Note: this comment is related to the Academy's public comments about Health People 2030.
Submitted by the Academy of Nutrition and Dietetics
September 29, 2017
On behalf of the Academy of Nutrition and Dietetics, I am pleased to offer comments on the proposed framework for the Healthy People 2030 initiative. The Academy represents over 100,000 registered dietitian nutritionists, nutrition dietetic technicians, registered, and advanced-degree nutritionists playing a key role in shaping the public’s food choices, improving people’s nutritional status, and preventing and treating chronic disease.
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 framework 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.
Vision — A society in which all people achieve their full potential for health and well-being across the lifespan.
The Academy supports the proposed vision statement, which is similar to our own updated vision statement: “A world where all people thrive through the transformative power of food and nutrition.”
Mission — To promote and evaluate the nation’s efforts to improve the health and well-being of its people.
The Academy supports the proposed mission statement, which is similar to our own updated mission statement, “Accelerate improvements in global health and well-being through food and nutrition.” We encourage the Committee to focus on evidence-based measures that can be evaluated to show the impact on the nation’s health. For example, by reducing malnutrition, we will reduce hospitalizations and many other poor health outcomes, while also reducing unnecessary health costs. The Academy looks forward to working with the Committee as measures are developed.
The proposed foundational principles are also aligned with the Academy’s principles for health care, and we support working across sectors and levels of government to implement policies to improve public health. Academy members provide vital nutrition services to prevent and treat chronic diseases, including diabetes, obesity, and cardiovascular disease, and also work across the health care sector to improve health literacy and reduce health disparities, so we are happy to support these efforts.
- Health and well-being of the population and communities are essential to a fully functioning, equitable society.
Agree. We particularly agree with the inclusion of both population and communities. We also like the elevation of the notion that an equitable society advances the health in all policies and for all individuals.
- Achieving the full potential for health and well-being for all provides valuable benefits to society, including lower health care costs and more prosperous and engaged individuals and communities.
Agree. We think the integration of results of economic analyses for Healthy People 2030 objectives should be included in the budget priorities for the government.
The accessibility of oral health prevention tools corresponds with the Committee’s plan to use resources efficiently. The low costs of oral hygiene tools make them efficient uses of resources as the committee seeks interventions that are scalable and sustainable.
- Achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy.
Agree. We know that gaining health literacy requires the equitable commitment to early introduction and continuous reinforcement of competencies to manage one’s own health and prevent disease and think this is a core value of Healthy People 2030.
- Healthy physical, social and economic environments strengthen the potential to achieve health and well-being.
- Promoting and achieving the nation’s health and well-being is a shared responsibility that is distributed among all stakeholders at the national, state, and local levels, including the public, profit, and not-for-profit sectors.
The nation’s health and well-being is a shared responsibility but cannot be thrust upon the individual; therefore, individuals from diverse communities need to be engaged as stakeholders and included in the Healthy People process. Included in HP 2030 should be recommendations geared to behaviors that individuals may achieve as well as systematic and institutional changes.
- Working to attain the full potential for health and well-being of the population is a component of decision-making and policy formulation across all sectors.
Ensuring all Americans have access to a minimum level of effective preventive nutrition care services offers a unique opportunity to lower long-term health care costs and improve health outcomes.
- Investing to maximize health and well-being for the nation is a critical and efficient use of resources.
Agree, but may consider adding “effective use” as well as critical and efficient. In the process of identifying objectives, attention should be given to cost-benefit analyses and existing data bases that can provide critical information on efficient and effective uses of resources.
Plan of Action
In the proposed plan of action, the Academy recommends that when identifying important areas of research, the Committee collaborate with other federal nutrition task forces, such as the Dietary Guidelines for Americans, in order to ensure that messages are consistent to improve health across the lifecycle. We support the use of evidence-based programs that are sustainable and scalable, in order to have the greatest impact on health.
- Set goals and objectives to guide policies, programs, and other actions that improve health and well-being.
We recommend that the Committee focus on objectives that are drivers of health, with special emphasis on preventive practices. It is important to reiterate that when preventive practices are effective, they should be continued rather than scaled back or necessarily deemphasized. For example, earlier efforts on dental caries prevention emphasized education in schools and fluoridation of water to great success, but the efforts have ceased and as a result, the current limited funding for oral health education in states combines with the fact that one-third of our water supply is not being fluoridated in disturbingly high prevalence of caries in children and adults.
- Identify regions and groups with poor health or at high risk for poor health in the future.
We agree with the findings in the American Academy of Pediatrics’ March 2016 policy statement “Poverty and Child Health in the United States that “children who experience poverty, particularly during early life or for an extended period, are at risk of a host of adverse health and developmental outcomes through their life course.” (Citing Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7(2):55–71pmid:9299837.) Consistent with previous U.S. estimates, the 2015 data indicate that households struggling with poverty experience food insecurity at greater rates than other households. (Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household food insecurity in the united states in 2015. 2016;ERR-215.) Food insecurity is a high priority for public health stakeholders, given its negative impact from both public health and economic perspectives. (Gundersen C, Kreider B. Bounding the effects of food insecurity on children's health outcomes. J Health Econ. 2009;28(5):971-983.) Documented outcomes include physical impairments related to insufficient or inadequate dietary intakes, psychological issues related to a lack of consistent and adequate food access, and socio-familial disturbances. (Rose D. Economic determinants and dietary consequences of food insecurity in the United States. J Nutr. 1999;129(2):517S-520S.) Across the life span, food insecurity often results in disrupted eating patterns that can lead to suboptimal nutritional status. ( Cook JT, Frank DA, Levenson SM, et al. Child food insecurity increases risks posed by household food insecurity to young children's health. J Nutr. 2006;136(4):1073-1076.; Gunderson et all 2009; Gunderson C, Ziliak JP. Food insecurity and health outcomes. Health Affairs. 2015;34(11):1830-1839; Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010;110(9):1368-1377; Hanson KL, Connor LM. Food insecurity and dietary quality in US adults and children: A systematic review. Am J Clin Nutr. 2014;100(2):684-692; Laraia BA. Food insecurity and chronic disease. Adv Nutr. 2013;4(2):203-212.) These changes in dietary consumption contribute to negative physical and mental outcomes and an increased risk of disease.
- Foster impact through public and private efforts to improve health and well-being for individuals of all ages.
One example of a public-private partnership to improve health is the Prevention and Public Health Fund, the nation’s only dedicated investment in prevention and public health. This fund provides resources to state and local communities to implement innovative programs to improve health and well-being. Academy members lead efforts at the federal, state, and local level to make eating well the easy, natural choice and to implement changes to polices, systems, and environments that support healthy behaviors.
- Provide tools for the public, programs, policy makers and others to evaluate progress toward improving health.
Objectives need to be measurable by tools such as NHANES, which is a great source of information for assessing whether objectives are being met. A renewed focus on oral and dental health could include review of the NHANES survey and subsequent inclusion objectives whose outcomes can be directly measured using that data (e.g., frequency of brushing, toothpaste use, flossing, and chewing gum). Stakeholders could then measure the outcomes in those population groups with highest vulnerability and least access to treatment.
- Share evidenced-based programs that are scalable and sustainable.
Agree. Also recommend research funding for community-based interventions needs to be increased, given prevention’s ability to save substantial costs by avoiding costly medical interventions.
- Report on progress throughout the decade from 2020 to 2030.
Agree. This permits multiple opportunities to correct deficiencies and utilize new research findings.
- Stimulate research and innovation toward meeting Healthy People 2030 goals.
Agree. There should always be a strong focus on evidence-based research.
- Develop and make available affordable means of health promotion, disease prevention, and treatment.
In concert with the stated principals of HP 2030, we agree that attention to lower cost interventions, both acceptable and feasible to the community, should be the focus of the HP objectives. In any recommendations of interventions to meet the HP objectives, consideration should be given to preventive measures that can be practiced by individuals and within community-based institutions such as schools, long term care facilities, and work places.
- Attain healthy, purposeful lives and well-being.
Academy members play critical roles in public and community health, engaging in work ranging from improving community access to healthy food to developing and implementing statewide interventions to prevent obesity, diabetes and other chronic diseases. Public health and community nutrition registered dietitian nutritionists are leaders at federal, state and community agencies, successfully implementing complex food and nutrition programs that improve the health of individuals and communities. Our members play a key role in shaping the public’s food choices, improving people’s nutritional status and preventing and treating chronic disease, and we look forward to collaborating with you to meet this goal.
- Attain health literacy, achieve health equity, eliminate disparities, and improve the health and well-being of all populations.
All activities associated with improving the nutritional status of Americans must include efforts to achieve health equity and reduce health disparities. Racial and ethnic minorities are generally in poorer health and at a greater risk of being food insecure. Academy members’ research, leadership and community-based efforts provide excellent examples of success stories that can be scaled up across the country.
- Create social and physical environments that promote attaining full potential for health and well-being for all.
- Promote healthy development, healthy behaviors and well-being across all life stages.
Nutrition plays a critical role in every stage of our lives. From conception through pregnancy, birth, childhood and into older age, good nutrition supports health and wellness, improving quality of life. From the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to the National School Lunch Act, our government has taken measures to protect the nutrition status of our children. Since 1965, the Older Americans Act has been the primary vehicle for delivering social and nutrition programs to older individuals. The Academy supports these programs that help keep Americans healthy throughout their lives.
For some diseases, early intervention, education, and access to simple tools at the individual level are critical to initiate sound healthy habits and maintain these habits throughout the lifespan. Examples of simple low-cost tools that can be made available at schools, community centers, and faith institutions could include a bathroom scale, portion measuring apparatus, tooth brush, tooth paste, sugar free gum, water fountains or pitchers of fresh, cool water, and exercise equipment.
- Engage with stakeholders and key constituents across multiple sectors to take action and design policies that improve the health and well-being of all populations.
Engagement with communities and stakeholder through the assets-based approach will help increase the capacity of communities and help them better utilize the resources they already possess. For example, oral health preventive care tools, such as toothbrushes, toothpaste, floss, and sugar-free gum, are universally available to consumers throughout the country and are considered assets that can be strategically utilized to promote better oral health outcomes.