October 7, 2017
The Honorable Sonny Perdue
Secretary of Agriculture
U.S. Department of Agriculture
1400 Independence Ave., S.W.
Washington, DC 20250
Re: Improving Customer Service: United States Department of Agriculture Reorganization
Dear Secretary Purdue,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the United States Department of Agriculture (USDA or the "department") Office of Budget and Program Analysis regarding the proposed reorganization of the department, "Improving Customer Service." Representing over 100,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Our members work in and with the USDA in numerous various capacities and consistently utilize the significant, critical evidence-based recommendations developed and promoted by the Center for Nutrition Policy and Promotion (CNPP) as the benchmark for much of their dietetics and nutrition practice.
The Academy questions the virtues of the proposal to merge the CNPP into the Food and Nutrition Service (FNS) given the likely negative impact of CNPP's loss of independence and the lack of evidence that a merger would improve the efficiency and effectiveness of either agency. Should the proposed merger be effectuated notwithstanding these concerns, a number of protections must be added to ensure our nation’s science-based nutrition policy is not compromised.
A. Need for A Focus on Nutrition Science throughout Government
Our nation is paying the price for overlooking the importance of nutrition in preventing and treating chronic diseases. For too long, our nation's health policy has failed to focus on disease prevention, wellness, or healthy lifestyles, although recent reform efforts intended to change that emphasis. Nearly half of Americans suffer from preventable chronic conditions, but relatively few resources have been committed to the broad array of potential solutions that influence whether and how individuals choose to achieve and maintain health. According to the Centers for Disease Control and Prevention (CDC), seven of the top ten causes of death in the United States are due to diet-related chronic diseases such as obesity, type II Diabetes, heart disease and chronic kidney disease. Treatment for these diseases accounts for 86% of national health care costs. Over twelve million children and more than seventy-eight million adults nationwide are obese. Obesity-related health care costs alone add up to $147 billion U.S. dollars every year.2 As a result, health care in the United States is the most expensive in the world, accounting for 17% of the gross national product.3
In addition to helping to prevent or manage chronic conditions, adequate and proper nutrition ensures that older adults maintain an appropriate weight. Between 2007 and 2010, more than one-third (35% of older adults had obesity,4 and although the Institute of Medicine (IOM) has cited obesity as the most common nutritional disorder in older persons, undernutrition continues to be a pervasive problem among older adults as well.5 Undernutrition is a particularly a costly problem for older adults in community settings, with a close connection between inadequate income and food insecurity.6 The consequences of undernutrition include increased risk of falls and subsequent injuries, which can not only impair an individual's ability to live independently but also translate into over $19 billion in health care costs for nonfatal falls nationwide.7
B. Ensure Independent Role of the Center for Nutrition and Policy Promotion
The work of Center of Nutrition and Policy Promotion serves as the scientific and nutrition guidance foundation for the programs in FNS and across the federal government. Notably, there is no overlap between the work of the CNPP and the FNS causing inefficiencies that could be reduced through the proposed merger; the CNPP considers the nutrition needs of the nation as a whole, whereas the FNS is focused on targeted populations. In the recent 2015 Dietary Guidelines for Americans (DGA), CNPP appropriately developed and directed recommendations for improving the nutrition and diets of Americans at the entities and individuals most able to effect the respective changes, whether on micro or macro levels. These entities and individuals — retailers, schools, industry, farmers, students, parents, and beneficiaries — represent the spectrum of customers USDA serves for whom the independence, accuracy, and effectiveness of the CNPP is critical.
Quite simply, CNPP continues to provide the strongest evidence-based nutrition guidance available to Americans. The DGA, MyPlate, MyWins, the Healthy Eating Index, and the USDA food plans are trusted and widely used resources Americans look to as they make daily decisions how to make more healthful choices, and the CNPP serves as the scientific and nutrition guidance foundation for these other federal food and nutrition education programs. The importance, effectiveness, and trustworthiness of these programs is not an accident, and the CNPP's independence has been a key factor in their value to customers of the USDA. If the CNPP, which along with the Dietary Guidelines Advisory Committee represents the last buffer against the politicization of and undue influence on the Dietary Guidelines for Americans, were to merge into the FNS and lose its independence, there is no assurance that unbiased, evidence based nutrition recommendations would be made available to the public at any stage of the DGA process.
C. Ensure Provision of Adequate Funding
The Academy notes that when CNPP joined the FNS mission area, there was no congressionally-appropriated funding to support any of the initiatives within CNPP. For years after the requirement to develop and revise the DGAs every five years, Congress did not directly appropriate any funds to support this work until 2016 when it added a one million dollar rider to the FY2016 appropriations bill charging the USDA to work with the National Academies of Science, Engineering and Medicine (NASEM) to thoroughly evaluate the process of developing the DGAs.
As a result of this rider, the NASEM defined several significant changes and improvements to be included in the process of creating the 2020-2025 DGAs, including more comprehensive recommendations for more specific populations considering the prevalence of diet-disease in the United States as well as a more transparent and rigorous methodological approach.8 This new responsibility is combined with another new requirement that the CNPP develop and promote an entirely new, second set of DGAs for infants aged birth through twenty-four months. Funding for the CNPP was already wholly inadequate to the previous DGA tasks assigned to it; executing these additional tasks in addition the previous tasks requires substantial, sustainable, specifically appropriated funding at a level far surpassing that previously allocated to DGA development.
D. Ensure Appropriate Leadership Guides Work of the CNPP
The CNPP's administrator is responsible for overseeing the integrity of the scientific and nutrition guidance foundation for the FNS and other federal food and nutrition programs, as well as nutrition education for all Americans. As such, the administrator must be a well-respected and highly experienced professional with credentials in dietetics or nutrition, medicine, or public health in addition to a solid professional background in nutrition science, population health, epidemiology, evaluation, and public policy. An administrator at the level of a Senior Executive Service career staff person must be in place prior to the initiation of the DGA process to ensure its integrity. Should the merger progress or the DGA process commence without such a qualified person at the helm of the CNPP, the integrity of the DGA process and the administration's commitment to meeting its statutory responsibility to develop and promote evidence-based nutrition recommendations will be questioned.
The National Academies of Sciences, Engineering and Medicine (NAS) recently released a congressionally mandated review of the DGA process. In its report, the NAS emphasizes: "It is important that the DGA be viewed as valid, evidence-based, and free of bias and conflicts of interest."9 The Academy asserts that one of the most effective strategies for meeting this standard in the forthcoming DGA process is by ensuring that the administrator of CNPP has the requisite knowledge, experience, independence, and authority.
The Academy appreciates the opportunity to comment on the notice Improving Customer Service regarding the proposed USDA reorganization. We trust you appreciate that the CNPP will need the right leadership, authority, and sustained financial support to effectively and efficiently carry out its responsibilities for developing and promoting evidence-based nutrition recommendations.
We are happy to discuss these comments in greater detail in the near future. Please contact either Jeanne Blankenship at 312/899-1730 or by email at email@example.com or Pepin Tuma at 202/775-8277, ext. 6001 or by email at firstname.lastname@example.org 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 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 Centers for Disease Control and Prevention: Nutrition, Physical Activity, and Obesity. Published October 24, 2016. Accessed September 29, 2017.
3 Jortberg BT, Fleming MO. Registered dietitian nutritionists bring value to emerging health care delivery models. J Acad Nutr Diet. 2014;114(12):2017-22, citing Berwick D, Nolan T, Whittington J. The Triple Aim: Care, cost, and quality. Health Affairs. 2008;27(3):759-769.
4 Fakhouri, T.H.I; Ogden, C.L.; Carroll, M.D.; Kit, B.K.; Flegal, K.M. (2012). Prevalence of Obesity Among Older Adults in the United States, 2007-2010. NCHS Data Brief (106):1-8. Retrieved February 4, 2013.
5 Institute of Medicine (2000). The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population.
6 National Academy of Sciences (2012). Nutrition and Healthy Aging in the Community: Workshop Summary. Sheila Moats and Julia Hoglund, Rapporteurs; Food and Nutrition Board; Institute of Medicine. P. 22.
7 Stevens J.A., Corso P. S., Finkelstein E. A. et al. (2006). "The Costs of Fatal and Nonfatal Falls Among Older Adults," Injury Prevention. Vol. 12(5):290–95.
8 National Academies of Sciences, Engineering, Medicine. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press; 2017
9 National Academies of Sciences, Engineering, Medicine. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press; 2017