Academy Comments to CDC re Worksite Health Scorecard

December 13, 2017

CDC Desk Officer
Office of Management and Budget
725 17th Street NW
Washington, DC 20503

Re: Information Collection: Worksite Health ScoreCard - Reinstatement with Change

Dear CDC Desk Officer,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention (CDC) at the United States Department of Health and Human Services (HHS) related to its information collection, "Worksite Health ScoreCard—Reinstatement with Change," published in the November 13, 2017 issue of the Federal Register. Representing more than 100,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States, and is committed to accelerating improvements in global health and well-being through food and nutrition. Members' achieve this mission in part through the provision of essential food and nutrition services to the public in multiple settings, including in the allied health, primary care, and corporate wellness settings.

The Academy supports the Worksite Health ScoreCard (HSC) project and emphasizes its particular support for the focus on preventive care and its concomitant potential to encourage provision of evidence-based preventive and wellness services in workplace settings in addition to novel research useful in developing and testing such services.

A. Significance of Worksite Health Environment

Given the significant amount of time Americans spend in the workplace, the health effects of our respective occupational settings cannot be understated. Assuming an eight-to-nine hour workday2 and noting that Americans are spending 41 percent of every food dollar on food purchased away from home,3 worksite food consumption should be recognized for its substantial expected contribution to overall nutrition and calorie intake and thus an effect on health status. The CDC already recognizes various nutrition and lifestyle habits as potentially useful targets for effective worksite interventions, such as increasing physical activity and fruit and vegetable intake, reducing red meat intake, and supporting healthy weight management.4

Americans' tendency to consume fewer fruits and vegetables than the Dietary Guidelines for Americans 2015 recommends is well-documented.5 In 2013, 39 percent and 23 percent of Americans reported consuming less than one serving of fruit and vegetables, respectively, per day.6 Simply providing a worksite cafeteria increased the likelihood of consuming at least two servings of either fruits or vegetable by 28 percent, and decreased the tendency to eat fast food twice weekly by 20 percent.7 Notably, a Healthy People 2020 objective specifically referenced improvement of worksite nutrition services.8

B. Need for Health Promotion and Disease Prevention

It is the position of the Academy that primary prevention is the most effective, affordable course of action for preventing chronic disease. Cost-effective interventions that produce a change in personal health practices are likely to lead to substantial reductions in the incidence and severity of the leading causes of disease in the United States.9 In an era of increasing health care expenditures and relative decreases in availability of federal funds, the value of cost-effective health promotion and disease prevention efforts is substantial.

Indeed, large studies looking at the relationship between modifiable risk factors and medical claims showed that several risk factors, including tobacco use, overweight and obesity, high blood glucose, high stress, and lack of physical activity, accounted for an estimated 25 percent of total employer healthcare expenditures.10 Accordingly, the HSC provides a prime opportunity to encourage and emphasize the potential role of worksite support systems to improve not only health, but also productivity and absenteeism.

The Academy strongly supports the federal government's helpful role in the assessment of effective worksite wellness measures through continuation of funding research, vetting relevant resources, and the sharing of best practices and strategies from successful evidence-based workplace wellness programs. Selected clinical and community preventive services that have a positive influence on personal health and are cost-effective in comparison with the treatment of disease should be highlighted and encouraged in agency guidance.11,12 The results of prevention effectiveness studies should provide a basis for CDC's public health program recommendations, guidelines for prevention, and a framework for resource-based decision-making.

C. Survey Suggestions

We offer the following general suggestions to improve the quality and utility of the survey:

  1. It is possible that one individual cannot answer all of these questions.  Wellness is often added to the job of a busy Human Resources manager and they may lack the health training and experience to understand which evidence-based programs and services are most cost effective for employees.
  2. Once data of Employee Characteristics are gathered, the survey should be sufficiently flexible to ask questions specific to the health care needs of each company's specific employee demographic.  For example, this could mean adjusting questions to reference health disparities and risk  factors which may be higher in a specific gender, in some ethnic groups, or at certain ages.
  3. Favor open-ended questions over closed-ended questions. If needed, alter selections of answers; for example:
    "If yes, what percentage of the employees:
    Enrolled in a weight management program that was at least 6 months, a measure of
    an effective program
    Completed a 6 month weight management program
    Showed positive outcomes for more than 6 months after the program"
    The same metric should be developed for every other wellness services, such as:
    While provision of water and healthy lunch selections is important, are the
    employees consuming  these products?
    Have sales of fresh and vegetables increased?
    Does the company have a walking loop, is it used, and by what percentage of
    Does the employee receive any type of incentive for being involved in programs?
    Are prenatal programs and services offered, what percentage of female
    employees are using them, and how early in their pregnancy do they access
    the services?

We also offer the following specific suggestions to improve the survey's quality and utility:

  1. Attachment C-1:
    • page 4, question 7: Since the qualifications for "nutritionists" varies significantly across the country and may include individuals with no specialized education or training, we recommend specifying "registered dietitian nutritionists or state licensed nutrition professional." RDNs remain the most cost-effective, qualified healthcare professional to provide nutrition based lifestyle interventions, including medical nutrition therapy (MNT) and evidence-based nutrition counseling and weight-loss management services. RDNs have demonstrated competencies and outcomes that differently and less qualified providers of non-medical nutrition services have been yet unable to demonstrate.  RDNs' evidence-based national practice guidelines and Evidence Analysis Library are leading, respected tools for effecting positive health outcomes.  The Institute of Medicine (IOM) found that "the registered dietitian is currently the single identifiable group of health-care professionals with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy."13
    • Page 7, #20: Given the substantial role of nutrition in chronic disease, as well as the demonstrated competencies and evidence-based recommendations of RDNs, we suggest including "nutrition counseling with a registered dietitian nutritionist or state licensed nutrition professional" in the subtext examples.
    • Page 11-12, #11 and #12: Given the lack of evidence to support use of "general interactive educational programming" and "lifestyle coaching," we recommend the use of "nutrition counseling by trained and qualified registered dietitian nutritionists or state licensed nutrition professional."
    • Page 11, Nutrition section: CDC recognizes that the success of a corporate wellness nutrition program depends on using evidence-based programs and methods. One of the primary goals of the Scorecard is to "Improve the health and wellbeing of employees and their families through science-based workplace health interventions and promising practices." To ensure worksites are accessing and utilizing evidence-based programs, appropriate nutrition experts should be a core component of the process.  Therefore, we recommend adding a separate question under the Nutrition section asking about the nutrition experts or programs that were used. For example, "During the past 12 months, did your worksite rely on the expertise of a registered dietitian nutritionist or state licensed nutrition professional when planning and implementing nutrition programs and initiatives/services?"
    • Page 11, Nutrition section:  We recommend including a question similar to #7 in the Musculoskeletal Disease section (page 20): "...provide health insurance that includes appropriate access to Medical Nutrition Therapy?"
    • Page 15, Tobacco section:  Since one reason preventing people from quitting smoking may be fear of weight gain, this may be a place to include a question about nutrition, such as, "During the past 12 months, did your worksite make healthy weight management services, like nutrition counseling with a registered dietitian nutritionist or state licensed nutrition professional, available to employees attempting to quit smoking?"
    • Page 16, Cancer section, #3: Since nutrition is linked to cancer prevention, include nutrition counseling provided by an RDN as an example. We encourage similar treatment with regards to questions in the High Blood Pressure, High Cholesterol, Diabetes/PreDM, and Weight Management sections.
  2. Attachment HSC SS B

D. Conclusion

The Academy appreciates the opportunity to comment on the proposed information collection for the " Worksite Health ScoreCard -- Reinstatement with Change " docket.  Please contact either Jeanne Blankenship at 312/899-1730 or by email at or Mark Rifkin at 202/775-8277, ext. 6011 or by email at with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Mark E. Rifkin, MS, RD, LDN
Consumer Protection and Regulation
Academy of Nutrition and Dietetics

1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Average hours employed people spent working on days worked by day of week. Bureau of Labor Statistics, American Time Use Survey, June, 2017. Accessed October 1, 2017.

3 Table A. Average annual expenditures by major category of all consumer units and percent changes, Consumer Expenditure Survey, 2011–14 BLS Reports, October, 2016. Accessed October 1, 2017.

4 Cancer Prevention in the Workplace Writing Group. Cancer Prevention and Worksite Health Promotion: Time to Join Forces. Prev Chronic Dis 2014;11:140127.

5 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans (Figures 2-3, 2-4). 8th Edition. December 2015.

6 Dodson EA, et al. The Impact of Worksite Supports for Healthy Eating on Dietary Behaviors. J Occup Environ Med. 2016 Aug;58(8):e287-93.

7 Ibid.

8 Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [cited October 7, 2017].

9 U.S. Preventive Services Task Force. "Guide to Clinical Preventive Services." Accessed June 23, 2016.

10 Goetzel R, Ozminkowski R. The Health and Cost Benefits of Work Site Health-Promotion Programs. Ann Rev Pub Health 2008; 29:303-23.

11 11U.S. Preventive Services Task Force. "Guide to Clinical Preventive Services" (accessed January 24, 2013).

12 Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC, Graham JD. Five-hundred life-saving interventions and their cost-effectiveness. Risk Analysis. 1995;15:369-390.

13 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population."  Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).