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How to Ensure That Teaching Kitchens Are Age-Friendly

      Abstract

      Health systems and community organizations have increasingly offered nutrition education through teaching kitchens. With an increasing number of older adults (>65 years) accessing these programs, teaching kitchens may consider age-friendly adaptations to their standard curriculum. Based on experiences with implementing Healthy Teaching Kitchens Across Veteran Affairs Health Care System, and by applying the 5M Geriatric Care Framework (Mind, Multicomplexity, Medications, Mobility, What Matters Most), several steps are proposed for teaching kitchens to be able to better accommodate older adults.

      Key Words

      INTRODUCTION

      By 2030, older adults will comprise roughly 20% of the US population. Older adults are more likely to have disabilities and multiple chronic health conditions. By the age of 85, 69% of these individuals have at least 1 disability (a physical or mental impairment limiting daily activities such as visual loss or inability to walk without assistance)
      Legal Information Institute
      The public health and welfare.
      compared with less than 10% of the community-dwelling population aged <65 years who have at least 1 disability.
      • Andrew W
      • Roberts SUO
      • Blakeslee L
      • Rabe MA
      The Population 65 Years and Older in the United States: 2016. American Community Survey Reports.
      Moreover, >80% of Americans aged >65 years are living with at least 1 chronic condition, such as hypertension or diabetes, and 50% have 2 or more.
      Centers for Disease Control and Prevention
      The State of Aging and Health in America 2013.
      ,

      National Council on Aging. Healthy aging facts. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/. Accessed May 31, 2019.

      With the persistent rise in chronic disease prevalence in older adults, it is important to ensure that programs accommodate the specific capacities and needs of older adults.
      Poor nutrition increases the risk of morbidity in older adults and is a factor leading to the development of several geriatric syndromes and ultimately frailty.
      Nutrition is a crucial determinant of health in older adults. Healthy aging and maintenance of function is supported by a high-quality diet that meets micronutrient (vitamin C, A, D, E, K, zinc, folate, calcium, iron, and B vitamins) and macronutrient (protein, whole grains, carbohydrate, fiber, fat) requirements.
      • Krok-Schoen JL
      • Archdeacon Price A
      • Luo M
      • Kelly OJ
      • Taylor CA
      Low dietary protein intakes and associated dietary patterns and functional limitations in an aging population: a NHANES analysis.
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      • Millán-Calenti JC
      Nutritional determinants of frailty in older adults: a systematic review.
      GBD 2017 Diet Collaborators
      Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.
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      Nutrition and prevention of cognitive impairment.
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      High prevalence of physical frailty among community-dwelling malnourished older adults: a systematic review and meta-analysis.
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      • et al.
      Global improvement in dietary quality could lead to substantial reduction in premature death.
      • Guasch-Ferré M
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      • Blondin SA
      • et al.
      Meta-analysis of randomized controlled trials of red meat consumption in comparison with various comparison diets on cardiovascular risk factors.
      • Yannakoulia M
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      • Scarmeas N
      Frailty and nutrition: from epidemiological and clinical evidence to potential mechanisms.
      Older adults are less likely to meet the recommended daily values of nutrients; for example, >30 % of older adults are estimated to be vitamin D deficient.
      • Boettger SF
      • Angersbach B
      • Klimek CN
      • et al.
      Prevalence and predictors of vitamin D-deficiency in frail older hospitalized patients.
      In addition, a recent assessment of National Health and Nutrition Examination Survey data found that more than a third to half of older adults did not meet the daily recommended protein allowance (0.8 g/kg/day) and were more likely to have lower micronutrient intakes and nutrient deficiencies.
      • Krok-Schoen JL
      • Archdeacon Price A
      • Luo M
      • Kelly OJ
      • Taylor CA
      Low dietary protein intakes and associated dietary patterns and functional limitations in an aging population: a NHANES analysis.
      Poor nutrition increases risk of morbidity associated with aging: osteomalacia, osteoporosis, muscle weakness, frailty, falls, pressure sores, hip fractures, hospitalization, rehospitalization, and ultimately premature mortality.
      • Krok-Schoen JL
      • Archdeacon Price A
      • Luo M
      • Kelly OJ
      • Taylor CA
      Low dietary protein intakes and associated dietary patterns and functional limitations in an aging population: a NHANES analysis.
      ,
      • Yannakoulia M
      • Ntanasi E
      • Anastasiou CA
      • Scarmeas N
      Frailty and nutrition: from epidemiological and clinical evidence to potential mechanisms.
      ,
      • Buys DR
      • Roth DL
      • Ritchie CS
      • et al.
      Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB Study of Aging with 8.5 years of follow-up.
      • Ramage-Morin PL
      • Gilmour H
      • Rotermann M
      Nutritional risk, hospitalization and mortality among community-dwelling Canadians aged 65 or older.
      • Pilgrim AL
      • Robinson SM
      • Sayer AA
      • Roberts HC
      An overview of appetite decline in older people.
      Multiple factors impact how older adults acquire, prepare, and consume food: normal and disabling physiologic changes; chronic disease and associated medications; access to food; relationship to food; socioeconomic status and isolation.
      • Whitelock E
      • Ensaff H
      On your own: older adults’ food choice and dietary habits.
      Thus, health systems and community organizations should encourage programming that supports older adults in meeting their nutrient requirements and may delay disability.
      Health systems and community organizations are increasingly conducting nutrition education in teaching kitchens, which are places to learn nutrition information, meal planning, preparation, basic shopping, and cooking skills. One example of a community-integrated nutrition program is Cooking Matters for Adults, which teaches low-income adults how to prepare and shop for meals through teaching kitchen classes and grocery store tours in >40 states.

      Cooking Matters. Volunteer. 2019. http://cookingmatters.org/node/2215. Accessed May 28, 2019.

      ,
      • Eisenberg DM
      Teaching kitchen collaborative research day February 7, 2018.
      Evidence is gradually building on how teaching kitchens may improve the quality of nutrition education for adults.
      • Hollywood L
      • Surgenor D
      • Reicks M
      • et al.
      Identification of behavior change techniques applied in interventions to improve cooking skills and food skills among adults.
      ,
      • Reicks M
      • Trofholz AC
      • Stang JS
      • Laska MN
      Impact of cooking and home food preparation interventions among adults: outcomes and implications for future programs.
      The Veterans’ Health Affairs Nutrition and Food Services currently offers nutrition education through a program called Healthy Teaching Kitchen (HTK) across the country. Recent analyses of veterans who attended these classes report high levels of satisfaction and self-perceived gains made toward their health goals, with one study suggesting improvements in cooking confidence and diet quality in older veterans with diabetes.
      • Black M
      • Lacroix R
      • Thielke SM
      • Chen S
      • Utech A
      • Souza M
      Healthy teaching kitchens adoption and outcomes across veteran affairs 2017–2018.
      ,
      • Dexter AS
      • Pope JF
      • Erickson D
      • Fontenot C
      • Ollendike E
      • Walker E
      Cooking education improves cooking confidence and dietary habits in veterans.
      Although half of veterans who attended classes in 2018 were aged >65 years, the Veterans Administrations’ HTK classes are not specifically designed for or tailored to older adults.
      • Pooler JA
      • Morgan RE
      • Wong K
      • Wilkin MK
      • Blitstein JL
      Cooking matters for adults improves food resource management skills and self-confidence among low-income participants.
      It is important to ensure that older participants can participate and benefit from HTK classes. HTK classes already address multiple components of healthy aging including social connection, nutrition, and self-care to promote independence but do not always attend to other factors that occur during aging. While specialized classes may not be necessary, classes should be age-friendly.
      • John A
      Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults.
      This paper shares a summary of participant feedback, suggesting ways that teaching kitchen classes can become more age-friendly through adopting a framework of 5M Care Philosophy (mind, multicomplexity, medications, mobility, what matters most).
      • Tinetti M
      • Huang A
      • Molnar F
      The geriatric 5M's: a new way of communicating what we do.
      This framework (Figure) was devised to simplify core concepts of geriatric care to help communicate outside the field of geriatrics and influence adaptations to health care systems attuned to the needs and preferences of older adults.
      • Tinetti M
      • Huang A
      • Molnar F
      The geriatric 5M's: a new way of communicating what we do.
      ,
      • Tinetti M
      How focusing on what matters simplifies complex care for older adults.
      The design and implementation of the Puget Sound HTK classes relied heavily on this model, appreciating its relevance to older adults’ active engagement in nutrition. Herein, each domain of the model is discussed and ways that HTK classes can be tailored for older adults.
      Figure
      Figure5M Age-friendly Framework to consider when designing teaching kitchen intervention. Adapted with permission from the Institute of Healthcare Improvement's Age-Friendly graphic and the work of Tinetti, Molnarm, and Huang.
      • Tinetti M
      • Huang A
      • Molnar F
      The geriatric 5M's: a new way of communicating what we do.

       Description of Evaluation

      Suggestions for establishing an age-friendly HTK class were based on experiences with leading HTK classes for older adults and veteran participant feedback. Specifically, HTK classes were conducted at the Veterans Affairs Puget Sound Health Care System starting November 2017 to June 2018. Each session consisted of a 6-week class that met weekly for 2 hours. These sessions used a core curriculum influenced by the Cooking Matters for Adults,
      • Reicks M
      • Trofholz AC
      • Stang JS
      • Laska MN
      Impact of cooking and home food preparation interventions among adults: outcomes and implications for future programs.
      Veterans Health Administration Nutrition and Food Service,

      US Department of Veteran Affairs, Nutrition and Food Services. Healthy Teaching Kitchen. 2013. https://www.nutrition.va.gov/Healthy_Teaching_Kitchen.asp. Accessed May 15, 2019.

      and MOVE! Programs.
      • Kahwati LC
      • Lewis MA
      • Kane H
      • et al.
      Best practices in the Veterans Health Administration's MOVE! weight management program.
      We conducted these activities as part of an operations evaluation, patient satisfaction, and quality improvement project, not research. This project was following the Veterans Administration's program guide 1200.21 and Veterans’ Health Administration Handbook 1058.05. As such, institutional review board approval was not sought or obtained. Adaptations to the curriculum for the benefit of older adults were initially informed by review of existing evidence-based literature of age-friendly programming by a multidisciplinary team consisting of 2 dietitians, an occupational therapist, and a geriatrician.
      • Hollywood L
      • Surgenor D
      • Reicks M
      • et al.
      Identification of behavior change techniques applied in interventions to improve cooking skills and food skills among adults.
      ,
      • Higgins MM
      • Barkley MC
      Tailoring nutrition education intervention programs to meet needs and interests of older adults.
      ,
      • Sahyoun NR
      • Pratt CA
      • Anderson A
      Evaluation of nutrition education interventions for older adults: a proposed framework.
      After each class a questionnaire asked participants, “What would you change to improve this class?” The curriculum was then adapted on an ongoing basis based on suggestions of 35 veteran participants who enrolled and completed an entire 6-week series. Veteran responses were reviewed and then matched to 1 of 5 domains in the 5M Care Philosophy framework. Other practice recommendations based on literature review and expert consultation with aging specialists in nutrition, geriatric medicine, and occupational therapy were also categorized into the same corresponding domains.
      • John A
      Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults.
      ,
      • Tinetti M
      How focusing on what matters simplifies complex care for older adults.

      US Department of Veteran Affairs, Nutrition and Food Services. Healthy Teaching Kitchen. 2013. https://www.nutrition.va.gov/Healthy_Teaching_Kitchen.asp. Accessed May 15, 2019.

      • Kahwati LC
      • Lewis MA
      • Kane H
      • et al.
      Best practices in the Veterans Health Administration's MOVE! weight management program.
      • Higgins MM
      • Barkley MC
      Tailoring nutrition education intervention programs to meet needs and interests of older adults.
      • Sahyoun NR
      • Pratt CA
      • Anderson A
      Evaluation of nutrition education interventions for older adults: a proposed framework.
      Tables were structured to include all responses and recommendations. Practice recommendations that were supported by participant responses were considered high priority and identified as such in the table. This program improvement project was done in a quality improvement manner, and therefore, a formal statistical analysis was not performed.
      Teaching kitchens can help facilitate nutrition education for successful aging.

      DISCUSSION

       Mind (Cognition, Mental Health, and Health Literacy)

      Approximately two thirds of adults aged >65 years have basic or below basic literacy levels.
      • Rudd R
      Health literacy studies.
      Furthermore, disorders that affect cognition, such as dementia and delirium, increase with age, affecting 1 in 20 individuals aged 65–74 years and 1 in 5 of individuals aged ≥85 years.

      2012–2016 American Community Survey 5-year estimates. US Census Bureau Web site. https://www.census.gov/acs/www/data/data-tables-and-tools/data-profiles/2016/. Updated June 17, 2018. Accessed May 20, 2019.

      Therefore, consideration of cognitive decline and reserve is important when developing curriculum and materials and employing health literacy guidelines.

      Office of Disease Prevention and Health Promotion. Health Literacy Online. 2016. https://health.gov/healthliteracyonline/full/. Accessed October 27, 2019.

      Providing group-based educational class is in essence a social prescription; group classes are 1 way to nurture the mental well-being and health of older adults and prevent social isolation.
      • Dickens AP
      • Richards SH
      • Greaves CJ
      • Campbell JL
      Interventions targeting social isolation in older people: a systematic review.
      Teaching Kitchen classes may address these concerns by incorporating specific techniques (Table 1).
      Table 1Veteran feedback and practice recommendations classified under the 5M domain of Mind (cognition, mental health, and health literacy)
      Veteran QuotesPractice Recommendations
      “I write everything down. I use all handouts and place them in a binder for reference to remember what we did.”

      “I like the hands-on portion by group and instruction.”

      “Each class we learn, cook, and eat… Having the cooking steps explained as they were done and being able to eat it.”

      “Time constraint… was stressful.” “Make it last for 3–4 hours instead of 2 hours.”

      “Being able to contribute… how easy each dish was to make, and the instructor explained specifically.”

      “Learning something new.”

      “I like camaraderie… involvement of instructors and veterans.”

      “Conversations among the group.”
      • Ask participants about their preferred learning styles and expectations.
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Consider incorporating peer-support and peer educators.
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Provide a consistent structure and framework for the classes.
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Plan for group discussion time to discuss issues and barriers. Provide time to practice overcoming those barriers.
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Coverless material in more time and repeat core concepts throughout each class, allowing substantial time for questions.
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Communicate in multiple instruction modalities (written, verbal, and participatory hands-on).
      Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.


      • Empower participants and families by communicating and educating them with the material they can understand.

      • Allow for family members and caregivers to attend classes when feasible.

      • Consider providing class reminder calls and maps to classroom locations to improve attendance.

      • Use a behavioral approach that incorporates goal-setting, problem-solving, enhancement of efficacy.

      • Cater lessons and recipes to all health literacy levels (fifth grade–graduate school level) and numeracy (fifth grade math–college level) to increase comprehension and satisfy intellectual needs of all attendees.
      a Denotes practice recommendations, which were supported by veteran responses (listed in left column) and literature review and were considered of high priority in program planning.

       Multicomplexity

      Older adults have complex health profiles; over two thirds of adults aged >65 years have 2 or more chronic conditions, are more likely to have a cognitive impairment, and be taking multiple medications.

      National Council on Aging. Healthy aging facts. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/. Accessed May 31, 2019.

      In addition, rates of disabilities increase dramatically with age.
      • Kremer S
      • Bult JH
      • Mojet J
      • Kroeze JH
      Food perception with age and its relationship to pleasantness.
      For example, rates of impaired vision and smell increase with age and may affect up to 50% of older adults because of both normal aging and a variety of diseases.
      • Boyce JM
      • Shone GR
      Effects of ageing on smell and taste.
      • Murphy C
      • Schubert CR
      • Cruickshanks KJ
      • Klein BE
      • Klein R
      • Nondahl DM
      Prevalence of olfactory impairment in older adults.
      • Schiffman SS
      Taste and smell losses in normal aging and disease.
      Poor oral health and dentition affects more than two thirds of older adults.
      • Tonetti MS
      • Bottenberg P
      • Conrads G
      • et al.
      Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - consensus report of group 4 of the joint EFP/ORCA workshop on the boundariesbetween caries and periodontal diseases.
      • Dye B
      • Thornton-Evans G
      • Li X
      • Iafolla T
      Dental caries and tooth loss in adults in the United States, 2011–2012.
      • Eke PI
      • Dye BA
      • Wei L
      • et al.
      Update onprevalence of periodontitis in adults in the United States: NHANES 2009 to 2012.
      Together, these factors can contribute to gustatory and taste dysfunction and poor diet.
      • Gopinath B
      • Russell J
      • Sue CM
      • Flood VM
      • Burlutsky G
      • Mitchell P
      Olfactory impairment in older adults is associated with poorer diet quality over 5 years.
      Physical impairments from deteriorating health are often compounded by social complexity and increase the risk of dependence, isolation, and inability to access care resources or community wellness programs. With age, living independently and caring for oneself becomes more difficult. By age 85 years, >40% older adults cannot live alone, and about 25% require assistance with self-care.
      • Andrew W
      • Roberts SUO
      • Blakeslee L
      • Rabe MA
      The Population 65 Years and Older in the United States: 2016. American Community Survey Reports.
      To address these concerns, teaching kitchen classes can consider various domains of health (Table 2).
      Table 2Veteran feedback and practice recommendations classified under the 5M domain of Multicomplexity (biopsychosocial, hearing and vision impairment, diminished taste, and multicomplexity)
      Veteran FeedbackPractice Recommendations
      Biopsychosocial
      “I would like to practice eating more balanced meals… I rely on the food bank.”

      “More cooking for 1 person.”

      “I buy generic [medications] to afford food bills.”

      “It showed me that I can plan and make a meal with healthy choices and not real expensive.”

      “It has give(n) (me) options that I did not know I had.”
      • Consider engaging various members of a multidisciplinary team: primary care providers, dietitians, dentists, and occupational/physical therapists to meet functional impairments with feeding, eating, or obtaining food and social workers to overcome social barriers to food resources.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Ensuring that meals and recipes are adjusted for 1 or 2 people rather than a recipe that serves 8.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Ensure that classes are low-cost or free for participants.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Screen for food insecurity and intervene by connecting to resources such as SNAP and local programs that serve Seniors (farmers markets, Meals on Wheels, food banks, community congregate meals) and providing educational tools to shop on a limited budget and cook without a full kitchen (eg, just a microwave or crockpot).
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Ensure a curriculum that is sensitive to life experience by catering to participant's cultural identity, health beliefs, language, and social situation. For example, recent immigrants with non-Western health beliefs, non-English speakers, and simply cooking for 1 person or on a fixed income.
      Hearing and vision impairment
      “Too much coaching from the sideline, would rather hear instructor better.”

      “When I could hear instructor and understand, it was great.”

      “Leaving class after dark.”
      • Ask participants if they have difficulty hearing.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Instruct participants to wear hearing assisted devices or have pocket-talkers on hand and encourage sitting close to the instructor.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Conduct class in quiet space.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Establish class rules to limit background noise.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Limit class size to 3-4 participants per instructor.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Speak slowly, clearly and face attendees, do not raise voice.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Ask participants if they have difficulty seeing.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Use large font (14–16 for paper materials; 36–40 for screen displays) and pick location of classes strategically ensuring adequate lighting.

      • Schedule day-time classes so participants avoid driving home at night.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Conduct class in a well-lit space.
      Diminished smell and taste, chewing and dentition impairment
      “Learning to cook with spices and herbs was my favorite part of class.”

      “I am hoping to find out healthier alternatives to improve digestion without having the benefit of teeth to masticate properly.”

      “Looking forward to better tasting recipes or ones I can substitute healthy ingredients.”

      “Have water on the tables during class.”
      • Focus on flavor using spices, herbs, strongly flavored ingredients, and seasoning techniques to minimize salt.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Use recipes that work well or offer a modification for individuals with poor dentition, poorly fitting dentures, or difficulty chewing and swallowing.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Know low-cost community dental resources and provide them to participants.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Have napkins and water available to help with dry mouth, taste, and comfort.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.
      Multiple comorbidities
      “I believe this class will help with my blood pressure and diabetes.”

      “Continued ability to combine healthier and substantive meals for myself.”
      • Understand that participants likely have chronic health conditions that require attention to diet to prevent frailty and promote independence.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Teaching classes tailored to specific chronic disease states like diabetes, hypertension, cognitive impairment, and osteoporosis to meet specific macronutrient and micronutrient needs.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.
      SNAP indicates Supplemental Nutrition Assistance Program.
      a Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.

       Medications (Polypharmacy and Costs)

      Polypharmacy, commonly defined as taking greater than 5 medications, is frequent in older adults.
      • Masnoon N
      • Shakib S
      • Kalisch-Ellett L
      • Caughey GE
      What is polypharmacy? A systematic review of definitions.
      This can affect nutritional status and be associated with reduced intake of fiber, fat-soluble and B vitamins and minerals, and increased intake of cholesterol, glucose, and sodium.
      • Maher RL
      • Hanlon J
      • Hajjar ER
      Clinical consequences of polypharmacy in elderly.
      For example, some medications can cause anorexia (antidepressants such as selective serotonin reuptake inhibitors); other commonly used medications (laxatives) reduce availability of calcium, vitamins A, B2, B12, D, E, K; metformin, a conventional diabetes medication, reduces absorption of B12.
      • Powers JS
      • Buchowski M
      Nutrition and weight.
      In addition, older adults who have trouble affording medications may also struggle to purchase food.
      • Pooler JA
      • Srinivasan M
      Association between supplemental nutrition assistance program participation and cost-related medication nonadherence among older adults with diabetes.
      Thus, in persons with poor adherence to medications or concerns with medication costs, it is pertinent to screen for food insecurity. Finally, it is reasonable to involve the primary care physician or pharmacist directly if participant has questions about medications and food interactions. HTK programs can address these issues through several practical steps (Table 3).
      Table 3Veteran feedback and practice recommendations classified under the 5M domains of Medication, Mobility, and What Matters Most
      Veteran ResponsesPractice Recommendations
      Medications (polypharmacy and costs)
      “I am on warfarin and my doctor said I can't eat that.”• Address food and medication interactions or involve primary care provider and pharmacist.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Consider tailoring class to discuss common medications and their interactions with food: statins and grapefruit juice, thyroid medication and food or supplements containing iron, calcium or magnesium, warfarin, and foods high in vitamin K (greens, broccoli, brussels sprouts, asparagus, green tea) or alcohol, if appropriate general insulin management.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Ask participants about dietary restrictions and if they are on medications to manage diabetes or blood thinners that may influence dietary recommendations.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.
      Mobility (gait and balance impairment and falling risk):
      “A more kitchen-like room.”

      “Too far to walk to the bathroom to wash our hands.”

      “Providing a practical more conducive kitchen space to help students and staff be more comfortable.”

      “Higher seats.”

      “It was an awesome class but should be more accommodating for those with limited mobility. Constant in and out of chairs can aggravate issues… we need more time.”
      • Have a class in an ADA accessible room and near ADA accessible bathrooms.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Provide options or alternatives to both sitting and standing during hands-on activities and use stable serving dishes and light-weight utensils.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Furnish using tables with adjustable heights and firm, non-bucket chairs with sturdy arms and backs.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Involve primary care physician, and physical and occupational therapists to help fit and provide adaptive equipment to those individuals with functional impairments (ie, dexterity issues; reduced functional reach; reduced handgrip strength), and to refer for home kitchen safety and mobility concerns.
      Matters Most (goals and preferences of the individual):
      “I feel very blessed and fortunate to have experienced this as I see it, the teachers while not being aware of it, were actually doing ministry. I don't mean religious. Ministry to me is when people act out and share their skill sand time with others they are acting in love and that is what life is all about.”

      “The presenters were very professional, informative and seemed to really care about us and give us all the information we needed. I always felt really good and safe here and very motivated. It was fun!”

      “Being together and cooking.”

      “Meeting new people.”

      “Camaraderie.”

      “Conversations among the group.”

      “Learning to prepare healthy meals for my family and myself.”

      “The people.”
      • Elicit goals and preferences regarding nutrition, cooking education, and food options.

      • Allow time for open exchange of communication with mutual respect.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Use a personalized approach, such as self-assessment of behavior, to align class to participants’ goals.

      • Utilize instructors who are empathetic and proficient in motivational interviewing and facilitating dialog.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Allow for multiple opportunities of interactive involvement that is also self-directed and self-paced such as preparing and tasting foods or modifying recipes.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.


      • Capitalize on social, familial, and religious ties that already exist to support healthy behaviors.

      • Encourage social engagement and participation by providing time for discussion and sharing of personal experiences.
      Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.
      ADA indicates Americans with Disabilities Act.
      a Denotes practice recommendations, which were supported by the veteran response and literature review and were considered of high priority in program planning.

       Mobility (Gait and Balance Impairment and Falling Risk)

      One of 3 adults aged >65 years will fall in the subsequent year, and falling is the leading cause of fatal and nonfatal injury in older adults.

      Centers for Disease Control and Prevention. Ten leading causes of death and injury. https://www.cdc.gov/injury/wisqars/LeadingCauses.html. Accessed December 9, 2019.

      Age-related changes and multiple coexisting health conditions magnify the loss of lower extremity strength, balance impairment, and disturbances in gait observed in older adults.
      • Trombetti A
      • Reid K
      • Hars M
      • et al.
      Age-associated declines in muscle mass, strength, power, and physical performance: impact on fear of falling and quality of life.
      Nutrition is a crucial component to preventing sarcopenia and frailty,
      • Yannakoulia M
      • Ntanasi E
      • Anastasiou CA
      • Scarmeas N
      Frailty and nutrition: from epidemiological and clinical evidence to potential mechanisms.
      both risk factors for falling and fractures.
      • He H
      • Liu Y
      • Tian Q
      • Papasian C
      • Hu T
      • Deng H
      Relationship of sarcopenia and body composition with osteoporosis.
      Class structure and environment should be accessible and usable to persons of many different levels of functional mobility. Healthy Teaching Kitchen classes can address this by structuring classes to allow broad participation (Table 3).

       Matters Most (Goals and Preferences of the Individual)

      Teaching kitchen programs are designed to improve participants self-efficacy related to cooking and food intake and help individuals maintain or increase their positive health behaviors. However, because of the heterogeneity of the older adult population, a thoughtful and individualized approach is needed. The definition of successful aging varies from person to person. It may be defined as freedom from disease with good physical, mental, functional, and social health, but it may also be more nuanced, including values such as a sense of spirituality, culture, humor, and purpose.
      • Buchowski MS
      • Sidani MA
      • Powers JS
      Minority elders: nutrition anddietary interventions.
      Therefore, HTK should target a participant's preferences by merely asking what matters most to them and what they want to get out of each kitchen class session. Some ways to do this are listed in Table 3.

      IMPLICATIONS FOR RESEARCH PRACTICE

      The 5M Care philosophy is a framework to help health care systems and public health programs adapt their interventions to the needs and preferences of older adults and can be applied to teaching kitchens.
      Maintaining an overall healthy diet is essential across the lifespan. Interventions that focus on nutrition education and behavior should be inclusive of all ages, particularly the growing population of older adults. To this end, teaching kitchen educators and implementers may consider the 5M Care Philosophy framework when designing their interventions. Further research is still needed on which of the elements are most critical and whether incorporating a teaching kitchen nutrition intervention is a valid way to meet the needs of a broad spectrum of older adults. By incorporating age-friendly principles into HTKs, older adults may benefit more from this type of nutrition intervention; the more rigorous study is warranted. With these manageable practice recommendations and few additional resources, teaching kitchen education or similar nutrition programming could feasibly implement curriculum accessible to all.

      ACKNOWLEDGMENTS

      This work was supported by the Veteran Affairs Office of Academic Affiliations and Veteran Health Affairs Nutrition and Food Service. The authors thank the Healthy Teaching Kitchen program dietitians and staff across the Veterans Health Administration, who serve veterans and contribute to Healthy Teaching Kitchens at Veterans Administration Puget Sound, Whole Health, Geriatric Research Education and Clinical Center, Mental Health, Voluntary Services, and Rehabilitation Medicine Service Lines. This study presents the findings and conclusions of the authors and does not necessarily represent the Veterans Administration. This study represents US government work and is public domain.

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