September 22, 2013
1600 Clifton Road, MS-D74
Atlanta, GA 30333
Re: 60Day 13-13H (Proposed Data Collection re CDC's Work@Health Program: Phase 2 Training and Technical Assistance Evaluation)
Dear Mr. Richardson:
The Academy of Nutrition and Dietetics (the "Academy") is pleased to comment on the proposed data collection for Phase 2 of CDC's Work@Health Program published in the Federal Register. The Academy is the world's largest organization of food and nutrition professionals, with more than 75,000 members comprised of registered dietitian nutritionists (RDNs), registered dietitians (RDs), dietetic technicians, registered (DTRs), and advanced-degree nutritionists. Every day we work with Americans in all walks of life — from prenatal care through old age — providing nutrition care and conducting nutrition research. We are committed to evidence-based strategies for improving the nation's health through food and nutrition and providing medical nutrition therapy (MNT)1 and other evidence-based nutrition counseling services that meet the health needs of all citizens. The Academy supports the proposed data collection and its purpose to design, implement, and evaluate effective science-based workplace wellness programs.
Recognizing the 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 and reducing risk for chronic disease. Registered dietitians and dietetic technicians, registered, are leaders in delivering preventive services in both clinical and community settings and in facilitating and participating in research in chronic disease prevention and health promotion. Diet, nutrition, and physical activity are critical factors in the promotion and maintenance of good health throughout the life cycle. 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.2 In an era of increasing health care expenditures and relative decreases in availability of federal funds, there is increasing demand on health promotion and disease prevention to be economically viable and to produce results.
As CDC recognizes, four of the ten leading causes of death — cardiovascular disease (CVD), stroke, some types of cancers, and type 2 diabetes — are associated with modifiable health behaviors including poor nutrition and are ripe targets for well-designed, evidence-based wellness and prevention programs.3 Almost 50 percent of adults in the United States have at least one chronic illness.4 In 2006, people with chronic diseases accounted for 84 percent of health care spending in the United States.5 Large studies looking at the relationship between modifiable risk factors and medical claims showed that several risk factors, including tobacco use, overweight/obesity, high blood glucose, high stress, and lack of physical activity, accounted for an estimated 25 percent of total employer healthcare expenditures.6
The government should continue to play a helpful role in the discovery of effective worksite wellness through continuation of funding research, and in the sharing of best practices by continuing efforts at the Centers for Disease Control and Prevention promoting evidence-based workplace wellness efforts. 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.7 Prevention-effectiveness studies assess the impact of public health programs, policies, and practices on health outcomes. The results of prevention-effectiveness studies should provide a basis for CDC's public health program recommendations, guidelines for prevention, and a framework for decision-making about resource allocations.
Curricula Should Recognize the Value of Individualized Programs
Employers should be made aware of substantial research showing that people encounter many barriers at many different levels preventing them from engaging in healthful eating behaviors and being physically active. Each barrier needs to be addressed in an individualized way and across a variety of settings to enable a person to improve their nutrition and be physically active. The socioecological model of prevention, which links environmental and policy systems changes with individual-level behavioral changes for nutrition and physical activity can be used to understand and address myriad individual, interpersonal, organizational, community, and societal barriers.8 The expected outcomes of this socioecological model are effective interventions that reduce the barriers to positive and sustained barriers to change.9 The Prochaska change model can help identify individuals needing different approaches in modifying behavior and making decisions and whether or not they are ready to move forward with making lifestyle changes. Registered dietitians, through screening processes recognized as effective by the USPSTF, can help identify which people are ready to make behavior changes.10
Use of Qualified Providers Enhances Program Effectiveness
CDC indicates its intention to train and certify instructors for the Work@Health Program. RDs are qualified, credentialed practitioners who are uniquely positioned and skilled to provide effective wellness and prevention programs. The United States Preventive Services Task Force (USPSTF) recommends and recognizes RDs as effective practitioners skilled in providing (1) behavioral counseling to promote a healthy diet in adults at increased risk for CVD,11 (2) screening for and management of obesity in adults,12 and (3) behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults.13 A recently released study found that overweight and obese adults who received individualized, RD-provided MNT (that cost insurers a mere $0.03 per month) had clinically and statistically significant reductions in weight and BMI and increases in number of minutes of exercise over two years compared to adults who were in an obesity management program but did not elect to receive MNT.14 MNT and other nutrition services provided by an RD are necessary and yield quality, evidence-based care to recipients, improve health outcomes, and lower health care costs.15
Through ongoing clinical involvement and rigorous participation in research on chronic disease prevention and health promotion, RDs have developed and delivered cost effective and clinically effective strategies transferable to skill-based workplace health training. The Academy urges CDC to define the specific qualifications and credentials for program instructors and defend such determination by publishing research studies CDC relied upon showing instructors with those qualifications and credentials have effectively provided relevant science-based wellness programs.
The Academy additionally recommends that employers encourage their employees to be counseled to consult recognized, credentialed health professionals and to seek referral for the treatment of chronic diseases such as diabetes that are discovered through participation in HRAs and/or biometric screenings. Intensive, individualized approaches toward behavior modification initiated subsequently may be more expensive, but they are also more effective and should be incentivized. When coupled with comprehensive worksite programs that address policy, systems and environmental changes, employees who receive individualized counseling will have a worksite environment that can support individual personal choices for the best potential health outcomes and return on investment.
The Academy appreciates the opportunity to comment on the proposed data collection and offers our assistance and evidence analysis regarding efficacy of various wellness and disease prevention programs. We also emphasize the importance of relying upon qualified providers with specialized expertise in planning and implementation of all phases of the Work@Health Program and accordingly hope you will look towards the Academy and our credentialing process. Please contact either Jeanne Blankenship or Pepin Tuma with any questions or requests for additional information.
Jeanne Blankenship, MS RDN
Vice President, Policy Initiatives and Advocacy
Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
1 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process. According to the Academy's definition, the provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/re-assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. [Academy of Nutrition and Dietetics. Definition of Terms List. Available at Scope of Practice. Accessed September 15, 2012.]
2 U.S. Preventive Services Task Force. "Guide to Clinical Preventive Services" (accessed September 16, 2013).
3 Anderson RN, Smith BL. Deaths: Leading causes for 2002. Natl Vital Stat Rep. 2005;53:1-89.
4 Wu SY, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health; 2000.
5 Centers for Disease Control and Prevention, "Preventing and Managing Chronic Disease to Improve the Health of Women and Infants" (accessed January 25, 2013).
6 R Goetzel and R Ozminkowski, "The Health and Cost Benefits of Work Site Health-Promotion Programs,"; Ann Rev Pub Health 2008; 29:303-23.
7 U.S. Preventive Services Task Force. "Guide to Clinical Preventive Services" (accessed January 24, 2013); 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.
8 McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351-377.
9 Matson-Koffman DM, Brownstein JN, Neiner JA, Greaney ML. A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: What works? Am J Health Promot. 2005;19:167-193.
10 Prochaska JO, DiClemente CC, Norcross JC (1992). In search of how people change. Applications to addictive behaviours. Am Psychol 47:1102.
11 U.S. Preventive Services Task Force. "Behavioral Counseling in Primary Care to Promote a Healthy Diet in Adults at Increased Risk for Cardiovascular Disease" (accessed January 24, 2012).
12 U.S. Preventive Services Task Force. "Screening for and Management of Obesity in Adults" (accessed January 24, 2012).
13 U.S. Preventive Services Task Force. "Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults" (accessed January 24, 2012).
14 Bradley DW, et al. The Incremental Value of Medical Nutrition Therapy in Weight Management. Managed Care, (accessed January 24, 2013).
15 Bradley DW, et al. The Incremental Value of Medical Nutrition Therapy in Weight Management. Managed Care, (accessed January 24, 2013).