December 15, 2018
Francis S. Collins, M.D., Ph.D.
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892
Re: Draft Strategic Plan for NIH Nutrition Research
Dear Dr. Collins,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit these comments to the National Institutes of Health (NIH) related to its November 15, 2018 request for information soliciting input on the Draft Strategic Plan for NIH Nutrition Research (the "Draft Strategic Plan"). Representing more than 104,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the world and is committed to a vision of the world where all people thrive through the transformative power of food and nutrition. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing medical nutrition therapy (MNT) and other nutrition care services, and designing, conducting, and implementing nutrition research.
A. Overarching Comments
The Academy supports first Draft Strategic Plan for Nutrition Research's purpose "to serve as a guide to accelerate basic, translational, and clinical research, as well as research training activities, over the next 10 years." We find the themes and cross-cutting research areas to be well-defined and effectively outline the many areas of promise across the translational research spectrum. To add additional value, we respectfully request that the NIH describe the methodology for choosing the themes and cross-cutting research areas in more detail, to enable the Academy and other nutrition-oriented stakeholders to develop their own respective research priorities in a manner that aligns with this framework.
The Academy strongly supports the federal government's efforts to coordinate and enhance its investment in critical food and nutrition research. For the last 35 years, the scientists advising in the development of the Dietary Guidelines for Americans have continually enumerated research gaps, some of which are identified continuously as the research never gets done and the gaps remain.2 We encourage the NIH to ensure due consideration is paid to the gaps identified by DGACs as detailed in Myers et al in addition to Appendix E-1 (Needs for Future Research) in the 2015-2010 Dietary Guidelines Advisory Committee Scientific Report.3
Finally, given the extensive training that registered dietitian nutritionists receive regarding the management of diet and the prevention and treatment of diet-related disease in both clinical and community settings, we encourage the NIH to consider specifying RDNs—and RDN clinician scientists, in particular—as key partners in facilitating the design, implementation, and rigor of nutrition research. We are pleased to see that RDNs are specifically referenced in section 5-1, but note they are in addition well-positioned to contribute to the stated priorities under other themes noted below as well, and may, in many cases, have regular contact with the sub-populations of interest.
B. Research As the Foundation
The Academy believes that research is the foundation of the dietetics profession, providing the basis for practice, education, and policy. In service of our mission to accelerate improvements in global health and well-being through food and nutrition, the Academy consistently demonstrates its commitment to "identifying the impact of nutrition on disease risk factors and treatment outcomes, presenting it to stakeholders to influence public policy, and translating it to practice to yield many more programs and opportunities for nutrition and dietetics practitioners."4 For nearly half a century, the Academy and its members have worked with the NIH and other funders in developing research protocols and conducting research with dietetics and nutrition components, and we welcome the opportunity for continued partnerships for the shared purpose of enhancing health, lengthening life, and reducing illness and disability.
Two years ago, the Academy's Council on Research convened a Research Priorities Strategies Development Task Force (RSPD TF) comprised of representatives from a variety of research areas (e.g., bench research, clinical research, and public health research) and Academy stakeholders (e.g., including the Council on Research, the Academy's Board of Directors, and the National Institute of Health) that is charged with revisiting the Academy's research priorities to align with the Academy's revised strategic plan5 and to establish a process to revisit these priorities regularly to reflect the interests and needs of both the public and our membership, in addition to ongoing and emerging research needs. The RSPD TF looks forward to continuing engagement as the NIH’s Strategic Plan for Nutrition Research is finalized and implemented.
Malnutrition is a leading cause of morbidity and mortality, especially among older adults6. Up to half of adults age 65 and older and as many as 39% of older adult patients may be malnourished or at-risk, and adults with malnutrition are five times more likely to die during a hospitalization and 54% more likely to be readmitted.7 Additionally, up to 31% of malnourished patients and 38% of well-nourished patients experience nutritional decline during hospital stays.8 Patients experiencing malnutrition are at an increased risk for complications; they are five times as likely to die in the hospital9 and have a 54% increase in readmissions compared to non-malnourished patients.10> The Academy and its members are strongly committed to having a global impact in eliminating all forms of malnutrition by collaborating to advance basic science research related to malnutrition and well-being and through the identification and treatment of all forms of malnutrition.11
1. Theme 2
We support Theme 2 (Assess the Role of Nutrition and Dietary Patterns in Development, Health, and Disease across Life Stages) of the Draft Strategic Plan in recognizing that "[a]ddressing malnutrition, as well as sarcopenia (loss of muscle tissue), in older adults is critical," but although we underscore the troubling prevalence of malnutrition in this population, we note malnutrition remains a significant concern for individuals across all life stages. Given the rates of malnutrition among hospitalized patients and the costs associated with readmittance, we support the inclusion of the specified planned research activities in section 2.4, particularly plans to "[d]etermine the impact of inadequate dietary intake in older adults on frailty and morbidity during hospitalization" and to "[c]onduct basic, interventional, or implementation research of nutritional approaches to reduce undernutrition in older susceptible populations."
2. Theme 4
The Academy supports the focus in Theme 4 (Enhance Clinical Nutrition Research to Improve Health Outcomes in Patients) of building the evidence base for treatment endpoints and nutrition support interventions. In addition, the Academy shares the Draft Strategic Plan's concern about limitations in current objective biomarkers for malnutrition. We recognize that despite the high prevalence of malnutrition in hospitals, a 2013 review of nationally representative data indicated that only 7% of patients had a diagnosis of malnutrition, which potentially leaves millions of patients undiagnosed and untreated. To help address this, the Academy collaborated with Avalere Health to develop the Malnutrition Quality Improvement Initiative, a dual-pronged approach to advance malnutrition care for hospitalized older adults that includes the implementation of an evidence-based toolkit as well as the adoption of four electronic quality measures.12 We support the NIH's proposed research to identify better biomarkers of nutrition in conjunction with these efforts, and we welcome the opportunity to work with the NIH to develop improved approaches for assessing nutritional status as detailed in its priority section 4.2.
D. Access to and Coverage of Nutrition Services by Qualified Practitioners
A key barrier to the achievement of Theme 5 (Advance Implementation Science to Increase the Use of Effective Nutrition Interventions) and the related priorities is that the vast majority of Americans simply will never receive these effective medical nutrition therapy services due to a lack of dedicated coverage or payment models that enable the employment of RDNs qualified to provide them, poor geographic access, and other financial or logistical reasons. We encourage the NIH to assess the impact of the availability of and coverage for MNT and nutrition counseling when indicated for individuals with disease states and conditions. With revised payment models and stronger recommendations for these interventions as mandatory elements of the standard of care, we can improve health and ameliorate their infrequent and inconsistent application resulting from the lack of RDNs in many clinical settings.
E. Training Priorities
The Academy highlights Theme 7 (Support Training to Build an Outstanding Nutrition Research Workforce) as particularly important. While we agree with the recommendation to expand PhD/RDN programs, we also recognize the important role that active practitioners could play in advancing the stated research goals through partnership with dedicated researchers. Thus, the NIH may consider expanding the current priorities to include both the training of scientists to work more effectively with interdisciplinary teams of practitioners (e.g., MDs, RDNs, RNs, etc.) and the training of practitioners to understand the role they could play in advancing nutrition science and to seek out and embrace opportunities to do so with researcher colleagues.
The Academy sincerely appreciates the opportunity to offer the NIH comments on the Draft Strategic Plan for Nutrition Research, and we would welcome the opportunity to assist the NCI going forward. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at firstname.lastname@example.org or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Government & Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy recently 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 Myers EF, Khoo CS, Murphy W, Steiber A, Agarwal S. A critical assessment of research needs identified by the dietary guidelines committees from 1980 to 2010. J Acad Nutr Diet. 2013;113(7):957-971.e1.
3 Dietary Guidelines Advisory Committee. 2015. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.
4 Stein K. Propelling the Profession with Outcomes and Evidence: Building a Robust Research Agenda at the Academy. J Acad Nutr Diet. 2016;116(6):1014-30.
5 Academy of Nutrition and Dietetics Strategic Plan. Available at https://www.eatrightpro.org/-/media/eatrightpro-files/leadership/bod/strategic-plan/academy-of-nutrition-and-dietetics_strategic-plan_sep-2017.pdf?la=en&hash=D00E3FE00D1475FB416E20004DECC3C136D5D7E5. Accessed December 14, 2018
6 Academy of Nutrition and Dietetics. Malnutrition Measures Specification Manual Version 1.2. 2017.
7 Pereira GF, Bulik CM, Weaver MA, Holland WC, Platts-Mills TF. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med. 2015;65(1):85-91. doi:10.1016/j.annemergmed.2014.07.018
8 Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100(11):1316-1322; quiz 1323-1324. doi:10.1016/S0002-8223(00)00373-4
9 Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013 #210. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.jsp. Published 2016. Accessed July 30, 2018.
10> Fingar KR, Weiss AJ, Barrett ML, et al. All-Cause Readmissions Following Hospital Stays for Patients with Malnutrition, 2013. HCUP Statistical Brief #218
11 Academy of Nutrition and Dietetics Strategic Plan. Available at https://www.eatrightpro.org/-/media/eatrightpro-files/leadership/bod/strategic-plan/academy-of-nutrition-and-dietetics_strategic-plan_sep-2017.pdf?la=en&hash=D00E3FE00D1475FB416E20004DECC3C136D5D7E5. Accessed December 14, 2018
12 Malnutrition Quality Improvement Initiative (MQii) – About. http://mqii.defeatmalnutrition.today/about-mqii.html. Accessed July 31, 2018.