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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 1 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 2 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 3 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 4 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 5 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 6 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 7 NOTES to Educator Authoritative sources of information about falls, fractures, and osteoporosis were used for all of the lesson plans. These sources include: 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 8 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 Y C L I N G O R L W D A N C I 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 K L A W E H N M A R C H I N P L A C E I S E T N E W G O A L S H M M H C T E R T S W M S O M N E D R A G R E A U V U I K J L V 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