Eat Better & Move More: A Community-Based Program Designed to Improve Diets and Increase Physical Activity Among Older Americans

Abstract

Objectives. We assessed outcomes of an integrated nutrition and exercise program designed for Older Americans Act Nutrition Program participants as part of the Administration on Aging’s You Can! campaign.

Methods. A 10-site intervention study was conducted. Preintervention and postintervention assessments focused on nutrition and physical activity stages of change, self-reported health status, dietary intakes, physical activity, and program satisfaction.

Results. Of 999 enrollees, the 620 who completed the program were aged 74.6 years on average; 82% were women, and 41% were members of racial/ethnic minority groups. Factors associated with program completion were site, health conditions, and nutrition risk. Seventy-three percent and 75% of participants, respectively, made a significant advance of 1 or more nutrition and physical activity stages of change; 24% reported improved health status. Daily intake of fruit increased 1 or more servings among 31% of participants; vegetables, 37%; and fiber, 33%. Daily steps increased 35%; blocks walked, 45%; and stairs climbed, 24%. Program satisfaction was 99%.

Conclusions. This easy-to-implement program improves diets and activity levels. Local providers should offer more such programs with the goal of enabling older Americans to take simple steps toward successful aging.

The Older Americans Act (OAA) Nutrition Program is the largest federally funded nutrition assistance program aimed toward adults 60 years and older.1^,2 Established in 1972, it is administered by the US Administration on Aging. Frequently called “meals on wheels” (this misnomer refers only to home-delivered meals), the program’s purpose was never limited to providing meals. Among its stated purposes—still applicable 35 years later—were promoting health, decreasing malnutrition, preventing physical and mental deterioration, and reducing social isolation. Today, the program annually provides about 250 million nutritious meals, other nutrition services, and socialization opportunities to 3 million adults older than 60 years. States and local communities successfully leverage OAA funds to build coordinated service systems at a rate of about $2 for every federal dollar.

The OAA Nutrition Program is available to all individuals 60 years or older regardless of income. However, it is targeted to those in greatest social or economic need, particularly to low-income members of minority groups and individuals residing in rural areas. The Nutrition Program is a primary source of support for many older people ineligible for services provided by means-tested programs with income criteria, such as food stamps. Indeed, the program is the chief service system of any type for older individuals slightly above the poverty level. Of the participants, 80% to 90% have incomes below the poverty level to 125% of the poverty level, 76% are older than 75 years, and 60% live alone.3

Participants’ voluntary contributions cover about 20% of the cost of a meal, and a single meal eaten at a community site is often their primary source of food for the entire day (for 60% of participants, this meal provides half or more of the total day’s food). Nutrition Screening Initiative Checklist scores, which indicate level of nutrition risk, are high for 43% of participants and moderate for 48%.3 Nutrition risk is based on factors or characteristics associated with an increased likelihood of poor nutritional status, commonly called malnutrition. These factors include the presence of various acute or chronic diseases and conditions, insufficient or inappropriate food intake, poverty, dependency on others or disability, and long-term or multiple medication use.

In addition to typically offering 5 midday meals per week at community sites and in homes, the program provides nutrition services that include screening, education, and counseling. It also provides linkages to other supportive in-home and community-based services such as homemaker–home health aide services, transportation, and even home repair and home modification programs. Each day, the 4000 local agencies serve as few as 20 clients to several thousand clients. Most agencies have modest budgets and depend on volunteer staff to a great degree.

The Eat Better & Move More (EBMM) program4 was developed specifically for local OAA Nutrition Program sites and the Administration on Aging’s national You Can! campaign.5 The latter, part of the Steps to a HealthierUS initiative,6 encourages all Americans, including older adults, to live longer, healthier lives by being physically active, eating nutritious diets, obtaining preventive screenings, and making healthful choices such as not smoking. Because nutrition and physical activity are cornerstones of successful aging,7 EBMM incorporates both of these elements. The program, which is simple, ready to use, and designed to fit modest local agency resources, fits the interests and needs of community-dwelling older adults who want to maintain their quality of life and independence. We sought to document EBMM’s effectiveness in a variety of community sites nationwide that serve diverse older populations, including members of racial/ethnic minority groups.

METHODS

Design

The multisite applied intervention study described here was a collaborative endeavor coordinated by the National Resource Center on Nutrition, Physical Activity and Aging in 2005 with 10 OAA Nutrition Program grantees. The lead person at each site (8 registered dietitians, 1 registered nurse, 1 Native American program manager) attended a 1.5-day workshop on protocol implementation. The center incorporated changes in data collection tools suggested by site leaders and provided technical assistance throughout the study via biweekly conference calls and a dedicated listserv.

Program Background

Two pilot studies were completed before development of the EBMM program. The first, in Florida and Iowa, assessed the feasibility of having older adults use step counters and keep daily step logs. Eighty percent of the 115 participating adults, who were aged 61 to 90 years and many of whom had multiple impairments, successfully wore counters and kept logs. The range of steps was 100 to 10000 at baseline, and the range was 430 to 13000 at the end of the program. A guidebook was piloted in Florida with a program group that received step counters, engaged in educational activities, and completed a walking program, and a comparison group that received step counters only. Members of the program group significantly increased the number of steps they took each day and improved their food intakes.

The EBMM Guidebook4 included 12 weekly sessions incorporating mini-talks and activities for group nutrition and physical activity sessions. Nutrition mini-talks emphasized the benefits of eating more fruits, vegetables, calcium-rich foods, and dietary fiber. In addition, given that many older adults were either overweight or underweight, mini-talks focused on sensible portion sizes. Nutrition topics, introduced during a particular weekly session and then reviewed and expanded on in the next session, addressed serious diet deficiencies or excesses. Physical activity mini-talks emphasized the benefits of walking. Participants learned how to use a step counter, perform simple stretching exercises, walk more at home and away, dress for all-weather walking, and stay hydrated.

Participants checked off food choices and recorded the number of steps taken each day on “Tips & Tasks” sheets. These take-home sheets briefly review the week’s nutrition and physical activity mini-talks. The step goal was personalized to each participant’s ability. A new goal with a modest 10% increase was suggested if the participant had reached the previous week’s goal. Otherwise, the same goal continued. Sites were encouraged to offer group walking sessions.

Sample

The National Resource Center on Nutrition, Physical Activity and Aging, with support from the Administration on Aging, posted an announcement on the center’s Web site, the US Administration on Aging’s site, and the center’s 5 Aging Network listservs. State Unit on Aging nutritionists and administrators were asked to distribute the announcement to area agencies and local providers in their state. The announcement encouraged both large and small OAA Nutrition Program sites, especially those serving non-White populations, to apply to take part in the intervention study.

From the 106 applications, a multidisciplinary panel selected 10 applicants according to several criteria: program description, no existing physical activity program at the location, ability to recruit 50 to 100 participants, and capacity to collect and electronically submit data. Program size, location, and clientele also entered into selection decisions. Grants of $10000 were awarded to the 10 programs, which were based in congregate dining centers, neighborhood recreation centers, and housing complexes in urban inner-city, suburban, and rural locations and a Native American reservation (Table 1 ▶).

TABLE 1—

Eat Better & Move More Program Enrollees, by Project Site: United States, 2005

Site (Location)	Total Enrollees, No. (%)a	Completers, No. (%)b	Noncompleters, No. (%)b
Active Aging Inc (Meadville, Pa)	170 (17)	121 (71)	49 (29)
Alameda County Area Agency on Aging (Oakland, Calif)	138 (14)	64 (46)	74 (54)
Citizen Potawatomi Nation (Shawnee, Okla)	39 (4)	22 (56)	17 (44)
Detroit Area Agency on Aging (Detroit, Mich)	141 (14)	68 (48)	73 (52)
East St. Louis Township Senior Citizens Activity Center (East St. Louis, Ill)	66 (7)	56 (85)	10 (15)
Hillsborough County Board of Commissioners (Tampa, Fla)	82 (8)	68 (83)	14 (17)
Kit Clark Senior Services, Federated Neighborhood Houses (Dorchester, Mass)	28 (3)	18 (64)	10 (36)
Senior Services of Snohomish County (Mukilteo, Wash)	74 (7)	26 (35)	48 (65)
Southeastern Wisconsin Area Agency on Aging (Brookfield, Wis)	46 (5)	24 (52)	22 (48)
Valley Program for Aging Services Inc (Waynesboro, Va)	215 (22)	153 (71)	62 (29)
Total	999 (100)	620 (62)	379 (38)

Note. Rates of program completion differed significantly (P < .001) by study site, ranging from 35% to 85%.

^aPercentage of all enrollees.

^bPercentage of enrollees by site.

A total of 999 older volunteer participants enrolled (Table 1 ▶). Sites screened potential participants using the EBMM Guidebook screening questionnaire. If 1 or more questions were answered affirmatively, participants were encouraged to obtain medical approval using the guidebook’s physician approval form. Inclusion criteria were as follows: (1) 60 years or older (50 years or older at the Native American site), (2) ability to walk with or without assistive devices, and (3) completion of a consent form. OAA regulations (45 CFR 1326.3) allow tribes to define age eligibility for Nutrition Program services; in most instances, the age is 50 years. Of the 45 Native Americans in the sample, only 5 (0.5%) were younger than 60 years. Discretion was given to site staff regarding exclusion of those with cognition problems.

Measures

The enrollment form included questions on demographic characteristics, health conditions, use of assistive devices, and access to or use of exercise programs. Data on functional ability and Nutrition Screening Initiative Checklist8 (a 10-item nutritional status screening tool including questions on illnesses and diseases, appetite, tooth loss or mouth pain, economic hardship, involuntary weight loss or gain, and functional limitations) scores were obtained from participant records when possible. The nutrition and health questionnaire was adapted from the Performance Outcomes Measures Project Congregate Meals Survey9 (an ongoing federally required performance measurement of OAA programs).

The physical activity questionnaire included the Modified Baecke Questionnaire for Older Adults10 (which assesses household and leisure activities). Scores on the “Timed Up and Go” test,11^,12 which quantifies functional mobility and has been shown to be reliably correlated with risk of falling, were used in evaluating all participants. (All forms and questionnaires are downloadable at http://nutritionandaging.fiu.edu. Contact information for the 10 sites is available at http://nutritionandaging.fiu.edu/You_Can/Mini_Grantees.asp. For assistance in implementing the program, contact the National Resource Center on Nutrition, Physical Activity and Aging at nutritionandaging@fiu.edu.)

The nutrition and physical activity questionnaires each included a “stage-of-change” question.13 As a means of keeping questionnaire length reasonable, only calcium-rich food intake was assessed with such a question. To indicate their current stage, participants selected from 5 statements reflecting each stage of change: precontemplation (“I do not eat 2–3 servings of milk, cheese, yogurt, and calcium-rich soy products per day, and I do not intend to begin eating 2–3 servings of milk, cheese, yogurt, and calcium-rich soy products per day in the next 6 months”), contemplation (“I do not eat . . ., but I intend to begin eating . . . in the next 6 months”), preparation (“I do not eat . . ., but I intend to begin eating . . . in the next 30 days”), action (“I have been eating . . ., but for less than 6 months”), and maintenance (“I have been eating . . . for more than 6 months”). The phrase “doing regular physical activity” was substituted in the exercise stage-of-change question.

Participants brought their “Tips & Tasks” sheet logs from the previous week to each weekly session. One-button counters (Accusplit X, ACCUSPLIT, San Jose, Calif) were used to calculate step-counting data.

Statistical Analysis

We used the χ² test and t test, as appropriate, to assess differences between participants who completed the program and those who did not. We conducted additional analyses focusing on those who completed the program. As a means of assessing preintervention-to-postintervention differences, we used the paired-samples t test, Wilcoxon signed rank test (z test), and McNemar test depending on the variable analyzed. For example, we analyzed preintervention-to-postintervention changes in Timed Up and Go scores, number of blocks walked, and weekly number of steps taken using the t test.

We analyzed ordinal variables (e.g., changes in numbers of servings of fruits and vegetables consumed) using the nonparametric Wilcoxon signed rank test. In the case of dichotomous variables, we used the McNemar test. For all tests, SPSS for Windows, version 14 (SPSS Inc, Chicago, Ill) was used in determining significance (P<.05) of results.

RESULTS

Among the enrollees, 620 (62%) had both preintervention and postintervention data on nutrition, physical activity, or both (“completers”). Rates of program completion differed significantly (P < .001) according to study site, ranging from 35% to 85% (Table 1 ▶). The mean age of completers was 74.6 years (SD = 7.5; Table 2 ▶). The oldest was 101; 5 were in their 90s, and 162 were in their 80s. Eighty-two percent were women, and 41% were members of racial/ethnic minority groups. Eleven percent had an 8th-grade education or less; another 45% had completed 1 to 4 years of high school. Most lived with family members (50%) or their spouse (38%).

TABLE 2—

Demographic Characteristics of Individuals Who Completed (Completers) and Did Not Complete (Noncompleters) the Eat Better & Move More Program: United States, 2005

	Completers		Noncompleters
Sample Characteristics	No.a	Mean (SD, Range) or %	No.a	Mean (SD, Range) or %
Age, y (n = 823)	596	74.6 (7.5, 53–101)	227	73.6 (7.6, 56–95)
No. of health conditions* (n = 852)	615	2.1 (1.9, 0–11)	237	2.4 (2.2, 0–15)
Uses assistive devices (n = 852)	615	0.4 (0.8, 0–6)	237	0.4 (1.0, 0–5)
Gender (n = 795)
Men	102	18	49	23
Women	478	82	166	77
Ethnicity (n = 830)
White	352	59	119	52
African American	149	25	56	24
Hispanic/Latino	24	4	20	9
Native American	34	6	11	5
Asian/Pacific Islander	42	7	23	10
Educational level (n = 822)
1st–8th grade	68	11	42	19
9th–12th grade	271	45	100	45
Some college	165	28	50	22
Bachelor’s degree	44	7	12	5
Graduate school	51	9	19	9
Living arrangements (n = 837)
Lives with spouse	229	38	89	39
Lives with family members	308	50	111	48
Lives alone	59	10	26	11
Other	11	2	4	2
Lives at or below poverty level** (n = 482)
Yes	43	12	27	23
No	322	88	90	77
Smokes*** (n = 838)
Yes	28	5	24	10
No	580	95	206	90
Nutrition risk score† (n = 533)
Low (0–2)	205	51	44	33
Moderate (3–5)	137	34	48	36
High (≥6)	59	15	40	30
Activities of daily living (n = 760)
0	529	92	164	90
1–6	49	8	18	10
Instrumental activities of daily living (n = 764)
0	494	85	143	78
1–9	86	15	41	22
Exercise programs in vicinity (n = 679)
Yes	381	77	135	74
No	115	23	48	26
Safe places to walk (n = 810)
Yes	521	88	195	90
No	72	12	22	10
Currently walk in available areas (n = 768)
Yes	401	71	139	69
No	165	29	63	31

^aSample sizes varied as a result of participant nondisclosure.

*P = .022 (independent samples t test); **P = .004 (χ² test); ***P = .003 (χ² test); ^†P < .001 (χ² test).

Completers had significantly fewer health conditions (P = .022) than did noncompleters, and fewer (15% vs 30%) were at high nutrition risk (P < .001; Table 2 ▶). Also, fewer completers (12% vs 23%) were at or below the poverty level (P = .004); however, more than half of all participants chose not to answer the income question, and most (80%–90%) Nutrition Program enrollees are at or near the poverty level.3 Fewer completers than noncompleters smoked (P = .003), but only 6% of participants overall were smokers. Otherwise, completers and noncompleters were similar (Table 2 ▶).

Completers’ Nutrition Outcomes

There was significant movement of participants through nutrition stages of change. At preintervention, 59% of the participants were at the maintenance stage, reporting that they had been eating 2 or 3 servings of calcium-rich foods daily for more than 6 months. Of the 41% not at the maintenance stage at pre-intervention, 73% made a significant advance of 1 or more stages toward maintenance, including 47% who advanced 2 or more stages (P < .001).

Changes in daily food intakes were as follows. Thirty-one percent of participants increased the number of servings of fruit they consumed by 1 or more servings, whereas only 18% decreased their consumption by 1 or more servings; 37% increased and 13% decreased their vegetable consumption by 1 or more servings; 33% increased and 16% decreased their fiber consumption by 1 or more servings; and 42% increased and 14% decreased their consumption of calcium-rich foods by 1 or more servings (all Ps < .001; Table 3 ▶). Thirty-one percent of participants increased their fluid intake by 1 to 3 glasses, whereas 18% decreased their intake by the same amount (P < .001).

TABLE 3—

Percentage Change in Numbers of Daily Servings Consumed From Preintervention to Postintervention, by Food Category: Participants Who Completed the Eat Better & Move More Program, United States, 2005

Category and No. of Servings Preintervention	Increased 2or More, %	Increased 1, %	No Change, %	Decreased 1, %	Decreased 2or More, %
Fruit† (n = 590)
0	1.4	1.9	0.2	. . .	. . .
1	2.2	15.6	10.5	0.8	. . .
2	. . .	9.5	23.1	5.4	0.0
3	. . .	. . .	17.8	10.5	1.2
Total	3.6	27.0	51.6	16.7	1.2
Vegetables† (n = 512)
0	1.5	1.7	0.0	. . .	. . .
1	3.4	14.8	8.1	0.2	. . .
2	. . .	15.3	24.4	4.6	0.2
3	. . .	. . .	17.5	7.0	1.2
Total	4.9	31.8	50.0	11.8	1.4
Fiber† (n = 544)
0	1.7	1.7	0.2	. . .	. . .
1	6.1	10.1	9.9	0.0	. . .
2	. . .	13.4	23.0	7.4	0.2
3	. . .	. . .	17.6	7.2	1.7
Total	7.8	25.2	50.7	14.6	1.9
Calcium† (n = 586)
0	2.3	5.1	1.4	. . .	. . .
1	3.4	15.5	13.1	0.7	. . .
2	. . .	15.4	18.3	5.8	0.2
3	. . .	. . .	11.8	5.8	1.2
Total	5.7	36.0	44.6	12.3	1.4
Water† (n = 541)
0	1.1	0.0	0.0	. . .	. . .
1–2	1.0	3.5	2.0	0.2	. . .
3–4	1.8	12.4	14.0	1.1	0.0
5–6	. . .	11.5	19.4	7.4	1.0
≥7	. . .	. . .	15.0	6.7	2.1
Total	3.9	27.4	50.4	15.4	3.1

Note. Ellipses indicate that the data are not applicable.

^†P < .001 (change from preintervention to postintervention).

Completers’ Physical Activity Outcomes

At preintervention, 58% of participants were at the maintenance stage in terms of regular physical activity. Of the 42% who were not at this stage, 75% made a significant advance of 1 or more stages toward maintenance, including 38% who advanced 2 or more stages. During week 2, participants averaged 3110 steps per day (Table 4 ▶). By Week 11, the number of steps per day had increased significantly to 4183 (an increase of 35%; P < .001).

TABLE 4—

Preintervention to Postintervention Changes in Mean Physical Activity Indicators: Participants Who Completed the Eat Better & Move More Program, United States, 2005

Physical Activity Indicator	No.	Preintervention, Mean (SD)	Postintervention, Mean (SD)	Pa
Steps walked	320	3110 (2448)	4183 (3257)	<.001
Blocks walked	390	10.0 (12.3)	14.5 (16.2)	<.001
Flights of stairs climbed	467	4.6 (9.0)	5.7 (9.0)	.021
Days walked per week	320	5.7 (1.4)	6.2 (1.4)	.008
Timed Up and Go score, sb	449	11.7 (5.3)	10.6 (4.3)	<.001
Exertion levelc	475	4.9 (1.4)	5.4 (1.2)	<.001

^aDependent samples t tests.

^bMeasured by trained program staff; all other data self-reported.

^cDegree of effort expended “when exercising in your usual fashion” (1 = none, 9 = very, very strong).

At preintervention, participants reported that they averaged 10 blocks walked and 4.6 flights of stairs climbed daily. At postintervention, number of blocks walked per day had increased significantly to 14.5 (an increase of 45%), and flights of stairs climbed had increased to 5.7 daily (an increase of 24%; Table 4 ▶). Number of days walked per week had increased significantly from 5.7 to 6.2 (an increase of 9%).

Timed Up and Go scores, measured by trained program staff, improved significantly from 11.7 seconds to 10.6 seconds (Table 4 ▶). The norm is 7 to 10 seconds, and individuals requiring more than 10 seconds are considered to have limited physical mobility and to be at increased risk of falling; those requiring more than 20 seconds are considered to be at high risk of falling. A level of improvement such as that observed here can be clinically significant in an at-risk population on the threshold of fall risk. Completers reported a significantly higher exertion level at postintervention (5.4) than at preintervention (4.9) on the modified 1 (none) to 9 (very, very strong) Borg scale (Table 4 ▶).

At preintervention, 6% of the participants perceived their health as excellent. Of the 94% of participants not reporting excellent health, 24% made a significant advance of 1 or more categories toward excellent, including 3% who advanced 2 or more categories (P < .008).

Finally, almost all of the participants (99%) indicated that they would recommend the program to others. Ninety-three percent reported that it helped them “eat better” and 90% reported that it helped them “move more.”

DISCUSSION

A limitation of this study was that completion rates differed significantly according to site. Influential factors may have included differences in staff and facilities.14 However, completion rates did not differ according to ethnicity, even though the samples at some sites were composed primarily of individuals from a single ethnic group. Population diversity was emphasized in the site selection process.

The lowest participant completion rate (35%) occurred at a high-rise housing site, the site whose participants had the highest mean nutrition risk score. Older adults residing in subsidized high-rise apartments often have more unmet needs than those living in traditional community housing.15 Despite these differences among sites, there is little reason to believe that they biased participation or outcomes. Encouragingly, EBMM outcomes were positive at all 10 sites, each of which, in accordance with the selection criteria, had no physical activity programming.

All of the participants were self-selected volunteers; there were no control groups in this demonstration project. There was concern that OAA Nutrition Program participants randomized into control groups would be upset and might no longer opt to receive services, a consequence detrimental to individuals as well as local sites. In a pilot study, a comparison group that received step counters but no other intervention increased (albeit not significantly) the number of steps they took per day.

The EBMM Guidebook and this demonstration project recognized the burden that applied research places on community agencies with limited funding and staffing, especially those generally unaccustomed to collecting data. Because this project focused on documenting outcomes, we did not collect implementation cost data. As a result of the extensive and time-consuming data collection process associated with the project, the implementation costs incurred at the 10 study sites are not representative of actual program costs. Facilitators’ salaries were the primary expenditures according to the sites’ final budget reports, and included in these salaries was considerable time devoted to collecting data. Without such substantial data collection, the cost of implementing the program would probably be low. Because it yielded significant outcomes at a variety of sites involving diverse populations, EBMM is cost effective.

With respect to age, gender, health conditions, nutrition risk scores, and ability to engage in activities of daily living and instrumental activities of daily living, participants were reasonably representative of older Americans. Age and gender distributions reflected those of OAA Nutrition Program participants. Nutrition and physical activity outcomes may have been attributable to EBMM mini-talks, discussions, “Tips & Tasks” handouts, walking sessions, step counters, or the combination of nutrition and physical activity as an integrated intervention. Also, the significant increase in number of steps walked may have promoted improved dietary intakes.16

Successful nutrition education interventions have common characteristics.17 They limit their intended messages, reinforce and personalize these messages, and provide hands-on activities and access to health professionals. Each of the 4 EBMM nutrition messages was introduced during a particular week and reinforced the next week. “Tips & Tasks” sheets encouraged individuals to attain personal goals. Check boxes served as visual reminders of daily goals. Short lists of healthful options within a featured food message enabled participants to personalize choices to improve their diets. Weekly mini-sessions included interactive activities based on actual food items, food labels, and program meals. Sessions were led by registered dietitians at 8 of the 10 sites; a registered nurse led another.

Seventy-seven percent of completers indicated that they had access to exercise programs, and most (88%) reported having a safe place to walk. More than 70% reported walking regularly in their community (Table 2 ▶). This finding is contrary to assumptions that older adults who reside in urban areas have no place to walk because of safety issues related to crime or uneven sidewalks and that paved roads are not available to those who live in rural areas and other surfaces are too uneven to use. The personalized step goal allowed individuals to progress more slowly if they were less active and more rapidly if they were already more active. Such self-pacing probably improved outcomes, facilitated self-efficacy, and encouraged adherence.

Most of the participants increased their physical activity levels. Evidence suggests that even modest increases in physical activity can lead to improvements in health, functioning, and quality of life.18^,19 Even activity of insufficient intensity to improve fitness has substantial health benefits related to increasing accumulated daily energy expenditures and maintaining muscular strength.18 The surgeon general’s 1996 report on physical activity and health recommended that all Americans engage in at least 30 minutes of activity most days of the week.20 The Behavioral Risk Factor Surveillance System shows that walking is the most frequently reported regular physical activity and that increasing frequency of walking is an effective strategy to facilitate adherence to recommendations.21

Research has shown that healthy older adults average 6000 to 8500 steps per day and that older adults with disabilities and chronic diseases average 3500 to 5500 steps.22 A universal goal in terms of number of steps taken per day is considered inappropriate because it can lead to failure and attrition.23 Thus, step goals can be low and still result in 30 minutes of moderate physical activity on most days of the week. In a study of sedentary women, those who reported a low number of steps taken at baseline were less likely to reach the goal of 10 000 steps a day than those who reported a higher number of steps at baseline.24 This finding supports targeting goals toward individuals’ physical activity levels, as was done in EBMM.

Conclusions

The EBMM intervention significantly improved nutrition and physical activity behaviors among the 620 individuals who completed the program, who were primarily female and were from ethnically/racially diverse backgrounds. The volunteer nature of the study may have influenced participants’ readiness to make changes. Approximately 75% of participants who were not at the maintenance stage at preintervention progressed 1 or more stages with respect to nutrition and physical activity. Daily intakes of fruits, vegetables, fiber, calcium-rich foods, and fluids increased significantly. Number of steps taken per day increased by 35%. Number of blocks walked increased, as did flights of stairs climbed and number of days of walking per week. Risk of falling decreased. Approximately 25% of those who were not in excellent health at preintervention improved their self-rated health, an important outcome given that self-rated health may predict functional abilities and mortality among community-dwelling populations.25

Overall, EBMM was even more successful than anticipated, in part because it is easy to use, inexpensive to implement, and tailored to meet the needs of older adults while being geared simultaneously toward changing nutrition and physical activity behaviors. Similar to other activity-promoting programs,26^,27 this project succeeded because of the enthusiasm of local staff, especially site directors and managers, and the involvement of health professionals and facilitators (registered dietitians and a registered nurse) who were culturally sensitive and, in many cases, able to answer questions beyond the intervention’s scope. Another important factor was the coordination of this demonstration project by the university-based National Resource Center on Nutrition, Physical Activity and Aging.

As mentioned, feedback regarding EBMM was overwhelmingly positive, with 99% of participants indicating that they would recommend the program to others. One of the participants noted: “Right from day one, I knew this program was going to be a winner. Every session was full of good information on eating and exercise.” According to another: “I was encouraged and learned that I needed to walk more. It also helped me understand the benefits of eating a variety of foods.” In the words of still another: “In my opinion, Eat Better & Move More was excellent. This was a terrific opportunity to learn more about being healthy by combining good nutrition and exercise.”

Practice and Research Implications

The results of this study have a number of implications for practitioners, service providers, and researchers. Because poor diets and inactivity, which are major obstacles to successful aging, are relatively common among older adults,28 integrated nutrition and physical activity programs such as EBMM should be offered more widely as a part of community programs. Each of these components has separately been shown to be effective at local OAA Nutrition Program sites,29^–31 and several studies integrating nutrition and physical activity have reported significant outcomes.32^–35

On the basis of findings indicating that nutrition education programs are enhanced by integrating physical activity and exercise under the guidance of trained instructors and registered dietitians, Wunderlich and McKinnon specifically recommended that sufficient federal funds be provided for programs that produce long-term health benefits for older adults.36 Another study on enriched foods and exercise37 also emphasized the need for additional investigations to confirm that integrated nutrition and fitness programs are more effective than either alone. Our study provides such confirmation, and our results are not surprising given the interrelationships among energy (calories) in food, energy (calories) expended in physical activity, diet quality and quantity, and health.

The 2005 Dietary Guidelines for Americans38 single out people older than 50 years as one of the “specific population groups” that need special consideration and provide additional nutrition and physical activity recommendations for them. The content of the EBMM Guidebook conforms to these evidence-based federal recommendations. The National Resource Center on Nutrition, Physical Activity and Aging has distributed 1000 guidebooks and 17500 step counters to aging network programs. As a result of requests for additional modules, a second EBMM Guidebook will be available in 2007.

Misinformation and confusion about nutrition and physical activity abound. Because older adults may need more encouragement than other groups to eat healthfully and be more active, higher levels of professional expertise are needed at local OAA Nutrition Program sites. We encourage dietitians, nutritionists, and exercise specialists to use the EBMM Guidebook and work with their health and social service colleagues to encourage health-promoting behaviors.

Medicaid reform39 trends show states moving away from their institutional bias toward community-based, consumer-directed services. Given that integrated, evidence-based programs such as EBMM promote health, improve quality of life, and help older adults maintain their independence, these programs deserve the support of policymakers, aging and public health networks, and other public and private agencies. Local providers should offer more such community-based programs with the goal of enabling older Americans to take simple steps toward successful aging.