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Nutrition and Aging, Florida International University, OE 200, Miami, FL ... University, Biscayne Bay, ACI-234, North Miami, FL 33181-3000 (E-mail: elfenbep@ fiu.edu). ... study evaluating college textbooks for aging content in introductory.
Aging in Community Nutrition, Diet Therapy, and Nutrition and Aging Textbooks Peggy Schafer O’Neill, MS, RD Nancy S. Wellman, PhD, RD, FADA Susan P. Himburg, PhD, RD, FADA Paulette Johnson, PhD Pamela Elfenbein, PhD, MSW

ABSTRACT. Using content analysis, this study evaluated the aging content and context in 11 nutrition sub-specialty textbooks: community nutrition (n = 3), diet therapy (n = 4), and nutrition and aging (n = 4). Pages with paragraphs on aging were identified in community nutrition and diet therapy textbooks, and 10% random samples of pages were evaluated in nutrition and aging textbooks. Paragraphs were assigned to one of four categories: gerontology, nutrition as primary, nutrition as secondary, or tertiary prevention. A total of 310 pages was qualitatively Peggy Schafer O’Neill is Clinical Dietitian, Hillcrest Nursing & Rehabilitation Center, 4200 Washington Street, Hollywood, FL 33021 (E-mail: [email protected]). Nancy S. Wellman is Professor and Director, National Policy and Resource Center on Nutrition and Aging, Florida International University, OE 200, Miami, FL 33199 (E-mail: [email protected]). Susan P. Himburg is Professor, Department of Dietetics and Nutrition, Florida International University, HLS 441, Miami, FL 33199 (E-mail: [email protected]). Paulette Johnson is Statistical Consultant, Florida International University, DM 409D, Miami, FL 33199 (E-mail: [email protected]). Pamela Elfenbein is Director of Education and Training, Center on Aging, Florida International University, Biscayne Bay, ACI-234, North Miami, FL 33181-3000 (E-mail: elfenbep@ fiu.edu). This study was supported in part by grant #90AM2390 from the Administration on Aging, U.S. Department of Health and Human Services, Washington, DC 20201. Gerontology & Geriatrics Education, Vol. 25(3) 2005 http://www.haworthpress.com/web/GGE © 2005 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J021v25n03_05

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66

GERONTOLOGY & GERIATRICS EDUCATION

analyzed using NUD*IST 5 software and quantitatively with percentages. Only 7% of community nutrition and 2% of diet therapy pages were devoted to aging. There was little integration of aging beyond the chapters on aging. Community nutrition had the most gerontology (30%) and primary prevention (43%) content. Diet therapy and nutrition and aging had more secondary prevention (33% and 42%, respectively) and tertiary prevention (27% each) content. Some important databases and studies were absent. Of the 1,239 ageism words, 10% were positive, 53% neutral, and 36% negative. Photographs were generally positive. Women, but not minorities, reflected current older adult demographics. Future textbook editions should address aging more comprehensively and positively to better prepare dietitians for the job market. Recommendations for authors, course instructors, and publishers are given. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2005 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Aging, content analysis, nutrition textbooks, community nutrition, diet therapy

Discipline textbooks are a partial reflection of how educational programs address aging issues, and the words describing older adults are of equal importance to the topics presented on aging (Chafetz, Holmes, Lande, Childress, & Glazer, 1998; Palmore, 1999). Students’ points of view and attitudes about working with a populations are influenced by the population’s representation in textbooks (Johns, 1997). Research has found that ageism, especially the negative stereotyping of older adults, is a contributing factor to discouraging health professionals from pursuing careers working with older adults (Kerschner & Pegues, 1998; Lomax, 1992; Palmore, 1999; Wetle, 1997). Research has also shown that reduced stereotyping has resulted from exposure to positive materials about older adults (Guo, Erber, & Szuchman, 2001; Ragan & Bowen, 2001). Educating students about the heterogeneity of aging can stimulate their interest, instill healthy attitudes, and provide the necessary, accurate, and current knowledge to help prepare for careers working with older adults (Center for the Health Professions, 1999; Stoller & Gibson, 2000). Many textbooks have been evaluated for aging content, including 91 high-school texts (Markson & Pratt, 1996), undergraduate sociol-

O’Neill et al.

67

ogy texts (Stolley & Hill, 1996), gerontology texts (Kalab, 1985), and psychology texts (Krauss Whitbourne, & Hulicka, 1990). A recent study evaluating college textbooks for aging content in introductory and lifecycle nutrition textbooks (Wellman, Kondracki, Johnson, & Himburg, 2004) reported that nutrition textbooks generally failed to present aging comprehensively or positively, and concluded that these texts might not help students develop positive attitudes about aging nor acquire the broad knowledge needed to work successfully with older adults. Consequently, it is not surprising that dietetics and nutrition students have neutral attitudes toward older adults, low knowledge of aging, and prefer to work with younger age groups (Kaempfer, Wellman, & Himburg, 2002). Similar findings have been documented for other health professions, including nursing, medicine, pharmacy, and social work (Burg, Waddell, Doty, Horne, Weilgas, & Davidson, 2001; Carmel, Swikel, & Galinsky, 1992; Knowles & Sarver, 1985; Williams, Lusk, & Kline, 1986). Based on an in-depth environmental scan (Jarratt & Mahaffie, 2002), the American Dietetic Association (ADA) recently identified aging as a strategic area for the profession. The American Dietetic Association (2000) position statement, “Nutrition, Aging, and the Continuum of Care,” points out the importance of adequate preparation of dietetics students for the changing health care environment. Almost nine in 10 older adults have one or more chronic diseases in which nutrition therapy can effectively improve health and quality of life outcomes (Committee on Nutrition Services for Medicare Beneficiaries, 1999), and nutrition therapy has been added to the list of reimbursable Medicare treatments. The Committee (1999) explicitly identified the registered dietitian (RD) as the preferred provider of nutrition therapy. Thus, dietetics and nutrition students, most of whom will take a national examination to become RDs, will likely be providers of nutrition services to the growing number of older adults in the future. All students are required to take community nutrition and diet therapy courses as part of the core requirements in undergraduate didactic programs. More often, the nutrition and aging course(s) is/are, depending on the curriculum and faculty expertise, taught in graduate programs (Rhee, Wellman, Castellanos, & Himburg, 2004). This study evaluated the aging content of community nutrition, diet therapy, and nutrition and aging textbooks.

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GERONTOLOGY & GERIATRICS EDUCATION

MATERIALS AND METHODS Content Analysis Berg (1998) describes content analysis as “an objective coding scheme,” and Duncan (1989) as “a technique, which lies at the crossroads of qualitative and quantitative methods.” Overall, content analysis can help determine the “actual” content of books and any type of media. It can improve the understanding of the effectiveness of nutrition education and counseling and ultimately effect student understanding, knowledge, and attitudes in working with clients (Shepherd & Achterberg, 2003). Textbook and Page Selection This study evaluated the content and context of aging in three community nutrition (CN), four diet therapy (DT), and four nutrition and aging (NA) textbooks (Table 1). The sample included all nutrition sub-specialty textbooks in these areas published between 1998 and 2001. Pages with paragraphs on aging were identified and analyzed in CN and DT textbooks. For NA textbooks, a 10% random sample of pages was used. This study also assessed whether important databases, summary publications, and longitudinal studies were included in the texts. Publishers’ permission to scan the identified text-only pages (excluding pictures and tables) was obtained. Three publishers did not grant permission. These books (Owen, Splett, Owen: Nutrition in the Community; Schlenker: Nutrition in Aging; Shils: Modern Nutrition in Health and Disease) were manually analyzed for content, context, and other relevant data. Pages in the other books were scanned using optical character recognition technology (OmniPage Pro 10, Phoenix, AZ; version 10.0, 2000) to convert the selected text pages to plain text files and subsequently to word documents. The 10% random samples of NA pages were obtained with the aid of S-Plus software (Insightful Corporation, Seattle, WA; student edition, 2000). A more comprehensive analysis of each individual text was done using Non-numerical Unstructured Data Indexing (NUD*IST) Software 5 (N5) program (Qualitative Solutions and Research Ltd, Scolari Sage Publications Software, Thousand Oaks, CA; version 5.0, 2000). The total number of pages on older adults was compared to total pages in each CN and DT textbooks. In addition, percentages were calculated comparing pages on older adults in dedicated chapters on aging to pages on older adults that were dispersed throughout the books.

69

Sub-specialty total:

Sub-specialty total:

*10% random sample of pages analyzed

1470

380(100)

380* 360*

Schlenker, E. D. (1998). Nutrition in aging.

Watson, R. R. (2001). Handbook of nutrition in the aged.

1470(100)

360(100)

510(100)

220* 510*

Chernoff, R. (1999). Geriatric nutrition.

220(100)

59(2)

8(2)

13(1)

18(4)

20(2)

104( 7)

37(6)

25(7)

42(8)

Total

American Dietetic Association. (1998). Nutrition care of the older adult.

Nutrition & aging

465

Williams, S. R. (2000). Basic nutrition & diet therapy.

3836

1882

480

Shils, M. (1999). Modern nutrition in health & disease.

1009

Peckenpaugh, N. J., & Poleman, C. M. (1999). Nutrition essentials & diet therapy.

Diet therapy

Mahan, L. K., & Escott-Stump, S. (2000). Krause’s food, nutrition & diet therapy.

1535

630

Owen, A. L., Splett, P. L., & Owen, G. M. (1999). Nutrition in the community. Sub-specialty total:

378

Endres, J. B. (1998). Community nutrition: Challenges & opportunities.

No. 527

Boyle, M. A., & Morris, D. H. (1998). Community nutrition in action.

Community nutrition

Total pages in book

n/a

n/a

n/a

n/a

51( 86)

8(100)

7(54)

18(100)

18(90)

87( 84)

32(86)

23(92)

32(76)

Number (%)

In chapters

Pages on aging

n/a

n/a

n/a

n/a

8(14)

0

6(46)

0

2(10)

17(16)

5(14)

2(8)

10(24)

Dispersed

TABLE 1. Number of Pages on Aging and Their Location in Nutrition Textbooks and by Sub-Specialty

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GERONTOLOGY & GERIATRICS EDUCATION

Content Analysis of Aging Topics, Photographs, References, and Ageism Terms Aging topics. The scanned texts were coded using paragraphs as the unit of text analysis. A codebook with gerontological topics of aging and subcategories was modified to include categories of primary, secondary, and tertiary prevention in relation to nutrition. Each paragraph was placed into one of these nutrition categories or into gerontology. Primary nutrition prevention focuses on health promotion; secondary on risk appraisal and risk reduction; and tertiary on nutrition therapy for chronic diseases and rehabilitation (Kaufman, 1990; Shamansky & Clausen, 1980). The number of paragraphs in each category is an indication of how the textbook portrays aging. The content analysis process evaluated the extent of coverage of gerontology and primary, secondary, and tertiary nutrition prevention in each book, based on the focus of each paragraph. References. A list of important databases, summary publications, and longitudinal studies on aging was developed to track the inclusion of such information in the textbook collection. Ageism terms. Within the scanned texts, N5 software was used to count and categorize ageism terms as positive, neutral, or negative (Palmore, 1999). Manual verification of the term’s reference to older adults was done, as some terms can be non-ageism adjectives. Counts of positive, neutral, and negative aging words were determined for each textbook to document the extent of word usage. Photographs. Pictures of older adults were compared to each book’s total number of pictures. They were coded as positive, neutral, or negative; by gender; and by minority status using a set of established guidelines. For example, people who generally looked independent, happy, and without obvious ailments were considered positive. Neutral images generally portrayed the older adult as neither happy nor sad and not needing assistance with daily living. Negative images portrayed older adults as dependent, ill, and/or generally discontented. Three raters, including the primary researcher, assessed all the photographs. Statistical Analysis Analytical methods included counts of pages with paragraphs on aging, percent calculation of integration of paragraphs into chapters on older adults versus information dispersed though the textbook, and the numbers of paragraphs among the nutrition sub-specialties.

O’Neill et al.

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RESULTS Textbook and Page Data A total of 310 pages on aging were identified and evaluated across the 11 textbooks including the 10% random sample of NA pages (Table 1). Only 7% of CN and 2% of DT pages were devoted to aging. There was little integration of aging in these books, as 85% of pages with aging content were in the chapters about older adults. This analysis was not done for NA textbooks. Content Analysis of Aging Topics, Photographs, References, and Ageism Terms Aging topics. Counts of paragraphs showed large differences in the aging topics emphasis in the 11 textbooks and among the three nutrition sub-specialties (Table 2). CN textbooks included the most gerontology (30%) and primary prevention (43%) and less secondary (15%) and tertiary prevention (5%) content. Gerontology and primary prevention were generally low in DT textbooks (24%, 11% respectively) and NA textbooks (18%, 10% respectively). Of pages with aging content, DT and NA textbooks had more secondary prevention (33%, 42% respectively) and tertiary prevention (27% each). Demographics, supportive services, and assessment received the most coverage overall, and ethical issues, stress, and theories of aging received very little coverage (Table 2). There was no discussion of ageism, discrimination, or prejudice against older adults. Health care issues such as caregiving, hospice, and quality assurance measures in long-term care were also not included. Case studies with older adults were used as instructional tools in only six books. Differences in the number of paragraphs among the nutrition subspecialties were observed for primary and secondary nutrition prevention. For primary prevention, the number of paragraphs for each of the CN textbooks was greater than for any of the DT and for NA. This was expected since CN textbooks’ educational objectives focus on health promotion and disease prevention. For secondary prevention, there was large variability of pages among nutrition sub-specialties. NA textbooks have inherently more content on aging, but their focus tends to be secondary prevention, which incorporates nutrition assessment and nutrient requirements of older adults.

0

0

34(52) 30(46) 1( 2)

Health promo/disease prevention Supportive services Training health professionals

1o prevention: sub-total 65(57)

Stress Theories of aging

0

1( 3) 0

Social support

0

0

63(72)

24(28)

87(47)

0

26(38)

0 1( 3)

1(1)

16(24)

Public policy

Quality of life

2( 3)

1(1)

16(24)

5(7)

1(1)

68(36)

Endres

Psychological, mental health

2( 6) 4(11)

Lifestyle factors

0 0

Financial aspects

Demographics Ethical issues

0 21(58)

Death & dying

7(19)

36(31)

Boyle & Morris

Aging process

Gerontology: sub-total

Topics

Textbook author(s)

Owen et al. 1( 2)

16(36)

28(62)

45(28)

0

0

4(12)

3( 9)

1( 3)

1( 3)

3( 9)

2( 6)

0

14(41)

1( 3)

5(15)

34(22)

Sub-specialty Total 197(43)

138(30)

Mahan & Escott-Stump 0

11(92)

1(8)

12(10)

7(21)

1(3)

0

1(3)

3(9)

1(3)

6(18)

1(3)

0

3( 9)

0

11(32)

34(30)

Sub-specialty Total

Williams

Peckenpaugh & Poleman 0

11(73)

4(27)

15(24)

0

0

2(50)

0

0

0

0

1(25)

0

1(25)

0

0

4(6)

0

0

0

0

0

0

0

3(20)

0

0

10(67)

0

0

0

0

2(13)

15(20)

0

7(100)

0

7(15)

0

0

0

3(16)

0

0

2(11)

1( 5)

0

5(26)

0

8(42)

19(40)

34(11)

72(24)

Paragraphs on aging: Number (%)

Shils

Diet therapy

Am Dietetic Association 12(38)

16(50)

4(13)

32(17)

0

0

0

1( 7)

4(27)

0

0

1( 7)

7(47)

2(13)

0

0

15( 8)

1( 3)

13(38)

20(59)

34(12)

1( 4)

0

0

0

0

4(15)

8(30)

0

0

1( 4)

0

13(48)

27(10)

Nutrition & aging a

0

4(80)

1(20)

5( 3)

0

0

1(1)

14(19)

8(11)

0

11(15)

1(1)

0

18(24)

0

21(28)

74(33)

Schlenker

Community nutrition

Chernoff

TABLE 2. Paragraphs on Aging Topics in Nutrition Textbooks and by Sub-Specialty

0

1(7)

13(93)

14(10)

0

0

1(3)

1(3)

4(11)

0

5(14)

0

1(3)

2(5)

0

23(62)

37(23)

Watson

72

85(10)

157(18)

Sub-specialty Total

73

0

Nutritional requirements

10% random sample of pages

a

Total paragraphs on aging

Aging case studies: sub-total

Nutrition therapy

115

0

2(100)

2(2)

12(10)

Nutrition assessment

3o prevention: sub-total

12(10)

Boyle & Morris

2o prevention: sub-total

Topics

Textbook author(s) Endres 187

0

5(100)

5(3)

9(33)

18(67)

27(14)

Owen et al. 158

34(22)

17(100)

17(10)

11(39)

17(61)

28(18)

Sub-specialty Total 460

34( 7)

24(5)

67(15)

Mahan & Escott-Stump 118

4( 3)

31(100)

31(26)

31(84)

6(16)

37(31)

Sub-specialty Total

Williams

Shils

3( 5)

20(100)

20(32)

13(62)

8(38)

21(33)

75

0

26(100)

26(35)

21(62)

13(38)

34(45)

48

7(15)

6(100)

6(13)

9(100)

0

9(18)

304

14( 5)

83(27)

101(33)

Paragraphs on aging: Number (%)

Peckenpaugh & Poleman 63

Diet therapy Am Dietetic Association 193

12( 6)

6(100)

6(3)

16(13)

112(88)

128(66)

273

0

145(100)

145(53)

35(52)

32(48)

67(25)

Chernoff

225

10( 4)

28(100)

28(12)

73(68)

35(32)

108(48)

0

55(100)

55(34)

42(74)

15(26)

57(35)

Watson 163

Nutrition & aging a Schlenker

Community nutrition

859

23( 3)

234(27)

360(42)

Sub-specialty Total

74

GERONTOLOGY & GERIATRICS EDUCATION

References. Textbooks were searched within their aging chapter, or all chapters of NA books, for references to several important national databases, summary publications, and longitudinal studies. Omissions included several databases (Table 3) that provide detailed information about aging cohorts. For example, the Third National Health and Nutrition Examination Survey (NHANES III) and the Continuing Survey of Food Intake of Individuals (CSFII) now pay closer attention to older adults having eliminated an upper age limit for their sample (National Center for Health Statistics, Centers for Disease Control and Prevention [NCHS, CDC], 1999; U. S. Department of Agriculture [USDA], 2003). One DT textbook (Peckenpaugh & Poleman) included no important sources about aging (Table 3); two others (Williams in DT) and (American Dietetic Association in NA) included only Healthy People and a single longitudinal aging study (Table 3). Only five referenced the Older Americans Nutrition Program although it is the largest federal nutrition assistance program for older adults (Ponza et al., 1996). None included either federal summary on the nutritional, social, economic, and other challenges unique to older adults (Federal Interagency Forum on Aging-Related Statistics, 2000; NCHS, CDC, 2003). Most of the 18 longitudinal studies (see Table 3 footnotes; also see reference list) that depict the heterogeneity of aging have regularly updated websites. Yet, only six textbooks mentioned any of them with half of these referencing only one. Ageism terms. Of the 1,239 ageism words identified, usage varied greatly. Overall, 10% were positive, 53% neutral, and 36% negative (Table 4). CN textbooks contained the greatest percentage of positive terms (28%) thanks primarily to one book’s influence. CN books also had 50% neutral and 22% negative terms. DT textbooks had only 1% positive and 59% negative terms. In the 10% random sample of pages in NA textbooks, only 1% of terms were positive, 62% neutral, and 37% negative. Photographs. Of the 130 total photographs in the 11 textbooks, 41 (32%) showed older adults (Table 5). In CN textbooks, 15% included older adults. In the three DT books with pictures, 12% were of older adults. Two of the four NA books had pictures and all 28 (100%) were of older adults. Photographs in all textbooks were generally positive (87%). Less than 13% of people in photographs were rated negatively, and none were considered neutral. There was an inter-rater reliability of 0.94 for all photographs with older adults. The proportion of older adults in photographs in CN (15%) and DT (12%) books reflected the current U.S. older population demographic of

75

Longitudinal aging studies (see below)

c

b

yes

yes

U. M. Center on demography on aging GA centenarian study (Johnson et al., 1993) Rotterdam study (Erasumus Medical Center) The health and retirement study (NIA) The Berlin aging study The Okinawa centenarian study i

h

g

Older Americans 2000: Key indicators of well-being (Federal Interagency Forum, 2002)

Health United States 1999 with Health & Aging Chartbook (NCHS CDC)

National summary publications

National evaluation of the Elderly Nutrition Program (Ponza et al., 1996)

Continuing survey of food intake of individuals & diet & health knowledge survey (USDA)

N. M. aging process study (Garry et al., 1989) San Luis Valley health & aging (Marshall et al., 1999) Longitudinal studies of aging (NCHS, NIA) d Baltimore longitudinal study of aging (NIH) e The SENECA study of Europe (European) f Alameda health study (Breslow & Breslow, 1993)

a

Endres a

yes

yes

Shils yes

yes

Chernoff b

c

d,e

yes

yes

yes

2010 2000 2000

Am Dietetic Association

Peckenpaugh & Poleman

d,f-h

yes

yes

yes

2000

Canadian study of health & aging Aging in Manitoba longitudinal study The nun study (University of Kentucky) The Amsterdam study Comparative study of aging & health in Asia New England centenarian study (Boston Univ.)

yes

yes

yes

Boyle & Morris 2000 2000 2000 2010

Owen et al.

Third National Health & Nutrition Examination Survey (NCHS CDC, 1999)

Nutrition & aging

Schlenker

Diet therapy

Mahan & Escott-Stump

Healthy People 2000 or 2010 (USDHHS, 1990 or 2000)

National databases

Textbook author(s)

Community nutrition

Williams

TABLE 3. Inclusion of National Databases, Summary Publications, and Longitudinal Studies on Aging in Nutrition Sub-Specialty Textbooks

e,i

yes

yes

2000

Watson

76

a

0

Williams, S. R. (2000). Basic nutrition & diet therapy.

0

Watson, R. R. (2001). Handbook of nutrition in the aged.

on 10% random sample of pages

5(2)

Schlenker, E. D. (1998). Nutrition in aging.

Total

130(10)

5(1)

0

Sub-specialty total

0

American Dietetic Association. (1998). Nutrition care of the older adult. Chernoff, R. (1999). Geriatric nutrition.

Nutrition & aging a

0

Shils, M. (1999). Modern nutrition in health & disease.

2(1)

0

Sub-specialty total

2(2)

Peckenpaugh, N. J., & Poleman, C. M. (1999). Nutrition essentials & diet therapy.

Diet therapy

123(28)

Mahan, L. K., & Escott-Stump, S. (2000). Krause’s food, nutrition & diet therapy.

Sub-specialty total

115(56)

4(3)

Owen, A. L., Splett, P. L., & Owen, G. M. (1999). Nutrition in the community.

4(4)

Endres, J. B. (1998). Community nutrition: Challenges & opportunities.

Positive

Boyle, M. A., & Morris, D. H. (1998). Community nutrition in action.

Community nutrition

659(53)

329(62)

27(29)

185(76)

96(55)

21(100)

106(40)

36(75)

9(33)

31(47)

30(25)

224(50)

84(41)

71(51)

69(67)

Number (%)

Neutral

450(36)

197(37)

66(71)

52(21)

79(45)

0

154(59)

12(25)

18(67)

35(53)

89(74)

99(22)

5(2)

64(46)

30(29)

Negative

TABLE 4. Number and Type of Ageism Terms on Pages with Paragraphs on Aging in Nutrition Textbooks and by Sub-Specialty

77

a b

1

Negative

1

Male

4 0

Non-minority Unknown

2

Endres 0

1

0

1

0

1

0

0

1(50)

2

Owen et al. 0

0

0

0

0

0

0

0

0

Sub-specialty total 0

5(100)

0

2(40)

3(60)

2(40)

0

3(60)

3(15)

20

Mahan & Escott-Stump 0

6

1

0

7

1

0

6

5(14)

35

Peckenpaugh & Poleman 0

1

0

0

1

0

0

1

1(4)

25

Diet therapy

0

0

0

0

0

0

0

0

0

0

Williams 1

4

1

4

2

2

0

4

4(18)

22

82

Sub-specialty total 1(7)

11(79)

2(14)

4(29)

10(71)

3(21)

0

11(79)

10(12)

0

AM Dietetic Association 0

0

0

0

0

0

0

0

0

1

Chernoff 0

1

0

0

1

1

0

0

1(100)

27

27

0

0

14

13

0

0

27

27(100)

Schlenker

Nutrition & aging

0

0

0

0

0

0

0

0

0

0

Watson

Community nutrition

Shils

selected according to criteria. some pictures included more than one older adult; each person was characterized separately.

0

Minority

Ethnicity

3

Female

Gender

3 0

Neutral

b

2(13)

16

Boyle & Morris

Positive

Characteristic

Pictures with older adultsa

Pictures of people

Textbook author(s)

27(96)

1(4)

0

14(50)

14(50)

1(4)

0

27(96)

28(100)

28

Sub-specialty total

TABLE 5. Number (%) and Characteristics of Pictures of Older Adults in Nutrition Textbooks and by Sub-Specialty

28(60)

17(36)

2( 4)

20(43)

27(57)

6(13)

0

41(87)

41(32)

130

Total

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12.3% (Administration on Aging [AoA], 2003). Likewise, the older adult gender ratio was close to today’s 141 females for every 100 males. This ratio increases with age, from 116 for the 65-69 age group to 240 for the 85+ group. CN textbooks pictures had a 150 gender ratio, reflecting the average for older adults. DT textbooks pictures had a 245 ratio, reflecting the ratio of the 85+ group. The 14% of photos in DT textbooks reflected the 16% older minority population today (AoA, 2003). However, there were no minorities in photographs in CN and NA textbooks. Inter-rater reliability was 1.00. DISCUSSION Content Analysis of Aging Topics, References, Ageism Terms, and Photographs Overall, the findings in these nutrition sub-specialty textbooks are consistent with those of a previous study of the aging content in introductory and lifecycle nutrition textbooks (Wellman et al., 2004). That study and the present one show that the combined 22 nutrition textbooks generally fail to present aging comprehensively, across topics, or positively. This study agrees with Palmore’s (1999) claim that health professionals learn little about normal aging and primarily about the pathology and diseases related to aging. There were gaps in the aging content of the 11 nutrition sub-specialty textbooks as coverage of aging topics varied. Important national databases are omitted in relation to older adults. The two federal summary report on aging are not referenced. Six of the 11 textbooks make no mention of any longitudinal study on aging. Admittedly, the typical time lag in publication of a textbook limits the incorporation of some of these references. However, most studies had been published two or more years prior to textbook publication dates. Photographs of older adults are positive overall with the proportion of pictures approximating the 13% of older Americans. Gender ratios in the seven books with pictures tend toward the current demographics of older adults on average, but DT textbook pictures reflect the ratio of the 85+ group. Four of the seven books depict more women than men. No older minorities are pictured in CN and NA textbooks. The nutrition sub-specialty textbooks in community nutrition and diet therapy are used in upper level undergraduate courses. Only a few

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universities offer undergraduate nutrition courses in aging but may use the nutrition and aging sub-specialty texts. They are more often used in graduate courses. Nevertheless, dietetics students will work with older adults in wellness, community, clinical, and long term care settings where they will provide the full range of preventive nutrition services, from general nutrition education to medical nutrition therapy. The sub-specialty texts should more comprehensively and positively present gerontological topics and nutrition as primary, secondary, and tertiary prevention for healthier aging. This will help students understand the heterogeneity of aging and acquire the knowledge and skills needed to work effectively with older adults. Similar to suggestions made by Wellman et al. (2004) for introductory and life cycle nutrition textbooks, we offer the following recommendations to improve coverage of aging in future editions of sub-specialty nutrition textbooks for community nutrition, diet therapy, and nutrition and aging. Textbook authors should: • Add newer information and references, expand discussion of underdeveloped topics, and revise the language that describes aging and older adults; • Invite specialist co-authors or chapter/section authors. Outside gerontological experts could be used; they can add valuable knowledge and insights about aging; and • Incorporate more current public domain data and information from primary sources and federal agency and summary reports. Course instructors should: • Become aware of textbooks’ shortcomings in aging content and consider those shortcomings when selecting course textbooks; • Require additional gerontological material and other readings to broaden students’ knowledge about aging; • Use case studies of older adults to highlight the myriad settings where preventive nutrition services are likely to be important; • Invite faculty colleagues who specialize in gerontology and dynamic clinical nutrition practitioners who work with older adults as guest lecturers; and • Recruit spirited endearing older adults to class to provide real-life examples of those who have made and continue to make diet and

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nutrition changes to help preserve their independence and quality of life. Publishers should: • Issue anti-ageism bias guidelines or implement those of national organizations, such as the American Psychological Association (2001). CONCLUSION Future editions of nutrition sub-specialty textbooks need to include more comprehensive coverage of aging to help students develop positive attitudes, greater knowledge, and a stronger interest in working with older adults. A broader impartial discussion of aging in these textbooks, especially regarding the positive role of nutrition as primary and secondary prevention in later years, would help prepare and encourage the future workforce of dietitians to meet the nutritional needs and interests of this burgeoning population segment. REFERENCES Administration on Aging. (2003). A Profile of Older Americans: 2003. Washington, DC: U.S. Department of Health and Human Resources. Retrieved April 7, 2004, from http://www.aoa.gov/ Aging in Manitoba 1996 longitudinal study. Retrieved April 7, 2004, from http://www. umanitoba.ca/academic/faculties/medicine/community_health_sciences/aim/ American Dietetic Association Position Statement. (2000). Nutrition, aging, and the continuum of care. Journal of the American Dietetic Association, 100, 580-595. Berg, B. (1998). Qualitative research methods for the social sciences. Boston, MA: Allyn & Bacon. Boston University School of Medicine. The New England centenarian study. Retrieved April 7, 2004, from http://www.bumc.bu.edu/Departments/HomeMain.asp? DepartmentID=361 Breslow, L., & Breslow, N. (1993). Health practices and disability: Some evidence from Alameda County. Preventive Medicine, 22, 86-95. Burg, M. A., Waddell, R., Doty, R., Horne, C., Weilgas, C., & Davidson, R. (2001). Student interest in geriatric medicine: Comparing beginning medical, nursing, and pharmacy students. Gerontology & Geriatrics Education, 21 (4), 1-12. Carmel, S., Swikel, J., & Galinsky, D. (1992). Changes in knowledge, attitudes, and work preferences following courses in gerontology among medical, nursing, and social work students. Educational Gerontology, 18, 329-342.

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