March 18, 2014
Rich Lucas Acting Associate Administrator, Office of Policy Support U.S. Department of Agriculture Food and Nutrition Service 3101 Park Center Drive, Room 1014 Alexandria, VA 22302
RE: Information Collection: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Nutrition Education Study (OMB Control Number: 0584—NEW)
Dear Mr. Lucas:
The Academy of Nutrition and Dietetics (the “Academy”) appreciates the opportunity to submit comments to the Food and Nutrition Service’s (FNS) January 17, 2014 information collection regarding the proposed WIC Nutrition Education Study. With over 75,000 members comprised of registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States committed to improving the nation’s health through food and nutrition across the lifecycle. The Academy’s members demonstrate this commitment to the nation’s most vulnerable through direct work with WIC participants, in public health agencies, and in formulating evidence-based nutrition criteria and public policy. We also wish to acknowledge Academy members who serve in the USDA and their positive influence on nutrition policy.
The Academy supports the proposed WIC Nutrition Education Study and believes an understanding of nutrition education practices and methods and their effectiveness is highly necessary for the proper performance of FNS’s functions.
The Academy agrees that nutrition education is “pivotal to WIC’s success in achieving its mission to safeguard the health of low-income women, infants, and children.” 2 3 Innovative, evidence-based interventions will “improve health status and achieve positive change in dietary and physical activity habits. . . [and will] emphasize the relationship between nutrition, physical activity, and health, all in keeping with the personal and cultural preferences of the individual.”3 FNS’s commitment to providing effective, evidence-based nutrition education services through a panoply of programs and initiatives is notable, especially in a time of increasingly scarce resources and heightened need. As FNS notes, “[a]chieving and sustaining positive changes in eating and nutrition-related behaviors is . . . a complex challenge.”4 Academy members working with the WIC population have had tremendous success in meeting this challenge by developing and providing innovative evidence based nutrition education programs that maximize WIC participants’ engagement and encourage lasting behavior change. The Academy would welcome the opportunity to meet with FNS in the near future to discuss in detail the issues raised herein and to share some of the effective, user-friendly nutrition education resources designed and used by our members.
Phase I: Features Affecting Nutrition Education
The proposed information collection notes a number of features the Academy agrees affect nutrition education, and we offer the following considerations and additional features not mentioned in the Federal Register. Nutrition education subjects regularly include details about the WIC food package, promotion and support of breastfeeding, recommended eating patterns and weight gain during pregnancy, and the appropriate timing for introducing solid foods to infants. At the outset, FNS should focus on the actual content of specific nutrition education interventions and the objectives on which the interventions focus. In addition, the Academy encourages FNS to specify the research features it deems “optimal for learning which interventions improve eating habits and support healthy lifestyles.”5
The Academy notes that many state WIC agencies provide excellent nutrition tools to local agencies and further note that significant variation exists in the provision of nutrition education at the local level. In addition to other service delivery elements, FNS should evaluate:
- Whether educators make referrals to other health care or social service providers upon learning of particular participant needs;
- The extent of coordination enabling participants to take advantage of opportunities to enroll in health care plans, whether Medicaid or private insurance;
- Whether nutrition education interventions are implemented as intended;
- Rates of no-shows for interventions and the extent to which no-shows are due to the transient nature of the WIC population;
- The effect of the loss of research subjects during the study period on conclusions about the effectiveness of nutrition education;
- How sites and educators “triage” modes and intensity of nutrition education based upon risk assessments of participants;
- How the timing of certification(s) affect nutrition education;
- How the timing and frequency of voucher issuance impacts the receipt and provision of nutrition education; and
- The effectiveness of customized nutrition education programs for toddlers in inculcating healthy behaviors.
Cultural Competence and Participant Demographics
Nutrition educators should have sufficient cultural and ethnic competence to effect WIC’s objectives. Academy members have had success customizing nutrition messages to WIC parents and children with lower literacy levels and limited English language skills and have developed promising training videos on cultural competency for WIC nutrition educators. Academy members report that an understanding and appreciation of cultural norms is particularly significant in promoting breastfeeding and desirable infant feeding habits. We recognize that there are special immigrant and minority concerns with language, literacy, and cultural issues, and we encourage FNS should identify barriers to adoption of recommended behaviors.
The Academy encourages FNS to identify and assess (1) particular participant characteristics that impact the frequency of nutrition education contacts; (2) successful modes of education and specific strategies for encouraging reluctant participants to return for follow-up nutrition education; and (3) qualitative (and to the extent it is derivable, quantitative) data indicating that certain ethnic and cultural demographic groups respond more favorably to particular modes of interventions.
Dosage and Duration of Interventions; Impact of Facilities and ResourcesWIC’s funding methodology is based on caseload rather than effectiveness of nutrition education, impacting staffing levels so significantly that there is often inadequate staff to provide intended education interventions. Some agencies thus allocate personnel resources toward achieving caseload targets at the expense of the highest quality nutrition education. Budgeting and staffing limitations also force nutrition educators to limit the intensity of sessions to as few as ten minutes and four sessions per year. Participants also may be required to wait to be seen at the site, resulting in some measure of dissatisfaction with the program and potentially reducing the number of visits by WIC mothers.6
The Academy encourages FNS to evaluate the frequency of nutrition education contacts between prenatal certification and childbirth and identify what variables appear to enhance frequency, including the frequency of participants return to WIC clinics and offices compared to the frequency in which they receive some form of nutrition education. For example, Academy members relate that quarterly dispensation of WIC benefits appears to reduce participants’ incentives to return to sites, resulting in fewer high-risk participants returning for more frequent nutrition education interventions. With regard to facilities, in a single agency it is not uncommon to have one main site (with regular hours) and multiple satellite offices (open only several hours a month). Many of these satellite offices present additional challenges with space constraints that prevent educators from providing education services tailored to participants. The Academy encourages FNS to assess whether outcomes and failure rates differ in main vs. satellite offices and in urban vs rural sites.
Academy members report that a number of satellite sites lack the technology and resources believed necessary to positively impact behavior change. The Academy encourages FNS to consider the extent to which dated computer systems and an inability to provide sufficient training in the collection and recordation of data may affect outcomes. The Academy understands that, for example, some state-provided video clips for nutrition education lessons cannot be utilized because local agencies lack resources for the equipment required to present the lessons during individualized settings at educators’ individual workstations.
Staff Characteristics and Qualifications
RDNs and DTRs are uniquely positioned to provide and lead teams providing nutrition education. They are skilled in motivational interviewing, adherence counseling, increasing self-efficacy, and addressing barriers to change. However, qualifications vary state to state and frequently even within states for a variety of reasons, including different qualifications required by private, non-profit and public governmental entities. Although many administrators and programs require the gold standard of the RDN credential for nutrition education providers, requirements for Competent Professional Authorities (CAPs) are substantially different throughout the nation. Thus, staff members at many agencies will likely need additional training to effectively implement successful nutrition education interventions, particularly those that have a participant-centered education focus.7 One important training need is for additional CAPs to develop bilingual language skills to better work with diverse populations.
Modes of Nutrition Education
The Academy notes that modes of education vary greatly from site to site and often include (1) individual and group nutrition education in-person interventions, (2) tailored technological, online interventions, and (3) the provision of educational materials to lower-risk participants. Academy members report increased success when adding an “activation component” in which participants reinforce the nutrition education goal through evidence-based activities and tasks. FNS should evaluate the success of new patient centered education approaches8 and the extent to which modes selected and delivered are dependent upon levels of risk. FNS should also detail how it intends to evaluate the comparative impact of nutrition education when participants with different risk factors receive different modes of education.
Phase II: Evaluating the Impact of WIC Nutrition Education
To draw credible conclusions about the impact of WIC nutrition education on participant health behaviors, FNS should clarify the specific objectives of nutrition education interventions being studied and assess the extent to which resources are sufficient to achieve the desired objectives. Specifically, FNS should note whether the proffered objective is (1) behavior change, (2) behavior change maintained over time, (3) dietary intake, (4) increased rates of infant breastfeeding, or (5) other goals or a combination thereof. It is critical that providers of particular nutrition education interventions are aware of the potentially varying objectives for these interventions and that FNS determine whether the interventions are being implemented as designed.
The Academy requests that FNS explain how the study design will ensure the validity and reliability of the data, particularly given that much of it is likely to be self-reported and susceptible to social desirability bias. The Academy encourages FNS to share the range of studies reporting content validity measuring mediating variables and criterion validity of intake instruments.9 We recognize that outcome assessments may show a correlation between interventions and intended outcomes, but that they cannot definitively demonstrate a causal relationship. Nothwithstanding, the Academy believes this study has the potential to provide useful insights about the impact of various nutrition education methods on participants and has broad relevance for the WIC program. The study should include qualitative data from nutrition educators sharing what they have found to be useful and effective for the WIC population and what has not.
The Academy is supportive of analyses identifying an association between exposure to WIC nutrition education and changes in participant health behaviors and other outcomes, including any physiologic measures. However, we note that some physiologic measures, such as BMI, may not reflect desired nor actual behavioral change success, particularly within the abbreviated time period of WIC eligibility. The Academy believes that FNS should consider the following nutrition education outcomes:
- Readiness for change;
- Food acquisition and management;
- Eating behaviors, including smoking and alcohol consumption, and whether these behaviors are validated against longer food frequency instruments;
- Breastfeeding habits, including the extent to which any change in maternal breastfeeding behavior is considered more broadly a change in the outcome measure of participants’ eating behavior;
- Appropriate/desirable infant feeding habits;
- Dietary intake;
- Physical and sedentary activity habits;
- Whether outcomes are maintained postpartum in the longer term (i.e., “stickiness”); and
- Whether the extent of impact is affected by the presence of any corroborative or contradictory nutrition education messaging (particularly related to breastfeeding) received from other trusted health care providers, such as physicians.
We encourage FNS to concurrently validate the data by comparatively analyzing the findings of this study with previous studies’ data and conclusions. Lastly, studies should “provide information on a variety of potential mediating factors that might contribute to the achievement of behavioral change goals in interventions.”10
The Academy appreciates the opportunity to comment on this important initiative and hopes to discuss these recommendations in greater detail in the near future. Please contact either Jeanne Blankenship at 202/775-8277, ext. 6004 or by email at firstname.lastname@example.org or Pepin Tuma 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
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics Pepin Andrew Tuma, Esq.
Director, 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 Federal Register Volume 79, Number 12 (Friday, January 17, 2014), Pages 3164-3167.
3 CFR 246.2.
4 FNS USDA Nutrition Education Research Summary: Message Framing, Use of Interactive Technology to Tailor Messages, and Intervention Intensity. Available at http://www.fns.usda.gov/sites/default/files/LitReview_Summary.pdf, accessed March 14, 2014.
5 FNS USDA Nutrition Education: Principles of Sound Impact Evaluation. Available at http://www.fns.usda.gov/nutrition-education-principles-sound-impact-evaluation, accessed March 14, 2014.
6 Deehy K, Hoger FS, Kallio J, et al. Participant-centered education: building a new WIC nutrition education model. J Nutr Educ Behav. 2010;42(3 Suppl):S39-46.
7 Deehy K, Hoger FS, Kallio J, et al. Participant-centered education: building a new WIC nutrition education model. J Nutr Educ Behav. 2010;42(3 Suppl):S39-46.
8 Deehy K, Hoger FS, Kallio J, et al. Participant-centered education: building a new WIC nutrition education model. J Nutr Educ Behav. 2010;42(3 Suppl):S39-46.
9 See, e.g., Contento IR, Randell JS, Basch CE. Review and Analysis of Evaluation Measures Used in Nutrition Education Intervention Research. Journal of Nutrition Education and Behavior. 2002;34(1):2-25.