The Role of Nutrition in Maintaining Health in the Nation’s Elderly

Evaluating Coverage of Nutrition Services for the Medicare Population

Committee on Nutrition Services for Medicare Beneficiaries

Food and Nutrition Board

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, DC



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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population The Role of Nutrition in Maintaining Health in the Nation’s Elderly Evaluating Coverage of Nutrition Services for the Medicare Population Committee on Nutrition Services for Medicare Beneficiaries Food and Nutrition Board INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, DC

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 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. 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. International Standard Book Number 0-309-06846-0 Library of Congress Card Number 00-103252 This report is available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055; call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s on-line bookstore at www.nap.edu. For more information about the Institute of Medicine or the Food and Nutrition Board, visit the IOM home page at www.iom.edu Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population COMMITTEE ON NUTRITION SERVICES FOR MEDICARE BENEFICIARIES VIRGINIA A. STALLINGS (Chair), Division of Gastroenterology and Nutrition, The Children’s Hospital of Philadelphia, Pennsylvania LAWRENCE J. APPEL, Welch Center for Prevention, Epidemiology and Clinical Research, John Hopkins School of Hygiene and Public Health, Baltimore, Maryland JULIA A. JAMES, Principal, Health Policy Alternatives, Washington, D.C. GORDEN L. JENSEN, Division of Gastroenterology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee ELVIRA Q. JOHNSON, Clinical Nutrition Services, Cambridge Health Alliance, Massachusetts JOYCE K. KEITHLEY, Rush University College of Nursing, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois ESTHER F. MYERS, 60th Diagnostics and Therapeutics Squadron/ SGOD, United States Air Force, Travis Air Force Base, California F. XAVIER PI-SUNYER, Division of Endocrinology, Diabetes, and Nutrition, St. Luke’s/Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York HAROLD POLLACK, Health Management and Policy, University of Michigan, Ann Arbor CAROL PORTER, Nutrition Services and Dietetic Internship, University of California at San Francisco DAVID B. REUBEN, Division of Geriatrics, University of California, Los Angeles ROBERT S. SCHWARZ, Division of Geriatrics Medicine, University of Colorado, Denver ANNALYNN SKIPPER, Nutrition Consultation Service, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois LINDA G. SNETSELAAR, Department of Preventive Medicine and Environmental Health, University of Iowa, Iowa City Staff ROMY GUNTER-NATHAN, Study Director GERALDINE KENNEDO, Project Assistant CARMIE CHAN, Project Assistant EDEN RAUCH, Intern (June to August 1999)

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutrition, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice-Chair), Division of Nutritional Sciences, College of Agricultural, Consumer and Environmental Sciences, University of Illinois at Urbana-Champaign LARRY R. BEUCHAT, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center and Tufts University, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas CHARLES H. HENNEKENS, Boca Raton, Florida ALFRED H. MERRILL, JR., Department of Biochemistry, Emory Center for Nutrition and Health Sciences, Emory University, Atlanta, Georgia LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, D.C. ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington A. CATHARINE ROSS, Department of Nutrition, The Pennsylvania State University, University Park ROBERT M. RUSSELL, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts ROBERT E. SMITH, R.E. Smith Consulting, Inc., Newport, Vermont VIRGINIA A. STALLINGS, Division of Gastroenterology and Nutrition, The Children’s Hospital of Philadelphia, Pennsylvania STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln Staff ALLISON A. YATES, Director GAIL E. SPEARS, Administrative Assistant GARY WALKER, Financial Associate

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Acknowledgments Appreciation is due to the many individuals and groups who were instrumental in the development of this report. First and foremost, many thanks are extended to the committee who volunteered countless hours to the research, deliberations, and preparation of the report. Their dedication to this project and to a very stringent time line was commendable, and the basis of our success. Many consultants also provided assistance and reviewed drafts of specific chapters. In particular, appreciation and thanks are extended to Rowan Chlebowski, MD, Division of Medical Oncology and Hematology, Harbor UCLA Medical Center, Torrance, CA; Bess Dawson-Hughes, MD, Calcium and Bone Metabolism Laboratory, Tufts University, Boston; Rosanna Gibbons, MS, RD, Consultant Dietitian in Home Care, Baltimore, Maryland; Talat Alp Ikizler, MD, Division of Nephrology, Vanderbilt University Medical Center, Nashville; John Kostis, MD, University of Medicine and Dentistry of New Jersey; and Andrew S. Levey, MD, Division of Nephrology, New England Medical Center, Boston. The report was also independently reviewed in its entirety by many individuals who were chosen for their diverse perspectives and technical expertise to assure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. These individuals included Bruce R. Bistrian, MD, PhD, Division of Clinical Nutrition, Beth Israel Deaconess Medical Center, Boston; Ronni Chernoff, PhD, RD, FADA, Geriatric Research Education and Clinical Center, John L. McClellan Memorial Veterans Hospital, Little Rock; Cutberto Garza, MD,

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population PhD, Vice-Provost, Cornell University; Stanley Gershoff, PhD, Professor of Nutrition, Emeritus, Tufts University, Boston; Margaret M. Heitkemper, PhD, RN, FAAN, Department of Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle; Jerome P. Kassirer, MD, Editor in Chief Emeritus, New England Journal of Medicine, Boston; Penny Kris-Etherton, PhD, RD, Department of Nutrition, Pennsylvania State University, University Park; Lauren LeRoy, PhD, Grantmakers in Health, Washington, DC; John E. Morley, MD, Division of Geriatric Medicine, St. Louis Veterans Affair Medical Center; Henry Riecken, PhD, Professor of Behavioral Sciences, Emeritus, University of Pennsylvania, Philadelphia; Louise B. Russell, PhD, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Jersey; and Philip J. Schneider, RPh, MS, College of Pharmacy, The Ohio State University, Columbus. Many individuals also volunteered significant time and effort to address and to educate the committee at its workshop and public meeting. Workshop speakers included Bess Dawson-Hughes, MD and Ernest Schaefer, MD of Tufts University, Boston; Linda Delahanty, MS, RD of the Massachussets General Hospital, Boston; V. Annette Dickinson, PhD of the Council for Responsible Nutrition, Washington DC; Marion Franz, MS, RD of the International Diabetes Center, Minneapolis; Samual Klein, MD of Washington University, School of Medicine, St. Louis; William Mitch, MD of Emory University, Atlanta; Tom Prohaska, PhD of the University of Chicago; Dennis Sullivan, MD of the University of Arkansas, Little Rock; and Mackenzie Walser, MD of Johns Hopkins University, Baltimore. In addition, organizations that provided either oral or written testimony to the committee included the American College of Health Care Administrators; the American College of Nutrition; the American Dietetic Association; the American Society for Clinical Nutrition; the American Society for Enteral and Parenteral Nutrition; Fresnisus Medical Care, North America; and the National Kidney Foundation. Other individuals who deserve special thanks are Tate Erlinger, PhD of Johns Hopkins University for his special assistance with the NHANES III database, Lisa Prosser, MS of Harvard University for sharing her prepublication data on cost analysis of dietary interventions, Marilyn Field, PhD of the Health Care Services Division, Institute of Medicine for her guidance throughout the report process, and Joan DaVanzo, PhD, Allen Dobson, PhD, and Namrata Sen, MHA of The Lewin Group for their patience and number-crunching abilities. So, it is apparent that many individuals from a variety of clinical and scientific backgrounds provided timely and essential support for this project. Yet, we would have never succeeded without the efforts, skills,

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population and grace that was provided in large measure by Romy Gunter-Nathan, MPH, RD, our study director for this project, from Geraldine Kennedo, Project Assistant, and from Allison Yates, PhD, RD, Director, Food and Nutrition Board, Institute of Medicine. Lastly, as the chair, may I express my sincere appreciation to each member of this committee for your extraordinary commitment to the project and for the wonderful opportunity to work with you on this important task for the medical and nutrition community and for the Medicare beneficiaries whose care we were asked to consider. Virginia A. Stallings, MD Chair Committee on Nutrition Services for Medicare Beneficiaries

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Contents EXECUTIVE SUMMARY   1 SECTION I INTRODUCTION AND OVERVIEW     1   INTRODUCTION   25      The Committee and Its Charge,   26      Overview of the Report,   28      Overview of the Medicare Program,   30      Medicare Coverage Decisions,   34      Medicare Coverage of Nutrition Services,   38 2   OVERVIEW: NUTRITIONAL HEALTH IN THE OLDER PERSON   46      Malnutrition,   46      Prevalence of Nutrition Related Conditions,   51      Screening for Nutrition Risk,   51 3   METHODS   59      Evidence Available,   60      Committee Deliberations,   61

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population SECTION II THE ROLE OF NUTRITION IN THE MANAGEMENT OF DISEASE     4   UNDERNUTRITION   65      Markers of Undernutrition,   66      Syndromes of Undernutrition,   76      Limitations of Current Evidence,   84      Summary,   85      Recommendations,   85 5   CARDIOVASCULAR DISEASE   93      Dyslipidemia,   94      Hypertension,   100      Heart Failure,   107      Research Recommendations,   111 6   DIABETES MELLITUS   118      Evidence That a Change in Risk Factors Changes Morbidity and Mortality,   119      The Role of Nutrition Intervention in the Management of Diabetes,   122      Providers of Nutrition Therapy for Diabetes,   126      Medicare Reimbursement for Diabetes Self-Management Training,   126      Limitations of Data and Future Research Needs,   128      Summary,   128      Recommendations,   129 7   RENAL DISEASE   132      Chronic Renal Insufficiency,   134      End-Stage Renal Disease,   142      Nutrition Therapy After Transplantation,   146      Future Areas of Research,   147 8   OSTEOPOROSIS   152      Role of Diet in Onset and Treatment of Osteoporosis,   153      Cost and Quality-of-Life Considerations,   157      Future Areas of Research,   158      Summary and Recommendations,   159

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population SECTION III NUTRITION SERVICES ALONG THE CONTINUUM OF CARE     9   NUTRITION SERVICES IN THE ACUTE CARE SETTING   165      Medicare Reimbursement in Acute Care, Short-Stay Hospitals,   165      Role of the Nutrition Professional,   166      Effects of Undernutrition on Functional Status in the Elderly,   170      Future Areas for Research,   171      Summary,   171      Recommendations,   171 10   NUTRITION SUPPORT   173      Literature Review,   175      Indications for the Use of Nutrition Support,   175      Gastrointestinal Diseases,   175      Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome,   180      Cancer and Bone Marrow Transplantation,   183      Acute Renal Failure,   185      Critical Illness,   187      Perioperative Nutrition Support,   189      Limitations of Nutrition Support Evidence,   194      Delivery of Nutrition Support,   195 11   NUTRITION SERVICES IN AMBULATORY CARE SETTINGS   213      Reimbursement for Nutrition Therapy in Ambulatory Care,   213      Accreditation Standards for the Ambulatory Setting,   215      Nutrition Services in Ambulatory Settings,   216      Effectiveness of Nutrition Therapy in Ambulatory Settings,   220      Future Areas of Research,   221      Summary,   221      Recommendations,   222 12   NUTRITION SERVICES IN POST-ACUTE, LONG-TERM CARE AND IN COMMUNITY-BASED PROGRAMS   225      Emerging Trends,   226      Skilled Nursing Facilities and Nursing Homes,   227      Home Health Agencies,   235      Community-Based Benefits,   241      Future Areas of Research,   244      Summary,   244      Recommendations,   246

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population SECTION IV PROVIDERS AND COSTS OF NUTRITION SERVICES     13   PROVIDERS OF NUTRITION SERVICES   257      Terms and Definitions,   257      Tiers of Nutrition Services,   258      Education and Skills Necessary for the Provision of Nutrition Therapy,   259      Licensure in the Practice of Dietetics,   260      Health Care Professionals Specializing in Nutrition,   260      Other Health Care Professionals,   266      Who Is Qualified to Provide Basic Nutrition Education or Advice?   270      Who Is Qualified to Provide Nutrition Therapy?   271      Summary,   271      Recommendations,   271 14   ECONOMIC POLICY ANALYSIS   274      Evaluation Methodologies,   275      Cost Estimates,   277      Economically Significant Averted Costs,   289      Summary,   304 15   OVERALL FINDINGS AND RECOMMENDATIONS   310      Medicare Coverage of Nutrition Therapy,   311      Administrative Recommendations Regarding the Provision of Nutrition Services,   317      Economic Policy Analysis,   321      Concluding Remarks,   322 APPENDIXES     A   Acronyms   327 B   Glossary   331 C   Workshop Speakers, Organizations Contacted, and Consultants to the Committee   338 D   State Licensure Laws for the Practice of Dietetics (as of June 1999)   340 E   The American Dietetic Association Foundation Knowledge and Skills and Competency Requirements for Entry-Level Dietitians   342 F   Advanced-Level Credentials in Nutrition   352 G   U.S. Preventive Services Task Force Rating of Professionals to Deliver Dietary Counseling   355 H   Summary of Cost Estimation Methodology for Outpatient Nutrition Therapy   357 I   Committee Biographical Sketches   361

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