DIETARY REFERENCE INTAKES DIETARY GUIDELINES: Nutrition Standards for Today s Older Americans

1. 1 DIETARY REFERENCE INTAKES & DIETARY GUIDELINES: Nutrition Standards for Today�s Older Americans NANCY WELLMAN National Policy & Resource Center on Nutrition & Aging JEAN LLOYD Administration on Aging

2. 2 Overview Background: DRIs - EAR, RDA, AI, UL Nancy Wellman Older Americans Act Review Jean Lloyd Issue Panel & Recommendations Nancy Wellman Implications & Program Implementation Jean Lloyd

3. 3 What are the Dietary Reference Intakes (DRIs)? Reference values of nutrients, primarily used by nutrition & health professionals Basis for assessing & planning diets of healthy people federal nutrition & food programs

4. 4 What are the purposes of the DRIs? To maintain nutritional adequacy To promote health To reduce risk of chronic disease To provide a measure for evaluating inadequacy and/or excess To assess intakes as distributions Across population groups In individuals To plan diets

5. 5 Separate values men women New values 51 - 70 yrs 70+ yrs What are characteristics of the DRIs?

6. 6 What are characteristics of the DRIs? Apply to healthy individuals Refer to average daily nutrient intakes May vary substantially from day to day without ill effect in most cases

7. 7 Who established the DRIs? Food and Nutrition Board, Institute of Medicine, National Academy of Sciences Panels of experts; chosen by the National Academy; independently selected Funded by DHHS, USDA, Health Canada, private industry Serially published: 1997 & continuing www.iom.edu

8. 8 What are the different DRI values? Estimated Average Requirement: EAR Recommended Dietary Allowance: RDA Adequate Intake: AI Tolerable Upper Intake Level: UL

9. 9 What is a nutrient requirement? A requirement is the lowest continuing intake that will maintain a defined level of nutriture. In the EAR.

10. 10 What is the EAR?Estimated Average Requirement Nutrient intake to meet the requirement of half the healthy people of an age & gender The MEDIAN (Think bell curve) Basis for establishing an RDA

11. 11 What is the RDA?Recommended Dietary Allowance Nutrient intake to meet the requirement for nearly all (97-98%) healthy people of an age & gender Derived from an EAR EAR + 2 standard deviations

12. 12 What is the AI?Adequate Intake Nutrient intake of healthy people assumed to be adequate Used when an RDA cannot be established Insufficient data to determine an EAR Based on observed intakes, experimental data, etc.

13. 13 What is the UL?Tolerable Upper Intake Level Highest daily nutrient intake likely to pose no risk of adverse health effects to almost all the general population Applies to daily use Not a recommended level No established benefits of higher level Increased risks at higher intakes

14. 14 Tolerable Upper Intake Level ULs vary among nutrients: some apply to intake from all sources -- food, fortified food, supplements, water (eg, calcium, vitamin D) some apply to intake from synthetic forms alone (eg, folic acid, niacin, magnesium) not all nutrients have ULs established presently (eg, vitamin B12)

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16. 16 Use of DRIs: Assessing Intakes For an Individual EAR: Use to examine the probability that usual intake is inadequate RDA: Usual intake at/above this level has low probability of inadequacy AI: Usual intake at/above this level has low probability of inadequacy UL: Usual intake above this level may place individual at risk of adverse effects from excessive nutrient intake For a Group EAR: Use to examine the prevalence of inadequate intakes within a group RDA: Do not use to assess intakes of groups AI: Mean usual intake at/above this level implies a low prevalence of inadequate intakes UL: Use to estimate % population at potential risk of adverse effects from excessive nutrient intake

17. 17 RDA is inappropriate for assessing groups RDA: intake levels that exceed requirements of 97�98 % of all individuals when requirements in the group have a normal distribution Thus, RDA: not a cut-point for assessing nutrient intakes of groups-- serious overestimation of the proportion of the group at risk of inadequacy would result

18. S Barr, Univ of British Columbia 18 Group Prevalence of Inadequate Intakes What proportion of individuals in a group have usual intake below requirements? The % below the EAR

19. 19 Using the EAR to assess groups Obtain data on usual nutrient intake from all sources (food & supplements). Adjust the intake distribution for intra-individual variability. Determine the proportion with intakes below the EAR - this is the proportion of the population with inadequate intakes. To date, no published studies using this method. Software available to encourage this approach (see next slide).

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21. 21 Planning for groups or individuals Dietary Reference Intakes for Planning: anticipated publication in July 2002. RDAs can be used in planning for groups or individuals � but not in assessing adequacy of intake.

22. 22 Why use the DRIs? Increase accuracy of dietary assessments, taking care that : dietary data are complete, portions are correctly specified, food composition data are accurate, methodologies & plans for sampling group intakes are appropriate.

23. 23 What are the Dietary Guidelines for Americans, 2000? Brief science-based statements & text published by federal government Provide advice for healthy Americans, age 2+ yrs, about food choices & physical activity to promote health & prevent disease.

24. 24 The Dietary Guidelines Mandated by law Published every 5 years Based on preponderance of scientific evidence Cornerstone of federal nutrition policy Basis for healthy nutrition choices Basis for nutrition education & promotion activities

25. 25 How are the Dietary Guidelines revised? Advisory Committee appointed to review Guidelines � open process Committee report presented to DHHS & USDA DHHS & USDA review report & public comments Secretaries of DHHS & USDA publish revised Dietary Guidelines.

26. The latest edition of the Dietary Guidelines was released on May 27, 2000, by the President. The guidelines were then discussed by Secretaries of Agriculture and Health and Human Services, at the National Nutrition Summit in Washington, DC, on May 30, 2000. The updated guidelines emphasize food choices in the context of the Food Guide Pyramid and stress physical activity and healthy weight maintenance. These Guidelines were designed to be more user-friendly and actionable, and to provide more specific advice on food choices than previous editions.The latest edition of the Dietary Guidelines was released on May 27, 2000, by the President. The guidelines were then discussed by Secretaries of Agriculture and Health and Human Services, at the National Nutrition Summit in Washington, DC, on May 30, 2000. The updated guidelines emphasize food choices in the context of the Food Guide Pyramid and stress physical activity and healthy weight maintenance. These Guidelines were designed to be more user-friendly and actionable, and to provide more specific advice on food choices than previous editions.

27. 27 Aim for Fitness Aim for a healthy weight Be physically active each day The first group, �Aim for Fitness,� includes two guidelines that were previously combined as one. �Aim for a healthy weight� and �Be physically active each day� were derived from the 1995 guideline �Balance the foods you eat with physical activity�maintain or improve your weight.�The first group, �Aim for Fitness,� includes two guidelines that were previously combined as one. �Aim for a healthy weight� and �Be physically active each day� were derived from the 1995 guideline �Balance the foods you eat with physical activity�maintain or improve your weight.�

28. 28 Build a Healthy Base Let the Pyramid guide your food choices Choose a variety of grains daily, especially whole grains Choose a variety of fruits & vegetables daily Keep food safe to eat The second group, �Build a Healthy Base,� includes 4 guidelines that build the foundation for a healthy diet, starting with using the Food Guide Pyramid as a guide for food choices. The second guideline in this group suggests choosing a variety of grains daily, and emphasizes whole grains. Next, choosing a variety of fruits and vegetables is also recommended. Lastly, a new guideline on food safety emphasizes keeping foods safe to eat. The second group, �Build a Healthy Base,� includes 4 guidelines that build the foundation for a healthy diet, starting with using the Food Guide Pyramid as a guide for food choices. The second guideline in this group suggests choosing a variety of grains daily, and emphasizes whole grains. Next, choosing a variety of fruits and vegetables is also recommended. Lastly, a new guideline on food safety emphasizes keeping foods safe to eat.

29. 29 Choose Sensibly Choose a diet that is low in saturated fat & cholesterol, & moderate in total fat Choose beverages & foods to moderate your intake of sugars Choose & prepare foods w/ less salt If you drink alcoholic beverages, do so in moderation The third group, �Choose Sensibly,� includes 4 guidelines that will help individuals make the overall best choices for optimal health, including guidance on fat, sugar, salt, and alcohol. These guidelines are choose a diet that is low in saturated fat and cholesterol and moderate in total fat; choose beverages and foods to moderate your intake of sugars; choose and prepare foods with less salt; and if you drink alcoholic beverages, do so in moderation. The third group, �Choose Sensibly,� includes 4 guidelines that will help individuals make the overall best choices for optimal health, including guidance on fat, sugar, salt, and alcohol. These guidelines are choose a diet that is low in saturated fat and cholesterol and moderate in total fat; choose beverages and foods to moderate your intake of sugars; choose and prepare foods with less salt; and if you drink alcoholic beverages, do so in moderation.

30. 30 The Food Guide Pyramid It also builds on the familiarity of the Food Guide Pyramid, which is now recognized by three-fourths of all Americans.It also builds on the familiarity of the Food Guide Pyramid, which is now recognized by three-fourths of all Americans.

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32. 32 Older Americans Act Review

33. 33 OAA Requirements SEC. 339 (2)(A)(i) State � shall ensure that project provides meals that comply with the Dietary Guidelines for Americans. SEC. 339 (2)(A)(ii) State � shall ensure that project provides to each participating older individual meals that provide � a minimum of 33 1/3% of the daily RDA � if one meal per day � 66 2/3% RDA if � 2 meals per day, & 100% RDA for 3 meals per day.

34. 34 What does this mean? Does the OAA (or AoA) require that an SUA implement the nutrition quality requirements of the OAA in a specific way? No, the OAA is flexible about how an SUA is to implement the OAA; it is a State responsibility to ensure that the requirements of the OAA are met. Does the OAA (or AoA) require an SUA to use a menu pattern? No, the OAA does not require an SUA to use a specific menu pattern; it is a State responsibility to determine HOW to implement the OAA nutrient requirements.

35. 35 What does this mean? Does the OAA (or AoA) require an SUA to monitor specific �lead� nutrients (calories, protein, calcium, iron, vitamin A, thiamine, riboflavin, niacin, vitamin C)? No, SUA are responsible for determining which nutrients to monitor to ensure that projects are meeting the OAA requirements. Many SUAs have not changed the nutrients that they monitor since the mid-�70s.

36. 36 What does this mean? Does the OAA (or AoA) require that each meal contain 30% fat or less? No, the OAA does not require that each meal contain 30% fat or less; it is an SUA�s responsibility to determine HOW to meet the requirements of the OAA, including the Dietary Guideline regarding the fat intake of older Americans.

37. 37 What does this mean? Does the OAA (or AoA) require that each meal contain no more than 800 mg sodium? No, the OAA does not require that each meal contain no more than 800 mg sodium; it is an SUA�s responsibility to determine HOW to meet the requirements of the OAA, including the Dietary Guideline regarding the sodium intake for older Americans.

38. 38 How Do States Implement the OAA Requirements? 1998 SUA Policies & Procedures Collection 40 (91%) had guidelines that meals comply with 33% RDA 35 (79%) had guidelines for compliance with Dietary Guidelines 34 (77%) had guidelines for meal patterns Some �standard� meal patterns require foods high in vitamin C daily & vitamin A 3 times/week.

39. 39 OAA Requirements SEC. 339(2)(A)(iii) ensure that the project�provide(s) meals that to the maximum extent practical, are adjusted to meet any special dietary needs of program participants

40. 40 What are �special dietary needs?� �Special dietary needs� include meals that meet Cultural or ethnic preferences, ie, culturally appropriate; Religious requirements, ie, Kosher, Hallal; Therapeutic or meals that are modified for health conditions, ie, 2 gm sodium, diabetic, renal, texture-modified, etc. Other interpretations include meals that provide client �choice� or selection of different meal components, ie, 2 different entrees or 3 different vegetables, choice of milk, etc.

41. 41 What Does This Mean? Does the OAA (or AoA) require that a local nutrition project provide �special diets�? No, the OAA requires that �special diets� be provided to the �maximum extent practical.� The definition of �maximum extent practical� has included such items as characteristics ofthe older adults to be served in the community, number of people with a specific need, capacity and capability of the provider, availability of different caterers/vendors, requirements of different funding sources, provider expertise, etc.

42. 42 How Do States Implement This Requirement? 1998 SUA Policies & Procedures Collection 37 (84%) had guidelines for special diets for health, religious or ethnic reasons 21 (48%) had guidelines for sodium & fat content of meals.

43. 43 OAA Requirements SEC. 339(2)(B) provides flexibility to local nutrition providers in designing meals that are appealing to program participants

44. 44 What Does This Mean? How does an SUA or local nutrition provider �ensure� that meals are appealing to program participants? States and AAAs allow local nutrition projects flexibility in writing the menus to meet local preferences while ensuring the menus meet nutrient requirements. States and AAAs require a customer assessment of meal quality, service, etc. on a regular schedule. States and AAAs may include a nutrition advisory council at state, AAA or local levels.

45. 45 How Do States Implement This Requirement? This is a new requirement in the 2000 amendments to the OAA and no data has been collected on how States are implementing it.

46. 46 Does the OAA Allow or Not Allow Specific Foods? FREQUENTLY ASKED QUESTIONS: Can we serve pizza? Do we have to serve skim milk? Why can�t we serve dessert? The OAA does not address any specific foods. States, AAAs, and local nutrition projects need to establish a common understanding of state and AAA requirements. Providing alternative selections, such as skim milk or 2% milk or fruit or cake are common ways to meet differing participant needs.

47. 47 OAA Requirements SEC. 339 (1) State � shall solicit the advice of a dietitian or individual with comparable expertise in the planning of nutrition services. SEC. 339 (2)(G) State � ensure that the project � ensures that meal providers carry out such project with the advice of dietitians �

48. 48 What Does This Mean? Does the OAA require that an SUA or a local nutrition service provider hire an RD or ICE? No, the OAA does not require an SUA to hire an RD or ICE. However, the OAA does require an SUA to solicit the advice of a RD or ICE. Nutrition services are more than menu review and includes other functions.

49. 49 How Do States Implement This Requirement? In 2002, 60% of SUAs have an RD on staff. In 1995, Serving Elders at Risk found 85% SUAs, 73% AAAs, 60% nutrition projects had access to staff with nutrition credentials 69% SUAs, 61% AAAs, 41% nutrition projects had access to an RD 40% SUAs, 36% AAAs, 41% nutrition projects had access to staff with other nutrition credentials

50. 50 How Do States Implement This Requirement? 1998 SUA Policies & Procedures Collection 35 (77%) had guidelines for the use of an RD or ICE at any level. 20 (45%) had guidelines for the services of an RD &/or Licensed Dietitian or ICE at the AAA or local provider level.

51. 51 OAA Requirements SEC. 331 (3) � State plans � establishment & operation of nutrition projects which may include nutrition education services & other appropriate nutrition services for older individuals. SEC. 339 (2) (J) State � shall ensure that projects provide for nutrition screening &, where appropriate, for nutrition education & counseling. �1998 SUA Policies & Procedures Collection 41 (93%) had guidelines for nutrition education 19 (43%) had guidelines for health promotion & disease prevention activities

52. 52 Summary: ISSUE PANEL February 11, 2002

53. 53 Dietary Reference Intakes & Dietary Guidelines in Older Americans Act Nutrition Programs �Summary: ISSUE PANEL February 11, 2002

54. 54 Cogent Research: Full-service marketing research & strategic facilitation firm, offering an array of qualitative & quantitative research tools. Expertise in food & nutrition issues: working with associations serving food industry, food companies, supermarkets, pharmaceutical companies, food-related product manufacturers. In-house team of session facilitators -- experts in session design, moderating, strategic plan development, session analysis. In food & health, facilitated sessions on obesity, scientific reporting, caffeine, allergies, clinical trials, etc.

55. 55 Panelists: University YVONNE BRONNER, ScD, RD, Director, Public Health Program, Morgan State University, Baltimore, MD NOEL CHAVEZ, PhD, RD, Associate Professor, School of Public Health, University of Illinois, Chicago EDWARD FRONGILLO, JR., PhD, Associate Professor, Cornell University, Ithaca, NY GORDON JENSEN, MD, PhD, Director, Vanderbilt Center for Human Nutrition, Nashville, TN MARY ANN JOHNSON, PhD, Professor, University of Georgia, Athens ROBERT RUSSELL, MD, Director & Senior Scientist, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA JOE SHARKEY, MPH, RD, Nutritionist & Doctoral Candidate, University of North Carolina, Chapel Hill, NC

56. 56 Panelists: Government JOSEPH CARLIN, MS, RD, FADA, Regional AoA Nutritionist, Boston, MA JOHANNA DWYER, DSc, RD, Assistant Administrator, Human Nutrition, USDA, Agricultural Research Service, Washington, DC NANCY GASTON, MA, RD, Senior Nutritionist, USDA, Center for Nutrition Policy & Promotion, Alexandria, VA YVONNE JACKSON, PhD, RD, Director, Office of American Indian, Alaskan Native and Native Hawaiian Programs, AoA, Washington, DC FLORISTENE JOHNSON, MS, RD, Senior Aging Prg.Specialist, AoA, Dallas,TX JEAN LLOYD, MS, RD, Nutritionist, AoA, Washington, DC BRIAN LUTZ, Acting Director, Office for Community-Based Services, AoA, Washington, DC KATHRYN MCMURRY, MS, Nutrition & Food Science Advisor, ODPHP, USDHHS, Washington, DC LINDA MEYERS, PhD, Deputy Director, Food & Nutrition Board, IOM, Washington, DC DEBRA NICHOLS, MD, MPH, PH Advisor, ODPHP, USDHHS, Washington, DC JO ANN PEGUES, MPA, RD, Regional AoA Nutritionist, Denver, CO

57. 57 Panelists: Aging Network & Industry DOUGLAS BUCK, PhD, FACN, State Nutritionist, CT Dept. Social & Elderly Services, Hartford JENNIFER DRZIK, MS, RS, LD, State Nutritionist, MD Dept. of Aging, Baltimore JULIE HODGES, PhD, RD, FADA, Director, Health Care Services, Zartic Foods, Rome, GA BERTHA HURD, BS, Nutritionist, Dept. of Aging, City of Los Angeles, CA LINDA LAVINE, RD, LD/N, Corporate Dietitian, GA Food Service, Inc., St. Petersburg, FL LINDA NETTERVILLE, MA, RD, Nutrition Prog. Mgr, Johnson County AAA, Olathe, KS MARTHA PEPPONES, MS, RD, Nutr Dir, Senior Services Snohomish County, Mukilteo, WA SUE ZEVAN, RD, State Nutritionist, Aging & Adult Administration, Dept. Economic Security, Phoenix, AZ

58. 58 Panelists: National Policy & Resource Center on Nutrition & Aging Heidi Silver, PhD, RD, CNSDAssociate Director & Research FacultyIssue Panel Project Director Lester Rosenzweig, MS, RDAssociate Director Peggy Schafer, RD, Graduate Assistant Dian Weddle, PhD, RD, FADA Associate Professor & Co-Director Nancy Wellman, PhD, RD, FADA Professor & Director

59. 59 Discussion Topics: Why must Older Americans Act Nutrition Program meals meet the most current Recommended Dietary Allowances & Adequate Intakes (as components of the Dietary Reference Intakes), & the 2000 Dietary Guidelines for Americans? Must each Older Americans Act Nutrition Program meal individually meet these requirements? Assuming that all Older Americans Act Nutrition Program meals are culturally appropriate, what nutrients should be targeted?

60. 60 Discussion Topics: How can Older Americans Act Nutrition Program meals be evaluated for meeting the Recommended Dietary Allowances, Adequate Intakes, & 2000 Dietary Guidelines? How can Older Americans Act Nutrition Program meals be adjusted to meet special dietary needs? How can nutrition services, including nutrition screening, education, & counseling, incorporate the Dietary Reference Intakes, 2000 Dietary Guidelines, & targeted nutrients recommendations? What nutrition-related issues need attention at future Issue Panels &/or in outcomes research?

61. 61 #1: Why must Nutrition Program meals meet most current RDA & AIs, and the 2000 Dietary Guidelines?

62. 62 #1: Why must Nutrition Program meals meet most current RDA & AIs, and the 2000 Dietary Guidelines?

63. 63 #2: Must each Nutrition Program meal individually meet these requirements?

64. 64 #3: Assuming all meals are culturally appropriate, what nutrients should be targeted?

65. 65 #4: How can meals be evaluated for meeting RDAs, AIs, & 2000 DGs?

66. 66 Use of Meal Patterns OAA does not specify using a meal pattern. Only a 1st step in menu planning Does not guarantee that meals will meet OAA standards; thus does not assure adequate intake Needs evaluation using computer analysis before being used to assure that it meets requirements Do state agencies use or require AAAs to use meal patterns? 1998 SUA Policies & Procedures Collection 34 (77%) had guidelines for meal patterns.

67. 67 1972 Meal Pattern 1 bread / alternatives 2 vegetables / fruits 1 milk / alternate 1 meat / alternate 1 fat Dessert, optional Beverages, optional

68. 68 Sample Meal Pattern to meet 1/3 RDA / AI 3 breads / alternative 2 vegetables 1 fruit 1 milk / alternate 1 meat / alternate 1 fat Dessert, optional Beverages, optional

69. 69 Use of Standardized Recipes OAA does not specify use of standardized recipes. standardized recipes ensure consistency in preparation of food items & nutrient content. Do state agencies use or require AAAs to use standardized recipes? 1998 SUA Policies & Procedures Collection 16 (36%) had guidelines for use of standardized recipes.

70. 70 Use of Menu Analysis OAA does not specify use of menu analysis to ensure compliance with nutrient requirements. Menu analysis ensures menus meet requirements. Do state agencies use or require AAAs to use menu analysis with specific software & data sources? 1998 SUA Policies & Procedures Collection 23 (52%) had guidelines for use of menu analysis.

71. 71 Use of Menu Analysis OAA does not specify different requirements when providing >1 meal a day. Menu analysis is method to ensure that 2 or 3 meals combined provide 67% or 100% RDA / AI, respectively. Some states have different meal patterns for different meals of the day: each meal provides all items on meal pattern.

72. 72 #5: How can Nutrition Program meals be adjusted to meet special dietary needs?

73. 73 #6: How can nutrition services, including nutrition screening, education, counseling incorporate DRIs, 2000 DGs, & targeted nutrients recommendations?

74. 74 Nutrition Education Defined as any set of learning experiences designed to facilitate voluntary adoption of eating & other nutrition-related behaviors conducive to health & well-being

75. 75 Nutrition Counseling An individualized process that can help manage personal nutrition care effectively. It is an essential service, particularly for those at risk. May be used to obtain more information, to review & strengthen acquired knowledge or desirable habits, or to help set personal goals & make individualized decisions.

76. 76 #7: What nutrition-related issues need attention at future Issue Panels &/or in outcomes research?

77. 77 #7: What nutrition-related issues need attention at future Issue Panels &/or in outcomes research? Implementing the forthcoming Dietary Reference Intakes Applications in Dietary Planning report of the NAS; Health disparities and minority issues; Weight management, including underweight, overweight, and obesity; Food service, including technology, food preparation and delivery, and food costs; Food safety issues; Title VI programs and services; Food security and hunger;

78. 78 Nutrition and physical activity, in relation to functionality; Nutrition care planning including screening and assessment, therapeutic interventions and supplement use; Effective nutrition education programs; Programmatic issues: unmet needs, waiting lists, screening criteria, customer assessment, resources and Registered Dietitian (or ICE) involvement; and Assessments of what Nutrition Program participants actual eat vs. what is served. #7: What nutrition-related issues need attention at future Issue Panels &/or in outcomes research?

79. 79 Implications & Implementations

80. 80 How will DRIs/RDAs & DGs affect OAA Nutrition Programs? Provide a basis for: nutrition services, which is more than meal provision standards for meal provision nutrition screening service interventions

81. 81 How will DRIs (RDAs/AIs) & DGs affect the OAA Nutrition Programs? Provide the basis for: nutrition education nutrition counseling lifestyle modification health and functionality risk reduction outcome measurement.

82. 82 Next steps for the Aging Network SUAs, AAAs, local nutrition service providers should begin to revise: Policies, procedures, guidelines Program guidance Quality assurance standards Monitoring, assessment, evaluation tools.

83. 83 Next steps for the Aging Network SUAs, AAAs, & local nutrition service providers should begin to revise: Outcome measurement tools Program planning Program operations such as menu planning, menu costing, nutrition screening, nutrition education, nutrition counseling.

84. 84 Next steps for the Aging Network SUAs, AAAs, & local nutrition service providers should begin to revise: Consumer education materials Health promotion/disease prevention programs & materials Provision of meals to meet special dietary needs.

85. 85 Next steps for the Aging Network SUAs, AAAs, & local nutrition service providers should begin to revise: Food service catering / vending contracts Training & technical assistance.

86. 86 Why do we need to assure nutrient quality? To impact nutritional status To impact health To impact functionality To impact quality of life To assist older adults in making healthy choices To measure & document outcomes