EVIDENCE OF NUTRITION IMPACT
Evidence of the impact of nutrition on maternal and child populations continues to mount.
- Inadequate weight gain during pregnancy has been linked to growth stunting and brain development problems. Poor prenatal nutrition may play a role in the development of chronic diseases in adulthood.
- Food insecurity or hunger in school age children is associated with increased illness and school absence and poor academic performance independent of poverty and illness.
- A controlled study measuring the association of school breakfast consumption and academic performance also showed that those who ate the school breakfast scored higher on exams than those without.
- National trends of poor food habits throughout childhood include increased soft drink consumption and an increase in caloric and fat consumption due to increases in snacking behavior.
- Iron deficiency anemia persists among infants, young children, adolescent girls, and pregnant women and is associated with cognitive deficits, decreased resistance to infection, fatigue, and impaired growth and development.
The relationship between chronic disease and nutrition during childhood and adolescence is established, and the current epidemic of obesity in children from ages 2–18 requires immediate interventions.
The challenge to nutrition training is to translate and disseminate this knowledge expansion clearly and regularly to maternal and child health professionals.
NUTRITION TRAINING PROGRAMS
The first graduate training program in public health nutrition was initially developed and financed with Social Security Act Title V funds in 1943.
By the early 1950s, five public health nutrition graduate training programs were funded around the country. Additional funding for public health nutrition graduate training became available in the 1950s through Social Security Act’s Title VII. While the locations of nutrition training programs have varied across the United States over the past 60 years, the commitment to training nutrition and health professionals in the areas of public health and community nutrition, pediatric and adolescent nutrition, maternal nutrition, perinatal and infant nutrition, and nutrition for children with special health care needs has remained the core component of all nutrition training grants. Currently the awards emphasize Centers of Excellence to improve Maternal and Child Health Leadership for promoting the healthy nutrition of the mother, child, and family through good nutrition.
Currently eight universities funded by the Maternal and Child Health Bureau (MCHB) offer nutrition training programs. Of these, University of California–Los Angeles, University of Minnesota, University of New Mexico, University of North Carolina–Chapel Hill, The University of Tennessee–Knoxville offer graduate training in public health nutrition, which leads to a masters or doctoral degree. Indiana University, The University of Alabama at Birmingham, and the Baylor College of Medicine offer one week to six month fellowships in pediatric or neonatal nutrition, as well as short-term (1–5 day) continuing education programs for health professionals. All eight programs offer continuing education opportunities for health professionals at the local, regional and national levels. The programs offer a variety of areas of nutrition expertise including maternal, infant, child and adolescent nutrition issues, children with special health needs, and public health.
From 1993 to 2000 the Maternal and Child Health Bureau supported masters level training programs that prepared 279 graduates. In addition, doctoral student enrollment increased from seven to 17 during this period and the programs mentored 102 doctoral students. Short term training programs provide important skill enhancement opportunities for practicing professionals. In the neonatal and pediatric training programs, 229 professionals completed a fellowship and, of those, 90% continued to work in MCH programs. Intensive courses on pediatric nutrition and maternal nutrition are offered annually and reached 1031 and 1097 professionals respectively. The University of Alabama at Birmingham offers an annual national videoconference which has reached 60,000 professionals growing from an audience of 3,000 to 10–12,000 per conference. Local continuing education activities offered by the graduate training programs reached over 10,880 professionals from every state in the U.S. Selected technical assistance and consultation activities of faculty are noted on the map inside.
Graduates of MCHB nutrition training programs have an impact at the national, regional, state, and local levels. The following six areas illustrate their leadership contributions or highlight this impact: Leaders in public health agencies, including HRSA, CDC, USDA and the Association of State and Territorial Public Health Nutrition Directors; Advocacy and community leadership, such as service on a local board of health, the Peace Corps in Ecuador, and a state hunger organization; Professional development and training directly through professional manuals, such as The Cost-Effectiveness of Nutrition Services for Children with Special Health Care Needs: A National Network, and leadership of the Western MCH Nutrition Leadership Network; Research and practice publications about high risk neonates and their nutritional needs, multi-cultural nutrition counseling competencies, child and adolescent obesity, and eating habits; National recognition through awards such as Dietitian for the Year given to a nutritionist in the US Public Health Service; Leadership in professional associations, including Public Health/ Community Nutrition and Pediatric Nutrition Practice Groups, ADA; and Food and Nutrition Section, American Public Health Association.
LEADERSHIP TO STRENGTHEN THE PUBLIC HEALTH INFRASTRUCTURE
Public health nutrition infrastructure was eroded during the past decade as health officials relied on funding from the WIC program to support nutrition activities, and moved previously designated maternal and child health funds to other program activities. The Nutrition Leadership Training Project Faculty filled the gap in a number of areas: trained state and regional nutritionists using a variety of distance education technologies for continuing education to reach professionals unable to travel; consulted with the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences; were recognized for their contributions and impact by the Medallion Award of ADA, the Agnes Higgins Award of APHA and ADA Practice Group awards; provided national leadership with the American Dietetic Association’s Pediatric Nutrition Practice Group and the House of Delegates; the Commission on Dietetic Registration (the credentialing agency for Dietetic Programs that certifies entry-level professionals); and the American Public Health Association’s Food and Nutrition Section.
The Nutrition Training Programs not only increase the number of public health nutritionists but also strengthen the capacity of personnel through on-going evaluation of curriculum and communication with leaders regarding needs and new demands.
The complexity of maternal and child nutrition requires increasingly sophisticated leaders. This is reflected in the increase of doctoral students, who are often returning practitioners.
DEVELOPMENT OF MODELS AND INNOVATIONS
With a decrease in the proportion of public health nutritionists to population in need, training program faculty often initiated or led model development and innovations to increase program effectiveness and to increase the efficiency of personnel. Some examples follow:
- A major advance in the field of pediatric nutrition was the development of criteria sets for the nutritional care of 25 different pediatric conditions or disease. This reference for practitioners makes their service delivery more effective and efficient.
- The American Dietetic Association established its first specialty board certification for the Pediatric Nutrition Specialty that helps to focus curriculum and guide experiences for practitioners who wish to advance to management and leadership positions.
- With the epidemic of childhood obesity the Guidelines for Childhood Obesity Treatment, Assessment and Referral provide managers a framework to estimate personnel needs, design service delivery, and evaluate strategies.
- The Guidelines for Adolescent Nutrition Services assists Adolescent Service Directors to engage nutritionists in their specialty program and better meet the needs of their adolescent clients.
- The Guidelines for Community Nutrition Supervised Experiences provides public health managers with a tool to “tutor” interested staff so they can work effectively with their clients and communities to bring about dietary change.
- To evaluate the extent to which working nutritionists could be prepared for public health nutrition, the Professional Practice Program in Nutrition piloted a public health nutrition curriculum using distance learning techniques and face-to-face teaching. It demonstrated that the four semester program could be taught in nine semesters part-time and students could graduate successfully.
- The Bright Futures project provided an excellent opportunity to update pediatric nutrition and establish pediatric physical activity practices. Bright Futures in Practice: Nutrition with its leaders guide and special growth chart materials is being distributed by the training programs, through annual teleconferences and extended contacts in the field.
- Bright Futures in Practice: Physical Activity is introducing new information to maternal child nutrition personnel and with the epidemic in childhood obesity, its practical guidance and suggestion are being eagerly received.
- There were participants from every state in continuing education activities offered by the Nutrition Training Programs. A sample of the technical assistance and consultation provided to states, regions, and the nation are identified on the map.
Baylor College of Medicine
MARION TAYLOR BAER
University of California-LA
University of Alabama at Birmingham
University of NC-Chapel Hill
University of New Mexico
University of Tennessee
Riley Hospital for Children
University of Minnesota
The Nutrition Training Programs have produced a wide variety of products with content that addresses the nutrition and health concerns of the diverse MCH population and their communities. The primary target audience for the products are working professionals and researchers, who impact the MCH population. Dissemination modes include print, presentations, audiovisuals, videotapes, satellite teleconferences, videostreaming, and web-based modules. All are available at the local, regional, national, and international levels. Although the primary focus of the programs is training, all Program faculty are involved with scholarly work as demonstrated by the 361 referred publications, 34 professional publications, 27 continuing education products, 10 proceedings, 23 abstracts, and 32 presentations authored by faculty. Program faculty have collaborated among themselves and with others, as demonstrated by collaborative research programs. Examples include:
- Dietary Intervention Study in Children (DISC) (University of Alabama)
- Pathways school-based intervention in American Indian children (University of Minnesota)
- Community-Based Public Health Initiative for prevention (University of North Carolina)
Consistent with the training emphasis, there have been 118 books, book chapters, and monographs and 16 committee monographs and statements. Program faculty have authored chapters in key reference texts for health care professionals, such as:
- Pediatric Nutrition Reference Manual
- Developmental and Behavioral Pediatrics
- Mosby’s Resource Guide to Children with Disabilities and Chronic Illness
- Nutrition Management of the Pregnant Adolescent
Leadership within MCHB’s Bright Futures initiative is demonstrated by co-editing and authoring of chapters for Bright Futures in Practice: Nutrition and Bright Futures in Practice: Physical Activity. Standards of practice and education are also products of the Program faculty, including, for example, Personnel in Public Health Nutrition for the 1990s and Strategies for Success: Curriculum Guide for Graduate Programs in Public Health Nutrition.
Leadership in developing and testing new modes of delivering continuing education has distinguished the programs.
Satellite teleconferencing and videostreaming to extend continuing education outreach initially was explored and tested by Program faculty at The University of Tennessee, Knoxville. This technology has been continued at Indiana University School of Medicine, University of Alabama-Birmingham and the University of Minnesota. Other modes continue to be explored, including web-based continuing education and modified train-the-trainer modules.
FUTURE – Minority Disparities in Health Outcomes
With the emphasis in Healthy People 2010 on disparities in minority health outcomes, the presence of diverse leadership in MCN programs is essential. Cultural competencies are included in the curricula of both short and long term training programs. Since 1994 the Nutrition Training Programs have trained 49 diverse nutritionists, including 23 African-American, nine Asian-American, seven Hispanic, and 10 other diverse ethnicities. Growth in the diversity of nutrition students is slow, but strategies are being initiated to increase summer internships and recruit directly from historically black and Native American and Hispanic institutions and communities.
MCN PERSONNEL – Maternal and Child Health Professionals
With the epidemic of childhood obesity, it is necessary to enlist every MCH professional in what it takes to improve children’s eating and physical patterns. Public and professional awareness of the problem and its impact on health; effective strategies to use in homes, schools, health care settings, communities, and the environment; and evaluation must be disseminated across the MCH field. The MCN Training Programs are logical centers for this activity.
Public Health Nutrition Work Force
HP2010 recognizes the importance of the public health infrastructure. Leadership is required to train the work force and provide knowledge and skill-based continuing education to meet the changing public health nutrition issues. The impending retirements of Baby Boomers is alerting health professionals to a shortage in senior personnel. Salaries continue to be low, which leads to early departures from the field if college students choose to enter at all. Reports are that competitive diverse college students are more likely to choose a health field that will demonstrate better return on their investment of time and money. New skills are continually required in practice. It is difficult to access training in these new skills due to computer limitations in agencies, decreased staff with increased tasks, and decreased budgets to reimburse for cost. Although there are new technologies and improved approaches to training, without investment at training sites to increase capacity of the programs, the economies of new training cannot be realized.
Nutrition for Children with Special Health Care Needs
From 1994 to 1998 a national course featuring the team approach to nutrition for children with special health care needs was tailored for 10 regional workshops held across the country. Participants attended as a team of two or three health profession-als from their organizations. It included staff from state and local health agencies and health and social organizations whose mission was comprehensive, community-centered, client-based care. A total of 575 people attended the courses which were taught at University of Southern California, University of Alabama at Birmingham, University of Washington, University of North Carolina, University of Kansas, and the University of Vermont. Almost 20% of the participants were health professionals representing diverse clients. Although the participants were predominately nutritionists, 20% were nurses and 35% other health professionals.
Academic Practice Faculty
There is a shortage of faculty for public health nutrition graduate programs who have the practice experience to make curricula and courses relevant and to conduct research to impact the MCH population. Because the academic programs are often small it may be difficult to support two full time faculty. For this reason doctoral trainees are important for both the future of public health nutrition and maternal and child nutrition programs.