Download Seniors Fight Falls and Fractures

Seniors Fight Falls and Fractures!
Introduction and Goals
“Seniors Fight Falls and Fractures!” is a joint initiative among the Georgia Division of Aging
Services, the aging services network, and the Department of Foods and Nutrition, University of
Georgia, and is part of the “Live Healthy Georgia – Seniors Taking Charge!” campaign.
“Seniors Fight Falls and Fractures!” is a community intervention designed for community
settings, such as senior centers that have Older Americans Act Nutrition Programs. The goals
are to encourage older people to talk with their doctor about falls, fractures, and osteoporosis;
increase physical activity; promote healthy eating; improve intake of milk products, calcium and
vitamin D; take medications properly; improve home safety; reduce the risk of falling; improve
vision care; and have a bone mineral density test.
Why Focus on Falls and Fractures?
Osteoporosis-related fractures are costly – but preventable (Burge et al., 2000). In Georgia, the
estimated annual number of osteoporosis-related fractures is expected to increase from 34,400 in
2010 to 43,800 in 2020, resulting in an annual cost of almost $500 million by 2020, with twothirds of these costs incurred by people age 75 and older. About 95% of hip fractures are caused
by falls. Up to 25% of community-dwelling older adults who sustain hip fractures remain in
long-term care for at least one year. Healthy eating and regular physical activity, improvements
in home safety and medication management, and regular check-ups can reduce the risks of
osteoporosis, bone fractures, and falls. Here are some more facts about fractures and falls in
Georgia:
Osteoporosis-related bone fractures and costs in Georgians aged 50+ in 2010
 800 to 1,600 deaths per year from hip fractures
 8,890 hip fractures ($34,766 in annual direct medical costs per fracture)
 34,463 total fractures
 $396 million in annual direct medical costs
Falls and fall-related injuries in older Georgians
 95% of hip fractures caused by falls
 Falls are a leading cause of traumatic brain injuries
 More than one-half of adults aged 85+ fall at least once each year
 More than one-third of adults aged 65+ fall at least once each year
 Older adults are more likely to be hospitalized from falls than younger adults
 9,000+ adults aged 65+ are hospitalized annually for falls
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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34% are discharged to long-term care
440 adults aged 65+ die each year from falls
Main risk factors for falls are muscle weakness, history of falls, problems with balance,
gait or vision, and use of an assistive device (e.g., cane or walker)
60% of fatal falls occur in the home
Cost and prevalence estimates were extrapolated from the following sources:
Burge, R.T., Worley, D., King, A.B. The Cost of Osteoporosis in Georgia: Projections for 2000
– 2025. Proctor & Gamble Pharmaceuticals. September 8, 2000.
http://www.gafp.org/documents/osteoporosis_cost_projection.pdf.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
2000 – 2007 Georgia Unintentional Fall Deaths and Rates per 100,000. Report generated by the
Web-based Injury Statistics Query and Reporting System (WISQARS).
http://www.cdc.gov/injury/wisqars/index.html.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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Community Intervention
Reducing the risk of falls, fractures and osteoporosis will save health care costs and improve the
quality of life for older Georgians. “Seniors Fight Falls and Fractures!” is a community
intervention to help reduce these risks in older people. The intervention includes eight lessons
that emphasize the health benefits of healthy eating and physical activity, provide menus and
recipes, and promote physical activities, such as walking and chair exercises. There are games
and activities to make the lessons fun.
The nutritional information is based on the new 2010 Dietary Guidelines for Americans that
recommends three servings of milk products daily and two to three cups of vegetables and one
and a half to two cups of fruits daily. The Georgia Division of Aging Services requires that
meals funded by state and federal funds under the Older Americans Act Nutrition Program meet
the 2010 Dietary Guidelines for Americans. So, people served by these programs receive at least
one milk product, such as one cup of milk, and at least three servings of fruits and vegetables
with lunch. Because the prevalence of diabetes and the risk of getting diabetes is high among
older people in Georgia, the menus and recipes illustrate healthy food patterns for people with or
without diabetes. The menus provide about 1,800 calories, and the number of carbohydratecontaining foods (15 grams per serving) is three to four in the meals and one to two in the
snacks.
Target Audience
The target audience of older adults at senior centers includes many individuals with lifestylerelated diseases such as osteoporosis, diabetes, hypertension, and heart disease that may benefit
from changes in diet and physical activity. Participants may also have low socioeconomic status
and face challenges when making changes in their diet, physical activity, and other health-related
habits. Those enrolled in the program may benefit from having a family member, friend, and/or
caregiver attend as well to help the participant implement the recommended changes in their
health behaviors.
Setting
This community intervention can be delivered at senior centers. Community-based interventions
conducted at senior centers have been shown to be effective in changing knowledge and
behaviors related to nutrition, physical activity, and health among older adults in Georgia (Bell et
al., 2009; Burnett, 2003; Cheong et al., 2003; Ellis et al., 2005; Fitzpatrick et al., 2008; Hendrix
et al., 2008; Johnson et al., 2006; Lee et al., 2010; McCamey et al., 2003; Redmond, 2004; Speer
et al., 2008; Teems et al., 2011; Wade, 2003). The intervention may benefit seniors in other
settings as well.
Educators
The lessons are designed to be delivered by a person with a background in health and wellness,
but not necessarily a nurse or registered dietitian. Educators can invite additional speakers with
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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expertise in various aspects of health and wellness from their local health department, hospitals,
pharmacies, and cooperative extension service.
Rationale for Evaluation with Pre-tests and Post-tests with Questionnaires
This program was evaluated by conducting pre-tests and post-tests of the participants (before and
after the lessons). The pre- and post-tests included a series of questions about knowledge and
behaviors related to prevention of falls, fractures, diabetes, and heart disease, as well as
practicing healthy dietary habits and physical activity. The evaluation helped determine how
well this program improves dietary, physical activity, and other health-related knowledge and
behaviors.
Timeline and Results of Evaluation
During November through December 2006, staff from The University of Georgia visited each
Planning Service Area to provide technical assistance to the Wellness Coordinator and their
educators with administering informed consent and the pre-test to older adult participants to
collect the required outcome information.
From January through April 2007, Wellness Coordinators, their educators, and other partners
delivered the educational interventions at senior centers in Georgia.
In May 2007, staff from The University of Georgia visited each Planning Service Area to assist
the Wellness Coordinator, their educators, and other partners with administering a post-test to
older adult participants to collect the required outcome information.
From June through August 2007, The University of Georgia analyzed the outcome information
and completed a report summarizing the findings of the study, which were disseminated to all
stakeholders.
A total of 691 participants completed the pre- and post-intervention questionnaires. The mean
age of the participants was 75 years, and most were female (84%). Almost half (46%) of the
participants were Black, and most reported good to excellent health (62%) despite the high
prevalence of chronic diseases. After the intervention, prevalence of all five modifiable risk
factors (low intake of calcium- and vitamin D-rich foods, non-use of a calcium-containing
supplement, non-use of a vitamin D-containing supplement, low physical activity, and high risk
of falling at home) for falls and fractures decreased significantly. The percentage of participants
who had 4-5 risk factors significantly decreased from 32% to 18% after the intervention,
although the majority (87%) continued to have at least one modifiable risk factor.
Overall, the intervention was successful in leading to behavior changes to decrease risk for falls
and fractures. Future interventions should focus on providing more opportunities for physical
activity at senior centers, as well as explore partnerships with local or state agencies or other
organizations to improve home safety and assist with provision of calcium- and vitamin Dcontaining foods and supplements.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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Teems, J., Hausman, D.B., Fischer, J.G., Lee, J.S., Johnson, M.A. Older adults attending Georgia
senior centers increase preventive behaviors for falls and fractures following a community-based
intervention, Journal of Nutrition in Gerontology and Geriatrics, 2011, 30(1):72-85.
Mary Ann Johnson, PhD, Professor of Foods and Nutrition and Faculty of Gerontology,
Department of Foods and Nutrition, The University of Georgia, Athens, GA,
[email protected].
Primary Reviewers
Joan G. Fischer, PhD, RD, LD, Tiffany Sellers, MS, Sohyun Park, PhD, and Elizabeth M. Speer,
BS, Department of Foods and Nutrition, The University of Georgia, Athens, GA.
Updates in 2011
Whitney Bignell, MS, Department of Foods and Nutrition, The University of Georgia, Athens,
GA
Acknowledgements
We thank Melinda Bell for developing the menus and recipes, Heather Stephens for developing
“Bingo for Better Health,” Wendy Giminski for drawing the fruit and vegetable characters,
Krysia Haag for drawing the chair exercise illustrations, and Nancy Omdahl for editorial
assistance. The financial support of the Georgia Division of Aging Services, the Department of
Foods and Nutrition, University of Georgia, and the Georgia Agricultural Experiment Station is
gratefully acknowledged.
Permission to Use These Materials
This material, including artwork, was developed with support from the Department of Foods
and Nutrition at The University of Georgia and the Division of Aging Services at the Georgia
Department of Human Resources. Permission is granted to reproduce, translate, abstract,
review or quote these materials in whole or in part for educational purposes only (not for
profit beyond the cost of reproduction) provided that the author(s) and The University of
Georgia receive acknowledgement as shown in this example notice:
Reprinted with permission from Department of Foods and Nutrition, The University of
Georgia, Athens, GA, and Division of Aging Services, Georgia Department of Human
Resources, Atlanta, GA, Authors, Title, and Date.
Suggested Citation
Mary Ann Johnson, Seniors Fighting Falls and Fractures! Department of Foods and Nutrition,
The University of Georgia, Athens, GA, 2006 original, 2011 revised,
http://www.livewellagewell.info/study/materials.htm.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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Seniors Fight Falls and Fractures!
Lesson One:
Five Goals to Fight Falls and Fractures
– First Talk to My Doctor
Lesson Two:
Be Physically Active Everyday
Lesson Three:
Calcium and Vitamin D Supplements
– Part of Healthy Eating
Lesson Four:
Eat Healthy – Calcium and Vitamin D in Foods
Lesson Five:
Eat Healthy – Other Foods for Bone Health
Lesson Six:
Take My Medications
Lesson Seven: Fight Falls with a Safe Home
Lesson Eight:
Putting it All Together to Fight Falls and Fractures
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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Seniors Fight Falls and Fractures!
Lesson One: Five Goals to Fight Falls and
Fractures – First Talk to My Doctor
Getting Ready
1.
2.
3.
Review lesson plan before each session.
Copy and staple the handouts that best meet the needs of your audience (one set for each
participant).
Gather supplies needed for lesson, recipe, and activities.
General Supplies
1. Handouts for participants. Consider purchasing stickers to put on the handouts of those who
meet their goals for following the “Five Goals to Fight Falls and Fractures.”
2. Pens or pencils for participants interested in writing on handouts.
3. Step counters for participants (if they don’t already have one).
Supplies When Preparing a Recipe for Participants (recommended, but note that this
lesson introduces step counters, so time for tasting the recipe will be limited)
1. Ingredients to prepare the recipe provided or another “bone healthy” recipe.
2. Supplies for tasting recipe, such as plates, forks or spoons, and napkins.
Beginning the Session
1. Introduce yourself by name and the organization that you represent. Take attendance.
2. Summarize the lesson by going over the objectives. Let the group know that the session will
be informal and that questions can be asked at any time.
Objectives for Participants
1. Know the risk factors for osteoporosis.
2. Set goals related to the “Five Goals to Fight Falls and Fractures.”
3. Learn how to use a step counter and record steps on a Step Count Chart.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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NOTES to Educator
Authoritative sources of information about falls, fractures, and osteoporosis were used for all of
the lesson plans. These sources include:
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Bone Health and Osteoporosis: A Report of the Surgeon General,
http://www.surgeongeneral.gov/library/bonehealth/
National Osteoporosis Foundation, http://www.nof.org
Centers for Disease Control and Prevention, National Center for Injury Prevention and
Control, http://www.cdc.gov/homeandrecreationalsafety/falls/index.html
Live Well Age Well, Osteoporosis, http://www.livewellagewell.info/osteoporosis.htm
Live Well Age Well, Fall Prevention, http://www.livewellagewell.info/fallprevention.htm
Script
Remember to take attendance.
Give participants their handouts.
Educator: read this story to your audience and help them answer the question on the next page.
A Story about Frank and Franny Fortune . . .
Frank and Franny Fortune farmed for 45 years in the far southern part of our state. Then, they
sold the farm to their son and his wife and lived with them for awhile. They liked living with
their family, especially because their daughter-in-law always cooked wonderful meals and made
sure that everyone ate right with plenty of low-fat milk, fruits and vegetables, lean meats, whole
grains, and other healthy foods. In fact, this daughter-in-law was a bit of a “health nut.” She
even wanted Franny and Frank to take supplements with calcium and vitamin D, but they said
they didn’t want to take any pills. “Besides,” said Frank, “Calcium and vitamin D supplements
are for girls, and I’m not going to take any of that sissy stuff.”
Franny and Frank had several chores to do outside each day on the large farm, because as you
know a farmer’s work is never done, and there is much to do on a farm. But, once their son’s
family started to grow and needed all the rooms in the house, Franny and Frank decided to move
to a small apartment in the neighboring town.
They enjoyed living in town, because it was so easy to drive to the grocery store, the doctor, and
church, and they could visit their many friends and never worry about being back in time to do
the farm chores. As time went by, Fran became less interested in grocery shopping and cooking,
since there was just she and Frank for meals. They were both proud that they had lost about 20
pounds each since moving to town.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
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They were having such a good time in town, that they hadn’t unpacked all of their boxes. So
their things were piled up and lying around on the floor, on the steps, and in the hallways. In
fact, you might say that their house was a bit cluttered. They couldn’t find their night lights or
their non-skid bath mat for the tub, so Fran fussed at Frank to find them. Since this new place
was smaller than their farm house, they had to put many of their kitchen items on the high
shelves and needed a stool to reach them. They had more throw rugs and lamps than they knew
what to do with, so they just put them wherever they would fit.
Since Frank had lived in the same farm house his whole life, he had trouble remembering where
the lights were, especially outside and on the stairs. Since they were now renting, Frank had to
fuss at the landlord to fix the broken steps and replace the light bulbs. That landlord could take
weeks to do these simple chores. Frank hadn’t gotten around to having his vision tested lately,
and his poor vision was compounding the problems with the lighting.
At one of their doctor visits, Franny was told she had high blood pressure and needed to start
taking medicine for it. Frank told the doctor that his arthritis was keeping him up at night even
with over-the-counter pain killers, so the doctor prescribed some strong pain medicine. Frank
and Franny bragged that otherwise they felt in really good health and didn’t feel that they needed
any other tests, such as the bone mineral density test their doctor told them about.
Shortly after they started their new medicines, Frank complained that he felt dizzy and Franny
fell a few times, which surprised them both because they had never had these problems before.
So they checked with their doctor for help with their medicines. Frank and Franny became
fearful of their dizziness and falling and stayed home more often. The more they stayed home,
the less they felt like going out. They were only going to church about once a month. Their
daughter-in-law had started doing their grocery shopping for them, so they didn’t have to go out
for that anymore.
Then one day, Franny had a bad fall on the steps that still held some unpacked boxes. Their son
rushed over, called the ambulance, and they found that Franny had a broken hip. With surgery
and rehabilitation therapy, there was a chance that Franny would walk again. Both Frank and
Franny were very distressed, and their son and daughter-in-law were quite worried.
Is there anything in Frank and Franny’s living situation or lifestyle that might have contributed to
the dizziness, falls, and fracture?? What could Frank and Franny Fortune do, and people like
them, to help fight falls and fractures??
Wait for group to discuss. Some things that the participants might mention that may help
prevent dizziness, falls and fracture include the following. Prompt your audience as needed.
At least once a year, talk to your doctor about your medicines, risk of falling, having your vision
tested to see if you need new glasses, and having a bone mineral density test as recommended by
Franny and Frank’s doctor.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
9
Fight falls with a safe home. There were many falling hazards in the home, such as unpacked
boxes, lamps, rugs, things on the steps, broken steps, no bath mat in the tub, and poor lighting.
Franny and Frank may not have been eating as healthy as they used to. Healthy eating helps
prevent dizziness, falls, and fractures. Losing 20 pounds without really wanting to or by not
eating well is not always a good thing.
Franny and Frank were proud that they didn’t take any over-the-counter medicines, not even
supplements with calcium and vitamin D. But many older people, including men, need
supplements of calcium and vitamin D, because typical diets do not provide enough of these bone
health nutrients. People should talk with their doctor about their need for these supplements.
Franny and Frank were less physically active than they used to be on the farm, so their strength,
balance, and coordination were declining. Being physically active everyday can help fight falls
and fractures.
You have mentioned many of the important things that people like Franny and Frank Fortune can
do to fight falls and fractures, and how important it is to talk with their doctor about falls and
fractures. We’ll discuss all of these things during the next several times that we meet. I hope
you find our discussions helpful to you and your loved ones.
Introduction
Has anyone heard of “osteoporosis”? Wait for participants to answer. Osteoporosis is the most
common bone disease. In this disease, bones lose calcium and other minerals. Then bones
become fragile and break easily. With osteoporosis, your body’s frame becomes like the frame
of a house damaged by termites. Termites weaken your house like osteoporosis weakens your
bones. Weak bones can break easily. Unfortunately, most people don’t know they have weak
bones until one of their bones breaks. For example, they might fall and break a bone, often in
their hip, spine, or arm.
Here is a “pop quiz” about osteoporosis. Please answer “yes” or “no” to these questions.
1.
Osteoporosis is a common health problem. Wait for responses. The correct answer is YES!
About 44 million men and women over the age of 50 in the United States have either
osteoporosis or are at risk for osteoporosis (because they have low bone mass). Half of the
women over age 50 will have an osteoporotic fracture before they die. In some cases of
osteoporosis, the most common visible sign is “dowager’s hump” (demonstrate by patting
back and stooping).
2.
Osteoporosis can be a very serious and deadly condition. Wait for responses. YES,
because osteoporosis can be a painful, devastating, and life changing disease. Hip fractures
can be very serious. About 20% of people with a hip fracture die the year after the fracture,
and many people never walk again and may need permanent care.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
10
3.
Osteoporosis is a normal part of aging. Wait for responses. NO. Osteoporosis is NOT a
normal part of aging. In fact osteoporosis is largely PREVENTABLE!
4.
Only white women get osteoporosis. Wait for responses. NO. People of all races and
ethnicities, as well as both MEN and women do get osteoporosis! So EVERYONE needs to
fight falls and fractures.
5.
If you break a bone after age 50, you are at high risk for breaking another bone. Wait for
responses. YES! So if you have broken a bone after age 50, be sure to have your doctor
test you for osteoporosis.
6.
Medical costs from osteoporosis are high. Wait for responses. The right answer is YES.
The fractures from osteoporosis cost our country billions of dollars each year. For example,
each hip fracture costs about $40,000 in medical care.
7.
If you have osteoporosis, will you always be able to feel it? Wait for responses. NO!
Osteoporosis is often called a “silent disease” because it develops slowly over time, without
symptoms, until a fracture occurs.
8.
If you get osteoporosis, there is something you can do about it. Wait for responses. The
right answer is YES! You must talk with your doctor, who may prescribe medications for
you. Along with taking your medications, you can eat healthier, take calcium and vitamin D
supplements if needed, be physically active, have your vision tested and get new glasses if
needed, and make your home safer to prevent falls.
We are going to spend the next few months together figuring out ways to fight falls and fractures
to help keep us healthy. We are going to discuss talking with your doctor, being physically
active, eating healthy, taking the right kind of dietary supplements, taking medicines correctly,
and being safe at home.
How many of you know someone who has fallen recently or had a broken bone? Wait for
participants to answer and discuss.
While we can’t prevent every fall and every broken bone, there are many things we can do to
improve our strength and balance, and to make our homes safer.
Five Goals to Fight Falls and Fractures – Talk With Your Doctor
Let’s take a look at the handout “My Five Goals to Fight Falls and Fractures.” Ask participants
to refer to this handout and review it with them.
The first few goals are things you can do everyday, such as be physically active, eat healthy and
take calcium and vitamin D supplements if needed, take your medicines as recommended by
your doctor, and fight falls by making your home safe.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
11
It is also vitally important that you talk with your doctor about your chances of having a fall or a
bone fracture. At your next visit with your doctor, talk with him or her about everything on this
list, and especially about possible side-effects of any medicines that could make you dizzy or
increase your risk of falling, as well as having your vision checked and having a bone mineral
density test. Talk with your doctor about any concerns you may have about falling. The chances
of falling are increased in those with muscle weakness, a history of falls, problems with balance,
gait or vision, and use of an assistive device, such as a cane or walker. We’ll talk about all of
these during our next sessions together.
These goals are explained in more detail on the handout titled “Figuring Out the Five Goals to
Fight Falls and Fractures.” Let’s figure these out by reviewing this handout together.
Carefully review each item with the participants.
The handout titled “Falls, Fractures, and Osteoporosis in Georgia” shows how common these
problems are in our state. Review the handout with your participants.
The next handout, “Are You at Risk for Osteoporosis?” has a checklist of risk factors that you
should discuss with your doctor. Take a minute to see how many of these risk factors you have.
Wait for participants to complete this. It may surprise you to see how many risk factors you
have. The next part of this handout has information about bone mass measurements as a part of
Medicare Preventive Services. Bring this handout to your doctor the next time you visit. This
will help you remember to ask questions and to remind your doctor to talk with you about your
bone health.
Some of you might have had a heel bone density test at a senior center or a health fair. A heel
bone density test is done by putting your bare foot in a machine that tests the bones in your heel.
If you have had this test, then be sure to take the information to your doctor. Since this is a
screening test, and not a diagnostic test, your doctor will order more bone density tests for you if
needed.
Menu and Recipe
In each lesson, we will look at a menu and a recipe for us to enjoy. Ask participants to refer to
the handout titled “Day One Menu.” For those of you counting your calories, the menus
included in each session provide about 1,800 calories and have moderate amounts of protein,
carbohydrates, and fats. The menu has three servings of whole grain foods, such as whole grain
bread, cereal, or brown rice.
Three and a half or more cups of fruits and vegetables, with at least one dark green vegetable and
one red or orange vegetable, are on the menu. Broccoli, spinach, and dark leafy greens are
examples of dark green vegetables. These recommendations for fruits and vegetables are based
on the new 2010 Dietary Guidelines for Americans. The recommendations are at least three and
a half cups daily of fruits and vegetables for sedentary older women who need about 1,600
calories and at least five cups daily for moderately active men who need about 2,200 calories.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
12
As you can see, the menu has three servings of low-fat milk products, which provide calcium for
bone and overall health. Milk, yogurt, and cheese are milk products with lots of calcium. At
some of our next sessions, we’ll talk more about getting the calcium you need from low-fat milk
products and other sources.
The menu has lots of ideas and a recipe that I hope you will try at home. If a recipe is provided
for participants to taste, then encourage them to describe the flavors and the healthy foods and
ingredients in the recipe. Be sure to tell participants what is in the recipe, in case anyone is
allergic to any of the ingredients.
These menus show healthy food choices and meal patterns. Be sure to follow specific dietary
recommendations or restrictions from your physician, registered dietitian, or other health care
professional. For example, people taking blood thinners, such as coumadin or warfarin, may be
told to limit their intake of dark green vegetables. If so, you can replace them with another nonstarchy vegetable(s). Many of the recipes also include raw fruits and vegetables, such as raw
onions, which can be cooked if you prefer.
The next fun part of today’s lesson is about physical activity.
We need to remember one more key goal. This goal is:
Be Physically Active Everyday!
Physical activity helps keep our heart, muscles, bones, and joints healthy. Regular physical
activity helps prevent and manage diabetes, high blood pressure, excess weight gain, heart
disease, and some types of cancer. Physical activity also lowers the risk of depression and
anxiety and improves our sense of well-being and self-esteem.
Does anyone know how much physical activity we should get each day? Have participants
share their answers. The 2008 Physical Activity Guidelines for Americans recommends at least
150 minutes of moderate physical activity per week, which is 30 minutes on most, and preferably
all, days of the week. Examples of moderate physical activities include brisk walking, line
dancing, biking, swimming, gardening, and doing chair exercises.
Even more health benefits are gained from more physical activity at higher intensities.
How many of you are already getting 30 minutes of moderate physical activity everyday? Wait
for show of hands. If so, what do you consider your daily physical activity? Gather responses.
Well, it looks as though some of us need a little encouragement and ideas about how to be more
physically active.
Every time we meet, we are going to discuss some ways to be more physically active and
actually do some activities right here together.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
13
Step Counter to Help Be Physically Active Everyday
One great way for us to be more physically active is by walking. Our goal is to do a little more
walking – not to run a marathon! Each time we meet, we will set a new personal step goal and
try to walk a few more steps than we did the previous week.
Some people may be afraid of doing more physical activity. But, the real danger is NOT being
physically active! A moderate and gradual walking program is safe for most people.
It’s important to talk with your doctor before increasing your physical activity. So, to receive a
new step counter, you should have completed the form titled “Physician’s Clearance to
Participate in Physical Activity and Walking.” If you haven’t completed this form or have not
yet received clearance from your doctor, then please see me after our session so we can take care
of this.
We will use step counters, which are a fun and easy way to watch our progress. Another name
for a step counter is a pedometer. Some of you may already have a step counter and have
learned how to use it. We’re going to review using a step counter again to be sure everyone is
comfortable using one.
Let’s review the handout called “Using My Step Counter Everyday!” This handout will show us
how easy it is to use a step counter.
Next, let’s review the handout called “Step Count Chart.” Show participants where to record
their step counts everyday.
Be sure to write down your steps at the end of each day, or pick another time when it is easy to
remember to write down your steps, such as right after your evening meal, when you take the last
of your medicines each day, or when you brush your teeth before you go to bed.
You may ask your senior center director if you can keep your Step Count Chart at the senior
center, and then you can write down your steps before you leave each day.
Let’s take a walk around the room to be sure our step counters are working. Depending on the
participants and the site, you may want to go outside for a walk.
I am going to write down your number of steps for next week, so be sure to record your
steps in your Step Count Chart. Be sure to bring your Step Count Chart back the next
time we meet so I can help follow your progress throughout our lessons.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
14
My Five Goals to Fight Falls and Fractures (Lesson 1)
Not Very
Often
My new
This Past Almost
Goal(s) For
Week
Everyday Everyday! Next Week
1. Be physically active
________ ________
________
________
2. Eat healthy and
take calcium and vitamin D
supplements if needed
________ ________
________
________
________ ________
________
________
3. Take my medicines as
recommended by my doctor
________ ________
________
________
4. Fight falls with a safe home
________ ________
________
________
5. Talk to my doctor about my medicines, risk of falling, vision and having a
bone mineral density test – at least once in the past year:
YES
NO
 What keeps me from fighting falls and fractures everyday?
_____________________________________________________
 How can I reach my goals to fight falls and fractures everyday?
_____________________________________________________
To help fight falls and fractures everyday:
 Remember the health benefits of fighting falls and fractures
 Ask for support from my family, friends, and doctor
 Think of easy ways to find time for my new habits
 If I sometimes forget, just be positive and try again
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
15
Figuring Out the Five Goals to Fight Falls and Fractures
1. Be physically active
 At least 30 minutes of moderate physical activity everyday
 Moderate physical activity feels “somewhat hard” and can include
walking, dancing, gardening, cycling, swimming, and chair exercises
2a. Eat healthy
 Consume 3 servings of low-fat milk products daily
 If I eat less than 3 servings of milk products, then
eat calcium-fortified foods such as calcium-fortified
orange juice, breakfast cereals, and soy foods
2b. Take supplements of calcium and vitamin D if not enough is
consumed
from food; many older people will need the following:
 Supplements with 200 mg to 1,000 mg calcium
 Supplements with 600 IU to 800 IU vitamin D
 Check with my doctor about the right amount for me
Calcium
Vitamin D
3. Take my medicines as recommended and ask my doctor about
 Medicines that might increase my risk of falling
 Medicines that might cause bone loss
 Medicines that might improve my bone health
4. Fight falls with a safe home
 Remove things I might trip over
 Keep things within easy reach
 Use non-slip mats in the bathroom
 Use handrails and lights in stairwells




Secure rugs
Install grab bars in the bathroom
Improve lighting in my home
Wear skid-resistant shoes
5. Talk to my doctor at least once a year about
 My medicines
 My risk of falling and how I can prevent falls
 My vision, having an eye exam, and getting new glasses
 A bone mineral density test
Ask my doctor about other tests I should have
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
16
Falls, Fractures, and Osteoporosis in Georgia
Osteoporosis-related bone fractures and costs in Georgians aged 50+ in 2010:
 800 to 1,600 deaths per year from hip fractures
 8,890 hip fractures ($34,766 in annual direct medical costs per fracture)
 34,463 total fractures
 $396 million in annual direct medical costs
Falls and fall-related injuries in older Georgians:
 95% of hip fractures are caused by falls
 Falls are a leading cause of traumatic brain injuries
 More than one-half of adults aged 85+ fall at least
once each year
 More than one-third of adults aged 65+ fall at least once each year
 Older adults are more likely to be hospitalized from falls than younger adults
 9,000+ adults aged 65+ are hospitalized annually for falls
 34% of patients discharged to long-term care
 440 adults aged 65+ die each year from falls
 Risk factors for falls are muscle weakness, history of falls, problems with
balance, gait or vision, and using a cane or walker
 60% of fatal falls occur in the home
Talk with your doctor about:
 Osteoporosis and risk of falling
 Having a bone mineral density test
 Having vision tested
 Managing medications
 Being physically active
 Eating healthy
 Taking supplements of calcium and vitamin D
From: Centers for Disease Control and Prevention,
http://www.cdc.gov/homeandrecreationalsafety/falls/index.html
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
17
Are You at Risk for Osteoporosis?
The more items you check, the higher your risk for osteoporosis:
1. _____ Are age 50 or older
2. _____ Are a woman (men also get osteoporosis)
3. _____ Have a family history of broken bones
4. _____ Have a personal history of broken bones
5. _____ Are small-boned
6. _____ Are white or Asian (all ethnic/racial groups are at risk)
7. _____ Have low body weight (less than about 127 pounds)
8. _____ Smoke or drink a lot of alcohol
9. _____ Do not eat enough calcium and vitamin D from foods and supplements
10. _____ Are not physically active
Bone Density Tests, Medicare
Medicare covers bone density measurements to determine your risk for a fracture
(broken bone). People are at risk for fractures because of osteoporosis, a disease
that weakens the bones. In general, the lower your bone density, the higher your
risk is for a fracture. This test helps you and your doctor choose the best ways to
keep your bones strong.
Medicare covers bone density tests for people with Medicare who are at risk:
1. Women over 65, especially those not taking estrogen.
2. Men and women whose x-rays show previous spine problems.
3. Men and women taking prednisone or steroid-type drugs or who are planning to begin
such treatment.
4. Men and women diagnosed with primary hyperparathyroidism.
5. Men and women being treated for osteoporosis to see if the therapy is working.
Your costs in the Medicare plan?
Deductibles and co-pays may apply. Medicare will only reimburse for this test if ordered
by your treating health care provider.
From: Medicare, http://www.medicare.gov/navigation/manage-your-health/preventiveservices/bone-mass-measurement.aspx
National Osteoporosis Foundation, http://www.nof.org, Phone: 202-223-2226
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
18
Day One Menu
Breakfast
Whole grain cereal (such as oat or wheat bran
flakes, wheat Chex, or corn bran), unsweetened
and fortified, ready-to-eat, ¾ cup
Milk, 1%, 1 cup
Orange, 1 small
Coffee
Nutrition Facts for Day 1:
1,738 calories
58 g total fat (30% calories)
11 g saturated fat (6% calories)
229 g total carbohydrate (53%
calories)
87 g protein (20% calories)
Snack
Yogurt, low-fat and low-calorie, vanilla or fruit
flavored, ¾ cup (6 ounce container)
Bran muffin, low-fat, 1 small (or ½ of a medium-large, about 1 ounce), spread with
1 teaspoon soft margarine
Lunch
Baked potato, with skin, 1 small (about 3 ounces), with chili and cheese
1 cup chili, made with 1 ½ ounces cooked ground turkey, ¼
cup kidney beans (canned, rinsed and drained), ¼ cup nosalt-added stewed tomatoes, chili powder to taste
Part-skim mozzarella cheese, shredded, 2 tablespoons
White seedless grapes, ½ cup (about 16)
Ice water
Snack
Graham crackers (2½-inch squares), 3 each
1/4 cup pumpkin dip, made with 1/4 cup canned pumpkin, 1 tablespoons fat-free
cream cheese, ¼ teaspoon cinnamon, sweetened with artificial sweetener
Evening Meal
Tuna or other fish, baked, 3 ounces
Pasta and vegetable toss, made with ½ cup cooked rotini or other short pasta, 1¼
cups sautéed vegetables (½ cup zucchini, ½ cup broccoli florets, 2 tablespoons
each diced red bell peppers and chopped onions), 2 tablespoons olive or canola
oil for sautéing, and salt-free Italian seasoning blend to taste
Whole wheat bread, toasted, 1 slice, brushed with 1 teaspoon olive oil
Milk, 1%, ½ cup
Ice water
Snack
Banana burst pudding, 1 serving (recipe provided)
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
19
Banana Burst Pudding
Serves 4
Ingredients:




1 (1 ounce) package sugar-free instant vanilla pudding mix
2 cups fat-free milk
8 vanilla wafers (2 per pudding cup)
2 medium bananas, sliced (½ banana per pudding cup)
Directions:
1. Combine pudding mix with milk and whisk until fully
combined per package instructions and refrigerate 5 minutes to set.
2. Spoon half of the pudding mixture evenly into each of 4 small bowls; crumble 1
vanilla wafer on top of each pudding cup.
3. Top each pudding cup with banana slices (allow half of a medium banana for
each pudding cup; leave enough slices for one more layer).
4. Build a second layer with the remaining pudding, vanilla wafers, and banana
slices as in the first layer.
5. Refrigerate pudding cups for at least 1 hour.
Nutrition Facts Per Serving:
155 calories
2 g total fat
1 g saturated fat
31 g total carbohydrate
5 g protein
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
20
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
21
Using My Step Counter Everyday!
1. Wear the step counter everyday, starting in the morning when I get up. Take it
off in the evening before I go to bed.
2. Wear the step counter on my waist directly above the knee. Attach the safety
strap to a belt loop or buttonhole or attach it with a safety pin to my clothes.
3. It won’t work in my pocket! So clip it to a belt or waistband, and make sure it
is close and flat against my body.
4. It is OK to safety pin the step counter to my clothes at my waist.
5. Avoid getting the step counter wet. Take it off when bathing or sleeping.
6. At the start of each day, press the “reset” button to set the counter to zero.
7. At the end of each day, write the total daily steps on my Step Count Chart.
8. For an average stride, 2,000 steps is one mile.
Setting Goals
During the first week, just see how many steps I usually do. Then, after each
week, set a new goal to walk a few hundred more steps each day. Write my goals
in the Step Count Chart.
For example, if the first week I walked about 1,200 steps
each day, then the next week, try to walk about 1,400 to
1,500 steps each day.
Problems and Solutions
If the display is blank or has funny characters:
 The battery may be run down, so replace the battery.
 Or the display was broken because it may have been
dropped, hit, got too hot, or got wet. Ask my instructor
for a new step counter.
Enjoy My Success and a Healthier Me!
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
22
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
23
Seniors Fight Falls and Fractures!
Lesson Two: Be Physically Active Everyday
Getting Ready
1. Review lesson plan before each session.
2. Copy and staple the handouts that best meet the needs of your audience (one set for each
participant).
3. Gather supplies needed for lesson, recipe, and activities.
General Supplies
1. Handouts for participants. Consider purchasing stickers to put on the handouts of those who
meet their goals for following more of the “Five Goals to Fight Falls and Fractures.”
2. Pens or pencils for participants interested in writing on handouts.
3. Step counters for participants (for participants that may have broken or lost theirs).
Supplies When Preparing a Recipe for Participants (Strongly Recommended)
1. Ingredients to prepare the recipe provided or another “bone healthy” recipe.
2. Supplies for tasting recipe, such as plates, forks or spoons, and napkins.
Beginning the Lesson
1. Introduce yourself by name and the organization you represent. Take attendance.
2. Summarize the lesson by stating the objectives.
3. Let the group know the lesson will be informal and they can ask questions at any time.
Objectives for Participants
1. Learn more about the “Five Goals to Fight Falls and Fractures.”
2. Learn the benefits of being physically active.
3. Discuss progress using the step counter, review Step Count Charts, and set new physical
activity goals.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
24
NOTES to Educator
Authoritative information about physical activity for older adults is available from:





Centers for Disease Control and Prevention,
http://www.cdc.gov/physicalactivity/everyone/health/index.html
Department of Health and Human Services, http://www.health.gov/PAGuidelines/
Agency for Healthcare Quality and Research and Centers for Disease Control and
Prevention, http://www.ahrq.gov/ppip/activity.htm
International Society on Physical Activity and Aging,
http://www.isapa.org/guidelines/ICG_ISAPA.pdf
Live Well Age Well, Be Active, http://www.livewellagewell.info/beactive.htm
Script
Remember to take attendance.
Give participants their handouts.
Five Goals to Fight Falls and Fractures
Welcome back to our lessons on Fighting Falls and Fractures! Last time we talked about setting
some goals each time we meet, so let’s look at the first handout that’s titled “My Five Goals to
Fight Falls and Fractures.” We are going to think of ways to follow these goals. Discuss
handout with participants. Last time we met we discussed the importance of talking with your
doctor about reviewing your medicines, your risk of falling, your vision, and having a bone
mineral density test.
Today we mainly are going to talk about eating healthier and about being more physically active.
So try to set some new goals for being more physically active. If you weren’t physically active
very often last week, then set a new goal to be physically active almost everyday next week. If
you are already physically active “almost everyday,” then set a new goal to be physically active
“everyday.”
What are some things that keep us from following these healthy habits to help us fight falls and
fractures? Wait for answers and discuss with participants.
Activity: Word Find
Look at the handout called “Find the Words to Fight Falls and Fractures with Physical
Activity.” Find a partner and let’s see how many of these activities we can find in the chart.
After we are done with the word find, we’ll move on to our menu and recipe.
Note to educator: Alternatively, if you are short on time, encourage the participants to take the
word find home to complete later.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
25
Menu and Recipe
Let’s look at a menu and a recipe for us to enjoy. Ask participants to refer to the handout titled
“Day Two Menu.” As you can see, the menu has three servings of milk products, which contain
lots of calcium to keep our bones healthy. The most popular milk products are milk, yogurt, and
cheese, and they all are rich in calcium. If you don’t eat three daily servings of milk products,
then taking a dietary supplement with calcium is very important for you. Also, nearly all older
people need a vitamin D supplement, because food and sunlight do not supply the high needs for
vitamin D by older people. We’ll talk more about calcium and vitamin D supplements the next
time we meet. Also, talk with your doctor about your need for supplements with these nutrients.
The menu has three and a half or more cups of fruits and vegetables, with at least one dark green
vegetable and one red or orange vegetable. If you prefer not to eat spinach, there are other dark
green vegetables such as collard greens, turnip greens, kale, and broccoli. The menu also
includes three servings of whole grain foods, such as whole grain bread, cereal, or brown rice.
These foods also help keep us healthy.
The menu has lots of ideas for healthy and delicious meals and snacks, and a recipe that I hope
you will try at home. Encourage participants to describe the healthy parts of the menu. If a
recipe is provided for participants to taste, then encourage them to describe the flavors, the
healthy foods, and ingredients in the recipe. Be sure to tell participants what is in the recipe, in
case anyone is allergic to any of the ingredients.
These menus show us healthy food choices and meal patterns. Be sure to follow specific dietary
recommendations or restrictions from your physician, registered dietitian, or other health care
professional. At some of our next sessions, we will talk about other calcium-rich foods besides
milk products. Also, people taking blood thinners, such as coumadin or warfarin, may be told to
limit their intake of dark green vegetables. If so, you can replace them with another non-starchy
vegetable. Many of the recipes also include raw fruits and vegetables, such as raw onions, which
can be cooked if you prefer.
The next great part of today’s lesson is physical activity. Who can remember our goal for
physical activity? Encourage participants to offer suggestions. Yes, the goal is:
Be Physically Active Everyday!
Why should people of all ages be physically active? Wait for answers. Physical activity
improves the health of our bones, joints, heart, and muscles. Being physically active improves
balance, strength, and flexibility, which may help prevent falls. So we can fight falls with
physical activity!
Regular physical activity also helps prevent and manage many chronic problems, including
diabetes, high blood pressure, excess weight gain, heart disease, and some types of cancer.
Physical activity lowers the risk of depression and anxiety and improves our sense of well-being
and self-esteem.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
26
Does anyone know how much physical activity we should get each day? Have participants
share their answers. The 2008 Physical Activity Guidelines for Americans recommends at least
150 minutes of moderate physical activity each week, which is 30 minutes on most, and
preferably all, days of the week. You can gain even more health benefits from a longer period of
more intense physical activity.
Is anyone already getting 30 minutes of moderate physical activity everyday? Wait for show of
hands. Well, it looks as though some of us need a little encouragement and ideas about how to
be more physically active. What do you consider your daily physical activity? Wait for answers
and discuss. Examples include walking, gardening, and some types of housework.
It’s easy to start by doing any new physical activity for just five or 10 minutes daily or every
other day. Then add a few more minutes each week. When doing 30 minutes all at once is too
much, then spread out your 30 minutes of physical activity over the whole day. Walking 10
minutes before or after each meal is a good way to spread out your physical activity. Be sure to
warm up first with a few minutes of slower walking. Remember to cool down after walking with
a few stretches that you are comfortable doing. We will learn some stretching exercises at some
of our next sessions.
Drink plenty of water before, during, and after physical activity, especially in hot weather and
when you feel hot. You may not even know you are sweating more than usual, but every drop of
sweat is worth it! So remember to drink plenty of water.
Every time we meet, we are going to discuss some ways to be more physically active and
actually do some activities right here together. At the next sessions, we will also learn chair
exercises to help us improve our flexibility, balance, and strength.
Step Counter to Help Be Physically Active Everyday
Our goal is to do a little more walking and add a few more steps and minutes each week. Every
time we meet, we will set a new personal step goal to try to walk a few more steps than we did
the previous week. Let’s look at the handout called “Fight Falls and Fractures with Physical
Activity Everyday!” and share these and other ideas for becoming more physically active.
Some people may fear doing more physical activity. But, the real problem is in NOT being
physically active! Physical activity helps keep our bones, joints, muscles, heart, and lungs
healthy. Physical activity helps prevent and manage many health problems, including
osteoporosis, and improves our sense of well-being and self-esteem. The risk of depression and
anxiety can be lower in those who are physically active. I hope all these benefits of walking and
being physically active make you want to be more physically active. A moderate and gradual
walking program is safe for most people.
Let’s see if we can find the many ways to be physically active on the handout called “Fight Falls
and Fractures with Physical Activity Everyday!” It’s important to talk with your doctor before
increasing your physical activity. So, to receive a new step counter, you should have completed
the form titled “Physician’s Clearance to Participate in Physical Activity and Walking.” If you
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
27
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
haven’t completed this form or have not yet received clearance from your doctor, then please talk
with me after our session so we can complete this paperwork.
We will use step counters, which are a fun and easy way to watch our progress. Step counters
are also called pedometers. Some of you may already have a step counter and know how to use
it. We are going to review using a step counter again to be sure everyone who would like to use
one is comfortable with it.
Be sure to write down your steps at the end of each day, or pick another time when it is easy to
remember to write down your steps, such as right after your evening meal, when you take the last
of your medicines each day, or when you brush your teeth before you go to bed.
You may ask your senior center if you can keep your Step Count Chart at the senior center and
then you can write down your steps before you leave each day.
Let’s take a walk around the room to be sure our step counters are working. Depending on the
participants and the site, you may want to go outside for a walk.
I am going to write down your number of steps for the past week, so if you have your Step
Count Chart with you, then I would like to look at it. Otherwise, I will just contact you in
the next few days to get the information.
We are done with our lesson today. Remember to practice your “Five Goals to Fight Falls
and Fractures” until we meet again soon!
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
28
My Five Goals to Fight Falls and Fractures (Lesson 2)
Not Very
Often
My new
This Past Almost
Goal(s) For
Week
Everyday Everyday! Next Week
1. Be physically active
________ ________
________
________
2. Eat healthy and
take calcium and vitamin D
supplements if needed
________ ________
________
________
________ ________
________
________
3. Take my medicines as
recommended by my doctor
________ ________
________
________
4. Fight falls with a safe home
________ ________
________
________
5. Talk to my doctor about my medicines, risk of falling, vision and having a
bone mineral density test – at least once in the past year:
YES
NO
 What keeps me from fighting falls and fractures everyday?
_____________________________________________________
 How can I reach my goals to fight falls and fractures everyday?
_____________________________________________________
To help fight falls and fractures everyday:
 Remember the health benefits of fighting falls and fractures
 Ask for support from my family, friends, and doctor
 Think of easy ways to find time for my new habits
 If I sometimes forget, just be positive and try again
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
29
Find the Words to
Fight Falls and Fractures with Physical Activity
P
A
R
K
F
A
R
A
W
A
Y
C
I
B
I
C
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C
L
I
N
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O
R
L
W
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A
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N
G
K
G
O
R
E
O
S
C
I
B
O
R
E
A
R
E
T
A
W
Bicycling
Dancing
March in place
Set new goals
Stretch
Walk and talk
Walk the dog
Yoga
W
A
L
K
I
N
G
F
R
I
E
N
D
K
L
A
T
D
N
A
K
L
A
W
T
G
G
O
D
E
H
T
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L
A
W
E
H
N
M
A
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C
H
I
N
P
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A
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I
S
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N
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W
G
O
A
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S
H
M
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T
S
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S
O
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N
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N
W
Z
Y
W
A
D
S
W
R
E
T
N
U
O
C
P
E
T
S
E
S
Clean the house
Garden
Park far away
Step counter
Swimming
Walking friend
Water aerobics
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
30
Day Two Menu
Breakfast
Creamy strawberry yogurt smoothie, 1 serving (recipe provided)
Whole wheat bread, toasted, 1 slice, spread with 1 teaspoon soft margarine
Hot tea OR coffee
Snack
Whole wheat crackers (such as Triscuit), low-sodium variety, 5 each
Milk, 1%, 1 cup
Ice water
Lunch
Roast beef sandwich, made with 2 ounces lean roasted beef, 1 small whole wheat
bun (about 2 ounces), 1 teaspoon light mayonnaise, 1 teaspoon mustard
Baked beans, canned, ½ cup
Baby carrots, ½ cup, with 2 tablespoons light ranch dressing for dipping
Ice water with a lemon wedge
Snack
Apple, with peel, sliced, ½ small, with 1 tablespoon peanut butter
Evening Meal
Oven-roasted skinless turkey breast (low-sodium variety if prepared), 3 ounces
Green peas, frozen, boiled, ½ cup
Biscuit, 1 small (2½-inch diameter), spread with 2 teaspoons sugar-free fruit
preserves
Side salad, made with 1 cup spinach, ½ cup mandarin oranges (canned in light
syrup or juice, drained), 2 tablespoons minced red onion, 1 tablespoon oil
vinaigrette dressing
Ice water
Snack
Air-popped
popcorn, 3 cups
Milk, 1%, 1 cup
Nutrition Facts for Day 2:
1,774 calories
55 g total fat (28% calories)
15 g saturated fat (8% calories)
229 g total carbohydrate (52% calories)
97 g protein (22% calories)
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
31
Creamy Strawberry Yogurt Smoothie
Serves 2
Ingredients:




1 cup 1% milk
1 cup low-fat, low-calorie strawberry yogurt
1 cup sliced strawberries (fresh or frozen as whole berries without syrup)
½ cup crushed or diced pineapple (fresh or canned in juice)
Directions:
1. Place all ingredients into a blender.
2. Blend on high until fully combined; pour into 2 tall glasses and serve chilled.
Nutrition Facts Per Serving:
170 calories
2 g total fat
1 g saturated fat
30 g total carbohydrate
10 g protein
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
32
Fight Falls and Fractures with Physical Activity Everyday!
1.
Use a step counter and set new goals.
2.
Clean the house and listen to music.
3.
Walk the dog.
4.
Work in the vegetable or flower garden.
5.
Walk in place and talk on the phone at the same time.
6.
Unload the groceries with several trips to and from the car.
7.
Move even when sitting – foot tapping, legs swinging up and down,
ankles making circles, and lowering and raising your arms.
8.
Walk around the neighborhood.
9.
Move during TV commercials. Stand up, stretch, march in place,
walk around the room, and go to the kitchen for a glass of water.
10. Join in the exercise and stretching classes at the senior center.
11. Find a walking friend and go to “walk-a-thons” and
charity walks.
12. Park far away from the store and walk to do
errands.
13. Start an active hobby such as yoga, dancing, walking
trails, bicycling, swimming, or water aerobics.
14. Play outside with your grandchildren.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
33
Seniors Fight Falls and Fractures!
Lesson Three: Calcium and Vitamin D
Supplements – Part of Healthy Eating
Getting Ready
1. Review lesson plan before each session.
2. Prepare to do chair exercises. Choose either Module A with balls (found elsewhere in this
document) or Tufts/CDC Growing Stronger, Part I (a separate booklet or online at:
http://www.cdc.gov/nccdphp/dnpa/physical/growing_stronger/growing_stronger.pdf).
3. Copy the handouts that best meet the needs of your audience (the last four may be less
important to your audience).
4. Make copies of chair exercise guide for each participant to take home.
5. Gather supplies needed for lesson, recipe, and activities.
General Supplies
1. Handouts for participants. Consider purchasing stickers to put on the handouts of those who
meet their goals for following more of the “Five Goals to Fight Falls and Fractures.”
2. Pens or pencils for participants to write on the handouts.
3. Step counters to replace those that are lost or broken. Balls for chair exercises (foam will not
bounce as much as air-filled, so foam balls may be a better choice).
4. Examples of multivitamin/mineral, calcium, vitamin D, and combined calcium-vitamin D
supplements from pharmacy or grocery stores located in your community.
5. Optional: If time permits, then play “Bingo for Better Health.” Supplies for bingo are bingo
cards for all participants (found elsewhere in the manual), large dry beans for bingo pieces,
hat or bowl, and prizes such as magnifying glasses, measuring cups, healthy snacks, bottled
water, spice blends, packets of artificial sweetener, low-calorie and shelf-stable milk
products, canned or fresh fruits and vegetables, night lights, and lotion or hand cream.
Supplies When Preparing a Recipe for Participants (Strongly Recommended)
1. Ingredients to prepare the recipe provided or another “bone healthy” recipe.
2. Supplies for tasting recipe, such as plates, forks or spoons, and napkins.
Beginning the Session
1. Introduce yourself by name and the organization that you represent. Take attendance.
2. Summarize the lesson by going over the objectives. Let the group know that the session will
be informal and that questions can be asked at any time.
Objectives for Participants
1. Learn more about the “Five Goals to Fight Falls and Fractures.”
2. Determine need for calcium and vitamin D supplements, and how to choose them wisely.
3. Do chair exercises to improve flexibility, balance, and strength, review Step Count Charts,
and set new goals to increase physical activity.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
34
NOTES to Educator
The recommended daily calcium intake for most people aged 51 and older is 1,200 milligrams
(mg). The recommended daily intake of calcium for men aged 50 – 70 years is slightly less at
1000 mg, as men tend to lose bone mass at a slower rate than women, who begin having
increased bone loss at menopause. This recommendation established is called the Recommended
Dietary Allowance, and was set by the Food and Nutrition Board, Institute of Medicine, National
Academies of Science in 2011 (http://www.nap.edu/catalog.php?record_id=13050). People who
avoid dairy products consume only about 300 mg from other dietary sources daily. Since milk
and yogurt have about 300 mg of calcium per cup, people who consume the recommended three
cups daily would not need a calcium supplement. Since most people do not consume this much
milk or yogurt, most people will need a calcium supplement. However, people should not
consume an excess amount of calcium, especially from calcium supplements. The Institute of
Medicine set the new tolerable upper intake level (UL) for calcium at 2000 mg per day. New
information suggests that risk for kidney stones increases with intakes above 2000 mg per day.
Calcium provided by food alone is generally not a problem, as it is difficult to consume this
amount of calcium from foods. However, people should talk to their doctors to determine the
right calcium supplement to use to avoid going over the upper intake amount.
The recommended daily vitamin D intake for older adults is 600 IU (International Units) for ages
51-70 and 800 IU for ages 71+. The new recommendation is based on the 2011 Dietary
Reference Intakes for Vitamin D and Calcium (Food and Nutrition Board, Institute of Medicine,
National Academies of Science, 2011, http://www.nap.edu/catalog.php?record_id=13050, page
1106). Specifically, this recommendation assumes minimal exposure to sunlight/ultraviolet band
radiation and getting vitamin D mostly from vitamin D-fortified foods and/or supplements.
However, this amount is difficult to obtain from typical foods. For example, milk only has 100
IU per cup. Most multivitamin/mineral supplements have 400 IU. Sunlight is not recommended
as the main source of vitamin D because sunlight is associated with skin cancer and aging skin
cannot make sufficient vitamin D to meet the high daily needs.
Many people may be confused about the new recommendations for vitamin D, as recent media
reports have suggested much higher amounts for optimal health. In fact, many supplements
found in stores contain 1000 – 10,000 IU! The review committee for the Institute of Medicine
looked at many studies of different health outcomes, such as diabetes and cardiovascular health,
but found that only studies with bone health as an outcome provided strong enough evidence to
set a recommendation. The committee determined that most benefits of vitamin D for bone
health are seen with intakes of 600 IU per day. Older adults ages 71+ need additional vitamin D
due to a large variation in physical changes within this group, such as kidney problems, lower
production of vitamin D, and other factors. Therefore, the committee estimated that a
recommendation of 800 IU (1/3 higher than other age groups) would be adequate for most older
adults. The upper tolerable limit (UL) for vitamin D (4000 IU) was also based on accounting for
a number of uncertainties, as toxic effects have been found with intakes of 5000 IU per day.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
35
For more information about vitamin D recommendations for older adults, contact
[email protected].
Calcium and vitamin D supplements have been shown to decrease falls and fractures in most
clinical trials in older people. The published meta-analyses of several of these studies are
available:




Cameron et al., 2010,
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005465/frame.html
Chung et al., 2009, http://www.ahrq.gov/downloads/pub/evidence/pdf/vitadcal/vitadcal.pdf
Cranney et al., 2007, http://www.ahrq.gov/downloads/pub/evidence/pdf/vitamind/vitad.pdf
Gillespie et al., 2009,
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007146/frame.html
Some of the studies that don’t show that supplements prevent falls and fractures may have given
the people too little calcium and vitamin D or the people in the study did not take the
supplements as recommended. Other information about dietary supplements can be found at:

Live Well Age Well, Dietary Supplements,
http://www.livewellagewell.info/supplements.htm
Glucosamine, with or without chondroitin or MSM, has been recommended for osteoarthritis (a
joint problem), which is a different disease than osteoporosis. Evidence for benefits is mixed.
More information about glucosamine and other dietary supplements for osteoarthritis is at:

The Arthritis Foundation, www.arthritis.org
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
36
Script
Remember to take attendance.
Give participants their handouts.
Five Goals to Fight Falls and Fractures
The first handout is titled “My Five Goals to Fight Falls and Fractures,” and today we are going
to think of ways to better follow these goals. Discuss handout with participants. What are some
things that keep us from following these healthy habits to help us fight falls and fractures? Wait
for answers and discuss.
Think about your goals from our last meeting. Let’s set some new goals today. One goal might
be to remember at your next visit to the doctor to ask them to review your medicines and
supplements with calcium and vitamin D, evaluate your risk of falling, have your vision tested,
and decide whether or not you need a bone mineral density test.
We are going to learn some new chair exercises today, so another goal might be to be physically
active everyday. Also, since we are going to focus on calcium and vitamin D supplements, we
can set goals for these supplements. How many of you have at least three cups of milk or yogurt
daily? Wait for responses. Well, most likely not too many of us. Did you know that most older
adults need a calcium and vitamin D supplement when they don’t consume three cups of milk or
yogurt daily? So perhaps a new goal might be to start taking calcium and vitamin D supplements
everyday, if you are not doing this already.
Reading Labels for Calcium and Vitamin D
Optional: If you feel your audience will benefit and can follow the numbers and calculations,
then use this section of the lesson. Alternatively, simply review the handout titled “Reading
Labels for Vitamin D and Calcium” to convey the important messages.
The easiest way to remember when you need a calcium supplement is to ask yourself, “Did I
have three servings of milk products today?” Also, nearly all older people need a vitamin D
supplement.
The calcium and vitamin D contents of some, but not all, foods are listed on the “Nutrition Facts
Panel” and for supplements are listed on the “Supplement Facts Panel.”
Labels on foods and supplements use a term called the “Daily Value” as the recommended
amount of calcium and vitamin D.
By federal regulations, these labels use 1,000 mg of calcium as 100% of the Daily Value and 400
IU of vitamin D as 100% of the Daily Value. But older adults need more than that. Most older
adults need 1,200 mg of calcium and 600 – 800 IU of vitamin D daily.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
37
Let’s look at the handout called “Reading Labels for Vitamin D and Calcium.” Because the
labeling on foods and supplements is for everyone, not just older people, the labeling can be a bit
confusing, especially for vitamin D as shown on this handout. We’ll use 800 IU in our
examples.
For example, the label on milk indicates that it has 25% of the recommended amount of vitamin
D, which means 25% of 400 IU or 100 IU. However, 100 IU is only 12.5% of what most older
people need. Similarly, a multivitamin/mineral supplement or a calcium/vitamin D supplement
that says it has 100% of the Daily Value for vitamin D actually provides 400 IU of vitamin D,
which is only 50% of the recommended amount. Foods, such as salmon, that are naturally rich
in vitamin D have nothing on the label about vitamin D. Salmon has more than twice as much
vitamin D per serving compared to milk.
The labeling for calcium is somewhat less confusing. To determine the amount of calcium just
multiply the percentage by 10, such that if the labels says 30% it has 300 mg of calcium (because
it is 30% of 1000 mg). However, 300 is really 25%, not 30%, of what most older people need.
Similarly, a multivitamin/mineral supplement or a calcium/vitamin D supplement that says it has
60% of the Daily Value for calcium, provides 600 mg of calcium, which is truly 50% of the
recommended amount. Foods, such as fresh dark green leafy vegetables, that are naturally rich
in calcium, do not have readily available information about their calcium content in the grocery
store.
The easiest way to get the right amount of these nutrients is to remember that milk products are
the richest source of calcium, so most people who do not consume the recommended three
servings of milk products daily will need calcium supplements. Nearly all older people will need
vitamin D supplements. A worksheet provided in this lesson will help you figure out your need
for vitamin D and calcium supplements.
Calcium and Vitamin D Supplements
Both older women and older men who do not consume three servings of milk products daily will
usually need calcium supplements. Nearly all older people will need a vitamin D supplement,
because food and sunlight do not supply the high amount of vitamin D needed by older people.
Here are some examples of calcium- and vitamin D-containing supplements available at local
stores. Pass around the supplement bottles.
Supplements of calcium and vitamin D help prevent falls and fractures. When you hear a report
that says they don’t help at all, it is usually because the people did not take enough calcium and
vitamin D to be helpful OR they took only calcium but no vitamin D. Both nutrients are needed
for healthy bones.
Several leading health agencies report that older people do not eat enough calcium and vitamin
D, so they may need dietary supplements to “fill the gap.” These health agencies include the
United States Department of Agriculture, the Office of the Surgeon General, and the Department
of Health and Human Services.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
38
Let’s review the handout called “Supplements to Fight Falls and Fractures.” We’ll discuss the
facts about calcium, the facts about vitamin D, and choosing supplements wisely. Review
handout with participants.
Now we are going to review the handout called “Worksheet for Supplements of Calcium and
Vitamin D.” This worksheet will help you find out how much calcium and/or vitamin D you
may need from supplements. First find the box on the left that best matches what you do each
day. Think about how much milk or yogurt you consume each day, such as less than one cup,
one cup, two cups, or three or more cups. Once you figure that out, consider whether or not you
take a multivitamin/mineral supplement; most of these have some vitamin D.
Participants may need extra help and time to find the information that applies to them, so review
this handout carefully with your participants.
Most people on average only have about one cup of milk daily or even less. You can count the
milk you put on your cereal, have in your coffee, in cream soups, in pudding, and as a beverage
to drink. Most people will probably be in one of the two shaded boxes marked “C” and “D.”
For example, you would be in box “C” if you have one cup of milk or yogurt daily and don’t
take a multivitamin. You would be in box “D” if you have one cup of milk or yogurt daily and
do take a multivitamin. The next time you go to the doctor, pharmacy, or grocery store you can
take this sheet with you to buy the right supplements for you.
Calcium supplements are usually calcium carbonate or calcium citrate; both are fine. If the
supplement you try first upsets your digestion, then try another brand or chemical form. It is
usually recommended to take no more than 500 mg or 600 mg of a calcium supplement at one
time, because it is easiest for the body to use this amount or less. It is fine to take up to 800 IU
of vitamin D at one time from one pill or tablet. It may be difficult to find a 200 IU vitamin D
supplement if you do consume one or two milk products and take a multivitamin/mineral
supplement containing vitamin D. You can take a 400 IU vitamin D tablet so long as you do not
exceed 4,000 IU per day. It is not necessary to take the supplements of calcium and vitamin D
together, but it might be easiest to remember to take them together.
As summarized on this handout, remember to talk with your doctor about taking supplements.
Take no more than one multivitamin/mineral daily. Most multivitamin/mineral supplements
have 400 IU of vitamin D per tablet, but read the label carefully. If yours is one of the newer
ones with 800 IU per tablet, then you do not need any other vitamin D-containing supplements.
Lastly, don’t take more than 2,000 mg of calcium daily or 4,000 IU of vitamin D daily from
foods plus supplements, unless your doctor has recommended higher amounts. For example, if
you have been diagnosed with vitamin D deficiency through a blood test, then your doctor will
have you take higher amounts of vitamin D for a few weeks or months.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
39
More Information about Dietary Supplements (Optional)
Optional. Use last four handouts about dietary supplements only if you feel your participants
are interested in the information, because they are not directly related to falls, fractures, and
osteoporosis. If you would like more information about dietary supplements, several other
handouts are provided. We’ll review each of them together.
Menu and Recipe
Let’s look at a menu and a recipe for us to enjoy. Ask participants to refer to the handout titled
“Day Three Menu.” As you can see, the menu has at least three servings of milk products.
Milk, yogurt, and cheese are milk products with lots of calcium. Be sure to choose the low-fat
varieties, such as skim or 1% milk, low-fat cheese, and low-calorie yogurts (with around 100 to
120 calories per 8-ounce serving). For those of you who don’t consume this much milk or other
milk products, taking supplements with calcium and vitamin D will be very important as we have
discussed today.
The menu has three and a half cups or more of fruits and vegetables, with at least one dark green
vegetable and one red or orange vegetable. Broccoli, spinach, kale, turnip greens, beet greens,
and mustard greens are all examples of dark green vegetables. Tomatoes and red bell peppers
are examples of red vegetables. Carrots, sweet potatoes, and pumpkin are the most commonly
known orange vegetables. Whole grain foods, such as whole grain bread, cereal, or brown rice
are also on the menu. These foods are all good for us, even for our bones!
The menu has many ideas and a recipe that I hope you will try at home. Encourage participants
to describe the healthy aspects of the menu. If the recipe is used for taste-testing, then ask the
participants to share their opinions. Be sure to tell participants what is in the recipe, in case
anyone is allergic to any of the ingredients.
These menus show healthy food choices and meal patterns. Be sure to follow specific dietary
recommendations or restrictions from your physician, registered dietitian, or other health care
professional. For example, people taking blood thinners, such as coumadin or warfarin, may be
told to limit their intake of dark green vegetables. If so, you can replace them with another nonstarchy vegetable. The raw fruits and vegetables in some menus can be cooked if you prefer.
The next wonderful part of today’s lesson is physical activity. Who can remember the key goal
about physical activity? Encourage participants to offer suggestions. Yes, the goal is:
Be Physically Active Everyday!
How much physical activity should we be getting everyday? Wait for answers. Right – at least
30 minutes of moderate physical activity everyday is a good goal.
Does anyone want to talk more about ways to be physically active everyday? Wait for answers
and encourage discussion.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
40
How many of you have been using a step counter? Wait for a show of hands.
Did you write down the number of steps in your Step Count Chart? Wait for responses.
Has anyone walked more since the last time we met? Wait for responses and ask participants
how they increased their steps.
Do you think you feel better by increasing your steps? That’s terrific! Wait for responses and
share in participants’ success.
Does anyone need any help with your step counter or need a new Step Count Chart? Respond as
needed. If help is needed, then tell these participants that you will help them at the end of the
lesson.
Let’s take a walk around the room to be sure our step counters are working.
Today we are going to participate in another physical activity, chair exercises. At future lessons
we’ll learn some new ones and practice some we’ve already learned. Try these at home, too!
These exercises are called chair exercises because you can hold onto a chair or sit in a chair
while doing them. So, some of these chair exercises can be done by people who may have
difficulty walking.
Begin chair exercises (Module A with balls or Tufts/CDC Growing Stronger, Part I). Strongly
encourage participants to try these with you and at home.
Activity: “Bingo for Better Health”
Optional: If time permits, then gather the group together to play “Bingo for Better Health.” The
bingo cards are printed at the end of all of these lessons. Give participants large dry beans for
bingo pieces and bingo cards that have a series of nutrition and health-related illustrations in
each bingo square. Play this game as normal bingo is played. Shuffle the stack of large bingo
pieces, select one to call out to participants, and show the bingo piece to participants. The first
participant to accurately declare bingo wins. Ideas for prizes include magnifying glasses to read
food and medicine labels, measuring cups, healthy snacks, bottled water, spice blends, small
packets of artificial sweetener, low-calorie pudding mix, shelf-stable milk or soy products (e.g.,
low-calorie milk powder, low-calorie cocoa packet, 8-ounce boxes of milk), canned or fresh
fruits and vegetables, lights (e.g., night light, flashlight, key-chain light, other battery-powered
lights), and small bottles of lotion or hand cream.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
41
My Five Goals to Fight Falls and Fractures (Lesson 3)
Not Very
Often
My new
This Past Almost
Goal(s) For
Week
Everyday Everyday! Next Week
1. Be physically active
________ ________
________
________
2. Eat healthy and
take calcium and vitamin D
supplements if needed
________ ________
________
________
________ ________
________
________
3. Take my medicines as
recommended by my doctor
________ ________
________
________
4. Fight falls with a safe home
________ ________
________
________
5. Talk to my doctor about my medicines, risk of falling, vision and having a
bone mineral density test – at least once in the past year:
YES
NO
 What keeps me from fighting falls and fractures everyday?
_____________________________________________________
 How can I reach my goals to fight falls and fractures everyday?
_____________________________________________________
To help fight falls and fractures everyday:
 Remember the health benefits of fighting falls and fractures
 Ask for support from my family, friends, and doctor
 Think of easy ways to find time for my new habits
 If I sometimes forget, just be positive and try again
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
42
Reading Labels for Vitamin D and Calcium
VITAMIN D: Most Older People’s Daily Need is 600 - 800 IU
What the label says
What the label means
Milk, 1 cup,
25% of Daily Value
100 IU of vitamin D,
which is only 12.5% of true needs
Orange juice, ½ cup,
12.5% of Daily Value
50 IU of vitamin D,
which is only 6.25% of true needs
Multivitamin/mineral supplement OR
other supplement with vitamin D,
100% of Daily Value
400 IU of vitamin D,
which is only 50% of true needs
Vitamin D supplement,
200% of Daily Value
800 IU of vitamin D,
which is 100% of true needs
CALCIUM: Most Older People’s Daily Need is 1,200 mg
What the label says
What the label means
Milk, 1 cup,
30% of Daily Value
300 mg of calcium,
which is 25% of true needs
Orange juice, ½ cup,
15% of Daily Value
150 mg of calcium,
which is 12.5% of true needs
Calcium supplement,
60% of Daily Value
600 mg of calcium,
which is 50% of true needs
Multivitamin/mineral supplement,
10% of Daily Value
100 mg of calcium,
which is 8% of true needs
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
43
Supplements to Fight Falls and Fractures
Facts about calcium:
 Eat 1,200 milligrams (mg) calcium daily from foods and supplements.
 300 mg calcium per cup can be found in milk, yogurt, calcium-fortified soy
milk, and calcium-fortified orange juice.
 300 mg calcium per day is the amount we get from most other foods.
 Do not exceed 2,000 mg of calcium daily from foods and supplements.
Facts about vitamin D:
 Older people’s skin cannot make enough vitamin D to keep them healthy.
 Sunscreen, when used properly, prevents our skin from making vitamin D.
 Older people need 600 IU (ages 51-70) or 800 IU (ages 70+) of vitamin D per
day from foods and supplements.
 Foods won’t provide this much vitamin D, so supplements are needed.
 Milk has 100 IU vitamin D per cup.
 Fish averages 100 IU to 400 IU vitamin D per three ounces.
 Do not exceed 4,000 IU vitamin D daily (unless approved by your doctor).
Choosing a supplement wisely:
1. _____ Shop at a place you trust, such as your local pharmacy or grocery store.
2. _____ Avoid buying supplements from the internet.
3. _____ Avoid supplements made with bone meal, dolomite, unrefined oyster
shells or coral calcium, unless it has “USP” or “purified” on the label.
4. _____ Calcium carbonate or calcium citrate are both good choices.
5. _____ Read the label to see how many tablets equal one serving. Check for
both calcium and vitamin D, because some have one and others have both.
6. _____ The perfect time to take your supplement is when you remember! Check
the label, because some should be taken with food and others without food.
7. _____ Keep supplements away from children, but in a place you can remember
such as in the kitchen where you can see them when you get a drink of water.
8. _____ Supplements cost only pennies per pill and are affordable for those who
do not consume the recommended three servings of milk products daily.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
44
Worksheet for Supplements of Calcium and Vitamin D
Find the box that best matches
what you do each day
(A) Eat less than 1 cup milk or yogurt
and don’t take multivitamin/mineral
Then consider
taking these supplements
2 tablets with 500 mg calcium each
1 tablet with 800 IU vitamin D
(B) Eat less than 1 cup milk or yogurt
and take multivitamin/mineral
1 tablet multivitamin with 400 IU vitamin D
2 tablets with 500 mg calcium each
1 tablet with 400 IU vitamin D
(C) Eat 1 cup milk or yogurt
and don’t take multivitamin/mineral
1 tablet with 600 mg calcium
1 tablet with 800 IU vitamin D
(D) Eat 1 cup milk or yogurt daily
and take multivitamin/mineral
1 tablet multivitamin with 400 IU vitamin D
1 tablet with 600 mg calcium and
400 IU vitamin D
(E) Eat 2 cups milk or yogurt
and don’t take multivitamin/mineral
1 tablet with 300 mg calcium
1 tablet with 800 IU vitamin D each
(F) Eat 2 cups milk or yogurt
and take multivitamin/mineral
1 tablet multivitamin with 400 IU vitamin D
1 tablet with 200 mg or 300 mg calcium
1 tablet with 400 IU vitamin D
(G) Eat 3 cups milk or yogurt
and don’t take multivitamin/mineral
Probably don’t need a calcium supplement
1 tablet with 400 IU vitamin D
(H) Eat 3 cups milk or yogurt
and take multivitamin/mineral
1 tablet multivitamin with 400 IU vitamin D
Probably don’t need a calcium supplement
Probably don’t need a vitamin D
supplement

____ Talk to your doctor before taking supplements.

____ Take no more than one multivitamin/mineral tablet daily.

____ If your multivitamin/mineral has 800 IU vitamin D, then you
don’t need any other vitamin D-containing supplements unless
recommended by your doctor.

____ Do not exceed 2,000 mg calcium daily or 4,000 IU vitamin D
daily from foods plus supplement (unless approved by your doctor).
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
45
Day Three Menu
Breakfast
Good morning breakfast sandwich, 1 serving (recipe provided)
Orange juice, calcium- and vitamin D-fortified, ½ cup
Coffee
Snack
Animal crackers, 8 crackers
Milk, 1%, 1 cup
Lunch
½ chicken salad sandwich, made with 1 slice toasted, whole wheat bread, 2 ounces
roasted boneless skinless chicken breast (low-sodium variety, cut into chunks),
1 teaspoon light mayonnaise, 1 small crunchy lettuce leaf
Cool side salad, made with 1 cup romaine lettuce or fresh spinach leaves, ½ cup
sliced strawberries, 2 tablespoons toasted, unsalted walnut halves (about 8
halves), 1 tablespoon oil vinaigrette dressing
Milk, 1%, 1 cup
Unsweetened iced tea
Snack
Tortilla chips, baked, ¾ ounce (about 10)
Bean and tomato dip, fat-free, ⅓ cup
Ice water with lime
Evening Meal
Grilled hamburger, made with a 3-ounce ground sirloin beef patty, 1 small
hamburger bun (about 2 ounces), 1 large lettuce leaf, 1 teaspoon each mustard
and ketchup
Coleslaw, made with ½ cup shredded cabbage, ½ cup shredded carrots, 1
tablespoon light mayonnaise, 1 tablespoon vinegar, 1 teaspoon honey
Corn, fresh or frozen, boiled, ½ cup, with 1 teaspoon soft margarine
Ice water
Nutrition Facts for Day 3:
Snack
1,830 calories
Peach, 1 small OR plum, 1 medium
63 g total fat (31% calories)
Yogurt, low-fat and low-calorie, vanilla or
18 g saturated fat (9% calories)
fruit flavored, ¾ cup
220 g total carbohydrate (48%
calories)
106 g protein (23% calories)
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
46
Good Morning Breakfast Sandwich
Serves 2
Ingredients:
 2 whole wheat English muffins, split in half and toasted
 2 teaspoons soft margarine
 2 large eggs, beaten with a splash of milk (or use ½ cup egg
substitute)
 2 tablespoons chopped chives (optional)
 ⅛ teaspoon coarsely ground black pepper
 ¼ cup shredded reduced fat cheddar cheese
Directions:
1. In a non-stick pan sprayed with cooking spray, scramble the eggs and pepper
together; just before eggs are finished, sprinkle in chives.
2. Spread ½ teaspoon margarine onto each toasted English muffin half.
3. Spoon half of the egg mixture onto each of the two bottom halves of the
English muffins.
4. Top the egg mixture on each muffin half with 2 tablespoons cheddar cheese.
5. Place the other English muffin top halves onto the egg and cheese mixture on
each to make a sandwich; serve immediately.
Nutrition Facts Per Serving
(using real eggs):
282 calories
13 g total fat
4 g saturated fat
28 g total carbohydrate
16 g protein
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
47
Do you Need a Nutrient Supplement for Healthy Aging?
It is best to eat a wide variety of healthy foods each day. Healthy
choices are fruits, vegetables, whole grains, low-fat milk products,
and lean meat, poultry, or fish. Sometimes it is hard to eat healthy
foods everyday, so supplements can be helpful.
You may need nutrient supplements if you do any of these:
___ Eat a low-calorie, weight-loss diet or are losing weight without
wanting to.
___ Are eating fewer than two meals per day.
___ Do not have three servings of milk products daily.
___ Have a disease of your digestive track and can’t absorb certain nutrients.
___ Smoke, because smoking lowers vitamin C levels in the body.
___ Drink three or more alcoholic beverages most days.
Tips for choosing and storing dietary supplements:
___ Talk with your doctor for advice, tell them what you are taking, and do not
self-prescribe.
___ Buy from a trusted source, such as a local pharmacy or grocery store.
___ Buy common name brands or store brands.
___ Avoid buying supplements from the internet.
___ Choose supplements with close to 100% of the Daily Value for most nutrients.
It is OK to exceed the Daily Value for calcium, vitamin D and vitamin B12,
because older people have high needs for these nutrients.
___ Check expiration dates and look for the initials “USP,” which means the
supplement meets certain quality standards.
___ Be very cautious with “herbal” supplements. Ask your doctor for advice and
tell your doctor what you are taking.
___ Stop taking “herbals” before surgery, because many promote bleeding.
___ Store supplements in a safe place away from children.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
48
Most older people can benefit from taking these nutrient supplements:
1. Multivitamin/mineral with vitamin D (400 IU) and vitamin B12 (at
least 12 mcg). Most multivitamin/mineral supplements have other
important nutrients such as vitamin C.
2. Calcium supplements providing 200 mg to 900 mg depending on
your intake of dietary calcium. Milk and yogurt have about 300
mg of calcium per cup. Most multivitamin/mineral supplements
have very little calcium. The total calcium from diet and supplements
should be 1,200 mg daily and should not exceed 2,000 mg daily.
 ___ If you consume no milk or yogurt, then consider taking supplements
to provide about 800 mg to 900 mg of calcium daily.
 ___ If you consume about one cup of milk or yogurt daily, then consider
taking a supplement with 500 mg to 600 mg of calcium.
 ___ If you consume about two cups of milk or yogurt daily, then consider
taking a supplement with 200 mg to 300 mg of calcium daily.
 ___ If you consume about three cups of milk and/or yogurt daily, then
you probably don’t need a calcium supplement.
3. Vitamin D supplements of up to 800 IU, depending on the intake of vitamin D
from other sources. Milk has 100 IU of vitamin D per cup. Most yogurts do
not have vitamin D and most other foods have very little vitamin D. The total
vitamin D from diet and supplements should be about 600 IU to 800 IU daily
and should not exceed 4,000 IU daily, unless directed to by your doctor.
 ___ If you don’t drink milk and don’t take a multivitamin, then consider
taking one tablet with 800 IU of vitamin D daily.
 ___ If you drink no milk and take a multivitamin with 400 IU of vitamin
D, then consider taking one tablet with 400 IU of vitamin D daily.
 ___ If you drink about one or two glasses of milk daily and take a
multivitamin with 400 IU of vitamin D, then consider taking one tablet
with 400 IU of vitamin D daily.
4. Fish oil supplement if you don’t eat at least 8 ounces of fatty fish weekly, such
as salmon. 1 to 3 grams of fish oil daily is about right for most people.
5. Vitamin E supplements are controversial. Some, but not all, studies show they
help the heart, immunity, memory, and dementia. Most multivitamin
supplements will contain 200 IU to 400 IU vitamin E.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
49
Dietary Supplement Misuse Among Older Adults
Used properly, nutrient supplements provide vitamins, minerals, and fish
oils, while some herbal supplements help manage some chronic
conditions. Because supplements are easy to buy and are “natural,” it is
easy to think they are safe in any dose for anyone at anytime. But,
dietary supplements can be dangerous when not used properly.
You may be misusing dietary supplements if you:
___ Think that taking a dietary supplement means you don’t have to eat
healthy or be physically active. Instead: eat a wide variety of healthy foods,
be physically active everyday, and choose supplements wisely.
___ Replace prescription medicines or therapy with a dietary supplement. Instead:
follow your doctor’s recommendations.
___ Buy supplements from the internet. Instead: buy from a trusted local
pharmacy or grocery store.
___ Take more than recommended on the label. Instead: follow label instructions.
___ Take supplements with meaningless claims, such as “cure-all,” “energy
booster,” “exclusive formula,” “all natural,” “weight-loss formula.” Instead:
consider taking the supplements listed below that may have health benefits.
You are using dietary supplements wisely if you:
___ Talk with your doctor about the right supplements for you.
___ Stop taking herbal supplements before surgery.
___ Use supplements and eat healthy and exercise daily.
___ Take no more than one multivitamin/mineral supplement daily.
___ Take calcium supplements if you don’t consume three cups of milk or yogurt
daily. Take up to 900 mg of calcium supplements daily, but
no more than 2,000 mg daily from foods and supplements.
___ Take supplements with up to 800 IU of vitamin D daily, but
no more than 4,000 IU daily from foods and supplements.
___ Take 1 to 3 grams of fish oil daily, if you don’t eat at least 8
ounces weekly of fatty fish, such as salmon or trout.
Talk with your doctor to be sure you are using supplements
wisely and safely!
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
50
Guide to Common Nutrient Supplements
Talk to your doctor before using any of these supplements
Name
What does it do?
Supplement Cautions
Tablets, capsules or pills*
Multivitamins with
Minerals
Calcium and
Vitamin D
Fish oil
Vitamin E
 Has important nutrients
 Helps meet daily nutrient needs
 Be sure it has vitamin D (at least
400 IU) and vitamin B12 (at least
12 mcg)
 Protects bones, improves balance  Do not exceed 4,000 IU vitamin
 Calcium and vitamin D from food D or 2,000 mg calcium daily
 Many older people need
plus supplements should add up to
600 - 800 IU vitamin D and 1,200
supplements of 200 to 900 mg
mg calcium
calcium and 400 to 800 IU
vitamin D
 Decreases heart disease
 May enhance blood thinners
 Decreases blood triglycerides
 May upset stomach
 May enhance blood-thinners
 May protect heart and immunity
 Do not exceed 1,000 IU daily
 Choose one with “d alpha”
Fiber supplements (examples)
Psyllium in products such as
Metamucil, Fiberall, Naturacil
 Laxative
 Lowers cholesterol
 May cause gas
 May lower blood sugar
Oral liquid nutritional supplements (examples)
Boost, Ensure,
Glucerna, Glucerna,
Nubasics, Resource
Instant Breakfast
 Nutrient beverages to supplement
diet
 Source of balanced nutrition
 Mix with milk to provide nutrient
beverage to supplement diet
 Source of balanced nutrition
 Should not replace meals unless
unable to eat enough regular
foods
 Should not replace meals unless
unable to eat enough regular
foods
*Be sure these supplements have on the label: USP (United States Pharmacopeia)
AND the words “standardized” or “guaranteed potency.”
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
51
Seniors Fight Falls and Fractures!
Lesson Four: Eat Healthy – Calcium and
Vitamin D in Foods
Getting Ready
1. Review lesson plan before each session.
2. Prepare to do chair exercises. Choose either Module B with balls (found elsewhere in this
document) or Tufts/CDC Growing Stronger, Part I (a separate booklet or online at:
http://www.cdc.gov/nccdphp/dnpa/physical/growing_stronger/growing_stronger.pdf).
3. Copy and staple the handouts that best meet the needs of your audience (one set for each
participant).
4. Gather supplies needed for lesson, recipe, and activities.
General Supplies
1. Handouts for participants. Consider purchasing stickers to put on the handouts of those who
meet their goals for following more of the “Five Goals to Fight Falls and Fractures.”
2. Pens or pencils for participants to write on the handouts.
3. Step counters to replace those that are lost or broken. Balls for chair exercises.
4. Plastic or paper plate with three sections, cereal bowl, and large glass to demonstrate the
plate method of meal planning.
5. Containers of calcium-rich foods such as skim or 1% milk, lactose-free milk, calcium- and
vitamin D-fortified orange juice and soy milk, calcium- and vitamin D-fortified breakfast
cereal, and canned salmon.
6. Supplies for “Bingo for Better Health” are bingo cards for all participants (found elsewhere
in the manual), large dry beans for bingo pieces, hat or bowl, and prizes such as magnifying
glasses, measuring cups, healthy snacks, bottled water, spice blends, packets of artificial
sweetener, low-calorie and shelf-stable milk products, canned or fresh fruits and vegetables,
night lights, and small bottles of lotion or hand cream.
Supplies When Preparing a Recipe for Participants (Strongly Recommended)
1. Ingredients to prepare the recipe provided or another “bone healthy” recipe.
2. Supplies for tasting recipe, such as plates, forks or spoons, and napkins.
Beginning the Session
1. Introduce yourself by name and the organization that you represent. Take attendance.
2. Summarize the lesson by going over the objectives. Let the group know that the session will
be informal and that questions can be asked at any time.
Objectives for Participants
1.
2.
3.
4.
Set new goals for following the “Five Goals to Fight Falls and Fractures.”
Learn about food sources of calcium and vitamin D.
Learn ways to overcome milk-intolerance or lactose-intolerance.
Do chair exercises to improve flexibility, balance, and strength, review Step Count Charts,
and set new goals to increase physical activity.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
52
NOTES to Educator
Authoritative information about calcium, vitamin D, and bone health is available:



DIPART (vitamin D Individual Patient Analysis of Randomized Trials) Group, 2010,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806633/pdf/bmj.b5463.pdf
Jackson et al., 2007,
http://www.ncbi.nlm.nih.gov/pubmed?term=vitamin%20d3%20risk%20fall%20jackson
Tang et al., 2007, http://www.ncbi.nlm.nih.gov/pubmed/17720017
For more information about calcium, vitamin D, and bone health, contact
[email protected]
The calcium and vitamin D contents of foods can be found at:
 USDA Nutrient Data Laboratory, http://www.nal.usda.gov/fnic/foodcomp/search/
Script
Remember to take attendance.
Give participants their handouts.
Introduction
Who remembers how many servings of milk products we should eat everyday? Collect answers.
That’s right – we should eat three. But, we know that many people find it hard to eat that many.
So today we are going to look at various ways to add more milk products to our daily diet. We’ll
also look at other foods that have lots of calcium and vitamin D, which will be especially
important for those who don’t consume many milk products.
Five Goals to Fight Falls and Fractures
The first handout is titled “My Five Goals to Fight Falls and Fractures” and we are going to
think of more ways to meet our goals. Discuss handout with participants. What stops us from
meeting our goals to fight falls and fractures? How can we change that? Wait for answers and
discuss.
Think about your goals from our last meeting. One goal is to ask your doctor to review your
medicines, see if you are at risk for falling, have your vision tested and get new glasses if
needed, and determine whether or not you need a bone mineral density test.
Does anyone feel they are doing better with their physical activity? Wait for responses. Does
anyone feel they are doing better taking their calcium and vitamin D supplements? Wait for
responses. Remember that most older adults need to take a vitamin D supplement for sure.
Many others need to take calcium supplements, especially if they do not consume three servings
of milk products everyday. You can make new goals to improve your supplement intake.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
53
Another goal is to eat healthier more days each week, such as by adding calcium- and vitamin Drich foods, which is what we are going to talk about today. Examples include skim or low-fat
milk and calcium- and vitamin D-fortified orange juice.
Food Sources of Calcium and Vitamin D
Look at the handout called “Calcium, Vitamin D, and Fat in Foods.” Clearly milk has the most
of both calcium and vitamin D. Yogurt has as much or more calcium than milk, but yogurt does
not always contain vitamin D. The other milk products listed don’t have as much calcium as
milk and generally do not have vitamin D. Read the labels carefully, because even some milk
products such as cheese and cottage cheese sometimes have additional calcium and vitamin D
added. Pre-sliced packaged cheese slices are usually ¾ ounce per slice. Two slices of this
cheese, 1.5 ounces, provides about the same amount of calcium as a glass of milk.
People who eat less than three servings of milk products daily must be sure to consume other
calcium-rich foods and will probably need calcium supplements. As shown in the table, other
good choices include soy milk with both calcium and vitamin D; orange juice with both calcium
and vitamin D; and leafy green vegetables, broccoli and okra. Some, but not all, ready-to-eat
breakfast cereals are fortified with calcium and vitamin D. Read the labels carefully to find the
soy milk, orange juice and breakfast cereals with the most calcium and vitamin D. Fish, such as
salmon, have a lot of calcium and vitamin D; however, most people don’t eat salmon everyday.
People who do not eat milk products consume about 300 milligrams (mg) of calcium from other
foods. But, most older adults need 1,200 mg of calcium after age 50, which is why these other
calcium-rich foods, as well as calcium supplements, are important.
The handout shows that generous amounts of vitamin D and calcium are not always in the same
foods. The need for vitamin D is very high (600 - 800 IU daily) compared to the amount in most
foods (100 IU or less).
Compare the amount of fat in the various foods. People who need 1,800 calories daily only need
about 60 grams of total fat, including 20 grams or less of saturated fat (the “bad” fat). So
switching from whole milk to one of the lower fat milk products will really help decrease the
intake of fat.
Pass around the food containers you brought with you that are rich in calcium and/or vitamin D.
Show participants the nutrition facts labels of the calcium- and vitamin D-fortified foods, such as
soy milk and orange juice, so they know where to look the next time they are shopping.
Lactose-Intolerance (or Milk-Intolerance)
A common reason that people avoid milk products is because they cause them to get gas, cramps,
or diarrhea. This problem is usually caused by “lactose-intolerance,” meaning that people can’t
easily digest the milk sugar called lactose. So, the lactose stays in the intestine causing gas,
cramps, and diarrhea.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
54
Lactose-intolerance is not very common in Caucasians, but is quite common in people who are
African-American, Native American, or Asian. To help overcome lactose-intolerance, try eating
milk products and other foods in the ways suggested in the handout “Nine Ways to Knockout
Lactose-Intolerance.” Review handout with participants.
Some people take pills such as Lactaid, Dairy Ease®, Digestive Advantage® or similar store
brands that contain the enzyme called “lactase” that breaks down the lactose in milk products.
Ask the pharmacist to help you find these products in the store. Simply follow the directions on
the label. Usually these pills are taken with the first bite of a milk product. You may need to
adjust the number of pills you take, because of variations in your tolerance to lactose, the amount
of lactose in various milk products (milk has more, while cheese has less), how much of a milk
product you eat at one time, and the amount of the lactase enzyme in the different brands and
versions of the pills. Usually, at least one pill needs to be taken at each meal or snack that
contains milk products. These pills usually cost at least 10 cents per pill, but can easily cost up
to 60 cents per pill, so read labels carefully and shop around.
There are lactase enzyme “drops” that can be added to milk to decrease the amount of lactose in
the milk. A product from Lactaid is available. Again, just follow the package directions.
Usually, the drops take a few hours or overnight to work. The milk will taste a bit sweeter than
regular milk, because this enzyme breaks down lactose into sweeter sugars.
Lactose-free milk products are also available in the dairy section of most grocery stores. Soy
milk is naturally lactose-free, so this is another good alternative. Just make sure it is calciumand vitamin D-fortified. Be prepared to spend around one-and-one-half to twice as much for
lactose-free milk or soy milk compared to regular cow’s milk.
If you prefer to get your calcium from non-milk products, then try to eat more calcium-rich foods
such as collards, mustard greens, broccoli, sardines, salmon with bones, calcium-fortified orange
juice and/or calcium-fortified cereals.
Plan My Plate: Calcium and Vitamin D at Lunch and the Evening Meal
Let’s see how we can put some of these foods together by reviewing the handout “Plan My
Plate.” This shows how much of certain foods, such as milk products, to eat at meals and snacks
for a balanced diet. If you don’t consume milk or other milk products with your meals or snacks,
then taking a calcium and vitamin D supplement becomes even more important.
Has anyone heard of the plate method? Wait for a show of hands. The plate method is a quick
and easy way to plan meals. It involves dividing your plate into sections and filling each section
with certain types of food.
Note to educator: The plate method is a visual way to plan healthy eating and was created to
help people with diabetes plan meals. The plate method used in these lessons is consistent with
dietary recommendations and carbohydrate counting for people with diabetes. The plate method
is a healthy way for everyone to eat, which is why it is included in these lessons.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
55
Show the nine-inch plastic or paper plate with raised dividers, a small bowl (½ cup), and glass
or cup (8 ounces). This nine-inch plate is the size of a plate you might use at home. The nice
thing about having the plate divided is that it helps to portion out your foods and have a variety
of foods. The portion sizes of these foods should be about the thickness of your finger (½ inch).
Here’s what else to remember:
1. Since we are talking about calcium and vitamin D, first fill the cup with a milk product, such
as one cup of skim milk, 1% milk, or low-fat/low-calorie yogurt. Puddings made with milk
count, so ½ cup pudding and ½ cup milk would work, too.
2. Another place that can have a milk product is in the protein section. So, next fill this small
section of the plate with a protein food, such as low-fat cheese or cottage cheese. Most of the
time the protein food here is “meat” such as lean beef, pork, poultry, or fish. A serving size
of meat is three ounces and is the size of a deck of cards or the palm of a woman’s hand.
3. Fill the largest section of the plate with two servings of starchy foods including grains and
starchy vegetables. For the grain, try whole grain bread, whole grain pasta or brown rice for
extra taste and fiber. Other choices are rolls, muffins, and cornbread. Serving sizes for these
starchy foods are shown on the plate and are one slice of bread, ½ cup of pasta, or ⅓ cup of
rice. Add a starchy vegetable such as ½ cup of corn, peas, white potato, sweet potato, winter
squash, or cooked dry beans or peas. Remember, vegetables are good for bone health, too!
4. Next, fill one small section of the plate with one or two servings of non-starchy vegetables.
The serving size for most vegetables is ½ cup, except for raw leafy greens, such as salads,
which is one cup. What are some non-starchy vegetables you could put in this section? Wait
for answers. Some more ideas for non-starchy vegetables include carrots, cabbage,
cauliflower, and tomatoes, as well as some with lots of calcium such as most cooked leafy
greens and broccoli.
5. Fill the bowl with ½ cup of canned, frozen, or fresh fruit for a side dish or dessert.
6. Most meals at senior centers follow this plate method, because they usually provide at least
two vegetables; one fruit; one serving of meat, poultry, or fish; one starchy food that is
usually whole grain such as whole grain bread; and one milk product such as 1% milk.
If this seems like too much food all at once, then save the fruit or the milk product for a snack
later in the afternoon.
Now, in each section, list some foods you enjoy and might eat at home. Think of foods and
beverages that you might eat for lunch or for the evening meal. Discuss with someone sitting
near you to make sure all of you have filled in each section with the recommended foods. Visit
as many groups as possible to see whether or not participants have filled their plates correctly.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
56
Calcium and Vitamin D at Breakfast
Who has some ideas for how we can eat more calcium and vitamin D at breakfast? Wait for
responses. Right! We can have an egg a few days a week, eat a fortified breakfast cereal, have a
glass of milk, or choose calcium- and vitamin D-fortified soy milk or orange juice. So tomorrow
when you sit down for breakfast, try to eat at least one calcium- and vitamin D-rich food.
Calcium and Vitamin D for Snacks
Any ideas on snacks rich in calcium and vitamin D? Wait for responses. Great ideas! Yes,
cheese sticks, cheese toast, cottage cheese, milk, soy milk, calcium-fortified juice and pudding
are all good ideas. So the next time you get hungry for a snack, think of one with calcium!
Calcium and Vitamin D Supplements
Be sure to review your handouts from our last session about supplements. Many older people
don’t have three servings of milk products daily and will need supplements of both calcium and
vitamin D. Talk with your doctor about taking the right supplements for you.
Menu and Recipe
Let’s look at a menu and a recipe for us to enjoy. Ask participants to refer to the handout titled
“Day Four Menu.” As you can see the menu has three servings of low-fat milk products, which
we talked about already today. There are three and a half cups or more of fruits and vegetables,
with at least one dark green vegetable and one red or orange vegetable on the menu. Three
servings of whole grain foods, such as whole grain bread, cereal, or brown rice are also on the
menu. These foods are also good for us.
The menu has lots of ideas and a recipe that I hope you will try at home. Encourage participants
to describe the healthy aspects of the menu. If the recipe is used for taste-testing, then ask the
participants to share their opinions. Be sure to tell participants what is in the recipe, in case
anyone is allergic to any of the ingredients.
These menus show healthy food choices and meal patterns. Be sure to follow specific dietary
recommendations or restrictions from your physician, registered dietitian, or other health care
professional. For example, people taking blood thinners, such as coumadin or warfarin, may be
told to limit their intake of dark green vegetables. If so, you can replace them with another nonstarchy vegetable. Some menus include raw fruits and vegetables, which can be cooked if you
prefer.
The next fun part of today’s lesson is physical activity. Who can remember the key message
about physical activity? Encourage participants to offer suggestions. Yes, the message is:
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
57
Be Physically Active Everyday!
How much physical activity should we be getting everyday? Wait for answers. Right – at least
30 minutes of moderate physical activity everyday is a good goal.
Does anyone want to talk more about ways to be physically active everyday? Wait for answers
and encourage discussion.
How many of you have been using a step counter? Wait for a show of hands. Did you write
down the number of steps in your Step Count Chart? Wait for responses.
Has anyone walked more since the last time we met? Wait for responses and ask participants
how they increased their steps. Do you think you feel better by increasing your steps? That’s
terrific! Wait for responses and share in participants’ success.
Does anyone need any help with your step counter or need a new Step Count Chart? Respond as
needed. If help is needed, then tell these participants that you will help them at the end of the
lesson.
Let’s take a walk around the room to be sure our step counters are working.
Last week, we did chair exercises together. They are called chair exercises because you can hold
onto a chair or sit on a chair while doing them. Did anyone practice these chair exercises in the
past few weeks? Wait for responses. Wonderful! Have you noticed some improvements in your
balance and flexibility? Wait for responses and share in participants’ success. The more often
you do these chair exercises the better you should feel.
We are going to add some new chair exercises today. Be sure to practice these at home, too!
Begin chair exercises (Module B with balls or Tufts/CDC Growing Stronger, Part I). Strongly
encourage participants to try these with you and at home.
Activity: “Bingo for Better Health”
Gather the group together to play “Bingo for Better Health.” The bingo cards are printed at the
end of all of these lessons. Give participants large dry beans for bingo pieces and bingo cards
that have a series of nutrition and health-related illustrations in each bingo square. Play this
game as normal bingo is played. Shuffle the stack of large bingo pieces, select one to call out to
participants, and show the bingo piece to participants. The first participant to accurately
declare bingo wins. Ideas for prizes include magnifying glasses to read food and medicine
labels, measuring cups, healthy snacks, bottled water, spice blends, small packets of artificial
sweetener, low-calorie pudding mix, shelf-stable milk or soy products (e.g., low-calorie milk
powder, low-calorie cocoa packet, 8-ounce boxes of milk), canned or fresh fruits and vegetables,
lights (e.g., night light, flashlight, key-chain light, other battery-powered lights), and small
bottles of lotion or hand cream.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
58
My Five Goals to Fight Falls and Fractures (Lesson 4)
Not Very
Often
My new
This Past Almost
Goal(s) For
Week
Everyday Everyday! Next Week
1. Be physically active
________ ________
________
________
2. Eat healthy and
take calcium and vitamin D
supplements if needed
________ ________
________
________
________ ________
________
________
3. Take my medicines as
recommended by my doctor
________ ________
________
________
4. Fight falls with a safe home
________ ________
________
________
5. Talk to my doctor about my medicines, risk of falling, vision and having a
bone mineral density test – at least once in the past year:
YES
NO
 What keeps me from fighting falls and fractures everyday?
_____________________________________________________
 How can I reach my goals to fight falls and fractures everyday?
_____________________________________________________
To help fight falls and fractures everyday:
 Remember the health benefits of fighting falls and fractures
 Ask for support from my family, friends, and doctor
 Think of easy ways to find time for my new habits
 If I sometimes forget, just be positive and try again
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
59
Calcium, Vitamin D, and Fat in Foods
Food
Milk, 1 cup
Whole
2%
1%
Skim
Buttermilk
Lactose-free milk
Other milk products
Yogurt, low-fat and low-calorie, ¾ to 1 cup
Cottage cheese, non-fat, 1 cup
Cheese, 1.5 ounces (or 2 x ¾ ounce slices)
Cream cheese, low-fat, 1 tablespoon
Ricotta cheese, low-fat, ¼ cup
Ice cream, low-fat, ½ cup
Other foods
Soy milk, calcium-fortified, 1 cup
Orange juice with calcium and vitamin D,
½ cup
Broccoli, leafy greens, cooked, ½ cup
Okra, cooked, ½ cup
Almonds, ¼ cup
Cooked dry beans, ½ cup
Cereal, ready-to-eat, ¾ to 1 cup
Salmon, with bones, 3 ounces
Other fish, 3 ounces
Calcium
(mg)
Vitamin D
(IU)
Fat
(grams)
300
300
300
300
300
300
100
100
100
100
100
100
8
5
2
0
2 to 5
Varies
300 to 400
100 to 200
200 to 300
20
170
70 to 130
0 to 100
0
0
0
0
0 to 50
0 to 3
0
5 to 9
3
5
4 to 20
300
150
100
50
Varies
0
50 to 150
60 to 90
70
20 to 60
10 to 1,000
200
50 to 100
0
0
0
0
0 to 40
400 to 650
50 to 100
0
0
15
0
0 to 3
4 to 6
Varies
 Most older people need 1,200 mg calcium daily and 600 - 800 IU vitamin D
daily, and should generally keep their intake of total fat around
Milk
60 grams or less (for an 1,800 calorie diet). Do not exceed
2,000 mg of calcium daily or 4,000 IU vitamin D daily,
unless recommended by your doctor.
From: USDA Nutrient Data Laboratory,
http://www.nal.usda.gov/fnic/foodcomp/search/
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
60
Nine Ways to Knockout Lactose-Intolerance
Some people avoid milk products because they can’t digest the milk sugar called
“lactose” very easily. This is called “lactose-intolerance” because their body
makes too little “lactase enzyme” needed to digest “lactose.” The “lactose”
remains in their intestine and can cause gas, cramps and/or diarrhea.
Here are some ways to help with this problem:
1. Drink less than one cup of milk at a time (start with ¼ cup serving size).
2. Drink milk with a meal or with other foods.
3. Eat milk products in small amounts spread out over the day.
4. Eat yogurt with active cultures, which has less lactose than
milk. Look for yogurt with the “made with live active
cultures” logo on the container.
5. Try hard cheeses, such as cheddar, instead of processed cheeses.
6. Drink lactose-free milk such as Lactaid or Dairy Ease®.
7. Add “lactase drops” to milk to make lactose-free milk at home.
These drops can be found in some grocery stores or pharmacies.
8. Take pills with the “lactase enzyme.” Ask your
pharmacist to help you find these in the store.
Usually, at least one pill is needed at each meal or
snack that contains milk products. The pills can
cost about 10 cents to 60 cents each, so shop
around. Just follow the package directions.
9. Try calcium- and vitamin D-fortified foods, such as
soy milk.
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
61
Plan My Plate!
PROTEIN FOODS
Meat, Fish, Poultry, Eggs,
Low-fat Cheese (2 to 3 oz)
or
Cottage Cheese (½ Cup)
NON-STARCHY
VEGETABLE(S)
1 or 2 Servings
½ Cup Most
1 Cup Raw Leafy Salad
STARCHY
GRAIN
1 Slice Bread or
½ Cup Pasta or
⅓ Cup Rice
FRUIT
½ Cup or
Small Piece
Fresh Fruit
Include the
fruit or milk in
your meal or as
part of your
snack.
STARCHY
VEGETABLE
½ Cup
MILK
PRODUCT
Skim Milk or
1% Milk or
Yogurt (1 Cup)
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
62
Day Four Menu
Breakfast
Whole wheat bagel, toasted, 1 medium (about 2 ounces), with 1 tablespoon peanut
butter, 2 tablespoons raisins
Milk, 1%, 1 cup
Nutrition Facts for Day 4:
Coffee*
1,832 calories
Snack
Yogurt, low-fat and low-calorie,
vanilla or fruit flavored, ¾ cup
Orange, 1 small
59 g total fat (29% calories)
15 g saturated fat (7% calories)
235 g total carbohydrate (51% calories)
100 g protein (22% calories)
Lunch
Butterbean salad, made with ½ cup butterbeans (canned, rinsed and drained), ½
cup sliced carrots (frozen or no-salt-added canned), 2 tablespoons chopped
green onion, 2 teaspoons olive or canola oil, 1 teaspoon lemon juice, salt-free
seasoning to taste
½ tuna sandwich, made with 1 slice toasted whole wheat bread, 2 ounces (¼ cup)
light tuna (canned in water, drained), 1 teaspoon light mayonnaise, 1 large
romaine lettuce leaf
Milk, 1%, 1 cup
Ice water
Snack
Broccoli florets, raw, ½ cup, with 2 tablespoons light ranch dressing for dipping
Wheat crackers, low-sodium variety, ¾ ounce (about 10)
Evening Meal
Boneless skinless chicken breast, grilled or baked, 3 ounces,
sprinkled with salt-free Italian seasoning blend
Cheese and rice stuffed tomatoes, 1 serving (recipe provided)
Corn on the cob, ½ large ear OR ½ cup cooked corn, fresh or from
frozen, with 1 teaspoon soft margarine for either option
Unsweetened iced tea with lemon*
Snack
Mini cinni fruit treat, made with 3 cinnamon graham crackers (2½-inch squares),
¾ cup fresh or frozen blueberries or other berries, 1 tablespoon light whipped
topping
*Coffee and tea may be sweetened with packets of artificial sweetener as desired
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
63
Herb and Rice Stuffed Tomatoes
Serves 2
Ingredients:







1 cup cooked brown rice*
2 ripe but firm medium tomatoes
2 teaspoons olive oil
1 small shallot, finely chopped (or sweet onion)
½ teaspoon dried basil
¼ cup shredded, part-skim mozzarella cheese
salt and pepper, to taste
* Instant brown rice can be cooked approximately 8 minutes in low-sodium
chicken or vegetable stock instead of water; a pinch of poultry seasoning
may also be added for flavor.
Directions:
1. Preheat oven to 350°F and line a small baking pan with aluminum foil
(preferably non-stick).
2. Cut a ½-inch thick slice off the top of each tomato; reserve the tomato tops.
3. Scoop the seeds, pulp, and juice from each tomato and discard; sprinkle a
pinch of salt and pepper into each of the hollowed out tomatoes.
4. In a small bowl, toss the cooked rice with the shallot, basil, and mozzarella
cheese to combine.
5. Spoon the rice mixture into the hollowed tomatoes, mounding slightly;
drizzle the top of each mound of rice with 1 teaspoon olive oil.
6. Place the reserved tomato tops on the stuffed tomatoes. Bake until the rice is
heated through, about 20 minutes; serve hot or at room temperature.
Nutrition Facts Per Serving:
228 calories
9 g total fat
3 g saturated fat
29 g total carbohydrate
8 g protein
Department of Foods and Nutrition, The University of Georgia, Athens, GA 30602
Division of Aging Services, Georgia Department of Human Resources, Atlanta, GA 30303
Updated September 2011
64