Lessons learned from China and its shift toward an elderly population highlight both the benefits and the risks conveyed by lifestyle determinants of late life health trajectories. Effective implementation of preventive nutrition strategies could play a key role in diminishing the future chronic disease burden. However, an intensive, on-going, and incredibly flexible approach will be necessary to accomplish mean- ingful dietary change. Many challenges exist, including the need for culturally and ethnically appropriate nutrition education, the difficulty of changing dietary beha- viors (see Chapter 2), and, most recently, a dramatic increase in global food costs.
3.10.1 Achieving Global Behavior Change in Older Adults
The Global Strategy on Diet, Physical Activity and Health of the WHO (49,50)urges prudent lifestyle behaviors to promote better health, yet available survey data suggest that these goals are not being fully met (51). For example, Pomerleau et al. (52) studied worldwide efforts to help reduce the burden of chronic diseases by increasing intakes of fruit and vegetables. They found positive effects with face-to-face education or counseling, as well as interven- tions using telephone contacts or computer-based information; however, the amount of improvement achieved was modest, with an approximate increase of only 0.1–1.4 fruit/vegetable servings per day. The investigators noted that more research is needed on approaches for promoting healthy behaviors, espe- cially in the developing world.
Acknowledging that behavioral change is always difficult to achieve, there is a common notion that it is especially difficult for older individuals to change their lifestyles and follow recommended healthy eating plans. However, there is evidence that older adults can both implement and benefit from health promotion programs that emphasize dietary changes(53,54). One major challenge for any behavioral intervention is to bridge the gap between having the knowledge of the dietary changes that are needed and actually implementing these changes. Investigators in the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) examined the knowledge, attitudes, and behaviors of subjects (mean age % 60 years) with T2D (n ¼ 3, 867) and at high risk for developing T2D (n ¼ 5,419). In agreement with other reports (55), they found that knowledge alone did not predict appropriate behavioral modifications. Despite reporting healthy attitudes and knowledge conducive to good health, the majority of subjects did not translate these positive traits into healthy behaviors with respect
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to diet, exercise, and weight loss (56). Suggestions for addressing this problem include counseling to assist the individual in establishing values, motivations and goals, and to guide them in coping with real and perceived barriers to behavior change. Estabrooks et al. (57) conducted behavioral assessments in a group of randomized controlled trial participants with T2D (n¼422) and found that when they personally set appropriate goals, there were significant corresponding beha- vioral changes over the 6-month study period. With regards to barriers, Folta et al.
(58) studied commonly reported barriers to achieving a heart-healthy diet in middle- and older-aged women and reported that time constraints and concerns about ‘‘wasting’’ food topped the list. In addition to the usual challenges, for some high-risk older persons, the barriers to good nutrition listed elsewhere in this text, for example, social isolation and a limited ability to shop for and prepare meals, also clearly come into play(59).
3.10.2 Soaring Global Food Costs and the Dual Challenge of Under- and Over-Nutrition
One of the most important barriers to achieving dietary behavior change in any culture is the cost and availability of foods that are rich in health-promoting nutrients (e.g., protein, vitamins and minerals, fiber) and are not excessive in terms of calories, sodium, certain fats (saturated, trans), and simple sugars. Generally, foods associated with a healthier nutrient profile and lower rates of obesity are more expensive than foods of poor nutrient density(60,61). These foods are also more perishable (thus more likely to be wasted after purchase) and more difficult to shop for than highly processed foods, which tend to be readily available, have long shelf lives, and be high in calories, fat, sugar, and/or sodium. Recent increases in food prices are exacerbating concerns about the global affordability of nutritious food. In the time period from March 2007 to March 2008, the global food price index showed a sharp increase (see Fig. 3.17), with escalations in prices for almost all food categories(62). There were multiple causes for this food cost crisis, including poor recent harvests, restrictive trade policies, the increasing price of oil, diversion of crops for bio-fuels, and increasing world demand for food in fast-growing economies of countries with large populations, including China and India(63). The dramatic rise in the proportion of income that must go for food hits hardest in the poorest countries and civil unrest has resulted in at least 20 countries(64). Leaders at the United Nations called for emergency aid to help avoid widespread starvation and the World Bank plans to offer emergency financing to boost agricultural productivity, projecting that food prices will remain elevated for at least another year(63,64).
While the increase in food costs is leading to critical concerns about nutritional adequacy for those with subsistence-level incomes, it also has implications for middle- income groups. As previously noted, in addition to being appealing and convenient, refined grains, sugars, and added fats are among the most affordable sources of dietary energy and yet often are of poor nutritional value (61). As rising food costs put increasing pressure on family food budgets, these foods are likely out of necessity to replace ‘‘healthier’’ choices such as fresh fruits and vegetables. In fact, in developed countries like the United States, obesity has been linked with the price disparity between Chapter 3/ Global Graying, Nutrition, and Disease Prevention 57
‘‘healthy’’ and ‘‘unhealthy’’ foods. Likewise, in emerging countries where there are substantial income and health disparities, over-nutrition is becoming a major nutri- tional concern, creating a ‘‘dual burden’’ to health of under-nutrition and obesity.
Mendez et al. (65) studied patterns of under- and over-nutrition in women of 36 developing countries (in Africa, Latin America, the Caribbean, Asia, and the Middle East) and found that in almost all countries overweight exceeded underweight as a nutritional problem. This helps to explain the ironic observation that increasing income does not necessarily predict better health outcomes(66,67). As previously noted in the findings from China, growth of disposable income in emerging economies is often associated with an acceleration of the kinds of health problems associated with dietary excess. It is clear that one size does not fit all with regards to needed nutritional improvements—some groups mainly need more nutrients, some need fewer calories, and some need both modifications to achieve a health-promoting diet.
3.10.3 Summary
The United Nations has identified promotion of healthy aging as one of the major emerging nutritional challenges that will dominate the global agenda in the coming years (68). In 2004, the World Health Assembly endorsed the Global Strategy on Diet, Physical Activity and Health of the WHO, which Fig. 3.17. Overall and specific food price indices by quarter from March 2007 to March 2008.
The food price index (a monthly measure of price changes in major food commodities traded internationally) has averaged as much as 80 points (57%) higher over this time period. The increase was driven by rising prices for almost all food commodities. The price of staple foods (grains, oils sugar) has increased by 50%, including an increase of 90% for rice.Sources: World Bank; Food and Agriculture Organization of the United Nations.
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recognizes the shift in the balance of major causes of death and disease toward non-communicable diseases. The nutritional guidelines outlined in this plan are as follows:
! Achieve energy balance and a healthy weight
! Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and toward the elimination of transfatty acids
! Increase consumption of fruits and vegetables, and legumes, whole grains, and nuts
! Limit the intake of free sugars
! Limit sodium consumption from all sources and ensure that salt is iodized
Clearly, an array of resources will need to be applied in an integrated, trans- disciplinary, international approach if nutritional interventions are to be successful in reducing the incidence of chronic disease(5,69). Regional political, epidemiolo- gical, environmental, infrastructural, and genetic determinants of health must all be taken into account(69)and health-promoting behaviors need to be integrated into the normal daily life if they are to be sustained(70). Innovative thinking and use of technology could hold promise—in the future it may be possible to create and integrate into the food supply unique new foods that are enhanced in flavor and texture, enriched with nutrients, and yet low in undesirable attributes (71). We recommend that both traditional and novel avenues be very actively pursued—the future health and well-being of the entire world may very well be at stake.