Incorporating the life course model into MCH nutrition leadership education and training programs.

Life course perspective, social determinants of health, and health equity have been combined into one comprehensive model, the life course model (LCM), for strategic planning by US Health Resources and Services Administration's Maternal and Child Health Bureau. The purpose of this project was to describe a faculty development process; identify strategies for incorporation of the LCM into nutrition leadership education and training at the graduate and professional levels; and suggest broader implications for training, research, and practice. Nineteen representatives from 6 MCHB-funded nutrition leadership education and training programs and 10 federal partners participated in a one-day session that began with an overview of the models and concluded with guided small group discussions on how to incorporate them into maternal and child health (MCH) leadership training using obesity as an example. Written notes from group discussions were compiled and coded emergently. Content analysis determined the most salient themes about incorporating the models into training. Four major LCM-related themes emerged, three of which were about training: (1) incorporation by training grants through LCM-framed coursework and experiences for trainees, and similarly framed continuing education and skills development for professionals; (2) incorporation through collaboration with other training programs and state and community partners, and through advocacy; and (3) incorporation by others at the federal and local levels through policy, political, and prevention efforts. The fourth theme focused on anticipated challenges of incorporating the model in training. Multiple methods for incorporating the LCM into MCH training and practice are warranted. Challenges to incorporating include the need for research and related policy development.

Retirement intentions of the public health nutrition workforce.

BACKGROUND: High retirement rates are anticipated throughout public health as baby boomers (those born between 1946 and 1964) near retirement. Predicting retirement intention would aid workforce planning. SUBJECTS AND METHODS: Participants were nutrition professionals/paraprofessionals 45 years and older in nutrition programs under official health agencies' authority who participated in a census enumeration and released their data for research. Secondary data analysis was conducted using selected factors from Beehr's Model of Retirement Behavior to determine whether significant (P < or = .05) differences exist for and can be used to predict retirement intention (within 10 years) and years until intended retirement. RESULTS AND CONCLUSIONS: Of the 4,460 individuals, 47.2% intended to retire within 10 years. Retirement intention was predicted by age category, years of experience in nutrition/dietetics and public health nutrition, agency type, retirement and vacation benefits, time in direct services, US Department of Health and Human Services region, and full-time/part-time status. Years until intended retirement was predicted by age category, years of nutrition/dietetics and public health nutrition experience, required training, and time in direct services. Results suggest retirement rates similar to the public health workforce overall. Findings can be used by managers/administrators to prepare their organizations for worker retirement or to influence retirement intention. Further research is necessary to determine other factors impacting retirement decision.

Biscuits, sausage, gravy, milk, and orange juice: school breakfast environment in 4 rural Appalachian schools.

BACKGROUND: The purpose of this study was to assess the school breakfast environment in rural Appalachian schools to inform school environment intervention and policy change. METHODS: A total of 4 rural schools with fourth- and fifth-grade students in East Tennessee were assessed. A cross-sectional descriptive examination of the school food environment where food service managers submitted school menus, production sheets, and vendor bid sheets as part of the dietary data collection protocol for a school-based nutrition intervention study. The school breakfast environment was characterized in terms of calories, fat, saturated fat, and fiber from foods served on a per person basis using menus entered into Nutrient Data Systems for Research and production sheets for amounts of each food item served. Food items were grouped by the meal components of the School Breakfast Program (SBP) and ranked according to the items served most frequently. RESULTS: Total fat provided slightly less than half the calories (43%); 15% of calories were from saturated fat. The top-ranked foods for each meal component were biscuits, sausage, 2% milk, orange juice, and gravy. CONCLUSIONS: Results suggest that clearer policies or regulations for the SBP are warranted to support policy efforts to promote childhood health. These should include technical assistance and provision of resources for school food service managers to provide low-fat meal options. Further research is needed to determine whether what is offered at school breakfast is actually consumed and how that might affect children's weight because of the high fat content.

Food group adherence scores assess food patterns compared to US Department of Agriculture Food Guide.

OBJECTIVE: The purpose of this study was twofold: (a) develop and test the potential usefulness of a new measure of dietary adherence to the US Department of Agriculture (USDA) Food Guide and (b) use this measure to assess the diets of children in the United States. DESIGN: Using 2 days of food intake data from the 1994-1996, 1998 Continuing Survey of Food Intakes by Individuals, food group adherence scores for individual food groups were calculated based on intake and recommendations from the USDA Food Guide. SUBJECTS: Two samples of children, age 2 to 3 years (n=2,815) and 4 to 8 years (n=3,769), were selected from the 1994-1996, 1998 Continuing Survey of Food Intakes by Individuals. STATISTICAL ANALYSIS: Descriptive statistics were computed by age and sex. Linear regression analysis was used to detect significant differences in adherence scores and number of servings consumed between age groups after adjusting for factors that impact intake. RESULTS: Comparing the two age groups, differences in the food group adherence scores for some food groups did not mimic the differences seen in mean number of servings from the same food group. For these two age groups of children, although the number of servings from the food groups significantly increased with increasing age, the adherence scores significantly decreased, reflecting decreased adherence to the recommended food patterns by age. CONCLUSIONS/IMPLICATIONS: Results suggest adherence to the USDA Food Guide decreases with increasing age in young children in the United States. Adherence scores may be a useful tool to describe adherence to the new USDA Food Guide. These scores could be used in program evaluation, surveillance, and epidemiological studies of diet and health.

Dietary patterns of young, low-income US children.

OBJECTIVE: The purpose of this study was to identify dietary patterns of young, low-income US children, describe differences in diet quality between identified patterns, and make targeted food recommendations to improve diet quality. DESIGN: Dietary patterns were assessed using dietary variables from the Pyramid Servings Database within the Continuing Survey of Food Intakes by Individuals 1994-1996, 1998. Healthy Eating Index (HEI) scores were used to validate identified dietary patterns. SUBJECTS/SETTING: Two subsamples of low-income children, aged 2 to 3 years (n = 1,242) and 4 to 8 years (n = 1,506), were selected from the Continuing Survey of Food Intakes by Individuals data. STATISTICAL ANALYSIS: Cluster analysis was performed to determine unique dietary patterns within the two subsamples. Linear regression analyses were used to compare energy intake, discretionary fat, added sugars, and HEI scores across cluster groups. Descriptive statistics were computed for each cluster. RESULTS: Cluster analysis identified six and seven distinct dietary patterns for the younger and older children, respectively. Four patterns were similar for both age groups. For the 2- to 3-year-old children, energy intake, overall HEI scores, and nine of the 10 HEI component scores differed among the four most prevalent dietary patterns. Among the older children, energy intake and six of the HEI component scores differed between the four most prevalent clusters but not overall HEI. CONCLUSIONS: Neither age group had a cluster of children who followed a balanced/moderate diet pattern consistent with Food Guide Pyramid recommendations. Children consuming almost every pattern identified could benefit by reducing added sugars and discretionary fat and increasing low-fat, low-sugar options from the vegetables, fruits, meat, and milk groups.

Lower risk of overweight in school-aged food insecure girls who participate in food assistance: results from the panel study of income dynamics child development supplement.

BACKGROUND: A quarter of US children are at increased risk of obesity-related health problems because of excess weight. The few national studies of child overweight and inadequate household resources available to purchase healthy foods, or food insecurity, have shown inconsistent results. We hypothesized that the inconsistency in these results may be attributed to a differential effect of participation in food assistance programs in food secure and food insecure households. METHODS: Using the 1997 Panel Study of Income Dynamics Child Development Supplement, we compared the risk of a child aged 5 to 12 years being at or above the 85th percentile of body mass index for age in food insecure and food secure, low-income households when controlling for participation in the Food Stamp Program and the national school lunch and breakfast programs as well as other covariates. RESULTS: We found that food insecure girls who participated in all 3 programs had a 68% reduced odds (odds ratio, 0.32; 95% confidence interval, 0.12-0.77) of being at risk of overweight when compared with food insecure girls in nonparticipating households and controlling for other factors. Girls in food secure households generally had no greater or less risk of overweight if they participated in any or all programs. Boys in both food insecure and food secure households had no greater or less risk of overweight by if they participated in any or all of the programs. CONCLUSIONS: These results support our hypothesis that food assistance programs play a protective role for low-income children's health, particularly in girls in food insecure households.

EFNEP: a nutrition education program that demonstrates cost-benefit.

OBJECTIVE: Data on the economic value of nutrition education programs, such as the Expanded Food and Nutrition Education Program (EFNEP), can help decision makers choose among alternative programs based on costs and benefits. A cost-benefit analysis of EFNEP was conducted to determine if participants' savings in food expenditures exceeded program implementation costs. DESIGN/SUBJECTS: Costs were collected over 6 months using expenditure reports and other records. Benefits were determined using prospective data from 371 women enrolled in EFNEP who completed a 24-hour food recall and behavior survey, and recorded the amount of money spent monthly on food at program entry and exit. Two treatment groups received nutrition education and one group did not receive education. One treatment group estimated food expenditures from recall and the other collected register receipts or recorded expenditures. Control group subjects reported expenditures from recall. Net present value (NPV) was calculated using mean EFNEP cost per participant subtracted from the mean change in family food expenditures per participant over a 5-year period at three discount rates. STATISTICAL ANALYSES: Analysis was designed to compare food expenditures among the two experimental groups and control group and food and nutrient intakes and survey scores between the combined experimental group and control group. RESULTS: The average EFNEP program cost perparticipant was $388, and graduating participants reported that family food expenditures decreased on average by $10 to $20 per month or $124 to $234 over a year. When benefits were projected to last 5 years, the NPV was $147 to $696 depending on the method of food expenditure estimation and the discount rate. At the same time individuals reduced food expenditures, they increased intakes of iron, vitamin C, vitamin B-6, and fiber. They added less salt when cooking and read nutrition labels more often. They also reported not running out of food at the end of the month as often. APPLICATIONS/CONCLUSIONS: Findings from this research showed that EFNEP is cost-beneficial. The magnitude of the savings in food expenditures is sensitive to the method of food expenditure reporting and assumptions about how long participants will retain the behaviors they learn.

Nutrition education is positively associated with substance abuse treatment program outcomes.

The scope and types of nutrition services provided in substance abuse treatment programs has not been well defined nor has there been an attempt to determine if associations exist between the provision of nutrition services and substance abuse treatment outcomes. The objectives of this study were to assess the provision (use and extent) of nutrition education in substance abuse treatment programs in facilities that provide a single or two or more substance abuse treatment programs, and to determine the possible association between nutrition intervention and substance abuse treatment program outcome measures (defined as changes in Addiction Severity Index [ASI] composite scores). A descriptive, single, cross-sectional survey of registered dietitians with clinical nutrition program management responsibility (n=152) was used to define the use and extent of nutrition services in substance abuse treatment programs. Positive associations between nutrition services provided, particularly nutrition education services and substance abuse treatment program outcome measures, were detected. When group nutrition/substance abuse education was offered, ASI psychological and medical domain scores improved by 68% and 56%, respectively (P<.05). Individual nutrition/substance abuse education was a predictor of ASI family/social domain change scores improving by 99% (P<.05). In those programs where group nutrition/substance abuse education was offered, moderate to strong correlations with various nutrition education services were observed, specifically in individual nutrition/substance abuse education (r=0.51; P<.05), group normal/nutrition education (r=0.64; P<.01), and individual normal/nutrition education (r=0.46; P<.05). Substance abuse treatment programs offering group nutrition/substance abuse education offered significantly (P<.05) more nutrition services overall. Findings support the position that nutrition education is an essential component of substance abuse treatment programs and can enhance substance abuse treatment outcomes. Dietitians should promote and encourage the inclusion of nutrition education into substance abuse treatment programs.

Food insufficiency is not related to the overall variety of foods consumed by young children in low-income families.

This study explored the relationship between food sufficiency status and redundancy of food choices, or dietary variety, among children in low-income families using the Variety Score from the Healthy Eating Index. Two samples of children ages 2 to 3 (n=1,242) and 4 to 8 years (n=1,506) were selected from the Continuing Survey of Food Intakes by Individuals 1994-1996, 1998 and then classified as either food sufficient, food sufficient with limitations, or food insufficient. Mean variety scores were low for all children, but did not differ by food sufficiency status for either age group. However, they did differ by Special Supplemental Nutrition Program for Women, Infants, and Children participation and region of the country for the younger and older children, respectively. Results suggest the importance of nutrition education and food assistance programs that enhance dietary variety. Further research should explore how food assistance program participation is related to dietary variety and the degree to which variety within food groups is related to food security.

Population risk factors and trends in health care and public policy.

Many factors affect the current and future practice of dietetics in the United States. This article provides an overview of the most important population risk factors and trends in health care and public policy that are anticipated to affect the current dietetics workforce and future of dietetics training and practice. It concludes with an overview of the state of the current workforce, highlighting the opportunities and challenges it will face in the future. Demographic shifts in the age and racial/ethnic composition of the US population will be a major determinant of future the dietetics profession because a growing population of older adults with chronic health conditions will require additional medical nutrition therapy services. Dietetics practitioners will work with an increasingly diverse population, which will require the ability to adapt existing programs and services to culturally diverse individuals and communities. Economic factors will affect not only the type, quantity, and quality of food available in homes, but also how health care is delivered, influencing future roles of registered dietitians (RDs) and dietetic technicians, registered (DTRs). As health care services consume a larger percentage of federal and corporate expenditures, health care agencies will continue to look for ways to reduce costs. Health promotion and disease prevention efforts will likely play a larger role in health care services, thus creating many opportunities for RDs and DTRs in preventive care and wellness. Increasingly, dietetics services will be provided in more diverse settings, such as worksites, community health centers, and home-care agencies. To address population-based health care and nutrition priorities effectively, dietetics practice will need to focus on appropriate evidence-based intervention approaches and targets. The workforce needs to be skilled in the delivery of culturally competent interventions across the lifespan, for all population groups, and across all levels of the social-ecological model for primary, secondary, and tertiary prevention. Because there is an assumption that the dietetics profession will experience rates of attrition of 2% to 5% based on historical workforce data, an important consideration is that the current dietetics workforce is limited in terms of diversity. An increasingly diverse population will demand a more diverse dietetic workforce, which will only be achieved through a more focused effort to recruit, train, and retain practitioners from a variety of racial, ethnic, social, and cultural backgrounds. In addition, the geographic distribution of RDs and DTRs must be addressed through strategic planning efforts related to dietetics training to provide access to and delivery of services to meet population needs. Furthermore, the health care workforce is projected to bifurcate as a result of growth in demand for the "frontline workforce" that works in direct patient contact. This bifurcation will require the dietetics profession to consider new practice roles and the level of education and training required for these roles in relation to how much the health care delivery system is willing and able to pay for services. There are many challenges and opportunities for the dietetics workforce to address the changing population risk factors and trends in health care and public policy by working toward intervention targets across the social-ecological model to promote health, prevent disease, and eliminate health disparities. Addressing nutrition-related health needs, including controlling costs and improving health outcomes, and the demands of a changing population will require careful research and deliberation about new practice roles, integration in health care teams, workforce supply and demand, and best practices to recruit and retain a diverse workforce.

The Public Health Nutrition workforce and its future challenges: the US experience.

OBJECTIVES: To describe the US public health nutrition workforce and its future social, biological and fiscal challenges. DESIGN: Literature review primarily for the four workforce surveys conducted since 1985 by the Association of State and Territorial Public Health Nutrition Directors. SETTING: The United States. SUBJECTS: Nutrition personnel working in governmental health agencies. The 1985 and 1987 subjects were personnel in full-time budgeted positions employed in governmental health agencies providing predominantly population-based services. In 1994 and 1999 subjects were both full-time and part-time, employed in or funded by governmental health agencies, and provided both direct-care and population-based services. RESULTS: The workforce primarily focuses on direct-care services for pregnant and breast-feeding women, infants and children. The US Department of Agriculture funds 81.7 % of full-time equivalent positions, primarily through the WIC Program (Special Supplemental Nutrition Program for Women, Infants, and Children). Of those personnel working in WIC, 45 % have at least 10 years of experience compared to over 65 % of the non-WIC workforce. Continuing education needs of the WIC and non-WIC workforces differ. The workforce is increasingly more racially/ethnically diverse and with 18.2 % speaking Spanish as a second language. CONCLUSIONS: The future workforce will need to focus on increasing its diversity and cultural competence, and likely will need to address retirement within leadership positions. Little is known about the workforce's capacity to address the needs of the elderly, emergency preparedness and behavioural interventions. Fiscal challenges will require evidence-based practice demonstrating both costs and impact. Little is known about the broader public health nutrition workforce beyond governmental health agencies.