June 2009 Issue

Intergenerational Programs — Uniting Young and Old for Good Nutrition, Physical Activity, and Wellness
By Christen C. Cooper, MS, RD
Today’s Dietitian
Vol. 11 No. 6 P. 44

If you have fond memories of baking cookies with your grandmother or fishing with your grandfather, you can appreciate the unique connections that can form between children and seniors. If you have experienced these bonds, you will recognize that intergenerational programs represent a largely untapped, viable resource for promoting good nutrition, physical activity, and wellness.

By 2030, roughly 20% of the national population will be older than the age of 65, and healthcare costs will have increased by 25%, according to 2007 statistics from the Centers for Disease Control and Prevention (CDC) and the Merck Foundation. Still, the majority of American seniors will be healthy enough to live independently. Today, only 5% of older Americans live in some sort of assisted living or nursing care facility, and 21% are noninstitutionalized and free of chronic conditions. National data show that people are moving to nursing homes at older ages. Among Americans aged 85 and older, nearly one quarter live in an elder care facility.1

Another demographic shift that has occurred over the past several decades is the geographic dispersion of families. In 1957, only 15% of older Americans had children living more than 30 minutes away; by 1975, that number jumped to 25%.1 This movement created a new reality for America’s elders: Children were no longer their parents’ default caregivers, and professionals were often contracted to take over this role. Today, “adoptive” families at institutions or retirement communities provide day-to-day support for some seniors, even if those seniors stay in contact with their own families.

Therefore, fostering common ground between older and younger Americans, even those who are not related, is becoming critically important. Today’s children are tomorrow’s caregivers and medical professionals, and they will need to understand the ideas, values, and concerns of this population.

As education scholars have pointed out, a number of seniors’ and children’s psychosocial needs are complementary (see Table 1). Some of these needs can be met when seniors and children come together to learn and share a variety of experiences.

A Model Program
One intergenerational program that successfully meets these needs is the partnership between New York’s Mount Kisco Child Care Center (MKCCC) and its neighbor, My Second Home. It’s a model intergenerational program, even though it was formed largely by accident. A decade ago, MKCCC served children exclusively, but it agreed to share space with My Second Home, a day care center for seniors. Members of both groups became interested in knowing more about each other, and an intergenerational program director was appointed to design activities and events.

After a decade of working together, the result is a meal program that serves mostly local, organic produce and other healthful foods on a daily basis. The seniors and kids plant, care for, and harvest a garden that they jointly create. The two generations also come together to prepare and eat the vegetables they grow. Additionally, the group participates in physical activity through playing games and taking trips. The program directly meets seniors’ needs to nurture, teach, and leave a legacy, as well as the corresponding needs of their “adoptive grandchildren.”

Program coordinators believe that the intergenerational model at MKCCC works because, in the words of one program coordinator, “When people get older, others tend to expect much less from them. When the seniors know that the kids are depending on them and looking to them to set an example, the older people will try a new food, even if they don’t like it. They’ll tell the kids why certain fruits or vegetables are good for them and then eat them to encourage the kids.” Such caring and sharing make for a comfortable, “safe” environment in which kids can experiment with new foods, try new types of movement, and gain confidence in good decision making.

Meeting Common Needs
Further potential for utilizing intergenerational programs to deliver nutrition education and promote physical activity lies in some important physical needs that children and seniors share. Focusing on this common ground may facilitate intergenerational program development and attract nutrition and physical activity funding geared for these special populations.

Preventive health programs for children are at a pinnacle of relevance. According to 2004 Institute of Medicine statistics, 9 million children over the age of 6 are classified as obese and therefore are at an increased risk of chronic diseases, so it is critical to turn kids on to lifelong healthful habits. In addition, discoveries in nutrigenomics are revealing specific ways in which foods eaten early in life impact human growth and development. Thus, there is growing support for promoting nutrient-dense, whole foods to children starting as early as the preschool years. Disease prevention, packaged in fun educational activities, can help kids adopt lifelong positive eating and exercise habits.

Science is also opening new avenues for disease prevention and health maintenance for seniors. Many people think of older adults as being past the point of prevention, but research suggests this is not the case. Whereas the Institute of Medicine formerly made nutrient recommendations for seniors by lumping all adults older than the age of 51 into one group, it is now working on nutrient recommendations exclusively for people older than the age of 65 because science is revealing important differences in health needs between different age groups of older people.2

Furthermore, an Institute of Medicine report indicated that the return on investment of medical treatment for cardiovascular disease was 4 to 1, but the investment in behavioral change returned a remarkable 30-to-1 return on investment, according to a 2002 statement by David W. Fleming, PhD, of the CDC. This is evidence that preventive programs can be wise and cost-effective investments for complementing—and in some cases replacing—conventional disease therapies.

Some of the nutritional and physical activity needs common to seniors and children include meeting government recommendations for fruit and vegetable intake, boosting dairy intake, limiting dietary sodium, increasing physical activity, and achieving and maintaining a healthy weight.

Fruits, Vegetables, and Whole Grains
According to current data on dietary intake from the USDA’s Center for Nutrition Policy and Promotion, seniors fall short on recommendations for dark green and orange vegetables, as well as for whole grains. There are numerous reasons for these shortcomings. For example, seniors who live alone may not regularly purchase fresh produce due to quick spoilage. Lack of familiarity is another barrier, as many seniors were not raised on whole grains and may be reluctant to try them. Some may have dentures or other chewing limitations that make the tougher texture of some whole foods troublesome. Additionally, some may fear that fiber-rich foods will irritate their digestive system.

Children fall short on total fruit, whole fruit, total vegetable, dark green and orange vegetable, and whole grain intake. Neophobia plays a significant role in children’s low whole food consumption. Programs that introduce kids to fruits and vegetables through gardening, cooking, and food tasting improve whole food acceptance and intake.3 Even though kids tend to eat fruit more readily than they eat vegetables, they still do not eat enough of either. However, this is a category in which seniors score quite well. Perhaps programs that introduce new plant foods, with seniors modeling ideal consumption and sharing favorite recipes, could motivate children to choose a wider variety of fruits and other nutrient-dense foods.

Milk
When it comes to milk, both children and seniors fall short of recommendations. Sweetened beverages have virtually replaced milk as the common mealtime beverage over the last half century. Scientists have feared the impact that this may have on children’s bones, since milk is a rich and highly absorbable source of both calcium and vitamin D. Seniors may avoid dairy due to lactose intolerance, but they arguably stand to benefit from milk and dairy as much as children, since their bone strength must be maintained to prevent fractures.

Whereas children get sun exposure playing outdoors, seniors tend to avoid the sun. This again raises the importance of vitamin D-rich foods or dietary supplements for seniors’ bone health. According to the latest recommendations, daily vitamin D intake should be 400 to 600 IU in the presence of sunlight and 800 to 1,000 IU in the absence of sunlight.4 Activities that get seniors outdoors—gardening or walking with kids—can help raise vitamin D levels and provide both exercise and enjoyment.

Some research also suggests that dairy is beneficial for weight management. However, calcium can also be obtained from dark green vegetables and some seafood sources. Vitamin D is found in fewer foods, but it is plentiful in fatty fish and fish oils. Taste tests of foods rich in calcium and vitamin D, the experience of growing and sampling different types of leafy greens, and, yes, eating that fish caught with “grandpa” may serve as intergenerational activities to promote calcium and vitamin D intake.

Sodium
Many seniors rely on canned or individually portioned prepared foods, since these are quick and easy and leave little plate waste. However, such foods are frequently high in sodium. It is well established that ingesting too much sodium can lead to high blood pressure and raise the risks for heart attack and stroke. Current recommendations state that most Americans should limit their daily sodium intake to about 2,300 mg, or 1 tsp of salt. Most Americans get far more than this, with about 80% coming from processed foods and only 10% added at the table or during cooking. Americans considered at risk for salt-related illnesses, a group that includes 69% of the population, are advised to limit sodium to 1,500 mg (less than 4 g/day), according to the CDC.

The American Heart Association, the CDC, and the FDA are working on strategies to reduce sodium in packaged foods by 50% over the next 10 years. This is important not only for seniors but also for children. By introducing fruits, vegetables, and whole grains—foods naturally low in sodium—to an intergenerational group, appreciation and preference for lower sodium foods can be fostered.

Physical Activity
Millions of American children spend their days in day care or school, and many elders spend their days at home or in nursing homes, independent living centers, or other institutions. Thus, the old and young have something else in common: They need more opportunities for physical activity.

It would be reasonable to question how energy-packed youngsters could feasibly team up with seniors. In all of the discussion of rising healthcare costs, the 21% of seniors who have no chronic diseases and live independently are frequently overlooked. It is this group that health educators can perhaps most productively target for preventive programs. These seniors have much to gain from maintaining their good health, including a continuously high quality of life and healthcare bills that remain under control. They may also serve as outstanding mentors and “coaches” for the young people with whom they interact in the dining room or on the walking track.

The very old and the very young may not be candidates for marathon training, but there are many moderate activities that they can enjoy together. Gardening provides a natural connection to healthful eating and is a proven means of effective nutrition education. Children tend to eat what they grow, even if the foods are not familiar or among their favorites before they grow them.3

Gardening’s low intensity makes it ideal for people of all ages, including those with physical limitations. However, it does offer some important physical challenges, such as bending, stretching, and weight bearing. It also provides gardeners the satisfaction of creating something meaningful that they can touch, smell, and taste once their work is finished. Additionally, gardening can help relax the mind and body. There are a number of documented intergenerational gardening programs that have been operating in various parts of the United States for years, keeping children and elders physically active and mentally engaged.

Walking is another key activity for multigenerational groups. Studies have shown that walking may be all that is needed to considerably reduce the risk of type 2 diabetes. Walking is also a weight-bearing exercise that helps decrease bone loss, and it works the muscles and heart. In addition, walking burns calories, thereby helping kids and seniors meet aerobic activity guidelines.

Overweight Prevention
Evidence increasingly supports the long-held notion that overweight is linked to a number of chronic diseases, including heart disease, diabetes, and cancer.
It has long been known that disease risk increases independently with increasing body mass index (BMI) and excess abdominal fat. Cardiovascular and other obesity-related disease risks increase significantly when BMI exceeds 25, with risks rising even more dramatically when BMI reaches and surpasses 30. Waist circumference measurements greater than 40 in. (102 cm) in men and 35 in. (89 cm) in women also indicate an increased risk of obesity-related comorbidities.5

The most recent report from the World Cancer Research Fund and the American Institute for Cancer Research stated that its No. 1 recommendation is to “be as lean as possible within the normal range of body weight.” This recommendation comes before many decisive recommendations, including increasing physical activity and increasing fruit and vegetable intake. The global perspective also puts obesity above too much alcohol, too much salt, and overusing dietary supplements as a root cause of cancer.

Directly linked to overweight is diabetes, which is expected to nearly triple in prevalence by 2050.6 Studies have shown that weight loss and physical activity in those with prediabetes can prevent or delay diabetes and return blood glucose levels to normal. The Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, showed that lifestyle intervention reduced the risk of developing diabetes by 58% during a three-year period. The reduction was even greater (71%) among adults aged 60 and older.

Obviously, children who are at increased risk for type 2 diabetes at younger ages have perhaps the most to gain from prevention, since they have more time to ward off the disease. Getting elders and children moving together, perhaps with the children modeling this time, would be a worthwhile intergenerational activity. Seniors with diabetes could stress prevention and discuss the barriers and limitations they have faced because of their disease. Comprehensive antiobesity programs that have educated older and younger school staff members, as well as obese children, have produced promising results.7

Interfamily Intergenerational Nutrition Education
Research shows that for people who live in intergenerational households, positive, open communication between generations is key to healthful eating. Intergenerational nutrition and physical activity and a unified emphasis on good health can begin at home.

A study performed by researchers at Penn State University in 2006 explored how youths, parents, and grandparents discuss food, eating, and health issues and how such discussion helped families develop intergenerational strategies to improve communication. Some families struggle with generation-specific or cultural beliefs that encourage what is defined as overweight by U.S. standards. Other families must try to balance the body shapes and sizes that parents believe are ideal with the realities of the bodies their children have. The study, which included members of 17 families, revealed that families communicate about healthful eating in a variety of ways, and many would welcome opportunities to learn about nutrition together and communicate about ways to improve nutrition and eating behaviors in the family environment.8

With the recent explosion of research on nutrigenomics, it’s not surprising that evidence suggests that overweight and obesity may be partially genetic. But only last year did scientists find a correlation between obesity in grandparents and obesity in grandchildren. The study, published in the Journal of the American Board of Family Medicine, reported that of the 2,591 kids aged 5 to 19 who were studied, those with obese grandparents, even if their parents were of normal weight, had a prevalence of overweight of 17.4%. By knowing their genetics, families may share a better understanding of their members’ body types and the ways each must eat to stay healthy.

Summary
There are few existing intergenerational programs in nursing homes, schools, day care centers, and community venues around the country, and thus there is little available literature on their effectiveness for delivering intergenerational health and wellness education. Intergenerational scholars believe that many facilities set up visitations or activities that unite kids and seniors but that many programs are infrequent, small, and rarely reported to a national audience.

One objective clearly expressed in the Healthy People 2010 objectives for educational and community-based programs is to increase from 12% to 90% the participation of seniors in at least one organized health promotion activity.2 Intergenerational programs that take kids to seniors’ homes or institutions or take seniors to schools and day care and community centers allow the two groups to share a facility and may be ideal ways to meet this goal.

A growing number of people in education, social work, and wellness are beginning to believe that such programs may hold importance and promise for the future. Whereas intergenerational programs used to be considered “cute,” they may soon be viewed as serious alternatives to expensive healthcare services, offering viable ways to keep children and seniors learning, growing, eating well, and staying active.

— Christen C. Cooper, MS, RD, is a Pleasantville, N.Y.-based freelance health and nutrition writer. She has worked in healthcare consulting in Latin America and the United States and holds a master’s degree in nutrition education from Teachers College, Columbia University.

 

References
1. Newman S, Ward CR, Smith TB, Wilson JO, McCrea JM. Intergenerational Programs: Past, Present and Future. Washington, D.C.: Taylor & Francis; 1997.

2. Sahyoun NR. Nutrition education for the healthy elderly population: Isn’t it time? J Nutr Educ Behav. 2002;34:S42-S47.

3. Contento IR. Nutrition Education: Linking Research, Theory, and Practice. Boston: Jones and Bartlett Publishers; 2007.

4. Heaney RP. NAMS continuing medical education activity. Menopause. 2006;13:859-862.

5. Lyznicki JM, Young DC, Riggs JA, Davis RM; Council on Scientific Affairs, American Medical Association. Obesity: Assessment and management in primary care. Am Fam Phys. 2001;63(11):2185-2196.

6. Boyle JP, Honeycutt AA, Narayan KM, et al. Projection of diabetes burden through 2050: Impact of changing demography and disease prevalence in the U.S. Diabetes Care. 2001;24(11):1936-1940.

7. Brownell KD, Kaye FS. A school-based behavior modification, nutrition education, and physical activity program for obese children. Am J Clin Nutr. 1982;35(2):277-283.

8. Kaplan M, Kiernan NE, James L. Intergenerational family conversations and decision making about eating healthfully. J Nutr Educ Behav. 2006;38(5):298-306.

Table 1: Complementary Psychosocial Needs of Older Adults and Children

Older Adults
Children

To nurture

To be nurtured

To teach

To learn

To have a successful life review

To learn from and about the past

To share cultural customs

To develop cultural identity

To communicate positive values

To have positive role models

To leave a legacy

To be connected to previous generations

— Information adapted from Newman S, Ward CR, Smith TB, Wilson JO, McCrea JM. Intergenerational Programs: Past, Present and Future. Washington, D.C.: Taylor & Francis; 1997.

 

Table 2: Nutritional and Physical Activity Recommendations Common to Children and Seniors

2005 Healthy Eating Index Component

Seniors

Children

Fruits, Vegetables, and Whole Grains

  • ↑Dark green vegetables
  • ↑Orange vegetables
  • ↑Whole grains
  • ↑All vegetables
  • ↑Dark green vegetables
  • ↑Orange vegetables
  • ↑All fruits
  • ↑Whole grains

Milk

  • ↑Calcium intake
  • ↑Low-fat dairy, if tolerated
  • ↑Low-fat dairy
  • ↑Calcium intake

Sodium

  • ↓Canned, processed foods
  • ↓Salty snacks
  • ↓Canned, processed foods
  • ↓Salty snacks

Physical Activity

  • ↑Moderate activity and vigorous activity, if tolerated
  • ↑Outdoor exercise and activities
  • ↑Bone-strengthening exercise
  • ↑Moderate and vigorous physical activity
  • ↑Outdoor exercise and activities
  • ↑Bone-strengthening exercise

Overweight Prevention

  • ↑Nutrient-dense foods, including fruits, vegetables, and legumes
  • ↓Energy-dense, nutrient-poor foods
  • ↑Physical activity
  • ↑Nutrient-dense foods, including fruits, vegetables, and legumes
  • ↓Energy-dense, nutrient-poor foods
  • ↑Physical activity
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