Obesity rates among older adults have remained high over the last decade (Hales et al., 2020). Good dietary choices are important because of their relationship with weight and risk factors such as insulin resistance (Panizza et al., 2020) as well as risk of frailty and mortality (Jayanama et al., 2021).

Many behavioral interventions provide guidance to participants on changing eating and physical activity habits; however, few track improvements in dietary habits explicitly such as increases in whole grain consumption or decreases in sodium intake or unhealthy fats (Gold et al., 2021). Because weight loss can be difficult to maintain (Wing & Hill, 2001), it is important to assess improvements in dietary habits and whether improvements can be more easily maintained. Additionally, with the diet quality of older adults often less than ideal (US Department of Health and Human Services and US Department of Agriculture, 2015), intervening on dietary habits may provide a valuable path to better health, separate from weight loss.

Food frequency questionnaires (FFQ), food records, and dietary recalls, are time-intensive dietary measures and require significant resources and expertise to administer (Farshchi et al., 2017). As such, these measures may be impractical for use in a community or clinical setting. The Rate Your Plate (RYP) tool is a short dietary questionnaire used for cholesterol screening and education in populations with or at risk of cardiovascular disease. It has been shown to be correlated with fat consumption (Gans et al., 1993) and been used to assess dietary improvements after case management in cardiac rehabilitation patients (Aspry et al., 2018) and in a community-based intervention for the prevention of chronic disease (Hammons et al., 2019). It is promising for use in translational lifestyle programs because it may be self-administered, quick to complete, and may reflect the Heart-healthy dietary behavior changes recommended for high-risk older adults with comorbidities seeking to lose weight.

In this report, we discuss the use of the RYP-Heart, an updated version of the original, for the assessment of dietary change in a community-based behavior intervention for older adults. Particularly among older adults with functional limitations precluding large gains in physical activity, it may make sense to highlight changes in one’s diet that all participants can make. In fact, dietary improvements may be an especially relevant target for older adults with functional limitations as limitations are associated with food insecurity and poor diet quality (Chang & Hickman, 2018).

Our aim was to determine if the Mobility and Vitality Lifestyle (MOVE UP) Program successfully induced sustainable dietary habit improvements among older adults over 13 months. Dietary habit modification may provide a complementary endpoint from which to assess the success of behavioral weight control interventions.

MOVE UP participants (N=298) with RYP-Heart data at baseline were on average 68.0 years old, had obesity (BMI: mean=34.8), yet a relatively high physical functioning score (mean=10.5). Participants had RYP-Heart scores (mean=50.9) in the “moderately healthful” range (Table 1). At 5 months, 255 participants had RYP-Heart data with 239 and 242 having data at 9 and 13 months, respectively.

Figure 1 displays adjusted and unadjusted mean RYP-Heart scores. The RYP-Heart score at baseline (unadjusted mean=50.9, points, Std=7.5) increased to 55.1 points (Std=6.4) by 5 months. RYP-Heart scores remained stable at 9 (unadjusted mean=54.7, Std=6.6) and 13 months (unadjusted mean=55.0, Std=6.1). At baseline 32.6% of participants fell into the “most healthful” category, but at 5, 9, and 13 months, 57.3%, 55.2%, and 55.8%, respectively were in the “most healthful” category (p<.0001).

In the linear mixed model, both the linear (b=0.96, SE=0.07) and quadratic time terms (b= -0.05, SE=0.01) were statistically significant (p<.0001), reflecting the increase in RYP-Heart score from baseline to 5 months and maintenance over 13 months, after adjusting for age, sex, and race (Table 2). There were no significant effects of sex (b=2.01, SE=1.11, p=0.07) or age (b=0.01, SE=0.08, p=0.90). Race was significant (Black: b=-2.13, SE=0.79, p<0.01; Other race(s): b=-0.90, SE=1.90, p=0.64) with white participants maintaining improved diet habits (Type 3 tests of fixed effects, p=0.03) better than Black participants; however, the magnitude of difference was small.

During the active phase of MOVE UP, there was an improvement of about four points in dietary habits—the equivalent of improving by 1 category for about 4 separate items. This level of improvement is similar in magnitude to that of other studies, (Aspry et al., 2018; Hammons et al., 2019) but less than seen in a 6-month dietary intervention among patients with dyslipidemia (Kulick et al., 2013). Despite not prescribing a specific dietary pattern, participants appear to have absorbed and acted on the healthy eating information provided. Importantly, during the maintenance phase of the study (months 5 to 13), improvements were maintained.

The increase in average score from “moderately healthful” to “most healthful” represents an important change in dietary choices. RYP-Heart scores at this level have been associated with better adiposity measures (Ganguzza et al., 2018). Because of the significant risk burden of cardiovascular disease among older adults (Yazdanyar & Newman, 2009), such improvements, if maintained, may greatly impact morbidity and mortality.

A strength of our study was the explicit assessment of dietary habits. Few weight loss interventions report on dietary habit change despite changes in dietary intake being key to weight loss. This report shows it is possible to intervene on dietary patterns in lifestyle programs and that diet may be an important endpoint to assess. As such it may serve as an example to community programs attempting to improve diet.

While we saw statistically significant changes in RYP-Heart scores, it is unclear how these changes relate to other diet quality scores calculated from more robust diet collection methods (e.g., dietary recalls). Future studies need to investigate how RYP-Heart scores relate to other measures of diet and to cardiometabolic indicators such as cholesterol.

In conclusion, RYP-Heart is an easy-to-use tool that may be sensitive to change in an older adult population. It is a viable approach to monitoring progress in community-based trials as it is quick, inexpensive, and significantly less burdensome than other dietary assessment methods. Being able to assess improvements in diet may be particularly appealing for participants who do not achieve weight loss but who are still making healthy changes.