely associated with negative experiences (OR 0.47, 95% CI 0.41–0.55), in bivariate analysis. In the multivariate models, emotional support explained eudaimonic well-being (OR 3.66, 95% CI 2.41–5.58), and evaluative well-being (OR 1.87, 95% CI 1.26–2.79), followed by physical health and food security, respectively. CONCLUSIONS: Food security, physical health and emotional support were strongly associated with SWB among older adults in this study. Food security is particularly important for QOL, and has a bi-directional relationship with these other predictors of SWB. Therefore, continued monitoring the food security of older adults in the region remains important. FUNDING SOURCES: N/A.

Rates of adverse cardiovascular events have increased among middle-aged adults. Elevated ceramides have been proposed as a risk factor for cardiovascular events. Diet quality and weight status are inversely associated with several traditional risk factors, however, the relationship to ceramides is less clear. This study aimed to determine associations of adiposity and diet quality with circulating ceramides in middle-aged adults (n = 96). Diet quality was estimated using the Healthy Eating Index 2015 (HEI-2015). Serum ceramide concentrations were determined by liquid chromatography&ndash, mass spectrometry. A ceramide risk score was determined based on ceramides C16:0, C18:0, and C24:1 and their ratios to C24:0. Participants who were classified as at &lsquo, moderate risk&rsquo, compared to &lsquo, lower-risk&rsquo, based on a ceramide risk score had significantly higher body mass index (BMI) values, as well as higher rates of elevated fibrinogen levels, metabolic syndrome, and former smoking status. BMI was positively associated with the ceramide C18:0 (R2 = 0.31, p &lt, 0.0001), the ratio between C18:0/C24:0 ceramides (R2 = 0.30, p &lt, 0.0001), and the ceramide risk score (R2 = 0.11, p &lt, 0.009). Total HEI-2015 scores (R2 = 0.42, p = 0.02), higher intakes of vegetables (R2 = 0.44, p = 0.02) and whole grains (R2 = 0.43, p = 0.03), and lower intakes of saturated fats (R2 = 0.43, p = 0.04) and added sugar (R2 = 0.44, p = 0.01) were associated with lower C22:0 values. These findings suggest that circulating ceramides are more strongly related to adiposity than overall diet quality. Studies are needed to determine if improvements in weight status result in lower ceramides and ceramide risk scores.

Background Palestinian refugees living in Lebanon continue to face social and economic exclusion that hinders their ability to improve their living conditions and livelihoods. This study aimed to investigate the effect of a two-pronged intervention that employed women through social enterprises to deliver a subsidised healthy daily school meal to elementary schoolchildren in Palestinian camps. Methods We established two healthy kitchens in community-based organisations in Palestinian camps; these kitchens employed 32 women to provide daily meals to children attending primary schools. We used mixed methods to assess the effect of participating in the intervention on the women's economic, social, and food security outcomes. We also assessed the impact of the subsidised meal programme on children's dietary diversity, nutritional status, school absenteeism, and achievement in two intervention schools, compared to two control schools. Difference-in-difference and regression analyses were conducted to examine the associations between participation and outcomes, controlling for potential confounders. Quantitative and qualitative data analyses were conducted using Stata 13·0 and NVivo 10, respectively. Written informed consent was obtained from women and parents, followed by assent from children prior to participation. All study protocols were approved by the Institutional Review Boards of the American University of Beirut and the University of Maryland. Findings At baseline, women's median household expenditure was US$169 per capita per month. Additional income due to the intervention was equivalent to US$110 per month, which translated into increases in total household and food expenditures (p=0·040), as well as a reduction in food insecurity (p=0·006). Qualitative data found improvements in morale, social support, and decision making. There were 648 children in the control group, and in the meal programme group there were 260 children with low participation (LP; participated less than 50% of total school days) and 454 with high participation (HP; participated more than 50% of total school days). There was a significantly greater increase in overall diet diversity score (Δ0·32, p=0·0060) and dairy consumption (odds ratio 1·2, 95% CI 1·1–1·3) in the HP group compared to controls. Both LP and HP groups were more likely to consume proteins, and less likely to consume sweetened beverages and desserts than controls. Furthermore, the HP group had a significant increase in haemoglobin (p=0·05) and both LP and HP groups had a significant decrease in school absenteeism (p=0·04) compared with controls. Interpretation This study provides evidence of the positive effect of the Healthy Kitchens, Healthy Children model on economic, food security, and social outcomes of marginalised women, as well as diet diversity, haemoglobin, and school outcomes of children. This intervention contributed to human capital gains in two generations of protracted refugees. Funding The Nestle Foundation for the Study of Problems of Nutrition in the World.

In the context of recent increases in international food prices, it is hypothesized that in rural communities retaining food production practices is important for protection against food insecurity at both the household and community levels, as well as for protection against the development of poor nutritional outcomes. To investigate this hypothesis, a crosssectional study of household food security and nutritional status was carried out in a rural community of settled Bedouins in Lebanon comprising 84 households with 474 individuals; this tribes recent history of settlement in 2 locations that differ by access to land and food production practices provides the context for this study. Food insecurity was found to be highly prevalent (49%) in this Bedouin community and was negatively associated with household food production (P < 0.05) and the consumption of fruits, chicken, meat, andfish (P< 0.05) and positivelyassociated with consumption of cereal products (P < 0.01). This study shows that in small rural communities in a transitional country, sustaining food production may protect from food insecurity. Agricultural livelihood support programs that promote continued involvement in food production at the household and community level, in conjunction with other income-generating activities, may build resilience against food insecurity and improve dietary diversity. J. Nutr. 143: 1666‐1671, 2013.

Eating disorders among young children are not well characterized. Diet and growth data were collected from toddlers (1-3 years old) at the time of diagnosis of infantile anorexia (IA) and up to 1 year after family counseling. Children (n = 62) were underweight (≤ −2 z-score weight-for-age). Boys (n = 34) had a greater ( P = .04) mean (standard error) weight-for-age percentile than girls (n = 28) and less evidence of wasting ( z-score weight-for-length = −1.8 (0.14) vs −2.3 (0.17), respectively; P = .04). After counseling, girls demonstrated better linear growth than boys (4.14 (0.18) vs 3.47 (0.18) cm/6 months, respectively; P < .002). Significant catch-up in length-for-age was observed across genders and diagnoses of 1.4 (2.07) growth percentiles and 0.13 (0.05) z-scores on the normal curve in 6 months ( P = .019). Head circumference correlated with dietary protein ( r = .23, P = .03), calcium ( r = .32, P = .004), and zinc ( r = .36, P = .001). Girls met or exceeded dietary reference intakes for energy, protein, iron, zinc, vitamin A, and calcium, and boys improved intake of these nutrients ( P < .05) but boys with IA fell short of recommended energy intake. Many children with IA reached tolerable upper intake levels for zinc and vitamin A, which warrants concern. These are the first data published on diet and growth among children with IA.

Only anecdotal information is known about foods available in the home of hospital-discharged older adults. This study describes the home food environment of this population and examines associations between health/nutrition risk factors and ability to shop and prepare meals. Data were collected from 512 hospital-discharged older adults residing in 6 U.S. states; food available within the home was assessed. Most households had a variety of food present; however, 20% of households lacked fresh fruit, 15% lacked fresh vegetables, and 35% had no fresh meat. About 35% of participants reported an inability to both prepare meals and shop for food. Among those unable to do both activities, the prevalence of depressive symptoms, food-related anxiety, and poor self-rated health was significantly (p0.01) higher than those able to do both activities. Homebound older adults may face additional challenges to recuperation from illness based on inability to prepare meals, regardless of availability of food following hospital discharge.

OBJECTIVES: To examine the associations between hardiness (defined as the ability to manage stress), depression, and emotional well-being and appetite in older adults. DESIGN: Cross-sectional. SETTING: Assisted-living facilities and senior centers in the Washington/Baltimore area. PARTICIPANTS: Two hundred ninety-two adults aged 60 and older. MEASUREMENTS: Depressive symptoms assessed using the 5-item Geriatric Depression Scale and categorized as 0 to 1 (normal, referent group) versus 2 to 5 (depressive symptoms present). Hardiness was measured using the 18-item Dispositional Resilience Scale II modified based on interviews with older adults and categorized as 67 or less (low hardiness) versus greater than 67 (normal, referent group). Appetite was measured using the Simplified Nutritional Appetite Questionnaire and categorized as 4 to 14 (poor appetite) versus 15 to 20 (normal, referent group). Emotional well-being was measured using a single question. RESULTS: Depression, hardiness, and emotional well-being were all significantly associated with appetite. In models controlling for confounders (data collection site, age, educational attainment, self-reported health, race, presence of chronic disease), fair to poor emotional well-being was most significantly associated with poor appetite (odds ratio (OR)=5.60, 95% confidence interval (CI)=2.60–12.07) and low commitment (a component of hardiness that indicates an individual's involvement in life) was also significantly associated with poor appetite (OR=1.35, 95% CI=1.13–1.61). CONCLUSION: These associations further elucidate the components of mental health that contribute to poor appetite in this population. Simple measures of self-reported mental health administered to older adults may predict poor appetite and lend themselves to potential interventions to prevent malnutrition and negative health outcomes.

Background Recent research has linked overall dietary patterns to survival in older adults. Objectives The objective of this study was to determine the dietary patterns of a cohort of older adults, and to explore associations of these dietary patterns with survival over a 10-year period. A secondary goal was to evaluate participants' quality of life and nutritional status according to their dietary patterns. Design The Health, Aging, and Body Composition Study is a prospective cohort study of 3,075 older adults. In this study, all-cause mortality was assessed from baseline through Year 10. Food intake was estimated with a modified Block food frequency questionnaire, and dietary patterns of 2,582 participants with complete data were derived by cluster analysis. Results Six dietary pattern clusters were identified, including a Healthy Foods cluster, characterized by higher intake of low-fat dairy products, fruit, whole grains, poultry, fish, and vegetables. Both the High-Fat Dairy Products and Sweets and Desserts clusters had a 1.4-fold higher risk of mortality than the Healthy Foods cluster after adjusting for potential confounders. The Healthy Foods cluster also had significantly more years of healthy life and more favorable levels of selected nutritional biomarkers than the other clusters. Conclusions A dietary pattern consistent with current guidelines to consume relatively high amounts of vegetables, fruit, whole grains, poultry, fish, and low-fat dairy products may be associated with superior nutritional status, quality of life and survival in older adults.

Background The Food Insecurity Experience Scale (FIES) is a UN FAO—Voices of the Hungry project (FAO-VoH) metric of food insecurity (FI). The FAO-VoH tested the psychometric properties of FIES with the use of global 2014 Gallup World Poll (GWP) data. However, similarities in its psychometric structure in sub-Saharan Africa (SSA) to allow aggregation of SSA results were untested. Objectives We aimed to 1) assess the validity of FIES for use in SSA, 2) determine the prevalence of FI by country, age group, and gender, and 3) examine the sociodemographic and economic characteristics of individuals with FI. Methods The Rasch modeling procedure was applied to data collected by GWP in 2014 and 2015 on 57,792 respondents aged ≥19 y in SSA. Results FIES largely met the Rasch model assumptions of equal discrimination and conditional independence. However, 34.3% of countries had high outfits (≥2.0) for the item “went without eating for a whole day.” Four countries had significant correlations for the items “were hungry but did not eat” and “ran out of food.” The overall prevalence of severe FI (SFI) was 36.4%, ranging from 6.0% in Mauritius to 87.3% in South Sudan. Older adults were at significantly higher risk of SFI than younger adults (38.6% and 35.8%, respectively, P

Purpose Dietary patterns may better capture the multifaceted effects of diet on body composition than individual nutrients or foods. The objective of this study was to investigate the dietary patterns of a cohort of older adults, and examine relationships of dietary patterns with body composition. The influence of a polymorphism in the peroxisome proliferator-activated receptor-γ (PPAR-γ) gene was considered. Methods The Health, Aging and Body Composition (Health ABC) Study is a prospective cohort study of 3,075 older adults. Participants’ body composition and genetic variation were measured in detail. Food intake was assessed with a semi-quantitative food frequency questionnaire (Block Dietary Data Systems, Berkeley, CA), and dietary patterns of 1,809 participants with complete data were derived by cluster analysis. Results Six clusters were identified, including a ‘Healthy foods’ cluster characterized by higher intake of low-fat dairy products, fruit, whole grains, poultry, fish and vegetables. An interaction was found between dietary patterns and PPAR-γ Pro12Ala genotype in relation to body composition. While Pro/Pro homozygous men and women in the ‘Healthy foods’ cluster did not differ significantly in body composition from those in other clusters, men with the Ala allele in the ‘Healthy foods’ cluster had significantly lower levels of adiposity than those in other clusters. Women with the Ala allele in the ‘Healthy foods’ cluster differed only in right thigh intermuscular fat from those in other clusters. Conclusions Relationships between diet and body composition in older adults may differ by gender and by genetic factors such as PPAR-γ Pro12Ala genotype.