Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators to diagnose malnutrition tool in hospitalized adults: a cohort study.

BACKGROUND: The lack of a widely accepted, broadly validated tool for diagnosing malnutrition in hospitalized patients limits the ability to assess the integral role of nutrition as an input and outcome of health, disease, and treatment. OBJECTIVES: This study aimed to evaluate the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (ASPEN) indicators to diagnose malnutrition (AAIM) tool and determine if it can be simplified. METHODS: A prospective cohort study was conducted from August 2019 to September 2022 with 32 hospitals in United States. At baseline, 290 adult patients were evaluated for a diagnosis of malnutrition using the AAIM tool, which assesses weight loss, inadequate energy intake, subcutaneous fat and muscle loss, edema, and hand grip strength. Healthcare outcomes were extracted from the medical record: composite incidence of emergency department (ED) visits and hospital readmissions within 90 d postdischarge; length of hospital stay (LOS); and Medicare Severity Disease Related Group (MS-DRG) relative weight (i.e., healthcare resource utilization). We used multilevel, multivariable negative binomial or generalized linear regression models to evaluate relationships between malnutrition diagnosis and healthcare outcomes. RESULTS: After adjusting for disease severity and acuity and sociodemographic characteristics, individuals diagnosed with severe malnutrition had a higher incidence rate of ED visits and hospital readmissions (incidence rate ratio: 1.89; 95% CI: 1.14, 3.13; P = 0.01), and individuals diagnosed with moderate malnutrition had a 25.2% longer LOS (95% CI: 2.0%, 53.7%; P = 0.03) and 15.1% greater healthcare resource utilization (95% CI: 1.6%, 31.9%; P = 0.03) compared with individuals with no malnutrition diagnosis. Observed relationships remained consistent when only considering malnutrition diagnoses supported by at least 2 of these indicators: weight loss, subcutaneous fat loss, muscle wasting, and inadequate energy intake. CONCLUSIONS: Findings from this multihospital study confirm the predictive validity of the original or simplified AAIM tool and support its routine use for hospitalized adult patients. This trial was registered at clinicaltrials.gov as NCT03928548 (https://classic. CLINICALTRIALS: gov/ct2/show/NCT03928548).

Factors Associated With Self-Reported Family Enrollment in Community Services After Referral by First Born Home Visitors.

OBJECTIVE: To examine factors associated with family enrollment in community services after receiving a referral from First Born home visiting staff in New Mexico. METHODS: Analyses of program administrative data from August 2010 to January 2020 for 1049 families with 5397 referrals were conducted in Stata 15.1 using mixed effects logistic regression; missing data were imputed. We examined the likelihood of a referral outcome being coded as "client enrolled in services" based on family self-report as a function of program, referral type and initiator, and staff and referral recipient characteristics. RESULTS: About one fourth of referrals resulted in enrollment in services, with the highest enrollment rate for early intervention (39%) and lower enrollment rates for behavioral health (18%) and domestic violence (14%) services. Reported enrollment in the referred-to service was significantly higher for older caseholders versus teens (odds ratio [OR]: 1.69, 95% confidence interval [CI] 1.07-2.67) and for children (OR: 1.33, 95% CI 1.06-1.67) and pregnant mothers (OR: 1.45, 95% CI 1.04-2.01) versus non-pregnant mothers and significantly lower for referrals initiated by home visitors (in discussion with family - OR: 0.62, 95% CI 0.49-0.79; based on screening results - OR: 0.52, 95% CI 0.37-0.72) versus family initiated referrals, for fathers versus non-pregnant mothers (OR: 0.49, 95% CI 0.32-0.75) and for Asian, Black, and multi-racial/ethnic group caseholders versus white caseholders (OR: 0.53, 95% CI 0.30-0.97). CONCLUSIONS: Quality improvement efforts and home visitor training on making sensitive referrals, anti-racism, and motivational interviewing could potentially improve family engagement with community services via the First Born home visiting model.

Medical Nutrition Therapy for Chronic Kidney Disease: Low Access and Utilization.

CKD affects approximately half of US adults aged 65 years and older and accounts for almost 1 out of every 4 dollars of total Medicare fee-for-service spending. Efforts to prevent or slow CKD progression are urgently needed to reduce the incidence of kidney failure and reduce health care expenditures. Current CKD care guidelines recommend medical nutrition therapy (MNT), a personalized, evidence-based application of the Nutrition Care Process (assessment, intervention, diagnosis, and monitoring and evaluation) provided by registered dietitian nutritionists (RDNs) to help slow CKD progression, improve quality of life, and delay kidney failure. MNT is covered by Medicare Part B and most private insurances with no cost sharing. Despite recommendations that patients with CKD receive MNT and insurance coverage for MNT, utilization remains low. This article demonstrates low utilization of MNT and inadequate numbers of RDNs and RDNs who are board certified in renal nutrition relative to the estimated number of Medicare eligible adults with self-reported diagnosed CKD by state, with noted disparities across states. We discuss interventions to increase MNT utilization, such as improving MNT reimbursement, augmenting accessibility of RDNs via telenutrition services and increasing health care provider promotion of MNT and referral to MNT to optimize CKD outcomes.

Academy of Nutrition and Dietetics Nutrition Research Network: The Saqmolo' Project Rationale and Study Protocol for a Randomized Controlled Trial Examining the Influence of Daily Complementary Feeding of Eggs on Infant Development and Growth in Guatemala.

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

Dietetic Workforce Capacity Assessment for Public Health Nutrition and Community Nutrition.

Worldwide, there is a continued rise in malnutrition and noncommunicable disease, along with rapidly changing dietary patterns, demographics, and climate and persistent economic inequality and instability. These trends have led to a national and global focus on nutrition-specific and nutrition-sensitive interventions to improve population health. A well-trained public health and community nutrition workforce is critical to manage and contribute to these efforts. The study describes the current public health and community nutrition workforce and factors influencing registered dietitian nutritionists (RDNs) to work in these settings and characterizes RDN preparedness, training, and competency in public health and community nutrition. The study was comprised of a cross-sectional, online survey of mostly US RDNs working in public health/community nutrition and semistructured telephone interviews with US-based and global public health and community nutrition experts. RStudio version 1.1.442 was used to manage and descriptively analyze survey data. Thematic analysis was conducted to evaluate expert interviews. Survey participants (n = 316) were primarily women (98%) and White (84%) with the RDN credential (91%) and advanced degrees (65%). Most reported that non-RDNs are performing nutrition-related duties at their organizations. Respondents generally rated themselves as better prepared to perform community nutrition vs public health functions. Interviews were conducted with 7 US-based experts and 5 international experts. Experts reported that non-RDNs often fill nutrition-related positions in public health, and RDNs should more actively pursue emerging public health opportunities. Experts suggested that RDNs are more desirable job candidates if they have advanced public health degrees or prior experience in public health or community nutrition and that dietetic training programs need to more rigorously incorporate public health training and experience. Significant opportunity exists to improve the preparedness and training of the current dietetic workforce to increase capacity and meet emerging needs in public health and community nutrition.

Responsive Feeding Recommendations: Harmonizing Integration into Dietary Guidelines for Infants and Young Children.

Responsive feeding (RF) involves reciprocal nurturing feeding practices between the caregiver and the child that encourage the child to develop preferences for healthy foods and beverages and to eat autonomously. In this commentary, we summarize RF-related findings from a recent US National Academies of Sciences, Engineering, and Medicine (National Academies) consensus study report examining consistency in infant and young child feeding (IYCF) recommendations in guidelines from high-income countries, and we discuss implications for future IYCF guidelines. Although existing guidelines included generally consistent messages about several RF behaviors, such as the importance of encouraging self-feeding and self-regulation in infants and toddlers, they generally did not present the recommendations as part of a cohesive RF interdisciplinary framework. Moving forward, evidence-based RF recommendations should be routinely incorporated and identified in dietary guidance for IYCF based on a consensus definition of RF grounded in sound responsive parenting and feeding frameworks. We recommend replicating the National Academies' scoping review in low- and middle- income countries and mixed-methods implementation science research to improve our understanding of how best to disseminate and implement RF-related recommendations across settings (e.g., home and early care and education centers), taking the social determinants of health into account.

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists.

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

Trends in Registered Dietitian Nutritionists' Knowledge and Patterns of Coding, Billing, and Payment.

The US health care system has been undergoing substantial changes in reimbursement for medical and nutrition services. These changes have offered opportunities and challenges for registered dietitian nutritionists (RDNs) to bill for medical nutrition therapy and other nutrition-related services. During the past 10 years, the Academy of Nutrition and Dietetics has periodically surveyed RDNs providing medical nutrition therapy in ambulatory care settings to learn about their knowledge and patterns of coding, billing, and payment for their services. In 2018, the Academy of Nutrition and Dietetics conducted the latest iteration of this survey. This article compares the results of the 2008, 2013, and 2018 surveys to examine changes in RDNs' knowledge of billing code use and reimbursement patterns over time; understand the potential influences on coding and billing practices in a changing health care environment; and understand the effects of newer practice settings and care delivery models on billing and reimbursement for medical nutrition therapy services. Results from these surveys demonstrate that during the past 10 years RDNs' knowledge of billing and coding has been stable and very low for RDNs not in supervisory roles or private practice. RDNs reported an increase in providing medical nutrition therapy services to patients with multiple conditions. Since 2013, a dramatic increase was noted in the reported proportion of reimbursement from private/commercial health insurance plans. Results also indicate that most RDNs are not aware of changes in health care payment. Individual RDNs need to understand and be held accountable for the business side of practice and their value proposition in today's health care environment.

Rural-Urban Differences in Baseline Dietary Intake and Physical Activity Levels of Adolescents.

INTRODUCTION: Differences in dietary intake and physical activity may explain the higher prevalence of obesity among adolescents living in rural versus urban settings. The objective of this cross-sectional secondary analysis was to compare baseline dietary intake and physical activity of adolescents by rurality. METHODS: We analyzed data on 940 adolescents who participated in ACTION PAC (Adolescents Committed to Improvement of Nutrition and Physical Activity), an obesity prevention and management intervention trial conducted from 2014 through 2017 in 8 public high schools in the southwestern United States. Dietary intake was assessed with the Block Food Screener, and participants completed an exercise log and wore an accelerometer to provide data on physical activity. We compared data by rural-urban commuting area (RUCA) codes and log population density by using multilevel models, with students nested within zip code and repeated measures for accelerometer analysis. RESULTS: After adjusting for socioeconomic status and ethnicity, accelerometer data indicated that moderate-to-vigorous physical activity was 8.17 min/d (P = .02) higher and sedentary time was 20.42 min/d (P = .02) lower in moderately urban areas than in the urban reference area. Each 1-unit increase in log population density was associated with higher reported intake of whole grains (0.02 ounce equivalents, P = .03), potatoes (0.01 cup equivalents, P = .02), and added sugar (0.37 tsp, P = .02) after adjusting for socioeconomic status and ethnicity. CONCLUSION: Differences in reported dietary intake and physical activity level by measures of rurality were small and inconsistent in direction to explain the disparities observed in rural versus urban areas.