Malnutrition and obesity are both common among Americans over age 65. There are also a host of other medical conditions from which older people and other Medicare beneficiaries suffer that could be improved with appropriate nutritional intervention. Despite that, access to a nutrition professional is very limited.

• Do nutrition services benefit older people in terms of morbidity, mortality, or quality of life?
• Which health professionals are best qualified to provide such services?
• What would be the cost to Medicare of such services? Would the cost be offset by reduced illness in this population?

This book addresses these questions, provides recommendations for nutrition services for the elderly, and considers how the coverage policy should be approached and practiced. The book discusses the role of nutrition therapy in the management of a number of diseases. It also examines what the elderly receive in the way of nutrition services along the continuum of care settings and addresses the areas of expertise needed by health professionals to provide appropriate nutrition services and therapy.

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON NUTRITION SERVICES FOR MEDICARE BENEFICIARIES
• FOOD AND NUTRITION BOARD
• Acknowledgments
• Executive Summary
  • THE COMMITTEE AND ITS CHARGE
  • NUTRITION SERVICES AND TRENDS THAT INFLUENCE THE DELIVERY OF SERVICES
  • NUTRITIONAL HEALTH IN THE OLDER PERSON
  • FINDINGS AND RECOMMENDATIONS FOR MEDICARE COVERAGE OF NUTRITION THERAPY
  • ADMINISTRATIVE RECOMMENDATIONS REGARDING THE PROVISION OF NUTRITION SERVICES
  • ECONOMIC POLICY ANALYSIS
  • CONCLUDING REMARKS
  • REFERENCES
• Section I. Introduction and Overview
  • 1. Introduction
    • THE COMMITTEE AND ITS CHARGE
    • OVERVIEW OF THE REPORT
    • OVERVIEW OF THE MEDICARE PROGRAM
    • MEDICARE COVERAGE DECISIONS
    • MEDICARE COVERAGE OF NUTRITION SERVICES
    • REFERENCES
  • 2. Overview: Nutritional Health in the Older Person
    • MALNUTRITION
    • PREVALENCE OF NUTRITION RELATED CONDITIONS
    • SCREENING FOR NUTRITION RISK
    • REFERENCES
  • 3. Methods
    • EVIDENCE AVAILABLE
    • COMMITTEE DELIBERATIONS
    • REFERENCES
• Section II. The Role of Nutrition in the Management of Disease
  • 4. Undernutrition
    • MARKERS OF UNDERNUTRITION
    • SYNDROMES OF UNDERNUTRITION
    • LIMITATIONS OF CURRENT EVIDENCE
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
  • 5. Cardiovascular Disease
    • DYSLIPIDEMIA
    • HYPERTENSION
    • HEART FAILURE
    • RESEARCH RECOMMENDATIONS
    • REFERENCES
  • 6. Diabetes Mellitus
    • EVIDENCE THAT A CHANGE IN RISK FACTORS CHANGES MORBIDITY AND MORTALITY
    • THE ROLE OF NUTRITION INTERVENTION IN THE MANAGEMENT OF DIABETES
    • PROVIDERS OF NUTRITION THERAPY FOR DIABETES
    • MEDICARE REIMBURSEMENT FOR DIABETES SELF-MANAGEMENT TRAINING
    • LIMITATIONS OF DATA AND FUTURE RESEARCH NEEDS
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
  • 7. Renal Disease
    • CHRONIC RENAL INSUFFICIENCY
    • END-STAGE RENAL DISEASE
    • NUTRITION THERAPY AFTER TRANSPLANTATION
    • FUTURE AREAS OF RESEARCH
    • REFERENCES
  • 8. Osteoporosis
    • ROLE OF DIET IN ONSET AND TREATMENT OF OSTEOPOROSIS
    • COST AND QUALITY-OF-LIFE CONSIDERATIONS
    • FUTURE AREAS OF RESEARCH
    • SUMMARY AND RECOMMENDATIONS
    • REFERENCES
• Section III. Nutrition Services Along the Continuum of Care
  • 9. Nutrition Services in the Acute Care Setting
    • MEDICARE REIMBURSEMENT IN ACUTE CARE, SHORT-STAY HOSPITALS
    • ROLE OF THE NUTRITION PROFESSIONAL
    • EFFECTS OF UNDERNUTRITION ON FUNCTIONAL STATUS IN THE ELDERLY
    • FUTURE AREAS FOR RESEARCH
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
  • 10. Nutrition Support
    • LITERATURE REVIEW
    • INDICATIONS FOR THE USE OF NUTRITION SUPPORT
    • LIMITATIONS OF NUTRITION SUPPORT EVIDENCE
    • DELIVERY OF NUTRITION SUPPORT
    • REFERENCES
  • 11. Nutrition Services in Ambulatory Care Settings
    • REIMBURSEMENT FOR NUTRITION THERAPY IN AMBULATORY CARE
    • ACCREDITATION STANDARDS FOR THE AMBULATORY SETTING
    • NUTRITION SERVICES IN AMBULATORY SETTINGS
    • EFFECTIVENESS OF NUTRITION THERAPY IN AMBULATORY SETTINGS
    • FUTURE AREAS OF RESEARCH
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
  • 12. Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs
    • EMERGING TRENDS
    • SKILLED NURSING FACILITIES AND NURSING HOMES
    • HOME HEALTH AGENCIES
    • COMMUNITY-BASED BENEFITS
    • FUTURE AREAS OF RESEARCH
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
• Section IV. Providers and Costs of Nutrition Services
  • 13. Providers of Nutrition Services
    • TERMS AND DEFINITIONS
    • TIERS OF NUTRITION SERVICES
    • EDUCATION AND SKILLS NECESSARY FOR THE PROVISION OF NUTRITION THERAPY
    • LICENSURE IN THE PRACTICE OF DIETETICS
    • HEALTH CARE PROFESSIONALS SPECIALIZING IN NUTRITION
    • OTHER HEALTH CARE PROFESSIONALS
    • WHO IS QUALIFIED TO PROVIDE BASIC NUTRITION EDUCATION OR ADVICE?
    • WHO IS QUALIFIED TO PROVIDE NUTRITION THERAPY?
    • SUMMARY
    • RECOMMENDATIONS
    • REFERENCES
  • 14. Economic Policy Analysis
    • EVALUATION METHODOLOGIES
    • COST ESTIMATES
    • ECONOMICALLY SIGNIFICANT AVERTED COSTS
    • SUMMARY
    • REFERENCES
  • 15. Overall Findings and Recommendations
    • MEDICARE COVERAGE OF NUTRITION THERAPY
    • ADMINISTRATIVE RECOMMENDATIONS REGARDING THE PROVISION OF NUTRITION SERVICES
    • ECONOMIC POLICY ANALYSIS
    • CONCLUDING REMARKS
    • REFERENCE
• Appendixes
  • Appendix A Acronyms
  • Appendix B Glossary
  • Appendix C Workshop Speakers, Organizations Contacted, and Consultants to the Committee
  • Appendix D State Licensure Laws for the Practice of Dietetics (as of June 1999)
  • Appendix E The American Dietetic Association Foundation Knowledge and Skills and Competency Requirements for Entry-Level Dietitians
  • Appendix F Advanced Level Credentials in Nutrition
  • Appendix G U.S. Preventive Services Task Force Rating of Professionals to Deliver Dietary Counseling
  • Appendix H Summary of Cost Estimation Methodology for Outpatient Nutrition Therapy
  • Appendix I Committee Biographical Sketches

This project was funded by the U.S. Department of Health and Human Services, Health Care Financing Administration Contract No. 500-98-0275. Any opinion, findings, conclusions, or recommendations expressed in this publication are those of the Institute of Medicine committee and do not necessarily reflect the view of the funding organization.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.