Detailed critique of a peer-reviewed article (below) .The article should discuss the strategic planning efforts that have been undertaken by either a public sector organization or a nonprofit organization and must include financial considerations and aspects of the undertaking. Address the questions listed below. What are the main points of the authors, and how did the organization decide to adopt a strategic planning process? Could the organization’s goals have been facilitated in the absence of strategic planning? Regardless of your response, in what circumstances can strategic planning be eliminated as a process in contention for implementation? What are some of the organizational and plan standards that appear to have been maintained in order to accurately measure and assess plan success? What is your assessment of the financial commitments that the organization made to the strategic planning initiative, and do you think that they are representative of more widespread public or third sector strategic planning efforts? What does the article suggest about the viability of strategic planning in the public or nonprofit sector? The critique should be at least two pages in length, be double-spaced, use Times New Roman, 12-point font, and utilize APA style. Be sure to cite all quoted and paraphrased material (either from the article being reviewed or any other sources you might choose to add) appropriately in APA format.
Baby boomers come of age: nutrition in the 21st century
Ronni Chernoff
Journal of the American Dietetic Association. 95.6 (June 1995): p650+.
Copyright: COPYRIGHT 1995 Elsevier Science Publishers
http://www.elsevier.com
Abstract:
The aging of the baby boom generation is expected to have a substantial impact on the profile of the country’s elderly population. For nutrition professionals, this development can have important implications. It is important to plan for the future in order to be better prepared to cope with these changes. Planning should take into account the professional environment, available resources, changing demographics and the political realities of the 21st century.
Full Text:
In the summer of 1994, Jesse Brown, Secretary of the Department of Veterans Affairs (VA), sent a message to all VA employees about health-care reform that is relevant in a broader context. Brown said stop worrying about the future; instead, put your energies into preparing for it. This is certainly an interesting and challenging thought, especially at this time in history. Looking toward the future can be an awesome task; planning for the future can be daunting unless we use our strategic planning skills, analyze the environment in which we expect to function, set our own agenda, and use our leadership capabilities to direct what will happen. We can see our visions become reality if we take the time to invest in the planning process and are not turned back by the obstacles that will undoubtedly arise in the path to achieving our goal.
THE BABY BOOM GENERATION
As we move rapidly toward the 21st century, the landscape changes in many ways. In understanding the landscape of the future, we must first look carefully at the next generation to come of age – the baby boomers – because they are different from earlier generations, not only in numbers but also in other characteristics. Baby boomers are facing a future of changing social contexts as the American family changes. Many of these changes may be attributed to new choices made by women in the baby boom generation. These women delayed having children; had fewer babies when they had them; are better educated; are more medically sophisticated than earlier generations of women (and we know that women are the primary health-care decision-makers); have entered the workplace and career tracks in greater numbers than their mothers; are more affluent than their parents; have divorced at greater rates; and now have their young adult children coming home to live with them. Just wait until baby boom women go through a generational menopause!
In addition, the ethnic and racial profile of the older population will change as the baby boom ages. For example, from 1990 to 2050, the Hispanic population will triple from 5.1% to 15.6%. In real numbers, there will be a sevenfold increase in Hispanic elderly, from 1.1 million to 7.9 million. The number of elderly African Americans will more than double in proportion from 8.2% to 20.3% and in actual numbers from 2.5 million to 9.6 million. Americans of other racial origins, including Asians and Pacific Islanders, American Indians, Eskimos, and Aleuts, will increase in proportion from 5.9% to 19.3% or in actual population from 500,000 to 5 million people (1) [ILLUSTRATION FOR FIGURE 1 OMITTED]. These real increases may have interesting consequences for the future.
Right now, significantly greater numbers of minority women live in poverty than ever before – 63% of African-American women and 61% of Hispanic women compared with 22% of white non-Hispanic women [ILLUSTRATION FOR FIGURE 2 OMITTED]. The incidence of age-related diseases will increase in poor minority women because of lifelong substandard medical care and the risk factors associated with a poor social environment in early and mid-life. Many of the chronic conditions associated with a poorer education and lower educational level, for example, obesity, hypertension, diabetes, and cancer, will presumably be prevalent in this group as they age. This will seriously challenge the health-care system.
Second, fewer health-care dollars will be available – a condition we are already seeing. Regardless of what happens with health-care reform in Congress, changes have already occurred at the state level. The current structure of reimbursement systems has meant that acute-care patients are being pushed from hospitals into skilled nursing or other long-term-care facilities. As an alternative, respite care units, hospice centers, adult day health centers, hospital-based home-care programs, and other types of home-care services are becoming available in some places. Nevertheless, not enough health-care beds exist at any level of care service to accommodate the needs of the baby boomers as they age (2).
Current responses to the growing older population include development of a new medical specialty in geriatric emergency medicine; formation of interdisciplinary geriatric assessment teams that provide an array of treatment goals and options for elderly patients; and establishment of acute-care geriatric medicine wards, in forward-looking medical centers. Nevertheless, geriatrics specialists are not being trained at the rate at which we will need them in medicine, in nursing, and in dietetics!
When baby boomers reach their 60s and 70s they will have better health than previous generations at the same age. Baby boomers have had unique life experiences that include better prenatal care; optimal preventive medicine during childhood (eg, immunization against many common childhood diseases, including polio, rheumatic fever, measles, chicken pox, mumps, diphtheria, and pertussis); better nutrition; and lower childhood accident rates with better survival. Just think of the impact that microsurgery has had on the reattachment and preserved functioning of severed appendages!
Baby boomers have had better work environments with decreased accident rates, less exposure to carcinogens, and greater access to health promotion programs. Baby boomers have also had better health practices including lower rates of smoking, greater time spent exercising, a greater awareness of preventive health measures, and a healthier diet. Baby boomers are often referred to as the sandwich generation because they are in the phase of life where they are still taking care of their kids but are now also taking care of elderly parents. For those who have not yet experienced the health-care system and have not yet discovered what works in the present system and what does not, they soon will. Baby boomers already have some unique characteristics that have resulted in their having an attitude toward health-care not seen in earlier generations (3).
For starters, baby boomers have a goal of wellness. They expect the health-care system to assist them with plans for healthy aging, not just to provide care when they become ill. Baby boomers are uncomfortable with physical decline and want more products and services that promote health. They want to stay youthful regardless of their age; remember, this is the generation that once had the mantra: “Don’t trust anyone over the age of 30.” Now they are all over 30! Baby boomers having grown up with the $6 Million Man, are familiar with biotechnology and alternative therapies, and have tried many of them.
Baby boomers are great consumers of information and, as already noted, they are the best-educated generation yet. They want to know what is happening to their bodies, what the treatment alternatives are, and what the potential consequences of different treatments will be. They want to be 50-50 partners in the decision making with their physicians and other health professionals. In addition, baby boomers tend to be more demanding consumers; this may be a holdover of not trusting those “old folks” over 30! They will demand services, products, information, and care in stronger terms than any earlier generation. At the same time, this generation has a greater fear of illness and disability than earlier generations (3). This is an ironic twist because baby boomers expect to live longer and better than their parents and grandparents. Nevertheless, the question arises of whether their needs and expectations will be met by a reformed health-care system.
Improvements in life expectancy always have a downside. For baby boomers this will likely be the challenge of nonfatal chronic diseases. How will chronic health-care delivery evolve over the next 30 years? Right now, there are not enough beds in long-term-care facilities in the United States to meet the needs of the approximately 1.5 million people in the age group (65 years and older) that uses them with some frequency. In 30 years, the numbers of those who will need chronic care is projected to rise to somewhere between 4 and 5 million. In addition, two to three times that many will likely receive long-term-care services in their homes (1).
Older adults are disproportionate users of health-care resources. Presently, elderly adults constitute one-eighth of the total US population but they are responsible for one third of the total health-care expenditures (4).
Other expected consequences of increased life expectancy include an increase in the number of people with functional disabilities (ie, people who require assistance with the activities of daily living such as bathing, feeding, transferring [eg, moving from bed to chair or rising from a chair], continence, dressing, and toileting) and dementia, particularly Alzheimer’s disease. The incidence of Alzheimer’s disease is approximately 50% in people over 80 years of age (1). All these statistics add up to the fact that the costs of caring for the aged baby boomers will be staggering!
The future will bring demands for more services and different options than presently exist in long-term care. The greater number of elderly persons will bring not only an increased need for nursing home beds but also an enormous demand for home health services because, given the choice, most elderly persons prefer to remain in their own homes. One of the problems that exists today is that services are fragmented and many people do not know that they exist! What is available? What are the eligibility requirements? What agencies can help? Where are they? Who is out there to help? Atkins et al (1) suggested that one way to manage this problem now is to establish an agency in each community to coordinate available programs and services for the elderly and to help families and individuals find what they need (1). Surely there is a role for dietetics professionals in this proposed method of managing available health-care services and resources.
Term Abbreviation
Independent practice association IPA
Preferred provider organization PPO
Health maintenance organization HMO
Physician-hospital organization PHO
Geriatric evaluation unit/
Geriatric evaluation and maintenance center GEU/GEM
Ambulatory-care center ACC
Skilled nursing facility SNF
Intermediate-care facility ICF
Home health agency HHA
Adult day health center ADHC
Hospital-based home care HBHC
FIG 3. Health-care delivery structures.
THE FUTURE DEMANDS CHANGE
One of the things we can count on happening is change. The health-care delivery system in this country is already recognizing that the demands of consumers, particularly the baby boomers, are driving changes at the community level. Results of several focus groups of recently discharged hospital patients conducted by Age Wave, a consultant firm focused on issues associated with aging, and Baxter HealthCare Corporation indicate that four major factors will influence the relative success or failure of health-care delivery institutions (3). The first is the pressing need for outreach and community-based programs. Demand is increasing for local primary-care facilities, prevention and education programs, and services for populations with special needs.
The second is the demand for information. Consumers want to make educated decisions regarding their health care and will demand time and answers from their primary-care provider. Health professionals need to learn the most important diagnostic skill – listening! Researchers at the New England Medical Center in Boston, Mass, demonstrated that patients who communicated effectively with their care providers tended to have better health outcomes (3). Our responsibility as health-care providers is to make sure that consumers have information in user-friendly forms. Although dietetics professionals are terrific at developing print materials, we need to become experts at developing computer software, electronic databases for consumers, cable television programs, audiotapes for the general public, and interactive materials.
The third factor is a demand for a true continuum of care that begins at an early age. Along with this desire for seamless delivery systems, there are issues that can be better addressed throughout the course of care delivery. For example, osteoporosis prevention should be targeted to adolescents not postmenopausal women. One possible result of this type of care is the positive effect it may have on compliance with treatment protocols. By contributing to the development of a strong, trusting relationship with the primary-care provider, this type of system may serve to avoid apparently conflicting advice; misunderstandings, and poor follow-through.
The fourth factor is the expectation that traditional health-care services will expand in a variety of ways. Consumers are beginning to anticipate diversity in their choice of services. Among these choices may be self-help programs, culturally unique services, wellness programs, and more individual responsibility. To accommodate all of these changes, the roles and responsibilities of providers will have to be modified.
NUTRITION SCREENING AS A FACTOR
The role of nutrition professionals is already changing. Interest in health promotion and screening is increasing. One example of this is the amazing success of the Nutrition Screening Initiative, which brought together three national organizations – The American Dietetic Association (ADA), the American Academy of Family Physicians, and the National Council on Aging. The concept of screening for nutritional risk has developed into a national effort and has brought many other health professionals to a new level of consciousness regarding nutrition. Clearly, screening for risk factors for chronic diseases and implementation of appropriate interventions can make a difference in slowing the progression of many age-related conditions and may contribute to their prevention or at least a delay in the first appearance of symptoms.
It is well known that nutritional status influences the development or progress of many diseases and can affect the extent to which functional independence is maintained. Effective intervention in older people is difficult, however; the risk factors must be evaluated and the determination of adequate nutrition must be defined. New ways must be found to assess nutritional status and nutritional requirements, perhaps by looking in places that have not been previously explored. For one thing, the Recommended Dietary Allowances (RDAs) must be age-adjusted to give us at least some stratification for older adults. What are the real energy, nutrient, and fluid needs of elderly persons? As the first wave of baby boomers rapidly approaches the age of 50, a better definition of the RDAs for the entire population of people over the age of 51 years becomes more important and more urgent, particularly as this new group will ask a lot of questions about nutritional requirements, healthful eating behaviors, and dietary patterns to maintain their youth. The release of data from the third National Health and Nutrition Examination Survey has provided normative data against which we will be able to compare elderly baby boomers (5).
What foodservices and products will be necessary to meet the needs of the aging population? What kinds of delivery systems and heating or cooking methods will be available in 15 years? What new food products will be available? Will new food ingredients be developed in a laboratory rather than by Mother Nature? The future may bring products such as protein in a pill, vitamin sprays, and nonabsorbable sugars – use your imagination!
New medications for chronic illnesses may allow greater bypass of dietary restrictions or perhaps we will have the knowledge to control both chronic and acute illnesses by earlier dietary intervention. Dietary counseling may be done by interactive computer, by videophone, or through technologies we have not dreamed of yet.
One trend that is already developing is that in order to establish or fund new programs for the elderly, policy makers are demanding sound, reliable, valid data on which to base recommendations or interventions. Clearly, there are barriers to dietitians performing research independently, but they are not unsurmountable. The ADA has already taken a leadership role in this area by promoting a research agenda for the profession and by supporting and participating in research efforts of our members (6). Some may not want to expend the commitment and energy needed to conduct research, but it is do-able and it is the future of our profession!
PLANNING FOR THE FUTURE
The Environment
The first area that we must address in planning for the future is the environment in which we expect to function. To implement ADA’s vision of shaping the food choices and impacting the nutritional status of the public, we must consider all the facets of the environment in which we practice. The environment of the near future will be characterized by changes in the delivery of health care (regardless of the future of health-care reform), changes in the population of patients to whom services are delivered, and changes in the location of service delivery. During the past decade it has become apparent that alterations in consumer lifestyle, including nutrition and diet modifications, will lead to demands for more screening programs and preventive services. Certainly we know that nutrition can influence the progress of many chronic conditions. Dietary factors are clearly associated with 5 of the 10 leading causes of death in older adults: coronary heart disease, some types of cancers, stroke, non-insulin-dependent diabetes mellitus, and atherosclerosis, and are also associated with the risk factors of obesity and hypertension.
Health-delivery structures, public and private insurance mechanisms, and terms of benefits and eligibility change dally. Most people are bewildered by all of the changes and options that have cropped up. Figure 3 lists some of the new delivery structures in health care. Insurance options include co-insurance, catastrophic insurance, Medigap, and long-term-care policies. The environment changes continuously and the confusion about health-delivery options increases for most people.
Resources
A second issue is assessing of the resources that will be available and necessary to achieve the goal of creating a nutrition services delivery system that will meet the needs of an aging population. What kinds of resources must be available if we are to implement and sustain our vision? Undoubtedly the first will be money! What will this new creation cost? What will be needed to fulfill what is often referred to as “recurring funds” (ie, funds that will be sustained through several budget cycles as opposed to a one-time appearance of a budget item)? What are the direct and indirect costs of overhead (eg, rent, utilities, maintenance and repairs, supplies) and personnel benefits? What about travel money, temporary help, printing costs, and other anticipated and, more important, unanticipated expenses? Needs for space, furniture, and other physical resources must be addressed for a project to become a reality.
The second most expensive resource that must be considered is human. Is there adequate staff available with the necessary skills to carry out the tasks associated with a program or project? Are enough students in the pipeline to continue to assume the responsibilities needed? Will they be adequately trained and educated to meet the demands of technology or service delivery in the changing environment? Where will students find jobs? How much competition will there be for new positions? Will students have skills that allow them to adapt, be flexible, and grow as the world changes? These questions must be considered when we prepare for the future.
Demographic Forecasts
Some of the answers to these questions about resources may be complicated by a third factor – demographic forecasts. One of the factors that will have a major effect on the demands for services and resources is what is commonly known as the baby boom generation. Between 1946 and 1964, 76 million people were born. As this group has gone through its phases of life it has had a major impact on our society, particularly because the groups preceding and succeeding it are much smaller. The front edge of this group is rapidly approaching the age of 50; by the time the last of the group reaches the age of 65, 20% of the population will be 65 or older and the absolute numbers of people over age 65 will have doubled from 32 million to 65 million people! The resources needed to sustain services and programs that exist today for older Americans may not, and probably will not, be there.
Political Realities of the 21st Century
The fourth area that must be considered is the anticipated political reality of the 21st century. The political context in which programs for the aging population are considered has changed greatly since most of these programs were put in place in past decades (7). Because public resources are now perceived as scarce and entitlement programs regularly come under scrutiny by Congress, there has been an erosion in the belief that older adults deserve government-provided benefits. Social Security, Medicare, and the Older Americans Act were all enacted between the time of the New Deal and the mid-1970s; since then, the compassion with which we view older people has changed, partly because of the power of the media and advertising. Older adults are now often depicted in the media as prosperous, hedonistic, selfish, and politically powerful. The reasons for this change include improvements in the economic status of elderly citizens due in part to Social Security and a “graying” of the federal budget (ie, one third of the federal budget goes to programs lawmakers and the public perceive as benefiting the elderly). The funds spent on entitlement programs have been blamed for the weakened economy, the explosion in health-care costs, and the federal deficit.
One major problem that is associated with the expenditure of federal dollars on health-care costs and other entitlements is that whereas the baby boom generation has been able to support the current older generation through its taxes, the succeeding generation will not be able to sustain the cost of supporting the baby boom generation when they start collecting from these programs. The ratio of those paying into Social Security through FICA payroll tax deductions to those who are receiving Social Security retirement benefits will change from 3.2:1 in 1980 to 2:1 in 2030 [ILLUSTRATION FOR FIGURE 4 OMITTED].
The trend toward declining income has been offset by the institution of eligibility requirements based on income for some of these programs. In 1993, the Omnibus Budget Reconciliation Act called for the taxation of 85% of Social Security benefits for individuals with an annual income of $34,000 and couples with an annual income greater than $44,000 per year (8). However, in broader economic terms, future benefits for older Americans will be more closely linked to whether the American economy produces sufficient resources to allow transfer of funds to programs that benefit the elderly. In recent years, Congress has targeted many of the entitlement programs to those who have a greater financial need. Increasingly, the link between age and economic status may be the eligibility criteria for old-age benefit programs.
ROLES FOR NUTRITION PROFESSIONALS
Nutrition professionals can assume many new roles as we move into the future. There is no reason that we should not be the appropriate professionals to direct health screening and health promotion programs. The experience of dietitians in the VA medical centers has shown that dietitians can lead interdisciplinary care and planning teams when the primary problem is nutrition related. Dietitians can be care coordinators, case managers, hospital administrators, investigators, teachers, program directors, consultants, marketing or sales managers, and clinicians. Dietitians can fill a host of other roles that perhaps we have not yet imagined.
We need to develop a new vision of ourselves. We must continue to work on how we are perceived by the public regardless of whether the public is consumers, other health professionals, the scientific community, or government. Few barriers cannot be overcome with some ingenuity and the willingness to break the old paradigms. We have the ability to affect the eating habits of the public, to change our own perception of who we are, and to set a new agenda. Setting the agenda requires us to reset our barometers, reevaluate what we do and how we are doing it, and recognize the realities of the changing health-care world.
Our vision must be grounded in reality. As much as dietitians are sure that we would do a better job if we ran the world, the likelihood of that happening is slim! But we can change the world one little bit at a time. Every long journey begins with one step and, to paraphrase Neil Armstrong, sometimes the small steps are truly great leaps.
We must be creative and not get stuck in old ruts. Sometimes it is risky to try something new and different, but where we would be today without such outlandish ideas as television, facsimile machines, personal computers, and post-it notes?
Consider all the possibilities. Imagine what people thought of Alexander Graham Bell and Henry Ford when they told us we would talk to people across the country and ride in horseless carriages. Consider where we might all be today if it were not for people like Lenna Frances Cooper. Lenna Frances Cooper was a leader by example. The legacy that she and others before us have bequeathed will allow us to take leadership yet another step farther to achieve whatever mission we have set for ourselves and to see our vision become reality.
The only bad idea is one that is never exposed to the hard light of scrutiny. Sometimes the greatest contributions come from missteps or mistakes that lead us down new paths. John F. Kennedy once said, “Some men see things as they are and ask why; I dream things that never were, and say why not?” Don’t ever be limited by things not done before; if generations before us were unwilling to take risks by considering all options, many products and services that are part of our everyday life would not be here now.
As we move into the 21st century and reset our goals, we must state them in clear and measurable objectives so that we have checkpoints along the way to measure our success. We must be willing to alter our path to accommodate the changes that will certainly occur.
CONCLUSIONS
With change as a given, we must realize that there will be obstacles in our way and some will require great perseverance to overcome. We can be like Don Quixote and tilt at windmills or we can hope that a knight in shining armor will rescue us from dragons we may not have chosen to fight, but we must keep in mind the fact that Quixote’s windmills were usually unscathed and that sometimes the dragon wins!
It is useful to maintain a positive attitude and to make the best of whatever challenges lie ahead. Many exciting challenges lie ahead of us as the baby boom generations comes of age. How we as professionals face the future may make a great difference, not only to ourselves but to this soon-to-be-older generation.
To give you a final thought on how dietitians are seen, I would like to quote one of my favorite works on aging, You’re Only Old Once! (9), by the famous philosopher Dr Seuss:
Dietician Von Eiffel controls the Wuff-Whiffer, our Diet-Devising Computerized Sniffer, on which you just simply lie down in repose and sniff at good food as it goes past your nose. From caviar souffle to caribou roast, from pemmican patties to terrapin toast, he’ll find out by Sniff-Scan the foods you like most. And when that guy finds out what you like, you can bet it won’t be on your diet. From here on, forget it!
We have the power to ensure a better quality of life to the baby boom generation as it comes of age and to guarantee that Dr Seuss’ scenario never becomes the reality. As we work toward achieving our mission and making our vision the gold standard, we will be better prepared for the future of the 21st century.
References
1. Atkins GL, Bengtson VL, Binstock RH et al. Old Age in the 21st Century: A Report to the Assistant Secretary for Aging, US Department of Health and Human Services. Syracuse, NY: National Academy of Aging, The Maxwell School, Syracuse University; 1994.
2. Butler RN. Will the baby boomers go bust? Geriatrics. 1990; 45(12):13-14.
3. Lumsdon K. Baby boomers grow up. Hospitals & Health Networks. 1993; 67(18):24-26.
4. Chernoff R. Demographics of aging. In: Chernoff R, ed. Geriatric Nutrition: The Health Professional’s Handbook. Gaithersburg, Md: Aspen Publishers; 1991:1-10.
5. Burt VL, Harris T. The third national health and nutrition examination survey: contributing data on aging and health. Gerontologist. 1994; 34:486-490.
6. The Research Agenda for Dietetics Conference Proceedings. Chicago, Ill: American Dietetic Association; 1992.
7. Posner BM, Levine E. Nutrition services for older Americans. In: Chernoff R, ed. Geriatric Nutrition: The Health Professional’s Handbook. Gaithersburg, Md: Aspen Publishers; 1991:415-448.
8. Easterlin RA, Macdonald C, Macunovich DJ. Retirement prospects of the baby boom generation: A different perspective. Gerontologist. 1990; 30:776-783.
9. Seuss Dr. You’re Only Old Once/New York, NY: Random House; 1986.
Ronni Chernoff is the associate director of the Geriatric Research Education and Clinical Center, John L. McClellan Memorial Veterans Hospital, and a professor of nutrition and dietetics at the University of Arkansas for Medical Sciences, Little Rock. Address correspondence to: Ronni Chernoff, PhD, RD, GRECC (182), John L. McClellan Memorial Veterans Hospital, 4300 W 7th St, Little Rock, AR 72205.
Source Citation (MLA 8th Edition)
Chernoff, Ronni. “Baby boomers come of age: nutrition in the 21st century.” Journal of the American Dietetic Association, vol. 95, no. 6, 1995, p. 650+. Hospitality ,Tourism and Leisure Collection, http://link.galegroup.com.libraryresources.columbiasouthern.edu/apps/doc/A17311230/PPTH?u=oran95108&sid=PPTH&xid=7a9994a9. Accessed 29 Mar. 2018.
Gale Document Number: GALE|A17311230
Baby boomers come of age: nutrition in the 21st century
Ronni Chernoff
Journal of the American Dietetic Association. 95.6 (June 1995): p650+.
Copyright: COPYRIGHT 1995 Elsevier Science Publishers
http://www.elsevier.com
Abstract:
The aging of the baby boom generation is expected to have a substantial impact on the profile of the country’s elderly population. For nutrition professionals, this development can have important implications. It is important to plan for the future in order to be better prepared to cope with these changes. Planning should take into account the professional environment, available resources, changing demographics and the political realities of the 21st century.
Full Text:
In the summer of 1994, Jesse Brown, Secretary of the Department of Veterans Affairs (VA), sent a message to all VA employees about health-care reform that is relevant in a broader context. Brown said stop worrying about the future; instead, put your energies into preparing for it. This is certainly an interesting and challenging thought, especially at this time in history. Looking toward the future can be an awesome task; planning for the future can be daunting unless we use our strategic planning skills, analyze the environment in which we expect to function, set our own agenda, and use our leadership capabilities to direct what will happen. We can see our visions become reality if we take the time to invest in the planning process and are not turned back by the obstacles that will undoubtedly arise in the path to achieving our goal.
THE BABY BOOM GENERATION
As we move rapidly toward the 21st century, the landscape changes in many ways. In understanding the landscape of the future, we must first look carefully at the next generation to come of age – the baby boomers – because they are different from earlier generations, not only in numbers but also in other characteristics. Baby boomers are facing a future of changing social contexts as the American family changes. Many of these changes may be attributed to new choices made by women in the baby boom generation. These women delayed having children; had fewer babies when they had them; are better educated; are more medically sophisticated than earlier generations of women (and we know that women are the primary health-care decision-makers); have entered the workplace and career tracks in greater numbers than their mothers; are more affluent than their parents; have divorced at greater rates; and now have their young adult children coming home to live with them. Just wait until baby boom women go through a generational menopause!
In addition, the ethnic and racial profile of the older population will change as the baby boom ages. For example, from 1990 to 2050, the Hispanic population will triple from 5.1% to 15.6%. In real numbers, there will be a sevenfold increase in Hispanic elderly, from 1.1 million to 7.9 million. The number of elderly African Americans will more than double in proportion from 8.2% to 20.3% and in actual numbers from 2.5 million to 9.6 million. Americans of other racial origins, including Asians and Pacific Islanders, American Indians, Eskimos, and Aleuts, will increase in proportion from 5.9% to 19.3% or in actual population from 500,000 to 5 million people (1) [ILLUSTRATION FOR FIGURE 1 OMITTED]. These real increases may have interesting consequences for the future.
Right now, significantly greater numbers of minority women live in poverty than ever before – 63% of African-American women and 61% of Hispanic women compared with 22% of white non-Hispanic women [ILLUSTRATION FOR FIGURE 2 OMITTED]. The incidence of age-related diseases will increase in poor minority women because of lifelong substandard medical care and the risk factors associated with a poor social environment in early and mid-life. Many of the chronic conditions associated with a poorer education and lower educational level, for example, obesity, hypertension, diabetes, and cancer, will presumably be prevalent in this group as they age. This will seriously challenge the health-care system.
Second, fewer health-care dollars will be available – a condition we are already seeing. Regardless of what happens with health-care reform in Congress, changes have already occurred at the state level. The current structure of reimbursement systems has meant that acute-care patients are being pushed from hospitals into skilled nursing or other long-term-care facilities. As an alternative, respite care units, hospice centers, adult day health centers, hospital-based home-care programs, and other types of home-care services are becoming available in some places. Nevertheless, not enough health-care beds exist at any level of care service to accommodate the needs of the baby boomers as they age (2).
Current responses to the growing older population include development of a new medical specialty in geriatric emergency medicine; formation of interdisciplinary geriatric assessment teams that provide an array of treatment goals and options for elderly patients; and establishment of acute-care geriatric medicine wards, in forward-looking medical centers. Nevertheless, geriatrics specialists are not being trained at the rate at which we will need them in medicine, in nursing, and in dietetics!
When baby boomers reach their 60s and 70s they will have better health than previous generations at the same age. Baby boomers have had unique life experiences that include better prenatal care; optimal preventive medicine during childhood (eg, immunization against many common childhood diseases, including polio, rheumatic fever, measles, chicken pox, mumps, diphtheria, and pertussis); better nutrition; and lower childhood accident rates with better survival. Just think of the impact that microsurgery has had on the reattachment and preserved functioning of severed appendages!
Baby boomers have had better work environments with decreased accident rates, less exposure to carcinogens, and greater access to health promotion programs. Baby boomers have also had better health practices including lower rates of smoking, greater time spent exercising, a greater awareness of preventive health measures, and a healthier diet. Baby boomers are often referred to as the sandwich generation because they are in the phase of life where they are still taking care of their kids but are now also taking care of elderly parents. For those who have not yet experienced the health-care system and have not yet discovered what works in the present system and what does not, they soon will. Baby boomers already have some unique characteristics that have resulted in their having an attitude toward health-care not seen in earlier generations (3).
For starters, baby boomers have a goal of wellness. They expect the health-care system to assist them with plans for healthy aging, not just to provide care when they become ill. Baby boomers are uncomfortable with physical decline and want more products and services that promote health. They want to stay youthful regardless of their age; remember, this is the generation that once had the mantra: “Don’t trust anyone over the age of 30.” Now they are all over 30! Baby boomers having grown up with the $6 Million Man, are familiar with biotechnology and alternative therapies, and have tried many of them.
Baby boomers are great consumers of information and, as already noted, they are the best-educated generation yet. They want to know what is happening to their bodies, what the treatment alternatives are, and what the potential consequences of different treatments will be. They want to be 50-50 partners in the decision making with their physicians and other health professionals. In addition, baby boomers tend to be more demanding consumers; this may be a holdover of not trusting those “old folks” over 30! They will demand services, products, information, and care in stronger terms than any earlier generation. At the same time, this generation has a greater fear of illness and disability than earlier generations (3). This is an ironic twist because baby boomers expect to live longer and better than their parents and grandparents. Nevertheless, the question arises of whether their needs and expectations will be met by a reformed health-care system.
Improvements in life expectancy always have a downside. For baby boomers this will likely be the challenge of nonfatal chronic diseases. How will chronic health-care delivery evolve over the next 30 years? Right now, there are not enough beds in long-term-care facilities in the United States to meet the needs of the approximately 1.5 million people in the age group (65 years and older) that uses them with some frequency. In 30 years, the numbers of those who will need chronic care is projected to rise to somewhere between 4 and 5 million. In addition, two to three times that many will likely receive long-term-care services in their homes (1).
Older adults are disproportionate users of health-care resources. Presently, elderly adults constitute one-eighth of the total US population but they are responsible for one third of the total health-care expenditures (4).
Other expected consequences of increased life expectancy include an increase in the number of people with functional disabilities (ie, people who require assistance with the activities of daily living such as bathing, feeding, transferring [eg, moving from bed to chair or rising from a chair], continence, dressing, and toileting) and dementia, particularly Alzheimer’s disease. The incidence of Alzheimer’s disease is approximately 50% in people over 80 years of age (1). All these statistics add up to the fact that the costs of caring for the aged baby boomers will be staggering!
The future will bring demands for more services and different options than presently exist in long-term care. The greater number of elderly persons will bring not only an increased need for nursing home beds but also an enormous demand for home health services because, given the choice, most elderly persons prefer to remain in their own homes. One of the problems that exists today is that services are fragmented and many people do not know that they exist! What is available? What are the eligibility requirements? What agencies can help? Where are they? Who is out there to help? Atkins et al (1) suggested that one way to manage this problem now is to establish an agency in each community to coordinate available programs and services for the elderly and to help families and individuals find what they need (1). Surely there is a role for dietetics professionals in this proposed method of managing available health-care services and resources.
Term Abbreviation
Independent practice association IPA
Preferred provider organization PPO
Health maintenance organization HMO
Physician-hospital organization PHO
Geriatric evaluation unit/
Geriatric evaluation and maintenance center GEU/GEM
Ambulatory-care center ACC
Skilled nursing facility SNF
Intermediate-care facility ICF
Home health agency HHA
Adult day health center ADHC
Hospital-based home care HBHC
FIG 3. Health-care delivery structures.
THE FUTURE DEMANDS CHANGE
One of the things we can count on happening is change. The health-care delivery system in this country is already recognizing that the demands of consumers, particularly the baby boomers, are driving changes at the community level. Results of several focus groups of recently discharged hospital patients conducted by Age Wave, a consultant firm focused on issues associated with aging, and Baxter HealthCare Corporation indicate that four major factors will influence the relative success or failure of health-care delivery institutions (3). The first is the pressing need for outreach and community-based programs. Demand is increasing for local primary-care facilities, prevention and education programs, and services for populations with special needs.
The second is the demand for information. Consumers want to make educated decisions regarding their health care and will demand time and answers from their primary-care provider. Health professionals need to learn the most important diagnostic skill – listening! Researchers at the New England Medical Center in Boston, Mass, demonstrated that patients who communicated effectively with their care providers tended to have better health outcomes (3). Our responsibility as health-care providers is to make sure that consumers have information in user-friendly forms. Although dietetics professionals are terrific at developing print materials, we need to become experts at developing computer software, electronic databases for consumers, cable television programs, audiotapes for the general public, and interactive materials.
The third factor is a demand for a true continuum of care that begins at an early age. Along with this desire for seamless delivery systems, there are issues that can be better addressed throughout the course of care delivery. For example, osteoporosis prevention should be targeted to adolescents not postmenopausal women. One possible result of this type of care is the positive effect it may have on compliance with treatment protocols. By contributing to the development of a strong, trusting relationship with the primary-care provider, this type of system may serve to avoid apparently conflicting advice; misunderstandings, and poor follow-through.
The fourth factor is the expectation that traditional health-care services will expand in a variety of ways. Consumers are beginning to anticipate diversity in their choice of services. Among these choices may be self-help programs, culturally unique services, wellness programs, and more individual responsibility. To accommodate all of these changes, the roles and responsibilities of providers will have to be modified.
NUTRITION SCREENING AS A FACTOR
The role of nutrition professionals is already changing. Interest in health promotion and screening is increasing. One example of this is the amazing success of the Nutrition Screening Initiative, which brought together three national organizations – The American Dietetic Association (ADA), the American Academy of Family Physicians, and the National Council on Aging. The concept of screening for nutritional risk has developed into a national effort and has brought many other health professionals to a new level of consciousness regarding nutrition. Clearly, screening for risk factors for chronic diseases and implementation of appropriate interventions can make a difference in slowing the progression of many age-related conditions and may contribute to their prevention or at least a delay in the first appearance of symptoms.
It is well known that nutritional status influences the development or progress of many diseases and can affect the extent to which functional independence is maintained. Effective intervention in older people is difficult, however; the risk factors must be evaluated and the determination of adequate nutrition must be defined. New ways must be found to assess nutritional status and nutritional requirements, perhaps by looking in places that have not been previously explored. For one thing, the Recommended Dietary Allowances (RDAs) must be age-adjusted to give us at least some stratification for older adults. What are the real energy, nutrient, and fluid needs of elderly persons? As the first wave of baby boomers rapidly approaches the age of 50, a better definition of the RDAs for the entire population of people over the age of 51 years becomes more important and more urgent, particularly as this new group will ask a lot of questions about nutritional requirements, healthful eating behaviors, and dietary patterns to maintain their youth. The release of data from the third National Health and Nutrition Examination Survey has provided normative data against which we will be able to compare elderly baby boomers (5).
What foodservices and products will be necessary to meet the needs of the aging population? What kinds of delivery systems and heating or cooking methods will be available in 15 years? What new food products will be available? Will new food ingredients be developed in a laboratory rather than by Mother Nature? The future may bring products such as protein in a pill, vitamin sprays, and nonabsorbable sugars – use your imagination!
New medications for chronic illnesses may allow greater bypass of dietary restrictions or perhaps we will have the knowledge to control both chronic and acute illnesses by earlier dietary intervention. Dietary counseling may be done by interactive computer, by videophone, or through technologies we have not dreamed of yet.
One trend that is already developing is that in order to establish or fund new programs for the elderly, policy makers are demanding sound, reliable, valid data on which to base recommendations or interventions. Clearly, there are barriers to dietitians performing research independently, but they are not unsurmountable. The ADA has already taken a leadership role in this area by promoting a research agenda for the profession and by supporting and participating in research efforts of our members (6). Some may not want to expend the commitment and energy needed to conduct research, but it is do-able and it is the future of our profession!
PLANNING FOR THE FUTURE
The Environment
The first area that we must address in planning for the future is the environment in which we expect to function. To implement ADA’s vision of shaping the food choices and impacting the nutritional status of the public, we must consider all the facets of the environment in which we practice. The environment of the near future will be characterized by changes in the delivery of health care (regardless of the future of health-care reform), changes in the population of patients to whom services are delivered, and changes in the location of service delivery. During the past decade it has become apparent that alterations in consumer lifestyle, including nutrition and diet modifications, will lead to demands for more screening programs and preventive services. Certainly we know that nutrition can influence the progress of many chronic conditions. Dietary factors are clearly associated with 5 of the 10 leading causes of death in older adults: coronary heart disease, some types of cancers, stroke, non-insulin-dependent diabetes mellitus, and atherosclerosis, and are also associated with the risk factors of obesity and hypertension.
Health-delivery structures, public and private insurance mechanisms, and terms of benefits and eligibility change dally. Most people are bewildered by all of the changes and options that have cropped up. Figure 3 lists some of the new delivery structures in health care. Insurance options include co-insurance, catastrophic insurance, Medigap, and long-term-care policies. The environment changes continuously and the confusion about health-delivery options increases for most people.
Resources
A second issue is assessing of the resources that will be available and necessary to achieve the goal of creating a nutrition services delivery system that will meet the needs of an aging population. What kinds of resources must be available if we are to implement and sustain our vision? Undoubtedly the first will be money! What will this new creation cost? What will be needed to fulfill what is often referred to as “recurring funds” (ie, funds that will be sustained through several budget cycles as opposed to a one-time appearance of a budget item)? What are the direct and indirect costs of overhead (eg, rent, utilities, maintenance and repairs, supplies) and personnel benefits? What about travel money, temporary help, printing costs, and other anticipated and, more important, unanticipated expenses? Needs for space, furniture, and other physical resources must be addressed for a project to become a reality.
The second most expensive resource that must be considered is human. Is there adequate staff available with the necessary skills to carry out the tasks associated with a program or project? Are enough students in the pipeline to continue to assume the responsibilities needed? Will they be adequately trained and educated to meet the demands of technology or service delivery in the changing environment? Where will students find jobs? How much competition will there be for new positions? Will students have skills that allow them to adapt, be flexible, and grow as the world changes? These questions must be considered when we prepare for the future.
Demographic Forecasts
Some of the answers to these questions about resources may be complicated by a third factor – demographic forecasts. One of the factors that will have a major effect on the demands for services and resources is what is commonly known as the baby boom generation. Between 1946 and 1964, 76 million people were born. As this group has gone through its phases of life it has had a major impact on our society, particularly because the groups preceding and succeeding it are much smaller. The front edge of this group is rapidly approaching the age of 50; by the time the last of the group reaches the age of 65, 20% of the population will be 65 or older and the absolute numbers of people over age 65 will have doubled from 32 million to 65 million people! The resources needed to sustain services and programs that exist today for older Americans may not, and probably will not, be there.
Political Realities of the 21st Century
The fourth area that must be considered is the anticipated political reality of the 21st century. The political context in which programs for the aging population are considered has changed greatly since most of these programs were put in place in past decades (7). Because public resources are now perceived as scarce and entitlement programs regularly come under scrutiny by Congress, there has been an erosion in the belief that older adults deserve government-provided benefits. Social Security, Medicare, and the Older Americans Act were all enacted between the time of the New Deal and the mid-1970s; since then, the compassion with which we view older people has changed, partly because of the power of the media and advertising. Older adults are now often depicted in the media as prosperous, hedonistic, selfish, and politically powerful. The reasons for this change include improvements in the economic status of elderly citizens due in part to Social Security and a “graying” of the federal budget (ie, one third of the federal budget goes to programs lawmakers and the public perceive as benefiting the elderly). The funds spent on entitlement programs have been blamed for the weakened economy, the explosion in health-care costs, and the federal deficit.
One major problem that is associated with the expenditure of federal dollars on health-care costs and other entitlements is that whereas the baby boom generation has been able to support the current older generation through its taxes, the succeeding generation will not be able to sustain the cost of supporting the baby boom generation when they start collecting from these programs. The ratio of those paying into Social Security through FICA payroll tax deductions to those who are receiving Social Security retirement benefits will change from 3.2:1 in 1980 to 2:1 in 2030 [ILLUSTRATION FOR FIGURE 4 OMITTED].
The trend toward declining income has been offset by the institution of eligibility requirements based on income for some of these programs. In 1993, the Omnibus Budget Reconciliation Act called for the taxation of 85% of Social Security benefits for individuals with an annual income of $34,000 and couples with an annual income greater than $44,000 per year (8). However, in broader economic terms, future benefits for older Americans will be more closely linked to whether the American economy produces sufficient resources to allow transfer of funds to programs that benefit the elderly. In recent years, Congress has targeted many of the entitlement programs to those who have a greater financial need. Increasingly, the link between age and economic status may be the eligibility criteria for old-age benefit programs.
ROLES FOR NUTRITION PROFESSIONALS
Nutrition professionals can assume many new roles as we move into the future. There is no reason that we should not be the appropriate professionals to direct health screening and health promotion programs. The experience of dietitians in the VA medical centers has shown that dietitians can lead interdisciplinary care and planning teams when the primary problem is nutrition related. Dietitians can be care coordinators, case managers, hospital administrators, investigators, teachers, program directors, consultants, marketing or sales managers, and clinicians. Dietitians can fill a host of other roles that perhaps we have not yet imagined.
We need to develop a new vision of ourselves. We must continue to work on how we are perceived by the public regardless of whether the public is consumers, other health professionals, the scientific community, or government. Few barriers cannot be overcome with some ingenuity and the willingness to break the old paradigms. We have the ability to affect the eating habits of the public, to change our own perception of who we are, and to set a new agenda. Setting the agenda requires us to reset our barometers, reevaluate what we do and how we are doing it, and recognize the realities of the changing health-care world.
Our vision must be grounded in reality. As much as dietitians are sure that we would do a better job if we ran the world, the likelihood of that happening is slim! But we can change the world one little bit at a time. Every long journey begins with one step and, to paraphrase Neil Armstrong, sometimes the small steps are truly great leaps.
We must be creative and not get stuck in old ruts. Sometimes it is risky to try something new and different, but where we would be today without such outlandish ideas as television, facsimile machines, personal computers, and post-it notes?
Consider all the possibilities. Imagine what people thought of Alexander Graham Bell and Henry Ford when they told us we would talk to people across the country and ride in horseless carriages. Consider where we might all be today if it were not for people like Lenna Frances Cooper. Lenna Frances Cooper was a leader by example. The legacy that she and others before us have bequeathed will allow us to take leadership yet another step farther to achieve whatever mission we have set for ourselves and to see our vision become reality.
The only bad idea is one that is never exposed to the hard light of scrutiny. Sometimes the greatest contributions come from missteps or mistakes that lead us down new paths. John F. Kennedy once said, “Some men see things as they are and ask why; I dream things that never were, and say why not?” Don’t ever be limited by things not done before; if generations before us were unwilling to take risks by considering all options, many products and services that are part of our everyday life would not be here now.
As we move into the 21st century and reset our goals, we must state them in clear and measurable objectives so that we have checkpoints along the way to measure our success. We must be willing to alter our path to accommodate the changes that will certainly occur.
CONCLUSIONS
With change as a given, we must realize that there will be obstacles in our way and some will require great perseverance to overcome. We can be like Don Quixote and tilt at windmills or we can hope that a knight in shining armor will rescue us from dragons we may not have chosen to fight, but we must keep in mind the fact that Quixote’s windmills were usually unscathed and that sometimes the dragon wins!
It is useful to maintain a positive attitude and to make the best of whatever challenges lie ahead. Many exciting challenges lie ahead of us as the baby boom generations comes of age. How we as professionals face the future may make a great difference, not only to ourselves but to this soon-to-be-older generation.
To give you a final thought on how dietitians are seen, I would like to quote one of my favorite works on aging, You’re Only Old Once! (9), by the famous philosopher Dr Seuss:
Dietician Von Eiffel controls the Wuff-Whiffer, our Diet-Devising Computerized Sniffer, on which you just simply lie down in repose and sniff at good food as it goes past your nose. From caviar souffle to caribou roast, from pemmican patties to terrapin toast, he’ll find out by Sniff-Scan the foods you like most. And when that guy finds out what you like, you can bet it won’t be on your diet. From here on, forget it!
We have the power to ensure a better quality of life to the baby boom generation as it comes of age and to guarantee that Dr Seuss’ scenario never becomes the reality. As we work toward achieving our mission and making our vision the gold standard, we will be better prepared for the future of the 21st century.
References
1. Atkins GL, Bengtson VL, Binstock RH et al. Old Age in the 21st Century: A Report to the Assistant Secretary for Aging, US Department of Health and Human Services. Syracuse, NY: National Academy of Aging, The Maxwell School, Syracuse University; 1994.
2. Butler RN. Will the baby boomers go bust? Geriatrics. 1990; 45(12):13-14.
3. Lumsdon K. Baby boomers grow up. Hospitals & Health Networks. 1993; 67(18):24-26.
4. Chernoff R. Demographics of aging. In: Chernoff R, ed. Geriatric Nutrition: The Health Professional’s Handbook. Gaithersburg, Md: Aspen Publishers; 1991:1-10.
5. Burt VL, Harris T. The third national health and nutrition examination survey: contributing data on aging and health. Gerontologist. 1994; 34:486-490.
6. The Research Agenda for Dietetics Conference Proceedings. Chicago, Ill: American Dietetic Association; 1992.
7. Posner BM, Levine E. Nutrition services for older Americans. In: Chernoff R, ed. Geriatric Nutrition: The Health Professional’s Handbook. Gaithersburg, Md: Aspen Publishers; 1991:415-448.
8. Easterlin RA, Macdonald C, Macunovich DJ. Retirement prospects of the baby boom generation: A different perspective. Gerontologist. 1990; 30:776-783.
9. Seuss Dr. You’re Only Old Once/New York, NY: Random House; 1986.
Ronni Chernoff is the associate director of the Geriatric Research Education and Clinical Center, John L. McClellan Memorial Veterans Hospital, and a professor of nutrition and dietetics at the University of Arkansas for Medical Sciences, Little Rock. Address correspondence to: Ronni Chernoff, PhD, RD, GRECC (182), John L. McClellan Memorial Veterans Hospital, 4300 W 7th St, Little Rock, AR 72205.
Source Citation (MLA 8th Edition)
Chernoff, Ronni. “Baby boomers come of age: nutrition in the 21st century.” Journal of the American Dietetic Association, vol. 95, no. 6, 1995, p. 650+. Hospitality ,Tourism and Leisure Collection, http://link.galegroup.com.libraryresources.columbiasouthern.edu/apps/doc/A17311230/PPTH?u=oran95108&sid=PPTH&xid=7a9994a9. Accessed 29 Mar. 2018.
Gale Document Number: GALE|A17311230