Academy Comments to ODPHP/HHS re Healthy People 2030 Proposed Objectives

January 17, 2019

Don Wright, MD, MPH
Director, Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
Rockville, MD 20852

Dear Dr. Wright:

Re: Comment on Proposed Objectives for Healthy People 2030

Dear Dr. Wright,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services related to its request for comments on proposed objectives for Healthy People 2030. 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 United States working to accelerate improvements in global health and well-being through food and nutrition.

A. Overarching Comments

Since its inception, the Healthy People initiative has been an important framework for national public health objectives that aim to promote health and prevent disease, and the proposed objectives will allow this work to continue to address the most pressing public health issues. In particular, we appreciate the acknowledgement and shift towards a focus on health equity, social determinants of health, and involvement of a broader constituency throughout the process.

In order for healthcare costs to decrease, investment in prevention and treatment should be prioritized, and a personalized medicine approach should be incorporated and reflected within the current objectives. We also encourage establishing objectives to empower more of our population with cooking skills, ensure Americans' access to healthy food and grocery stores, community gardens or farmers markets, and access to local food banks for those in need.

Finally, we would be remiss if we did not note the significant cost-effectiveness and clinical-effectiveness of medical nutrition therapy (MNT) provided by registered dietitian nutritionists in managing and treating a range of disease states and medical conditions referenced in the proposed objectives for Healthy People 2030. Specifically, MNT can effectively help manage or treat various cancers, chronic kidney disease, diabetes, heart disease, hypertension, hyperlipidemia, HIV, and obesity, and individuals with these diseases or conditions should be referred an RDN for medically indicated nutrition care services.

B. Adolescent Health (AH)

The Academy proposes a new core objective and a developmental objective for Adolescent Health.

  • 1. New Core Objective: "Reduce the percentage of 9th through 12th grade females who are trying to lose weight"

In the 2017 Youth Risk Behavior Survey (YRBS), almost 60% of high school females reported they were trying to lose weight, even though an average of 70% of females were measured as being normal or underweight, from self-reported height and weight.  (In the sample surveyed, 12% of females 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 females 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 females in particular are more likely to engage in unhealthy weight control behaviors (UWCBs) such as fasting, taking laxatives or diet pills, and vomiting.2 These UWCBs are not limited to those who are normal 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 females.3 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.4,5

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.6,7 In a large 10-year longitudinal study, females 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.8 In another 10-year prospective study, irregular eating and a history of dieting in adolescence were predictive of future weight gain for both males and females.9

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.10 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. The Academy believes this is a pressing public health issue worthy of inclusion in the Healthy People 2030 objectives.

For this core objective, the data source would be the Youth Risk Behavior Surveillance System (YRBSS), conducted by the Centers for Disease Control and Prevention, Division of Adolescent and School Health, noting that for baseline data, the most recent YRBSS data is for the year 2017 and that sufficient additional data points will be present because the YRBSS is conducted every two years.

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.11 Similarly, the American Academy of Pediatrics recommends any adolescent who wants to go on a weight loss diet consult first with a pediatrician.12 Neither 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.13,14,15 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.16

  • 2. New Developmental Objective: "Reduce the percentage of middle school youth who are actively trying to lose weight"

In 2017, 10 states included a question for middle schoolers on whether or not they were trying to lose weight.  On average, over 50% of females and 38% of males answered yes to this question.  In the same survey, only 28% of females and 25% of males describe themselves as slightly or very overweight.

In addition to surveying youth grades 9-12, the YRBSS also includes a middle school survey conducted by interested states, territories, tribal governments and large urban school districts. In 2017, 10 states, 9 large urban school districts, and 3 territories included a question about weight loss in their survey. Although this does provide baseline data, the data is limited in scope to certain areas of the country and may not be large enough to be considered representative.  For all of the reasons mentioned above in the previous objective including increased risk for obesity, eating disorders, and depression, middle school youth actively trying to lose weight is a major public health concern and should be included in the Healthy People 2030 objectives.

C. Arthritis, Osteoporosis, and Chronic Back Conditions (AOCBC)

We encourage a new developmental objective (AOCBC-2030-D03) to "Decrease amount of prescription drug use for chronic pain by implementing more integrative and functional modalities or referring to integrative practitioners, including integrative RDNs." We encourage the inclusion of integrative health practices into many of the proposed approaches, and note the focus on integrative care by the National Institutes of Health and many other renowned institutions. As the focus on opioids in the proposed objectives of Healthy People 2030 indicate, there is an ongoing and growing problem with the overuse of prescription drugs to treat chronic pain and a disparity in the availability of alternative treatments,17 and this proposed objective recognizes the value of other modalities as valid substitutes or complements for prescription drugs.18,19

D. Chronic Kidney Disease (CKD)

MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of many chronic diseases, including renal disease, as well as in the reduction of risk factors for these conditions. Medicare has reimbursed MNT for chronic kidney disease (CKD) since 2002, but is presently underutilized. As primary prevention, strong evidence supports optimal nutritional status as a cost-effective cornerstone in the maintenance of health, well-being, and functionality. As secondary and tertiary prevention, MNT is a cost-effective disease management strategy that reduces chronic disease risk, delays disease progression, enhances the efficacy of medical/surgical treatment, reduces medication use, and improves patient outcomes including quality of life.20 Notably, recent research shows that patients with CKD receiving MNT were able to delay the time to dialysis and improve significant nutritional biomarkers, thereby saving Medicare money and improving patients' quality of life.21

People with diabetes are at high risk of chronic kidney disease (CKD) and its complications. Evidence recognizes the connection between improved diet and CKD with diabetes and prediabetes.22,23,24 Accordingly, we support four new developmental objectives related to CKD:

  • (CKD-2030-D01) Increase percentage of people with diabetes and CKD receiving MNT by 25%;
  • (CKD-2030-D02) Increase percentage of people with prediabetes and CKD receiving MNT by 25%;
  • (CKD-2030-D03) Decrease the number of people with diabetes who have CKD 3 or higher by 25%; and
  • (CKD-2030-D04) Decrease the number of people with prediabetes who have CKD 3 or higher by 25%.

E. Diabetes (D)

Over 30 million Americans have diabetes and an additional 84 million adults are at risk of developing the disease, the annual cost of which is now a staggering $322 billion and rising.  The Academy associates itself with the comments submitted by the Diabetes Advocacy Alliance, to which it signed-on, and we appreciate that Healthy People 2030 includes a number of objectives that are focused on improving the prevention, detection and management of diabetes. We recognize the desire to reduce the number of objectives overall from those included in Healthy People 2020, but note the importance of many of the diabetes objectives that could be modified or added.

  • For objective number D-2030-05, we are concerned about the elimination from the parallel Healthy People 2020 objective of the word "dilated" to describe the annual eye exam, as dilation is critical to detecting diabetic retinopathy. See page S-36; 40 – Table 4.4 (or pages 44; 48 of the PDF) in the American Diabetes Association's Standards of Medical Care in Diabetes—2019.
  • We support a new objective (D-2030-NEW) or a modification of D-2030-05 to "Increase percentage of people with diabetes receiving a dilated retinal exam by 25%" using the National Health Interview Survey (NHIS), from CDC/NCHS.

The provision of Diabetes Self-Management Education and MNT, which together we presume to be included within the term "formal diabetes education" in objective D-2030-08, improves outcomes,25,26,27,28,29,30,31,32 produces significant cost-savings,33,34,35,36 and is unfortunately woefully underutilized.37,38 Given these significant benefits for these underutilized modalities, we encourage ODPHP to consider the following:

  • For objective number D-2030-08, we question why the word "ever" was added to this objective as compared with the parallel Healthy People 2020 objective. Further, we encourage the inclusion of a goal of 50% such that there is a modified objective to "Increase the proportion of persons with diagnosed diabetes who ever receive Diabetes Self-Management Education to 50%."
  • Because we remain concerned about the inclusion of the word "ever" into objective D-2030-08, we would add a developmental objective related to annual diabetes education received to "Increase the proportion of persons with diagnosed diabetes who have annual personalized Diabetes Self-Management Education by 30%" or at minimum to "Increase the proportion of adults with diabetes who receive annual diabetes self-management education or training."
  • Include a new developmental objective to "Increase the proportion of people receiving MNT for diabetes by 25%."
  • Include a new developmental objective to "Increase the proportion of people receiving MNT for prediabetes by 25%."
  • Include a new developmental objective to "Decrease uncontrolled diabetes related health consequences and hospital visits by 50% by referring 95% of newly diagnosed persons with diabetes to RDNs for MNT."

With regard to the developmental objective D-2030-D01, "Increase the proportion of eligible individuals completing CDC-recognized lifestyle change programs," we would encourage personalized education to avoid having patients referred over and over again to the same class, and instead target the training to what the person is ready do and needs the most.

Given the fact that people with diabetes are at high risk of CKD and its complications, we would add a new developmental objective to "Reduce the percentage of persons with diabetes developing renal disease by 30%."

Finally, we encourage ODPHP to consider adding several other developmental objectives that recognize the importance of social determinants of health and the extent of health disparities related to diabetes:

  • Add an objective related to  diabetes and food security or diabetes and insulin security (or more generically diabetes and medication security)
  • Add an objective to "Reduce the clinical outcome disparities across racial/ethnic lines among people with diabetes."
  • Add an objective to "Reduce the cardiovascular morbidity and mortality rates among people with diabetes."
  • Add an objective to "Reduce the proportion of adults with diabetes who also have overweight or obesity."
  • Add an objective to "Reduce the proportion of women who develop gestational diabetes."
  • Add an objective to "Increase the proportion of adults and youth with diabetes who meet physical activity recommendations."
  • Add an objective to "Increase the proportion of adults and youth with diabetes who meet recommended levels of fruit and vegetable intake."

F. Educational and Community-Based Programs (ECBP)

For ECBP-2030-D01, "Increase the percentage of middle and high schools that provide case management for chronic conditions," the Academy suggests that an easy addition to the above objective would be to include a simple screen of checking the back of the neck and knuckles of the hand for acanthosis nigricans.  This screening would identify insulin resistance in young people so they can be referred to diabetes prevention programs much earlier.

G. Heart Disease and Stroke (HDS)

With regards to how to meet objective HDS-2030-05, "Reduce the mean total blood cholesterol levels among adults," the Academy notes that in 2007, CVD caused approximately one death per minute among women in the United States.  Dietary modification and exercise have a direct effect of reducing mean total blood cholesterol values associated with cardiovascular disease.39 Common dietary advice includes:

  • Reduce saturated fats. Saturated fats, found primarily in red meat and full-fat dairy products, raise your total cholesterol. Decreasing your consumption of saturated fats can reduce your low-density lipoprotein (LDL) cholesterol — the so-called "bad" cholesterol, but the benefits of reduced saturated fats is not realized if they are replaced with carbohydrates such as added sugars or refined grains.
  • Eliminate trans fats. Trans fats, sometimes listed on food labels as "partially hydrogenated vegetable oil," are often used in margarines and store-bought cookies, crackers and cakes.  Trans fats raise overall cholesterol levels. The Food and Drug Administration has banned the use of partially hydrogenated vegetable oils by Jan. 1, 2021.
  • Eat foods rich in omega-3 fatty acids. Omega-3 fatty acids have heart-healthy benefits, including reducing blood pressure. Foods with omega-3 fatty acids include salmon, mackerel, herring, walnuts and flaxseeds.
  • Increase soluble fiber. Soluble fiber can reduce the absorption of cholesterol into your bloodstream and is found in such foods as oatmeal, kidney beans, brussel sprouts, apples, and pears.
  • Add whey protein. Whey protein, which is found in dairy products, may account for many of the health benefits attributed to dairy. Studies have shown that whey protein given as a supplement lowers LDL cholesterol and total cholesterol as well as blood pressure.
  • Exercise on most days of the week and increase your physical activity. Exercise can improve cholesterol. Moderate physical activity can help raise high-density lipoprotein (HDL) cholesterol, the so-called "good" cholesterol. With your doctor's approval, engage in at least 30 minutes of exercise five times a week or vigorous aerobic activity for 20 minutes three times a week.

The Academy also proposes a new developmental objective to "Decrease CVD related surgeries by 30% in population through enhanced prevention or decreasing triglycerides to less than 150 for 75% of adults."

H. Mental Health and Mental Disorders (MHMD)

With regard to objective MHMD-2030-04, "Increase the proportion of adults with serious mental illness (SMI) who receive treatment," the Academy believes that professional treatment that includes ongoing nutrition counseling should be available to all individuals struggling with eating disorders. The prevalence of suicides by individuals suffering from eating disorders is significant, with one-fifth of deaths from anorexia nervosa coming from suicide.40 We note that nutrition rehabilitation is a critical component of recovery that is all-too-often neglected or overlooked. Prevention needs to also be a priority when considering research and clinical objectives related to managing the prevalence of mental health illnesses.

I. Maternal, Infant, and Child Health (MICH)

With regard to objective MICH-2030-08, "Increase the proportion of pregnant women who receive early and adequate prenatal care," we note that it is important to identify and educate women and their families on the relationship between taste exposure in utero and preference for tastes later in life and can potentially affect health outcomes.  Examples of influential foods include sugars, fats, salt and alcohol. Many pre- and post-partum women are unaware of this relationship; however when informed, many take prompt action to alter their dietary intakes to reduce various foods that impart flavors. Therefore, we encourage this topic to be included in the standard for prenatal education and care, and we recognize the need for obstetricians to be targeted for their engagement on this issue.

With regard to meeting objective MICH-2030-15, "Increase the proportion of infants who are breastfed exclusively through 6 months," the Academy believes that continued professional clinical lactation support should be available to expectant and new parents to encourage attainment of the Healthy People 2030 breastfeeding goals. Women face many challenges after breastfeeding initiation that require adequate information, encouragement and practical support to preserve the breastfeeding relationship. Services of a qualified lactation professional competent in clinical skills should be incorporated into the standard practice of care during the perinatal phase of a woman's life and the first 1,000 days of an infant's life to optimize the health of both the mother and child through prolonged breastfeeding. We recognize that the current focus is on increasing the proportion of infants ever breastfed and/or exclusively breastfed at specified ages: birth, 3 months, 6 months, and 1 year, in addition to noting "lactation support" in the worksite. The Academy emphasizes that these goals are more realistic when optimal support is in place for new mothers. We also note the importance of collecting initiation data to ensure clarity and the importance of adopting and applying a consistent definition of both the meaning of "breastfed" and "exclusively breastfed," as variations in understanding have significant implications.

Finally, we encourage adoption of a developmental objective to "Increase the proportion of children and mothers assessed for eligibility for the Special Supplemental Program for Women, Infants, and Children (WIC) and enrolled into the program if eligible." We note that the timing of enrollment can be impacted by the length of time premature infants may be in the Neonatal Infant Care Unit, and stress the importance of timely enrollment post-discharge.

J. Nutrition and Weight Status (NWS)

The Academy appreciates the use of people-first language related to the disease of obesity and offers comment to either elucidate or clarify a number of the proposed objectives for NWS:

  • For NWS-2030-01, "Reduce household food insecurity and in doing so reduce hunger," we note this can be achieved by adding subsidies to healthy food options such as fruits and vegetables, adding an education component such as SNAP-Ed providing real options for purchasing and preparing healthy foods on tight or no budgets, and encouraging so-called Good Samaritan laws to allow increased donations of otherwise thrown-away foods.
  • The Academy believes that NWS-2030-02, "Reduce the proportion of adults who have obesity," is definitely needed. We encourage the ODPHP to set a realistic, measurable weight loss goal (such as 20% from 2020 levels) or even propose minimum weight goals of 3% for individuals with overweight or obesity. Given their effectiveness in achieving these goals, we encourage ODPHP to include RDNs in support language to facilitate weight loss goals. In addition, we suggest encouraging the provision of anti-bias training as a requirement for continuing education, in medical schools, and in other schools training health care providers as we know that many people with overweight and obesity avoid the doctor because of bias and the way they are treated.
  • We note that with respect to NWS-2030-04, "Increase the proportion of physician office visits made by adult patients who have obesity that include counseling or education related to weight reduction, nutrition, or physical activity," we are concerned that this wording excludes counseling and education provided by RDNs outside a primary care physicians office, which the U.S. Preventive Services Task Force recognizes is significantly more effective than counseling by primary care providers. Most physician offices are not equipped to have RDN counseling, and we suggest changing this objective to "Increase the proportion of physician office visits made by adult patients who have obesity that include counseling or education related to weight reduction, nutrition, or physical activity or referrals to a dietitian or weight management program or consultations with an RDN or other qualified health care provider." Insurers should reimburse providers with demonstrable results such as registered dietitian nutritionists, exercise physiologists, and behavioral counselors for a clinically sufficient number of visits and additionally determine "success" through more data than just weight, such as improved quality-of-life or improved metabolic markers.  We note that progress can be realized even before patients achieve the designated modest weight loss in the designated time frame, if, for example, they achieve increased knowledge and skills (i.e., preparation stage of change) and often exhibit improved metabolic markers without much weight status change.  In general, we note that primary care physicians do not generally have the time, training, inclination, financial incentive, or expertise this type of counseling.
  • For many of the proposed NWS objectives, we suggest the value of enhanced Family and Consumer Sciences courses in schools emphasizing a variety of life skills as part of the solution. By offering similar opportunities for parents and adults to easy and affordable access to these courses, an even more substantial value may be realized.
  • We strongly support the proposed objectives NWS-2030-06, NWS-2030-07, NWS-2030-09, and NWS-2030-10.
  • For NWS-2030-12, we suggest modifying the proposed objective to read "Increase consumption of calcium in the population aged 2 years and older from food sources" to make clear the value of obtaining this mineral from whole foods and not additional supplementation.
  • For NWS-2030-13, we suggest modifying the proposed objective to read "Increase consumption of potassium in the population aged 2 years and older from food sources" to make clear the value of obtaining this mineral from whole foods such as fruits and vegetables and not additional supplementation.
  • For NWS-2030-14, we suggest modifying the proposed objective to read "Increase consumption of calcium in the population aged 2 years and older from food sources" to make clear the value of obtaining this mineral from foods such as fortified dairy and fatty fish and not additional supplementation.

K. Older Adults

The framework and approach outlined for the Healthy People 2030 objectives highlight the importance of goals that focus on improving the health and well-being of Americans across the lifespan. As older adults represent a growing proportion of the U.S., including goals relevant to an aging population is important, and we are pleased to see that Healthy People 2030 includes a section on older adults.

Good nutrition is key to the health of older adults. However, to date, diet quality and excess body weight have been the primary areas of focus in government goals for nutrition, including nutrition for older adults. For example, all the Nutrition and Weight Status objectives in the Healthy People 2030 proposal that focus on adult populations are about obtaining healthy food and reducing obesity.

However, these objectives do not touch on an issue key to the older adult population: malnutrition, a nutrition imbalance that affects both overweight and underweight patients, and its care. We propose that a Developmental Objective on reducing older adult malnutrition, particularly in acute care settings, should be added to the Older Adults category.

  • 1. Why Malnutrition?

Malnutrition is unfortunately a common issue across all care settings. In the acute care hospital setting, it is estimated that approximately 20 to 50 percent of admitted patients are malnourished or at-risk of malnutrition.41,42,43,44,45 According to the National Resource Center on Nutrition and Aging, nearly 35-50 percent of older residents in long term care facilities are malnourished.

Because malnutrition in older adults is often linked to economic and social factors, it can lead to more health disparities. The Congressional Black Caucus Institute, in their 2017 Transition Report, recommended that policymakers "[r]ecognize malnutrition as a preventable occurrence in acute care hospitals and support appropriate screening and treatment efforts."

Malnutrition can cause adverse and costly outcomes. Research documents malnourished older adults make more visits to physicians, hospitals, and emergency rooms. The nutritional status of malnourished patients can continue to worsen throughout an inpatient stay, which may lead to further increased costs. Studies show that malnutrition, as a contributing factor to post-hospital syndrome, can increase a patient's risk for a 30-day readmission, often for reasons other than the original diagnosis.46

For example, 45% of patients who fall in the hospital have malnutrition; costs for falls overall to Medicare totaled $31 billion in 2015.47,48 Falls prevention is included as an objective in Healthy People 2030, and including an objective encouraging malnutrition care would address this concern as well.

Older adult malnutrition is not currently being widely addressed by the American healthcare system. Many physicians and nurses receive no training on older adult malnutrition and little training on nutrition generally during their studies, and there is a general lack of access to registered dietitian nutritionists throughout the healthcare system. Most people are unaware of the significance of malnutrition as an issue, and though there are widely available screening and diagnostics tools, they are not being used.

Despite these serious concerns, malnutrition has not been included in our national health objectives nor is it reported in key health indicators for older adults. Malnutrition care has also been omitted from most prevention and wellness, patient safety, care transitions, and population health strategies. And while addressing malnutrition aligns with goals of the U.S. Department of Health and Human Services' (HHS) National Quality Strategy, to date, malnutrition care has not been integrated into public or private quality incentive programs.

  • 2. Evidence-Based Practices to Eliminate Malnutrition

Recently published research suggests that adopting malnutrition standards of care is a feasible and valuable endeavor. With systematic screening, assessment, diagnosis and intervention, malnutrition can be identified and addressed to effectively reduce mortality rates, readmission rates, and complication rates such as increased length of stay and cost of care.

Quality malnutrition care has been shown to create savings and improve patient outcomes. As HHS Secretary Alex Azar stated in comments to the Hatch Foundation for Civility and Solutions on November 14, 2018:

Data from the Agency for Health Research and Quality at HHS found that Americans with malnutrition are twice as costly to treat at the hospital as those who come in well-nourished. In fact, malnutrition is involved in 12 percent of non-maternal, non-neonatal hospital stays—$42 billion each year in healthcare spending. Naturally, a number of private health providers and payers have already tried addressing this issue: One ACO in Chicago, for instance, began screening high-risk patients for malnutrition, and then supporting them after discharge from the hospital with follow-ups, referrals, and nutrition coupons. The savings were huge: more than $3,800 per patient.

At a time when public scrutiny of federal expenditures for healthcare features prominently on the national stage, HHS has good reason to focus on the lowest-cost alternatives that can achieve savings. In short, clinical evidence and best practices support the need for early identification, diagnosis, intervention, and effective transitions of care for patients who are at-risk of malnutrition or malnourished.

As Secretary Azar recognized, malnutrition is a costly and dangerous problem—but savings can be achieved for our health care system through identifying patients with malnutrition and providing malnourished patients with appropriate nutrition care support both during and after discharge from acute care. Adding a Developmental Objective focused on malnutrition to the Older Adults category of Healthy People 2030 makes sense from  practical, economic, and patient care perspectives. The recognition of malnutrition as a national goal should help mobilize health care organizations and other health care stakeholders in supporting the implementation of care processes for the nutrition care of malnourished older adults, which should thereby improve outcomes, prevent readmissions, and reduce costs.

L. Conclusion

The Academy appreciates the opportunity to comment on the proposed objectives for Healthy People 2030. Please contact either Jeanne Blankenship by telephone at 312-899-1730 or by email at or Pepin Tuma by telephone at 202-775-8277 ext. 6001 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

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
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 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.

3 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.

4 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.

5 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.

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

7 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.

8 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.

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

10 Berge, 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).

11 Tips for Parents – Ideas to Help Children Maintain a Healthy Weight. Centers for Disease Control and Prevention website. Available at Accessed January 17, 2019.

12 website. Available at Accessed January 17, 2019.

13 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).

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

15 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.

16 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.

17 Cheng T, D'amico S, Luo M, et al. Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community. J Altern Complement Med. 2018.

18 Ashrafioun L, Allen KD, Pigeon WR. Utilization of complementary and integrative health services and opioid therapy by patients receiving Veterans Health Administration pain care. Complement Ther Med. 2018;39:8-13.

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20 Grade 1 data. Academy Evidence Analysis Library, [Grade Definitions: Strength of the Evidence for a Conclusion/Recommendation Grade I, "Good evidence is defined as: "The evidence consists of results from studies of strong design for answering the questions addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of serious doubts about generalizability, bias and flaws in research design. Studies with negative results have sufficiently large sample sizes to have adequate statistical power."

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