Academy Comments to CDC's Community Preventive Services Task Force

January 23, 2020 

Amy Lansky, PhD, MPH
Acting Director, Community Guide
Office of the Associate Director for Policy and Strategy
Centers for Disease Control and Prevention
1600 Clifton Road NE, Mail Stop V25-5,
Atlanta, GA 30329

Re: Priority Topics for the Community Preventive Services Task Force (CPSTF); Request for Information

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Community Preventive Services Task Force regarding priority topics for the task force to examine over the coming years. The Community Guide is a valuable resource for dietitians working in community-based and primary care settings. Below are suggested areas of study for the CPSTF's obesity, adolescent health, and health equity portfolios.

1. Obesity

Team-Based Care for Patients with Obesity and Provider Education

The CPSTF recommended in 2016 the use of team-based care for patients with type 2 diabetes.1 In 2008, the CPSTF found insufficient evidence to make a recommendation regarding multicomponent provider interventions to prevent or control obesity.2 At the time, there were not enough studies with patient-level outcomes to recommend interventions that combine education, feedback, reminders, or other system support to change providers' knowledge, attitudes, and practices related to obesity. The CPSTF should undertake a similar review of the use of team-based care for patients with obesity and the education of providers to deliver such care. 

Much greater attention has been paid over the last decade to provider education for the treatment of obesity, including the need for team-based care and interprofessional education to produce competent clinicians. Coverage for obesity treatment services has increased within state Medicaid plans and state employee health insurance plans, which provides greater access to these services and paves the way for greater utilization.3,4

Nutrition education in medical schools is inadequate and must be more robust and central to the core curriculum. "The more physicians learn about the effectiveness of nutrition for the prevention and treatment of noncommunicable diseases, the more likely they are to consult with RDNs and refer patients for medical nutrition therapy. The more interprofessional education that occurs between medical students, other health professional students, and RDNs, the more likely all health care professionals will understand and value the role of the RDN in improving the quality of care provided to patients."5

In 2015, an integrated framework for the prevention and treatment of obesity was put forth by a group convened by the then-Institute of Medicine.6This framework was an iteration of the Chronic Care Model tailored to obesity. It touched on the needs of interdisciplinary provider training, system incentives, and clinic-community integration. In 2019, a proposed standard of care for treating adult obesity was published in consultation with dozens of provider, payer, educator, and patient groups.7 Included in the standards for all providers was the need to recognize the "multidisciplinary skill set needed to participate effectively in an interprofessional care team" for the treatment of obesity. This standard

Also relevant are the Provider Competencies for the Prevention and Management of Obesity (the "Obesity Competencies"), which is a set of discipline-agnostic core competencies for all health care providers who treat patients with obesity (and not just merely those who treat patients for obesity).8 Included are two competencies and five sub-competencies related to interprofessional obesity care that advise that all health care providers should recognize the benefits of working interprofessionally to address obesity and should apply the skills necessary to work not only with other members of the health care team, but also with community-based organizations to develop an integrated clinical-community care plan. These competencies filled a major gap in interprofessional obesity education and have paved the way for creating and evaluating educational and training programs on their education of health care providers to deliver high-quality interprofessional obesity care.9.10.11

To support the integration of the Obesity Competencies into medical, nursing, dental, and other health care disciplines' curricula, the STOP Obesity Alliance has undertaken a project to curate curricular resources that serve to help students meet one or more of the obesity competencies.12 The group has also published a number of case studies on schools or training programs that have substantially integrated the Obesity Competencies into their curricula.13

Increasing Food Security to Reduce Obesity

The CPSTSF has yet to explore the role that food insecurity plays in the incidence and continued management of obesity and diabetes. The literature has repeatedly found associations between food insecurity and obesity, mediated by a number of social and economic factors.14 These associations are particularly strong among low-income, working-age adults.15 Food insecurity has also been associated with higher HbA levels.16

The Task Force should consider conducting a review of upstream strategies to reduce obesity and diabetes incidence and improve diabetes management through improvements in food security. Such strategies could include improving rates of participation in SNAP, WIC, child nutrition programs, and other food assistance programs aimed at reducing food insecurity.

2. Adolescent Health

Reducing Adolescent Dieting Behavior

As part of its adolescent health and obesity portfolios, the CPSTF should consider specifically studying ways to reduce dieting behavior among adolescents.

In the 2017 Youth Risk Behavior Survey (YRBS), almost 60% of high school girls reported they were trying to lose weight, even though an average of 70% of girls were measured as being normal or underweight, from self-reported height and weight. (In the sample surveyed, 12% of girls were measured as having obesity [>= 95th percentile for body mass index, based on sex- and age-specific reference data from the 2000 CDC growth charts] and just under 18% of girls were overweight [>= 85th percentile but < 95th percentile using the same reference data], according to self-reported height and weight.) What is more, when asked, "How do you describe your weight?" only 37.5% of female students perceived themselves to be "slightly overweight" or "very overweight." Therefore, at least 30% of female high school students who measured as normal or underweight were trying to lose weight, even though they may not have perceived themselves to be overweight.

A review of the literature demonstrates that weight loss efforts may not be a preferred method of weight management for adolescents, even in those who are overweight or have obesity. Although it is not possible to determine from the YRBS what types of behaviors adolescents are using to try to lose weight, historical trends indicate that in the U.S., adolescent girls in particular are more likely to engage in unhealthy weight control behaviors (UWCBs) such as fasting, taking laxatives or diet pills, and vomiting.17

These UWCBs are not limited to those who are normal weight or underweight. In a nationally representative sample of young adults, researchers found those classified as overweight or having obesity were more likely to engage in UWCBs, especially girls and women.18 Dieting and UWCBs can lead to poorer nutritional intake (specifically, lower intakes of calcium and vegetables) and have been associated with extreme weight control behaviors, body dissatisfaction, and depression in both overweight and non-overweight adolescents.19,20 They are also predictive of a higher likelihood of disordered eating (e.g., UWCBs, extreme weight control behaviors, binge eating with a loss of control) and eating disorders (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder) into early adulthood. Perhaps more compelling relative to Healthy People 2030, dieting and UWCBs during adolescence predict significant future weight gain in adulthood.21,22 In a large 10-year longitudinal study, girls using UWCBs during middle and high school experienced an increase in BMI in early adulthood by an average of 2.34 units over non-dieters.23 In another 10-year prospective study, irregular eating and a history of dieting in adolescence were predictive of future weight gain for both men and women.24

These effects can also be intergenerational. Parental encouragement to diet is significantly associated with a higher risk of obesity or overweight, dieting, binge eating, engaging in UWCBs, and lower body satisfaction even 15 years after adolescence. What's more, dieting during adolescence leads to an increase in weight-focused communication in the home environment when adolescents grow up to be parents, transmitting the negative effects of early dieting onto their children.25 Discouraging weight loss behaviors in adolescence and encouraging evidence-based interventions has the potential to decrease overweight and obesity, whereas unsupervised weight loss efforts have been shown to do the opposite.

In terms of clinical practice, the CDC states the goal for children who are overweight is to reduce the rate of weight gain while still allowing for normal growth and development. They state that children should never be placed on a weight reduction diet, or strive for weight loss, without consultation with a health care provider.26 Similarly, the American Academy of Pediatrics recommends any adolescent who wants to go on a weight loss diet consult first with a pediatrician.27Neither group recommends weight loss for adolescents who are of normal or underweight status. These recommendations are made because childhood and adolescence are important stages of growth where nutritional deficiencies can impact development. In the 2020 Dietary Guidelines for Americans, the Department of Health and Human Services and the Department of Agriculture intend to include specific recommendations for healthy eating behaviors in adolescents for the first time, which will further inform evidence-based practices.

Multiple reviews of evidence-based practices for obesity prevention in adolescents recommend focusing on addressing social, physical and environmental influences - including nutrition education, physical activity and healthy eating and activity-friendly environments – at a community or population level. Most commonly, this includes comprehensive, multidisciplinary school-based strategies for health promotion. They do not recommend individual or behavior-based weight loss regimens, given the unique needs of adolescents and the lack of impact on the many environmental factors that influence adolescent weight status.28,29,30 In a recent review article, Voelker et al discussed the importance of also integrating healthy body image development into all obesity prevention strategies to avoid consequences of physical inactivity, eating disorders and dysfunctional exercise, all of which are associated with negative body image in adolescents and further promote weight gain.31

The Academy believes that unhealthy weight control behaviors among adolescents is a pressing public health issue that has thus far not been included as a factor in the UPSTF's adolescent health or obesity work.

3. Health Equity

Breastfeeding disparities

Breastfeeding disparities for racial/ethnic minorities ways to reduce these disparities through community-based interventions should be a focus for the CPSTF. 

African American breastfeeding rates remain far below the guidelines established by Healthy People 2020.32Approximately 74.0% of African American mothers initiate breastfeeding. Comparatively, white mothers initiate at a rate of 86.6%. In addition to the breastfeeding disparities, African American infants' mortality rates are double the rates of their Non-Hispanic White counterparts, and in some regions within the country three-fold higher. Despite the expressed goal of Healthy People 2020 to reduce and/or eliminating health disparities and to increase the proportion of infants who are breastfed exclusively through 6 months, African Americans infants continue to endure these health disparities.33 CPSTF should consider conducting a review to determine if there are evidence-based strategies to curb the disparities of breastfeeding rates.

4. Conclusion

The Academy appreciates the opportunity to comment to the Community Preventive Services Task Force regarding priority topics of future exploration. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at jblankenship@eatright.org or Hannah Martin by telephone at 202/775-8277, x6006 or by email at hmartin@eatright.org with any questions or requests for additional information.

Sincerely,

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

Hannah Martin, MPH, RDN
Director
Legislative & Government Affairs
Academy of Nutrition and Dietetics

1 Community Preventive Services Task Force. (2016) Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes. Available at: https://www.thecommunityguide.org/findings/diabetes-management-team-based-care-patients-type-2-diabetes. Accessed Jan. 21, 2020.

2 Community Preventive Services Task Force. (2008) Obesity: Multicomponent Provider Interventions. Available at: https://www.thecommunityguide.org/findings/obesity-multicomponent-provider-interventions. Accessed Jan. 21, 2020.

3 Jannah, N., Hild, J., Gallagher, C., & Dietz, W. (2018) Coverage for Obesity Prevention and Treatment Services: Analysis of Medicaid and State Employee Health Insurance Programs. Obesity 26(12): 1834-40.

4 STOP Obesity Alliance. (2019) Research: Coverage for Obesity Care. Available at: https://stop.publichealth.gwu.edu/research1. Accessed Jan. 22, 2020.

5 Hark LA, Deen D. (2017) Position of the Academy of Nutrition and Dietetics: Interprofessional Education in Nutrition as an Essential Component of Medical Education. J Acad Nutr Diet 117(7):1104-1113.

6 Dietz, W. et al. (2015) An Integrated Framework for the Prevention and Treatment of Obesity and Its Related Chronic Diseases. Health Affairs 34(9): 1456-63.

7 Dietz, W. & Gallagher, C. (2019) A Proposed Standard of Obesity Care for All Providers and Payers. Obesity 27(7): 1059-62.

8 Bradley, D., Dietz, W., and the Provider Training and Education Workgroup. Provider Competencies for the Prevention and Management of Obesity. Washington, D.C. Bipartisan Policy Center, June 2017. Available at: https://obesitycompetencies.gwu.edu/wp-content/uploads/2018/10/Obesity-Care-Competencies.pdf. Accessed Jan. 22, 2020.

9 Barr H. (2018) Competent to collaborate: towards a competency-based model for interprofessional education. J Interprof Care 12(2):181–7.

10 Englander, R., Cameron, T., Ballard, A.J., Dodge, J., Bull, J., & Aschenbrener, C. (2013) Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med 88(8): 1088–94.

11 Kris-Etherton, P., et al. (2014) The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Am J Clin Nutr 99(5 Suppl): 1153S–66S.

12 STOP Obesity Alliance. (2019) Provider Competencies & Resources. Available at: https://obesitycompetencies.gwu.edu/browse-articles. Accessed Jan. 22, 2020.

13 STOP Obesity Alliance. (2019) Curricular Case Studies. Available at: https://obesitycompetencies.gwu.edu/case-studies. Accessed Jan. 22, 2020.

14 Franklin B. Jones, A., Love, D., Puckett, S., Macklin, J., & White-Means, S. (2011) Exploring mediators of food insecurity and obesity: a review of recent literature. Journal of Community Health 37(1), 253-264.

15 Gregory, C., A., & Coleman-Jensen, A. (2017). Food insecurity, chronic disease and health among working-age adults. Economic Research Report, 235. Washington, DC: U.S. Department of Agriculture, Economic Research Service.

16 Berkowitz, S., et al. (2018) Food insecurity, food "deserts," and glycemic control in patients with diabetes: a longitudinal analysis. Diabetes Care 41:1188-95.

17 Chin, S., Laverty, A., & Filippidis, F. (2018). Trends and correlates of unhealthy dieting behaviours among adolescents in the United States, 1999–2013. BMC Public Health, 18(1), 1-8.

18 Nagata, J., Garber, M., Tabler, A., Murray, K., & Bibbins-Domingo, J. (2018). Prevalence and Correlates of Disordered Eating Behaviors Among Young Adults with Overweight or Obesity. Journal of General Internal Medicine, 33(8), 1337-1343.

19 Larson, Neumark-Sztainer, & Story. (2009). Weight Control Behaviors and Dietary Intake among Adolescents and Young Adults: Longitudinal Findings from Project EAT. Journal of the American Dietetic Association, 109(11), 1869-1877.

2 Crow, Eisenberg, Story, & Neumark-Sztainer. (2006). Psychosocial and behavioral correlates of dieting among overweight and non-overweight adolescents. Journal of Adolescent Health, 38(5), 569-574.

21 Patton, G., Selzer, Coffey, Carlin, & Wolfe. (1999). Onset of adolescent eating disorders: Population based cohort study over 3 years. BMJ, 318(7186), 765-768.

22 Neumark-Sztainer, Wall, Larson, Eisenberg, & Loth. (2011). Dieting and Disordered Eating Behaviors from Adolescence to Young Adulthood: Findings from a 10-Year Longitudinal Study. Journal of the American Dietetic Association, 111(7), 1004-1011.

23 Neumark-Sztainer, Wall, Story, & Standish. (2011). Dieting and Unhealthy Weight Control Behaviors During Adolescence: Associations With 10-Year Changes in Body Mass Index. Journal of Adolescent Health, Journal of Adolescent Health.

24Kärkkäinen, Mustelin, Raevuori, Kaprio, & Keski-Rahkonen. (2018). Successful weight maintainers among young adults—A ten-year prospective population study. Eating Behaviors, 29, 91-98.

25Berge, J., Winkler, M., Larson, N., Miller, J., Haynos, A., & Neumark-Sztainer, D. (2018). Intergenerational Transmission of Parent Encouragement to Diet From Adolescence Into Adulthood. Pediatrics, 141(4), Pediatrics, April 2018, Vol.141(4).

26 Tips for Parents – Ideas to Help Children Maintain a Healthy Weight. Centers for Disease Control and Prevention website. Available at https://www.cdc.gov/healthyweight/children/index.html. Accessed January 17, 2019.

27 Healthychildren.org website. Available at https://www.healthychildren.org/English/ages-stages/teen/nutrition/Pages/Fads-and-Diets.aspx. Accessed January 17, 2019.

28 Ayliffe,B., & Glanville,T. (2010). Achieving healthy body weight in teenagers: Evidence-based practice guidelines for community nutrition interventions. Canadian Journal of Dietetic Practice and Research, 71(4).

29 Reilly, J. (2006). Obesity in childhood and adolescence: Evidence based clinical and public health perspectives. Postgraduate Medical Journal, 82(969), 429-437.

30 Flynn, M., Mcneil, D., Maloff, B., Mutasingwa, D., Wu, M., Ford, C., & Tough, S. (2006). Reducing obesity and related chronic disease risk in children and youth: A synthesis of evidence with 'best practice' recommendations. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 7 Suppl 1, 7-66.

31 Voelker, D., Reel, J., & Greenleaf, C. (2015). Weight status and body image perceptions in adolescents: Current perspectives. Adolescent Health, Medicine and Therapeutics, 6, 149-58.

32 Centers for Disease Control and Prevention. (2019) Breastfeeding Facts. Available at: https://www.cdc.gov/breastfeeding/data/facts.html. Accessed Jan. 21, 2020.

33 DeVane-Johnson, S., Woods-Giscombé, C., Thoyre, S., Fogel, C., & Williams, R. (2017). Integrative Literature Review of Factors Related to Breastfeeding in African American Women: Evidence for a Potential Paradigm Shift. Journal of Human Lactation, 33(2), 435–447.