 Good afternoon, everybody. My name is Mark Oranis and I'm an Associate Scientific Director with the Canadian Longitudinal Study on Aging and I'm going to be hosting today's webinar. And just as a note for procedure, we have disabled most people's talk features because if too many people have the talk feature activated, it creates feedback. So with respect to questions from the audience, after our speaker finishes her presentation, we will take questions from the audience. But please type your questions in the chat box. That should be at the lower left of your screen. And I will read out the questions to Heather. So we'll get going now. It is my great pleasure to introduce our speaker today. Dr. Heather Teller is a professor in the Department of Kinesiology at the University of Waterloo. She's an expert in nutrition and older adults. And in her research, she attempts to improve the nutritional state and health of older adults, whether they be community dwelling adults or whether they live in institutions. She's developed a wide collaborative network for research in community and clinical settings. And she has a great role in translating this research and knowledge to practitioners, families, and older adults. She has three primary research screens, all in nutrition, risk screening, nutrition and healthy aging in older adults, and nutrition and dementia. Heather has actually developed one of the tools, the screen tool, that we are currently using as a data collection measure in the Canadian Longitudinal Study on Aging. And she'll be talking about older Canadians, food intake, and nutritional status, how the CLSA will advance knowledge. Heather? Great. Thanks very much, Mark. It's a pleasure to talk to you today about the research that is going on in Canada around nutrition and to specifically talk about the CLSA and how it can help us to know a little bit more than we do know now about older adults' nutrition habits. First off, I want to clarify some key terms for you, specifically what is malnutrition, nutrition indicators, nutrition risk, and how we assess nutrition status, then why nutrition is relevant to looking at specifically in older adults, some of the sorts of information we already have on nutrition for Canadians and specifically older adults, what we currently know about the food intake of these older adults, and then watch into some of the key features of the CLSA and specifically the screen tool and some research questions that can be addressed with this wonderful data set that we have available to us. So first off, malnutrition is, depending on who you talk to, you may get a different definition of malnutrition, but I really like this definition because it seems to encompass the range of what we think of when we think of someone not having the nutritional intake to meet their needs in the way that's going to support their health and function. And so it's an old definition from a World Health Organization that works well because it covers not only the undernourishment that can result from insufficient food intake, but also overnutrition caused by excess food intake. And more specifically also identifies that this can be a nutrition nutrient deficiencies itself or an imbalance due to disproportionate food intake or nutrients being utilized in the body. The key is that when these things are happening, they're malnourishment when they affect the body tissues, the function and the overall health of the individual. If we think about nutrition indicators, that's usually a single parameter that tells us something about a component of the nutritional status of a person. So we think about body weight, for example, a blood measure such as serum of human or hand grip strength, all of those are single parameters. They tell something about nutrition, but they may not give us the whole texture of nutritional status of the individual. Nutrition risk, on the other hand, is thinking about the concept of the fact that you have a variety of these potential risk factors or indicators of malnutrition that will, if they continue to move forward, lead to malnutrition in the individual. And so it's a trajectory we think of that people are on a path of not consuming sufficient nutrients to meet the body's needs. And if they continue on that path, they then start to have the physical deficits around function and health, which is malnutrition. In the acute care setting, we often think of it this way, and this is a model put up by White at all in 2012. And so, again, you see this idea that it's a trajectory or a linear path from being well-nourished to severely malnourished. And it can lead, it can be part of the, the reason is lack of food intake or an adequate food intake. But in the acute care setting, we also see often inflammation because the disease state or the acute care challenge that is occurring in the body leads to inflammation. That on top of that impaired food intake leads to increased requirements for the, for a person to meet their needs. And when those two things go in combination, we get much more severe malnutrition. So you move quickly from being well-nourished and into moderate malnutrition when you have inflammation and lack of food intake. And then finally, we see severe malnutrition when we see hypermetabolism or catabolism, which might be seen with a trauma, for example, in acute care settings. So some of them would be well-nourished on a Monday, but be severely malnourished a week or two later if they've gone through a significant trauma that's caused by malnutrition and catabolism and catabolism. In the public health sector, we also think of it as a linear process, but we often think a little bit more upstream in terms of risk factors that lead to impaired food intake, which over a long period of time as that continues, starts to lead to the issue of subclinical malnutrition or overt malnutrition. So if you look at the slide on the far left-hand side, you see the determinants of food intake. And this would be things like socioeconomic status, living situation. When we think of the risk factors that can lead to poor food intake, specifically for the older adult, these are things like appetite, pro-apatite, sculling problems, chewing problems, having food-related activity, living problems, such as lack of grocery shopping capacity or transportation to a grocery store. All of these would be risk factors that could impair food intake. And food intake is often the first thing we see changing in the older adult in the community setting that might suggest that they're having a problem with malnutrition. If that continues long term, they move into subclinical malnutrition where we start to see body changes, such as body weight and anthropometric changes or biochemistry changes. That becomes overt malnutrition when those changes are significant and start to affect the function of the body. So you can see here that in addition to giving this linear process, this diagram also shows our primary prevention can be used in terms of looking at the determinants of food intake and risk factors that may be present. Where secondary prevention and specifically screening might be useful in terms of identifying individuals who are at risk. And then finally, tertiary prevention where we know someone has the condition of malnutrition trying to reverse it. On the bottom part of this slide in this diagram, we also see potential interventions that might be used. You can see that in a public health framework, this would vary obviously as compared to acute care. So in the public health area or primary care, interventions like education, interventions that address the risk factors like cooking skill or meal programs that overcome the issue of access to food in the community, those are all the interventions that would help to address the issue of nutrition risk and our malnutrition. And when someone becomes overtly malnourished, more targeted interventions such as meal supplementation or individualized counseling are useful in this setting as well. I now want to turn our attention to what we mean by nutritional status and understanding how we assess that. So malnutrition as giving the definitions is a very diverse concept, looking at both over-nutrition and nutrition as well as micronutrient deficiencies on their own, are the imbalance of those and they impact the function and health of the individual. So how we figure this out? There basically is no single indicator that sufficiently describes the nutritional status to determine malnutrition or nutrient deficiency. This means that we have to look at a variety of parameters or nutrition indicators to get a sense of the actual nutritional status of an individual and clinical expertise is needed to differentiate which indicators to use when to fill in that picture. Standardized measurements that are used that are comprehensive an example would be some difficult assessment. It actually covers off many of these components that are on the circle here of what we would consider part of an individual nutrition assessment. So typically when a dietitian or another practitioner who does nutrition assessment does it, they include some or all of these components when looking at nutritional status of the individual. They want to know something about the food intake of the individual. They want to know something about the body composition, so fat mass versus muscle mass or even squealed mass in terms of bone. Clinical exam looking for risk factors that might lead to impaired food intake or utilization of nutrients in the body. Physical exam which shows the sum of the potential nutrient deficiencies or lack of energy and protein and macronutrients specifically in the body. And then finally biochemical measures which might be used for individual micronutrients like B12, for example. As I said, no single indicator gives us the clear picture. If we take for example B12 itself, serum B12 has challenges with being able to identify clearly when someone has a subclinical or full deficiency of B12. So a single indicator on its own doesn't work. We need to look at a variety of measures across these components to get a true sense of nutritional status. So you can see that when we're trying to look at nutritional status and diagnose malnutrition, it becomes very difficult in the context of research and in the context of surveillance such as the CLSA and other large court studies and other surveillance tools that have been put into place. As a result, what we see instead being used is often individual indicators like body mass index or body weight and height. And people use these as a crude indication of the potential nutrition problems for our population and individuals within that population. We also see indices being used. Body mass index is actually an embassy taking the weight in relation to the height of the individual. There's other indices out there that are also used that look at biochemical measures, for example, in addition to body weight and maybe age and gender. There's also standardized checklists that are used. And then finally, there's screening tools that have been used and developed. One is Screen 2, which we'll talk about in more detail as it's used in the CLSA. There's also the mini nutrition assessment, which is developed specifically for older adults in a clinical environment, STAC, MST, which is a non-nutrition screening tool, and NUSP, which is a similar screening tool used in the UK. All of these have been validated and tested for reliability, but they may not be necessarily validated in a realistic situation. So just to give you an example here, some of these tools have used researchers to actually compare the screening tool to the criterion that they consider to identify nutrition. That's not the real-life scenario when we're doing screening. We typically want a frontline person doing the screening who may or may not have very much education around nutrition to identify nutrition risk. So some of these tools may not be validated for the context specifically in the community setting for the CLSA when we think about that. As well, they're not necessarily relevant for community or public health contexts. Many of these tools look at the risk factors that are much more upstream, such as appetite, swelling problems, chewing problems, et cetera. So now let's turn our attention to why malnutrition is a relevant issue for us to be looking at and thinking about older adults in Canada. We know that in acute care, that if someone comes into the hospital in a malnourished state, they're more likely to have more morbidity, a slower appetite, a slower healing of the wound if they have an existing wound on their body, more likely to have infections during that hospital stay, more complications, and a longer convalescence. All of those lead to impaired quality of life for the older adult. They also translate obviously into healthcare utilization issues. So we typically see on average two days or more stay for a hospitalized patient who is malnourished. This is often due to increased treatments because of complications and infections and wound healing problems. We also see a heightened level of mortality in hospital and within 30 days of hospitalization. And we know from studies throughout the world that the costs of malnutrition in acute care setting are approximately 60% more than they are for a person who is well nourished. We have much more data in acute care setting than we do have in the community settings. That's why I present these data for you to show you the importance and the relevance of nutrition. We need to remember though that people become malnourished in the community and they come into acute care in that state. So malnutrition is definitely occurring in the community and also likely has significant effects on health and outcomes for patients or individuals living in the community. We look to literature about chronic disease. I've just shown a few key studies here and some common knowledge that we have about diet and client disease. We know that if we limit saturated fat, cholesterol, and trans fat this can prevent cardiovascular disease. We also know that if we emphasize the omega 3 fatty acids DHA and EPA they can promote cardiovascular health and improve instant sensitivity. We also have a long standing body literature that shows fruit and vegetable intake associated with decreased cardiovascular disease, diabetes, and cancer. And fish intake is associated with decreased cardiovascular disease. So we know these things about diet and need then to support the practices around high quality nutrient death diets for older adults to promote their nutrition and overall health. Specific to the older adult population we also know that food intake nutrient dense diet promotes less frailty. If we take the example of dementia we know that a high saturated fat diet and a diet high in calories and alcohol is associated with the incidence of dementia. We also know that these diets are often low in antioxidants, fish, methionine, and other vitamins. In a study that was prospective some had all identified that women who had a low protein take it baseline about 0.7 grams per kilogram per day lost 40% of their muscle mass over a year period as compared to those who had a higher protein intake at 1.1 grams per kilogram per day. This shows very directly the impact of protein itself on the skeletal muscle structure of older adults. And now this has changed our thinking about sarcopenia and how it might address frailty in older adults in terms of nutrition as well as exercise. And these women they also saw low levels of serum vitamin D, crotinoid, selenium zinc and B12. All of those also predicted disability. So back to the point that a high quality diet not only prevents chronic disease but also promotes well-being for the older adult and perhaps potentially decrease the incidence of dementia as well. In terms of Canada and our nutrition information I've tried to accumulate here as much as I know of the various nutrition surveys that have been done in the last 20 or 30 years or so. And I'm sure there's a few here but these are the key ones that are out there that are available in terms of data that we know has been useful for describing the nutrition intake and nutritional status or nutrition risk of populations in Canada. So back in the 1980s and 1990s there was a series of provincial surveys funded by each provincial government that were done and they included things like the food frequency questionnaire or 24-hour recall to try to understand the food behaviors of individuals and specifically older adults. The CCHS 2008 used the Screen 2, the Brevier version which I'll describe a little bit more in detail later, as well as general health measures. The Medetable follow-up study also used Screen 2 since 2007 and its nutrition survey component. The getting health measures survey includes height, weight and micronutrient levels as well as the food frequency questionnaire and it goes up until I believe the new 70s in terms of the age range of the population that's included. And then finally we have the New Osh Co-Heart which is probably the most in-depth nutrition study ever done in Canada to date. It included 324 recalls, food frequency questionnaire and several nutrition indicators as well as robust measures around health, well-being and quality of life. So what do we know from those studies that have been adapted to date? Well, it generally got from the surveys that were done in the 1980s and 90s since that poor intake was occurring across all four food groups in the older adult population. We see this across all of the surveys that were done. We also saw for those surveys that did micronutrient analysis that several nutrients were consumed at low levels. From the CCHS 2.2 which is the 2008 survey that older adults 65% did not consume five fruits and vegetables a day. And we know that 34% of older adults are at nutrition risk using the screen 2 abbreviated tool. So this demonstrates a significant challenge when thinking about nutritional status and nutrition risk as well as food intake of older adults in Canada. So why does poor food intake occur in this population? A variety of studies identified such as food apathy, reduced digital capabilities, restricted income, depression, social isolation, neglect, medication use, cost of impairment, dentition, and multi-morbidity as reasons why poor food intake occurs in older adults and makes them especially vulnerable to poor nutrition and even non-nutrition. In the CCHS 2008, we showed here the prevalence of some of the key risk factors that might be promoting poor food intake in the population. So just for example, 42% reported over in the lowest income bracket, 49% were living alone, 44% had disability. Again, this is a population survey with the telephone administration being used. So this is a population sample and to see the prevalence of some of these risk factors and determinants of food intake and nutritional status demonstrates again the relevance to us of why we should be looking at nutrition in trying to promote better quality diets, nutrient-dense diets for older adults in Canada. In terms of looking at specifically the prevalence of nutrition problems in Canada, we have that population sample from the Ramanage Study based on the CCHS 2.2, 2008. And here are shown the risk level, 34%. There's also some of the key variables on the screen to abbreviate a tool to show the prevalence of individual variables. On the right-hand side, I show a vulnerable sample which was recruited from 23 service agencies in three cities in southwestern Ontario. And these individuals were attached to, for example, meals and meals programs or cognitive dining programs. And so they're much more vulnerable than the population sample from South Canada. But you get a sense of the divergence in the prevalence of risk as well as some of the key risk factors. So for example, you see that 37% had low food and vegetable intake in the stats Canada sample versus almost 50% in the vulnerable sample. With the Manitoba follow-up study, the screen 2 was used as well in that survey, so it's a nutrition risk measure, 19% were considered to be at higher risk. However, it may have improved over five years showing that the potential weight change decreased that risk for older adults. This is the power of use in allowing you to do an analysis, a data collection analysis like the Manitoba study, and you can see that actually people can improve in one of those things that predict that improvement. 20% that were at low risk declined over five years and that risk was attributed to, that increased risk attributed to decreased appetite and low food intake for the population that was part of that study. The nutrition risk was also considered to be five-year mortality and with each point declined in the screen 2, there's a 4% increase in mortality in adjusted models showing again the importance of nutrition as being an independent predictor of health outcomes in the population. This study also supports the validity of the screen 2 because they demonstrate the predictability around mortality of this tool. Indicating health measures survey, the 60 to 79-year-age group, there's been some data reported in the literature. About 31% had dental treatment need based on the assessment of the dental dentition of the individual. 25% had vitamin D less than 50 nanomoles per liter when they used the Seer measures for that. Those who drank one or more glass of milk a day had a mean level, though 75 nanomoles per liter versus those who did not consume milk. So showing and demonstrating the benefit of eating just one glass of milk a day in terms of vitamin D level. And then another key stat that I thought was relevant to this group of 6% of women had low serotonin showing potentially anemia in the population as well of older adults. So there's some data to show you what we already have, excuse me, but also the potential need in terms of doing more research around nutrition. So for newage, which is the most robust data collection to date in Canada around nutrition living sample and food intake and nutritional status, this study has provided a lot of research around our understanding of nutrition in the community. And it's a way forward thinking about the COSA and further studies that could be done. With this satisfaction, for example, it's identified in almost 51% of older adults in this group of individuals. Interaxiolaging was common at about 7% and obesity at about 25%. So showing the range of things that we're thinking about when it comes to nutritional status in the older adult population, seeing everything from anorexia through to obesity, and of course, weight dissatisfaction there as well. In terms of antioxidants being consumed, we find that the food intake consumption was positively set with serum values. So it validates some of those serum measures in terms of looking at that, but also shows the robustness of the food data collection measures in the new lodge. And finally, positive determinants of diet quality women are higher education, diet knowledge number of meals and hunger, and negatively associated with diet quality with dentition. So some of these associations with food quality and with diet quality are relevant when thinking about the COSA data because we have many of these robust measures as well around risk factors and determinants of food intake that might be relevant to look at in future research. So on to the Canadian study on aging. The benefits of this data collection is first that it's longitudinal and it's going to allow us to understand determinants and exposure associated with specific outcomes in a way that we have never been able to do before because it's long term data collection over many years. It's a covert study of sufficient size, even considering nutrition that might happen over time. So we'll be able to explore in detail some key ideas and notions around nutrition and how it may be impacted by various risk factors. So we can see potential for self-studies of selected populations who might have a very specific determinant you want to look at because of the robustness of the sample size will have that capacity in this data set. As well, we see aging from very diverse perspectives and there's a larger age range than just the older adults. It goes from 40 and onwards. And so there's multiple dimensions of aging and a process of healthy aging can even be picked up as some of the data that's being collected. So it gives us more of a robust picture I think in terms of thinking about how to promote better health through food and nutrition education and other quality practices for the older adults. There's lots of modifiable factors that have been put into the data collection. The things that we can change, not things that we cannot change such as disease state, for example. This allows us to think about interventions if we can understand better what so many things are influencing food behavior may be. And finally, there's been a large collection of researchers involved in this data collection providing expertise to the selection of measures as well as the inclusion of a variety of data collection procedures to make sure that this is a high quality and rigorous data collection. As a result, this is an unparalleled research opportunity in Canada and will be exceptional in terms of looking at nutrition research as well. Specifically, some of the methods of the CLSA is 50,000 individuals 45 to 85 years of age and they're being followed for 20 plus years. There's repeated data collection every three years and there's a core questionnaire which has demographic, social, physical, clinical, psychological, economic, and healthcare use. 30,000 of those participants go through this CLSA comprehensive where they have in-person physical measures including blood, urine, physical exam, diet, medications, disease symptoms, a neuropsychological exam, physical measures. The CLSA tracking is a telephone interview for 20,000, which are representative of the Canadian population and it's based on the CCHS2008 sample. They have questionnaires that are being used to track the population over time. As well as an annual questionnaire based on data collection to retain the sample and there's the opportunity to link to administrative data such through the health record number such as giving a sense of hospitalization of an individual. So very robust data collection. To look specifically at the comprehensive group of 30,000 or so, there's functional performance measures, activities of daily living, instrumental activities of daily living, grip strength, balance, physical functions such as balance for me to walk, time to go and chair rise, waist to hip pressure, bone mineral density, aortic calcification, as well as chronic internal media thickness, height, standing, sitting, and weight, and blood and urine are stored and measured for key variables. The questionnaires that are part of this comprehensive group of patient or group of participants include falls, pain, oral health, diet supplements, the nutritioner's screen tool which is screened to abbreviated we'll talk more about in just a moment, physical activity, psychological distress, personality traits, social inequality, transportation ability, built-in environment, wealth, and there's an in-home questionnaire that focuses on short diet. It's like a 360 questionnaire, we'll talk about that in more detail in a moment as well. Satisfaction life, the ADLs and IDLs, and care and caregiving. So you can see it's incredibly robust data collection that we have in terms of looking at nutrition risk in relation to some of these other variables. The short diet questionnaire specifically has 36 items. It's a frequency only frequency questionnaire which includes the day, the week, the month, and the year, the consumption during those time frames. It looks it off for all of the four food groups, emphasize this whole brain in the mega-3 eggs, types of oils, and looks specifically low and regular fats and dairy, and counter fortified foods and fluids. So it's not a comprehensive three-fifth questionnaire which we might have seen in other smaller cohorts, but when you think about this as being done with 30,000 people, it's extremely robust to look at key healthful behaviors that can promote improved health outcomes. In the CLSA tracking, which is the 20,000 people that are being involved who are not getting the physical measures being done, these are the measures that are being collected. And so there's some overlap obviously so you can look at these groups in combination. And just to emphasize here that the screen too is being used as well as a fast food frequency questionnaire, a food insecurity questionnaire, and a team coffee consumption question. So it picks up on some of those items from the short diet questionnaire as well. So on to screen two. There are 14 items in the screen, the full one, and those that are highlighted here in blue with an asterisk shown are those that are the abbreviated version which is used in the CLSA. So we have a sense of weight change, skipping meals, appetite, eating alone, fruit and vegetable intake, fluid intake, swallowing, and cooking difficulty. These measures can be used as a continuum, as a scale for nutrition risk, but they can also be used as an independent variable in terms of looking at, say for example, appetite on its own as a predictor of something like a fall in the future. It has a transbustis bill in that it is a valid and reliable measure as used as a screening tool for the eight items. This is an example question which is a food question. It asks how much food do some person consume a day and gives examples of those foods that would be considered. And you can see why it's essential to see change over time because we have response categories that give a range of response. And so if you remember back to the Manitoba follow-up study, they could see the difference in individual items that occurred over a period of time to see where improvements were made that reduced the risk of some of their participants. So just to the validity and reliability of the screen to the abbreviation specifically, we use the criterion for nutrition ranking, nutrition risk using standardized framework to identify what we were considering nutrition risk in the validation study of the screen to abbreviate it. The cut point of lesson 38 out of 48 total score has a relatively good area under the curve and relatively good sensitivity specificity for a screening tool. You can see that the interest into class correlation is quite high as well. In terms of discriminant ability that's been shown in the CCHS 2008 where the screen to abbreviate version was significantly associated with things we would think to be determinants of poor food intake such as income and living alone. We also know that the screen to abbreviate has predictability. The prevent study which was conducted back in the early 2000 timeframe screen one was used in this data collection not screen two but a site variation for some additional items around weight, body weight change. But essentially the abbreviated version of that tool also was able to predict 18 month mortality. It was independent predictor when accounting for age, gender, perceived health, living alone, and a history of inside falls which were also associated with deaths over 18 months in bivariate analyses. The hazard variation was quite good and it was the only other significant variable outside age when put into the model with all the other variables. In terms of health and day quality of life looking specifically at good health days in that data set and whole life satisfaction. Multivariate models used for repeated measures and low risk kind of on average two better health days per month and it was significantly predictor of that health and day quality of life as well. So there is the predictability, the discriminant predictability as well as the liability of this screen two abbreviated version. And just to show you here this is the abbreviated version looking at the proportional hazards for death. And you can see that those who had risk more likely to die over the 18 month period the green line there versus those who did not have the same risk. So in terms of some research questions that might result from using screen two as well as the short die questionnaire the 37 item or the 36 item food safety questionnaire in the CLSA. There's lots of questions and I just put up some that I thought of as a researcher in this area. In terms of measurements hand grip strength for example is used often in a nutrition assessment and we're getting more and more the utility of that measure and understanding what it can mean in terms of muscle strength and mass for the in terms of the individual who might have malnutrition. And so there's the utility of perhaps looking at hand grip strength and its constructility in relation to other variables as well as in relation to screen two abbreviated version for example which hasn't been done yet. We can also look more at the screen two in terms of predictability and constructility looking for discrimination among specific groups and how that might be more robust than our current sample that we have the data in terms of some of the data collections have done. The healthy eating patterns based on the diet questionnaire can actually come up with some brief tools perhaps based on that 36 item food safety questionnaire that might say something about healthfulness of diet and develop new indices around diet based on these food safety questionnaire items. Anybody even be able to come up with some sort of healthy living indices for example which might be combination of a variety of measures within the CLSA data collection that's something to say about nutrition of the older adults. And we think about analytical questions so looking for associations for example or in terms of temper relationships looking for something that happened before an outcome and ultimately as well. There's several questions that I have thought about and just some of them are here on this slide for you. But for example factors that influence food choice there are some theoretical models out there around food choice for the general population as well as for older adults and those need to be validated and updated to make sure that they truly are giving us a full sense of what is the determinants of food behavior and food choice in older adult populations especially as they age and over time. There's potential to have qualitative sub-stage that come out of the CLSA. So perhaps to identify recently riddled individuals in the CLSA data set there might be the opportunity to then do qualitative studies around monitoring and getting a sense of how they adapt to their new situation of eating in the set. She comes out of a doctoral work of a PhD student who just defended a couple weeks ago. She had done this work and we saw this opportunity as a next step for the CLSA and for her work and moving forward these ideas around understanding that behavior better. Oral health and food intake. There's very little data on oral health and so this robust data collection around oral health in the CLSA will give us an opportunity to look at food intake behaviors as well as nutrition risk in a way that we have not been able to do so before. The built environment and mobility and how they may impact nutrition risk as well as personality. How that may impact food intake and change in food intake over time as well as nutrition risk. As well as life satisfaction. How nutrition may be part of that. We tend to think about predicting health data outcomes at falls or hospitalizations. So we'll have a much more robust data set than ever before. No longer convenient samples, but this population sample giving us a sense of how nutrition risk is an independent predictor and how big independent predictor it may be in these outcomes that we're interested in. Including psychological outcomes as well such as satisfaction. And also what predicts keeping that diet resilience going over time as people age. That's really important for us to know to understand who can be resilient despite having potential risk factors that would lend themselves towards potentially poor food intake, but for some reason these individuals are resilient. So understanding that better might lead us to intervention ideas for older adults and how to support individuals to be resilient. So in summary, I think we have an unprecedented opportunity to study nutrition risk and diet quality in a very large longitudinal cohort. Valve measure of nutrition risk appropriate for this population which is upstream and giving us that then a sense of nutrition risk that might be modifiable is something unique to this data set as well because screen two has been used as compared to some other screening tool. The diet questioner itself gives us an opportunity to focus in on food quality and frequency of key food items that would lead to be helpful to promote the health of and quality level older adults. And finally because of the very diverse data collections being conducted as part of CLSA we're going to have much more holistic view of health and thus the opportunities to explore analytically some really unique research questions we have not been able to explore to date. So thank you very much for your attention and if we have any questions we can. Great. Thank you very much Heather for the excellent presentation and as you said now it's time for questions. So if anybody from the audience has a question please utilize the chat feature and type in your question and I will read it out to everyone and illicit Heather's response. So while we're waiting for people to type their questions just a general question and when I give my students and my intro to epidemiology course module on nutritional I talk about some of the challenges of measuring food and dietary intake such as recall bias. It's very difficult for people to remember even what they ate last week and you can perhaps overcome that by giving them 24 hour food frequency questions. So nutrition questionnaires almost every day but then they start to not fill them out. So how are some of those challenges dealt with in the nutritional at the community? Yeah that's a great question Mark and so nutrition first off status is context to measure and diet within that and all of the components if you're very back to that circle that I showed are very difficult to measure and diet specifically can be very challenging. So when we think about diet there's limitations to every single measure we can use and so doing a combination of measures such as uses in the CLSA is the way to go. And when you have a sample size of 50,000 people you have to think about what do we really need to know and what's going to give us the kinds of information we want to move forward with and so often in very large samples you then use a food frequency questionnaire because of that challenge of doing a robust data collection of a single day for example. A single day on its own isn't very meaningful unless you have at least a subset of a data of a sample where you can get a sense of that variation but then it is still just a single day for the majority of folks and so it limits what you can say about individuals. If you want to say something about a population a 24 a recall gives you quite a nice ability to do that but it doesn't allow you to look at in some ways some of the things you might want to look at in terms of individual associations so a person for example who might be having hospitalization down the road a 24 a recall a year before they say very little about that but something like nutrition risk the screen tool that is being used we know predicts that so it should be a better measure of what's going on nutritionally for the individual. So diet alone can be very challenging to link to key outcomes unless you have a robust data collection for diet and that usually takes many 24 recalls to get a sense of that for the individual and understand their eating and so often what we see will be three 24 recalls and to collect three 24 recalls takes a lot of effort and a lot of time to analyze that data properly so it's a very expensive initiative so in 50,000 people it's very very challenging to do that and why the choice is not made in the CLSA to do that. Great thank you. A couple of written questions what is the availability of blood samples so CLSA is collecting blood samples from people who agree to give a blood sample amongst the 30,000 group that's getting the in-home and data collection site visits. Those blood samples will not be available yet at least that's my understanding sometime in 2015 anyone interested in accessing CLSA data I refer you to the CLSA website where you will find specific web pages dedicated to providing you with information about CLSA data that are available data that will be available in the future and also the website gives you the procedure for going about requesting access to the data. Another question here there has been some research discussing whether saturated fat really has an impact on cardiovascular disease and the poster is asking if you could comment on that. I'm not a saturated fat expert I can tell you that first off and so I've seen some that work to that suggests that perhaps we've overemphasized saturated fat and it may be other things that we need to be looking at in the diet such as the trans fat etc. and so I would have to defer to say I don't have a sufficiently educated opinion to be able to say do we reverse our commentary at this point around or education at this point around saturated fat. There certainly is controversy I agree and we need to look at some of the new data collections coming out around the importance of saturated fat on its particular cardiovascular disease. Great thanks the next question what do you think is the most effective intervention for improving nutritional status in the elderly institution? That's a great question and I would have to say eating with other people is probably the most important thing we know that when people eat with others regardless where it is that they eat they eat more that social facilitation supports food intake it supports new it supports quality of life and so having older adults involved in eating with others whether it be family whether it be a congregate dining site whether it be a church group whatever those are key parts of helping them to eat better and then I think my second point would be to have older adults realize that their nutrition can impact their health there's many older adults who don't see that as that link is there they may have seen it when they were younger thinking that yes I need to eat well I want to work for example have the energy to do work but they don't recognize that their nutrition needs are actually in terms of nutritional nutrients the same for most of the nutrients that we are recommending in terms of required nutrients they're the same at their age of 85 and so they need to have a more nutrient dense diet and then they would have had the younger years and most of them don't realize that. Great thank you another question when do we anticipate the first wave of nutritional information will become available from the CLSA so any data that has been collected in the 30,000 group that's the in-home interview and data collection site visit group those data are expected to become available sometime I believe in the spring of 2015 okay so another question you're being thanked for a great presentation and then how much Canadian data is available for the eldest of the old so we're talking people between 80 and 85 years or greater. Yeah I think that's a limited data collection group so if you look at the CCHS 2008 you don't see very many of those people in that data set and in the new watch as well they had it was a healthy cohort that they were starting with and so you don't see those very oldest old and so we're limited often to convenient samples for that group and so Alain Fayat who's a researcher like myself at sugarcane has done a lot of research in older adults attached to home care for example who are vulnerable I've done a little bit of work around vulnerable older adults and that prevents study so it tends to be just these convenient sample studies that gives us a demonstration that we definitely have a highly vulnerable career around nutrition risk and potentially malnutrition depending on what the measures are that haven't taken that are significantly challenged when it comes to nutrition maybe even malnourished and so that group there may not be in the large population studies in the way that we perhaps Mark can maybe answer that a little bit further if there's any targeted recruitment being done for that oldest group. Right so CLSA has an upper recruitment limit of 85 we've gone above that perhaps maybe by a year or so and anyone recruited into the CLSA in the highest of the age group so we're doing 45 to 85 so if they've been recruited into the CLSA at 80 or 83 or 84 we'll follow them for as long as they're around for us to follow them but I don't have exact numbers of people who would fall into the upper stratum of our age groups but they are there and like I say we'll follow them for as long as we can and I think there's something to be said that perhaps we'll find some survivors in this sample too that we don't see in the typical convenient samples where we find people in community agencies where they're going to be more vulnerable automatically so there's this potential of the CLSA to find people that have had good behaviors and are surviving long term and that's understanding perhaps the importance of diet to that survivorship. Excellent okay so are there any other questions from anyone? I think we've answered all the questions. Oh okay there's one I did not see it. Could you please comment on the general policy on data sharing in the future particularly thinking about researchers outside Canada so I don't know if that's a question about data sharing in respect to the Canadian longitudinal study on aging certainly international researchers will be able to complete data access requests and obtain CLSA data that's certainly an avenue that is open to international researchers. I don't know Heather if you have any thoughts on that question. No of course I don't. I don't know of any research that's open to external or international researchers if you best to contact the individuals that might be involved. I don't believe the stats Canada data would be available outside of Canada. I'm honestly not sure myself but I think new eyes you'd have to talk to LNPAT but I suspect it's not available to people to make the data available that's my understanding. So Heather thank you very much for agreeing to present today it was a very informative and interesting presentation and we really really really appreciate your presenting it to us. Great thanks very much Mark. Great so this will be the last webinar for 2014 and we will send out notices once we have our next set of speakers Thank you everyone.