Population Risk Factors and Trends in Health Care and Public Policy Betsy Haughton, Edd, RD, LDN; Jamie Stang, Phd, MPH, RD, LN

WORKFORCE DEMAND STUDY Results and Recommendations

Population Risk Factors and Trends in Health Care and Public Policy Betsy Haughton, EdD, RD, LDN; Jamie Stang, PhD, MPH, RD, LN

EXECUTIVE SUMMARY 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. Further- more, 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. J Acad Nutr Diet. 2012;112(suppl 1):S35-S46.

HERE ARE MANY FACTORS THAT nomic conditions that have an impact on to immigration (4); the proportion of res- have an impact on the current and access to healthful food, and shifts in pub- idents who were born outside of the future practice of dietetics. Demo- lic policy all affect the demand for and uti- United States increased from 6% to 12% graphic shifts in the US population, lization of dietetics services. Although it between 1980 and 2007 (5). changes in the prevalence rates of can be difficult to project future trends, The racial and ethnic distribution in the Tacute and chronic diseases, consumer current data are useful for estimating the United States will continue to change trends in health care, changes in eco- influence of these indicators. through the middle of this century. By This article, part of a series of technical 2050, it is estimated that 50% of the popu- articles to guide the dietetics profession Meets Learning Need Codes 1000, 1040, 1080, lation will be white non-Hispanic, 14% as we move forward to meet the changing 4000, and 4080. To take the Continuing black, 24% Hispanic, 8% Asian, and 4% other demands for dietetics services, will at- Professional Education quiz for this article, log (3). The shift in the racial and ethnic back- in to www.eatright.org, click the “My Profile” tempt to gather and evaluate data regard- link under your name at the top of the ing these factors and determine how they ground of the US population will require homepage, select “Journal Quiz” from the will affect dietetics training and practice. that dietetics practitioners be knowledge- menu on your myAcademy page, click This article will also provide a snapshot of able of the health care needs and food-re- “Journal Article Quiz” on the next page, and the current dietetics workforce, including lated customs of people from a variety of then click the “Additional Journal CPE Articles” backgrounds, including those from other button to view a list of available quizzes, from strengths, weaknesses, and gaps. which you may select the quiz for this article. parts of the world. Furthermore, differ- POPULATION RISK FACTORS ences in health behaviors and beliefs, traditional health practices, chronic disease Demographic Trends Affecting risk factors and prevalence rates of disease, disparities in health risk factors and Statement of Potential Conflict of Interest the Practice of Dietetics and Funding/Support: See page S46. In 2009, there were 307 million residents outcomes, and trends in disability will in the United States, an increase of 26 mil- have an impact on the demand for and re- lion since 2000 (1). The US Census Bureau quirements of dietetics services. Dietetics Copyright © 2012 by the Academy of Nu- estimates the US population will com- education and training programs will trition and Dietetics need to provide appropriate learning op- 2212-2672/$36.00 prise approximately 420 million people doi: 10.1016/j.jand.2011.12.011 by 2050 (2,3). More than 30% of the portunities so that dietetics practitioners growth in the US population is attributed are prepared to meet the needs of an in-

creasingly diverse population of consum- tions of daily activity, there is a variety of increasing demand of families and indi- ers. reasons why individuals lack access to viduals living in poverty, opportunities to The age distribution across the US popu- healthful foods, including limited access consult with or administer these pro- lation is also expected to change dramati- to food within the community, lack of grams and services will present for RDs cally over the next few decades. Through housing with food storage and prepara- and DTRs. the middle of the century, the percentage of tion capabilities, and economic factors Access to an adequate supply of health- older Americans—individuals aged 65 years that affect the ability to purchase food. ful foods is an issue that affects people of and older—will increase from 12% to 20% of The proportion of individuals living in all income levels and is of concern to the entire population, representing the poverty is currently estimated at 14.3% many dietetics practitioners. Data from largest shift to date in age-related demo- (8). There are disparities in rates of pov- the US Department of Agriculture suggest graphics. Currently, approximately one erty, however, with 9% of whites, 26% of that approximately 6% of US households quarter of the US population is younger blacks, 25% of Hispanics, and 12% of Asian experience access-related problems that than age 18 years, a proportion that is pro- Americans living in poverty. More than limit the purchase of the type or quality of jected to remain largely unchanged one in five children lives in poverty, com- food. Among US households, 3% live from through at least 2050 (1-3). Furthermore, pared with 13% of people aged 18 to 64 one-half mile to 1 mile from a supermar- although people aged 18 to 44 years and years and 9% of adults aged 65 and older. ket and lack access to a vehicle or other 45 to 64 years currently compose approx- Among those living below the poverty mode of transportation; 2% live at least 1 imately 38% and 25% of the population, re- line are 7% of working families, 25% of mile from a supermarket and do not have spectively, by the middle of the century, households affected by unemployment, vehicle access (13)—this situation is more these percentages are anticipated to de- and 15% of households affected by layoffs prevalent in low-income rural and urban cline to 34% and 22%, respectively. (9). Compared with individuals living in areas, the same areas in which food inse- The changes in percentages of people higher-income households, individuals curity rates are higher. aged 65 and older will occur because of living in poverty are less likely to have ad- RDs and DTRs in the community nutri- generational changes in birth rates as well equate access to health care services and tion and public health sectors will con- as increased life expectancy. Life expec- adequate food supplies. tinue to play an important role in the area tancy has increased dramatically in the Approximately 15% of the US popula- of food insecurity and food access. These past century among all racial and ethnic tion experienced food insecurity—de- roles will include direct service provision; groups; however, racial and ethnic dis- fined as a reduced quality, variety, or program management; outreach and parities in life expectancy exist. White desirability of diet with little or no indica- marketing of programs; evaluation of males born in 2006 can expect to live 76 tion of reduced food intake—in 2008 food and nutrition assistance programs; years, whereas their black counterparts (10,11). Approximately 6% of US residents and, over the next few decades, adminis- can expect to live 70 years; white fe- reported very low food security, defined tration of food and nutrition assistance males born in 2006 can expect to live 81 as multiple indications of disrupted eat- programs designed to meet the needs of years compared with 77 years for black the increasingly diverse population. ing patterns and reduced food intake females (6,7). Furthermore, although (10,11). The prevalence of food insecurity women have consistently lived longer varies greatly, with the highest rates Trends in Chronic Diseases and than men and continue to do so, the sex among families living in poverty, single- gap in life expectancy has been closing, Health Conditions parent families with children, and non- and it is anticipated that this trend will Overweight and obesity are common white households. Individuals and fami- continue during the next few decades. health conditions associated with an in- lies living in large cities or rural areas Longer lifespans and an aging popula- creased risk for cardiovascular disease, tion will likely result in increased preva- experience food insecurity more often stroke, type 2 diabetes, some types of can- lence of chronic diseases more common than those living in suburbs or small cities cer, hypertension, osteoarthritis, and gall- among older adults, such as hypertension, and towns. bladder disease (14-18). Currently, 68% of diabetes, end-stage renal disease, some Regional differences exist with food in- adults have a body mass index (BMI; cal- types of cancer, Alzheimer’s disease, and security—it is most common in the South, culated as kg/m2) Ͼ25 (classified as over- dementia and will affect the demand for moderately common in the Midwest and weight) and 34% are obese, with a BMI dietetics services as these chronic health West, and least common in the Northeast. Ͼ30 (14). Among adults, 6% have a BMI conditions frequently dietary interven- Families and individuals living in poverty Ͼ40. Although the prevalence of over- tion. Older adults are also more likely to are eligible for food-assistance programs, weight and obesity has increased consid- be admitted to hospitals and nursing such as the Supplemental Nutrition Assis- erably in the past several decades, recent homes, where dietetics practitioners (reg- tance Program (SNAP); the Special Sup- data suggest that the rates have remained istered dietitians [RDs] and dietetic tech- plemental Nutrition Program for Women, more stable in the past 8 years (14). nicians, registered [DTRs]) will oversee Infants, and Children (WIC); Child and The incidence of overweight (BMI their nutrition care. Adult Care Feeding Program; Summer Ն85th percentile but Ͻ95th percentile for Home care services for elderly people Food Service Program; and The Emer- age and sex) among US children and ado- also will be in demand as life expectancy gency Food-assistance Program (12). lescents is 32% (19). Seventeen percent of increases, and RDs and DTRs will be Food-assistance program use is common youth are considered obese (BMI Ն95th needed to manage the nutrition care of among food-insecure households, with percentile), and 12% have a BMI Ն97th acutely and chronically ill older adults 55% utilizing the National School Lunch percentile for age and sex. Overweight and are likely to work as part of a compre- Program, SNAP, and/or WIC (13). One in and obesity among youth are correlated hensive home health care team. five food-insecure households obtains with higher rates of hyperlipidemia, hy- However, much of this impact on de- food from a food pantry and 3% eat meals pertension, liver disease, sleep disorders, mand is contingent on funding. An in- at an emergency food kitchen. All children orthopedic disorders, and obesity later in creased need does not automatically re- can participate in the National School adulthood (20). As with adults, the dra- sult in increased reimbursement. Breakfast and Lunch Programs; however, matic increase in rates of child and adoles- the costs of the meals vary by family in- cent overweight and obesity seen in the Socioeconomic Factors Limiting come. Similarly, all adults older than 65 past 2 decades seems to be leveling off; years can participate in congregate dining however, it is not clear if this trend will Access to Healthy Food programs with out-of-pocket costs vary- continue long-term (19). Access to food will continue to be an issue ing by income status. As food-assistance The health care costs associated with for many Americans. In addition to limita- programs continue to grow to meet the obesity and related comorbid conditions

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are thought to be substantial. A recent in the United States who are at higher risk dietary intervention and moni- study indicates that health care costs re- for these conditions. toring. lated to obesity are mounting for private Approximately one third of cancers are • Schools are mandated to pro- and public payers (21). Diet and physical related to poor nutrition and lack of phys- vide food substitutions or mod- activity are considered the cornerstones ical activity, with up to 20% of cancer mor- ifications for children with spe- of lifestyle management in preventing tality related to overweight and obesity cial health care and/or dietary and treating overweight and obesity (26). These lifestyle risk factors have been needs (30). among youth and adults (15,20). associated with higher rates of cancer in • Specialized nutrition support is Heart disease is currently the leading the breast, ovaries, endometrium, colon, often required for preterm and cause of death among US adults, followed kidney, esophagus, pancreas, and gall- low birth weight babies. bladder. Being overweight or obese can by cancer, stroke, chronic lower respira- RDs and DTRs will play a vital role in increase the likelihood of cancer recur- tory disorders, accidents (unintentional meeting the needs of individuals with rence and decrease survival rates for some injuries), and diabetes (22,23). Age-ad- limitations of activity in home, schools, types of cancer. RDs will continue to play justed rates of mortality from cardiovas- and social service and community agen- an important role in the treatment of can- cular disease and stroke have decreased cies serving disabled individuals and res- cer using MNT, and RDs and DTRs increas- substantially in the past 50 years; how- idential care settings, in addition to more ingly will be involved in cancer preven- ever, the rates of underlying chronic con- traditional acute-care facilities. ditions that contribute to cardiovascular tion by providing nutrition education and MNT is a key component in treating and cerebrovascular mortality remain lifestyle management, including obesity many of the chronic conditions men- high. Hypertension, a risk factor for both prevention and treatment. tioned previously; in fact, it is considered diseases, is present in 32% of adults aged A substantial proportion of the US pop- the cornerstone of treatment for diabetes, 45 to 64 years, with 51% of adults aged 65 ulation suffers from a limitation of activ- hypertension, and cardiovascular disease to 74 years reporting hypertension (22). ity; that is, reductions in physical, mental, (24,31-33). If there is funding, increases in Nutrition, physical activity, and weight and emotional well-being that interfere rates of these chronic conditions should management are key elements in the pre- with the ability to engage in age-appro- create more demand for RDs to provide vention and treatment of hypertension, priate daily activities, including the plan- MNT services in acute-care, ambulatory- heart disease, and stroke (24). ning, preparation, and consumption of care, and community-based settings. Elevated serum cholesterol levels place meals, related to chronic health condi- Lifestyle risk-factor modification and individuals at higher risk for cardiovascu- tions (27,28). Currently, 9% of school-aged weight-management services are essen- lar disease. During the past 2 decades, the children and up to 25% of adults aged 18 to tial components of health-promotion and proportion of the US population with high 65 years have a limitation of activity (29). disease-prevention programs. RDs and In adults older than 65 years, the rate of cholesterol levels declined from 20% to DTRs will play a more frequent role in pro- limitation of activity in the noninstitu- 16%, partly as a result of public education viding lifestyle and weight-management tionalized population is estimated at 62%. and screening for hypercholesterolemia services as part of health-promotion and For older adults, the typical causes are pri- and the introduction of medications to disease-prevention efforts within work- marily musculoskeletal conditions, fol- reduce serum cholesterol levels (22). sites, schools, community clinics, health lowed by mental illness, heart disease, Women are more likely to have elevated clubs, social service programs, and other hearing loss, diabetes, pulmonary disease, cholesterol levels than are men of the community settings. and dementia. Among children, learning same age. For example, 24% of women disabilities, attention-deficit hyperactiv- TRENDS IN HEALTH CARE AND aged 65 years and older have elevated ity disorder, other neuromuscular condi- PUBLIC POLICY cholesterol levels compared with 11% of tions, speech disorders, and intellectual men in that same age bracket. Medical nu- Traditionally, health care has been deliv- disability are the leading causes of activity ered in acute-care settings through hospi- trition therapy (MNT) and advice to in- limitations. Preterm birth (birth before 37 crease physical activity and reduce intake tals and hospital-based services. Ad- weeks’ gestation) and low birth weight vances in health care and industry-wide of dietary and saturated fat, often pro- Ͻ (birth weight 2,500 g) are risk factors for implementation of cost-savings strategies vided by RDs, are considered the first lines disabilities among children. In the past 4 of treatment for hyperlipidemia (24). have led to a dramatic change in the deliv- decades, rates of low birth weight and ery of health care services. Individuals in- Diabetes is a risk factor for cardiovascu- very low birth weight (birth weight lar disease and an individual cause of creasingly receive health care services in Ͻ1,500 g) have increased (22). As technol- ambulatory rather than acute-care facili- mortality. The age-adjusted rates of dia- ogy to save the lives of premature and ties. In 1990, there were 1,213,327 hospi- betes have increased in the past 2 de- very-low-birth-weight babies advances, tal beds available in the United States, but cades. Recent estimates suggest that 11% it is expected that rates of disability by 2007, there were 945,199 beds avail- of the adult population older than 20 among children secondary to these causes able (22). Many former hospital-based years has diabetes (22,23,25). Rates of di- will also increase. services, including renal dialysis, minor abetes increase with age—2.5% of adults Nutrition services are key components operations, and management of condi- aged 20 to 39 years old, 10% of adults aged of treatment for many of the causes of tions such as newly diagnosed diabetes 40 to 59 years, and 23% of adults aged 60 limitations of activity, such as the follow- are now performed on an outpatient ba- and older have diabetes. Rates are higher ing: sis, often in independent facilities that are among nonwhite populations and among • Individuals with sight and mus- not associated with a hospital or other men of all racial and ethnic backgrounds. culoskeletal disorders often re- health care system. Prediabetes, or impaired glucose toler- quire specialized education to Patients with complex medical condi- ance, is present in an estimated 7% of US enable them to shop for and tions, often requiring ongoing MNT ser- adolescents and 26% of US adults, or 57 prepare food and to feed them- vices, are discharged early from hospitals million Americans (25). It is expected that selves. with increasing frequency (22). Data from rates of diabetes and prediabetes will con- • Many of the medications used the National Hospital Discharge Survey tinue to increase as the population ages. to manage symptoms of physi- show that the average length of inpatient Other factors that can increase diabetes cal and mental health-related hospital stay was 7.3 days in 1980, but rates include high rates of overweight and chronic conditions that limit only 4.8 days in 2005 (34), with most pa- obesity among children and adults and in- daily activity have implications tients spending 3 days or less in a single creases in the number of nonwhite people for nutritional status requiring visit. More and more often, patients are

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required to seek care in an outpatient set- who meet health targets (such as weight there are myriad intervention models and ting or in their homes. Thus, RDs will more loss and improved serum lipid profiles), approaches, this article will briefly intro- commonly provide MNT in smaller and and reimbursement for annual well- duce life-course interventions—comple- more specialized facilities within commu- ness exams. An emphasis on developing mented by health-equity approaches that nity health centers and related organiza- health-promotion and disease-preven- are delivered across the levels of the so- tions or within the homes of homebound, tion programs in rural and underserved cial-ecological model—as a conceptual ill patients rather than within acute-care areas is included in this new health care framework to consider the current dietet- settings. legislation, which might provide ex- ics workforce in relation to population MNT has been proven cost-effective, panded roles for RDs, particularly in the priorities. These interventions will be de- particularly with regard to outpatient nu- area of annual wellness exams. Rural scribed in this section and are depicted in trition services for chronic health condi- health initiatives can also increase the de- the Figure. tions such as diabetes, hyperlipidemia, mand for RDs and DTRs to offer telehealth and hypertension (35,36). (There is evi- services, defined by the Academy of Nutri- Life-Course Theory-Based Interventions. dence for health care cost improvements tion and Dietetics as follows (40): One way to conceptualize the importance from inpatient MNT, but it is not as strong of nutrition across the life cycle is life- as the evidence for outpatient nutrition ...the use of electronic information course theory, which proposes that bio- services.) Home management of complex and telecommunications technolo- logical and behavioral risk and protective medical conditions requiring parenteral gies to support long-distance clinical factors determine health trajectories nutrition has been shown to reduce health care, patient and professional (42,43). Specifically, optimal health tra- health care costs by $4,860 to $5,400 per health-related education, public jectories result when risk factors are re- month (Canadian dollars)* (37). As health health, and health administration, duced and protective factors are in- care costs continue to rise, such cost-ef- [that] includes both the use of inter- creased throughout life, but especially fective services offered within homes will active, specialized equipment, for during key developmental periods. Di- likely increase. Preventive health care ser- such purposes as health promotion, etetics practitioners then, have a role in vices will also play an increasingly impor- disease prevention, diagnosis, con- healthy aging from preconception on- tant role. sultation, and/or therapy, and non- ward by timing appropriate and effective In 2010, the Patient Protection and Af- interactive (or passive) communica- interventions that will have future and fordable Care Act (HR 3590) became law. tions, over means such as the long-term impacts on health (44). These Under this legislation, the next decade ex- Internet, E-mail, or fax lines, for com- interventions are to reduce risk factors pects to see reforms in the current health munication of broad-based nutrition and increase protective risk factors during care system designed to expand health information that does not involve each critical developmental period and care coverage to most Americans, to re- personalized nutrition recommenda- typically are delivered to individuals, duce the growth of health care costs over tions or interventions. families, and small groups. time, and to ensure that Americans have The Centers for Medicare and Medicaid As the overall US population ages, the access to affordable health insurance that dietetics workforce will need knowledge meets their lifetime needs (38). Following Services recognizes RDs as health care providers who can provide telehealth services and skills related to geriatric nutrition and are two important aspects of this historic delivery of services in a variety of access legislation that will affect the provision of for select medical conditions, including diabetes and some forms of kidney disease points, including senior home care with dietetics and nutrition services in the next and without home-delivered meals, as- decade (39): (41). Telehealth and other electronic forms of conveying MNT and/or health-promo- sisted living and extended care facilities, • the reorientation of the health and nursing homes. They also will need to care system away from acute tion and disease-prevention services will open avenues for RDs to reach individuals be skilled not only in chronic disease pre- disease management and to- vention and treatment, but also in how to ward a preventive care and and groups that might not currently have access to dietetics services. Dietetics educa- work with elderly people, who might wellness model; and have limited mobility and might wish to • the implementation of an im- tion programs will need to teach future practitioners the skills necessary to adopt remain actively engaged in their own food proved health care delivery and purchasing, food preparation, and storage payment system that integrates and utilize electronic health communication technologies. activities. It will not be enough to advise health care services of multiple these individuals regarding “what” and providers through an emphasis on A mandate for nutrition labeling on select restaurant menus and vending ma- “how” to eat, as these active seniors will medical homes and community want and need to prepare and consume health centers. chines is also included in the Patient Pro- tection and Affordable Care Act. This meals consistent with their mobility. At Funding for public health and preven- requirement will provide additional op- the same time, as new health technologies tion services included in the Patient portunities for RDs and DTRs to work with help sustain and extend life, dietetics Protection and Affordable Care Act will commercial foodservice operations to an- practitioners will need skills to help pro- strengthen community-based services alyze recipes, develop more nutrient- mote health for young and old, including such as employee screenings and well- dense foods, and improve menu options those with metabolic disorders, develop- ness programs, incentives for employees for individuals who wish to eat a healthful mental delays, and physical activity limi- diet away from home. tations.

*This study was performed using Intervention Approaches to Health Equity and Social Determinants Canadian dollars as the measurement. Address Population-Based Health of Health Models. Health disparities dis- proportionately affect particular popula- The conversion to US dollars would be Care and Nutrition Priorities $3,738-$4,154 (based on a conversion tion groups, such as minority popula- factor of $1.3 Canadian:$1 US dollar, Addressing these population priorities re- tions, those less educated, and those quires a dietetics workforce that is skilled living in poverty (45,46). Individuals using the average historical Canadian/ in delivering interventions informed by within these groups might know what a American exchange rate data found at research across the lifespan; for all popu- healthful diet is, but what they consume http://research.stlouisfed.org/fred2/ lation groups; and across all levels of the is inﬂuenced by social, governmental, data/EXCAUS.txt on January 10, social-ecological model for primary, sec- and legal systems that negatively affect 2012). ondary, and tertiary prevention. Although their ability to consume a healthful diet

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public policy community organizational pre-conception end of life interpersonal Population Differences individual Population Differences

Tertiary Prevention Secondary Prevention Primary Prevention

RD & DTR Workforce Figure. Framework for dietetics practice as prevention and interventions across the social-ecological model to promote health and eliminate health disparities through the life course. Figure concept courtesy of Shannon Looney, Knoxville, TN. and be physically active—for example, act with others who are different from force needs to be culturally competent as fresh fruits and vegetables might not be themselves, but also to the means by well as diverse. available or affordable, and neighbor- which their workplaces make services hoods might be unsafe for physical ac- culturally accessible to all. Levels of Prevention. The life-course ap- tivity (47,48). If dietetics practitioners Whether dietetics practitioners are in- proach is consistent with promoting are to help address health disparities to teracting with individual patients or cli- health and preventing overweight and optimize health trajectories, then they ents, families, community members, or obesity and chronic diseases. Primary pre- need knowledge and skills regarding en- other health professionals with whom they vention requires approaches to avert bio- vironmental and policy interventions work, they need to have awareness, knowl- logical risk factors, such as elevated serum that integrate principles of social jus- edge, and skills that enable effective cross- cholesterol and hypertension, and to in- tice, human rights, and social capital and cultural interactions that positively affect crease protective factors, such as access that can focus on the economic and so- interventions and professional exchan- to safe and affordable, healthful foods. cial barriers that promote or prevent ges (52-55). Although individual cultural Examples of primary prevention are en- the procurement, preparation, and con- competence is important, dietetics practi- vironmental and policy approaches to sumption of healthful foods (49,50). tioners also need the knowledge and skills increase physical activity, such as These interventions require population- to participate in crafting institutional pol- street-scale urban design and land-use and system-level knowledge and skills icies and practices that are culturally policies (60), policies to support local food of dietetics practitioners. competent and in collecting and using systems, nutrition and calorie labeling in disparity data that can be applied to de- restaurants and vending machines, policy Culturally Competent Interventions sign effective interventions for specific interventions about types of foods avail- and Systems. One characteristic that life- populations (38,56,57). able in schools (61,62), worksite wellness course, social determinants of health, and Closely aligned with cultural compe- programs to promote healthful eating and health-equity interventions have in com- tence is workforce diversity (58,59), physical activity (63), point-of-decision mon is that they need to be culturally which is frequently described by demo- prompts to encourage stair use (60), social competent to be accessible to all. Cultural graphic characteristics of the workforce, support interventions in communities to competence is defined by Cross and col- such as race and ethnicity, compared with increase physical activity (64), and behav- leagues (51) as “a set of congruent behav- those of the population served. Although ioral interventions to reduce screen time iors, attitudes, and policies that come to- diversity itself will not make individuals (65). gether in a system, agency, or among or organizations culturally competent, it Secondary prevention requires ap- professionals and enable the system, will help to promote use of nutrition and proaches to reduce existing risk factors. agency or those professionals to work ef- health care services by under-repre- These interventions can be delivered with fectively in cross-cultural situations.” Ac- sented groups, who are more likely to individuals and small groups, such as cording to this definition, cultural compe- seek services from professionals whom intensive behavioral interventions for tence relates not only to how individual they see as similar to themselves (58). adults with hyperlipidemia (66) and for dietetics practitioners practice and inter- Thus, the dietetics and nutrition work- sustained weight loss in obese adults (67).

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Secondary prevention also can be deliv- adopting new policies that are imple- Workforce Diversity ered as targeted media campaigns for mented and institutionalized as standard RDs are, as a group, predominantly fe- early detection and screening and as nu- practice (72). male, white/non-Hispanic or Latino, and trition education and food-assistance pro- Community-level interventions are in- grams to reduce nutritional risk, such as tended to change the neighborhood and in their mid-40s; a substantial proportion that provided through WIC. community environments where people are considering retirement by 2019 Tertiary prevention requires clinical ap- live—for example, by improving access to (74,75). The proportion of males is very proaches to treat disease. Examples are healthful foods and safe places to be phys- low among RDs and DTRs (4% of DTRs and case-management interventions to im- ically active. Example interventions are 3% of RDs). prove glycemic control in diabetes-man- participatory research strategies that DTRs are more diverse with regard to a agement programs (68), behavioral and engage community members in assess- number of racial and ethnic indicators. family-based counseling as part of multi- ing their neighborhood environments, More DTRs compared with RDs are black component pediatric weight-management including access to healthful and afford- (6% of DTRs vs 2% of RDs), Hispanic or La- programs to treat overweight children able food, and then in developing pro- tino (4% vs 3%), or “other” (2% vs 1%), and (35,36), and multicomponent coaching and jects to reduce barriers and take ad- fewer are white/non-Hispanic (78% vs counseling interventions to reduce and vantage of opportunities. Policy and 84%) or Asian (3% vs 5%). A striking differ- maintain weight loss (69). system-level interventions are intended ence in the two groups is that DTRs in gen- Each of these three prevention levels to change the social structures, policies, eral are older than RDs, with a median age requires different knowledge and skill and systems that affect many of the other of 48 years compared to a median age of sets. Primary prevention requires practi- intervention targets in the social-ecologi- 45 years among RDs. Only 12% of DTRs, tioners to consider interventions that cal model; these intervention strategies compared with 25% of RDs, are younger change the wide range of influences on in- include political action, lobbying, and pol- than 35 years. More than 20% of DTRs and icy advocacy to reform health care, individual and population behaviors. Sec- RDs (23% for both) are 55 years or older, cluding the role of nutrition and dietetics ondary prevention requires practitioners which is the time frame for considering and nutrition and menu labeling regulation to consider how to reduce risk factors, early retirement and retiring (74,75). In- which can be influenced not only by the development and food-assistance guide- deed, based on historical workforce data, environments where people live, work, lines. Community-, policy-, and system- there is an assumption of an attrition rate (a and play, but also by how people interact level interventions focus on population with each other and what they know health. percentage that comprises CDR-creden- about what constitutes a healthful diet tialed dietetics practitioners who will leave the workforce for reasons of emigration, ex- and how to select, prepare, and consume Research and Practice it. Tertiary prevention requires practitio- tended leave, retirement, or death) of 2% to ners to focus on disease treatment and The overall dietetics workforce will need 5% in dietetics (76). This suggests an aging then, specifically, to consider how to en- knowledge and skills to participate in pri- workforce comparable to that of the US gage the individual and the family and mary, secondary, and tertiary interven- population overall and of other health pro- caregivers with whom he or she interacts tions across the life course and target dif- fessions, including nursing (77). to control, treat, and ameliorate the dis- ferent levels of the social-ecological As a largely female, older, and white/ ease through MNT. model. The knowledge and skills used, non-Hispanic workforce, these data sug- which require critical thinking skills for gest that the profession has an important Intervention Targets. While primary, analysis and decision making for partici- responsibility to address not only cultural pating in activities such as analyzing re- secondary, and tertiary prevention de- competence as the nation becomes in- search publications, will need to be in- scribe the purpose of nutrition interven- creasingly more diverse, but also diversity formed by current research. It also is tions, the social-ecological model concep- of the future workforce itself through re- important to recognize the important role tualizes intervention targets (70,71), cruitment and retention strategies to pro- that some dietetics practitioners will have which influence what and how people eat mote diversity and replacements due to in generating and contributing to this re- and how physically active they are. At the search, which can range from the most ba- retirements. individual level, interventions are de- sic level (eg, from the genomic, subcellu- signed to change what people know, their lar, cellular, and multiorgan system skills, and behaviors, so that they have im- Current and Future Practice Areas levels) to that of human behaviors related proved eating and health outcomes; these to eating and physical activity and to that The majority of RDs and DTRs, 48% and intervention strategies increase motivation, of environments and policy that influence 51%, respectively, currently practice in self-efficacy, and behavioral capability. At these behaviors (eg, levels of the social- clinical health care (Table 1). This suggests the interpersonal level, interventions are ecological model) (73). that almost half of all RDs and DTRs are designed to change how people within an especially involved in tertiary and sec- individual’s social network influence that ondary prevention and in individual-level person’s eating and physical activity; these Current Dietetics Workforce: Who and interpersonal-level interventions re- intervention strategies include parenting Are They and How Do They lated to clinical health care. It is less clear interventions, buddy programs, and ap- how the remaining DTRs and RDs are proaches to change social norms about ap- Practice? practicing relative to the three prevention propriate food-portion sizes. Interventions In 2008, the Academy of Nutrition and Di- levels or the social-ecological model. at the individual and interpersonal levels etetics Foundation and Commission on include nutrition counseling in outpatient Dietetic Registration (CDR) completed a However, there is growing emphasis on settings and peer group sessions in WIC fa- comprehensive needs assessment of US the importance of primary prevention cilities or a worksite. dietetics practitioners using a stratified and environmental and policy interven- At the institutional/organizational level, probability sample (74,75). Results from tions with regard to their impact on pop- interventions are designed to change the this study estimated a total of 75,418 RDs ulation health—and this translates to an policies, practices, and environments of and 4,027 DTRs at that time. Current data important role for dietetics practitioners where people go to school, work, and eat about this workforce can be considered in who are trained with the necessary skill away from home—for example, moving a relation to population priorities and used sets. How dietetics practitioners position school from simple awareness of the need to estimate future workforce needs to ad- themselves to be part of these interven- to change competitive food policies to dress these priorities. tions might be critical for future practice.

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Table 1. Primary practice areas for registered dietitians and dietetic technicians, registered, working in the dietetics profession: 2008 needs assessment compared to new practice areas

Registered Dietetic technician, Primary practice area (2008)a dietitian (%)a registered (%)a New practice areas (2010)bcd

Clinical, inpatient 21 29 Clinical health care Clinical, outpatient 17 1 Clinical, long-term care 10 21 Community nutrition 11 8 Health promotion/disease prevention Food and nutrition management 8 15 Management of food and nutrition services Consultation/business practice 4 1 NAe Education/research 8 5 Research Higher education Multiple 11 10 NA Other 4 3 NA Public policy/advocacy

aSource: Rogers (75). bSource: American Dietetic Association. Report to the House of Delegates: Final Report of the Phase 2 Future Practice and Education Task Force. July 15, 2008, unpublished. cSource: Gilbride J, Parks S, Dowling R. Framework for analyzing supply and demand for the dietetics profession. 2011, unpublished. dSource: Collier (78). eNAϭnot applicable.

Shifting Intervention Approaches ers, insurers, and individuals will con- 9.2% and 13.9%, respectively, from 2008 to and Changing Practice Roles tinue to look for ways to control health 2018, these increases are less than that care costs, particularly related to person- projected for other sectors of the health Comprehensive health care reform stipu- nel. Health care workforce projections care workforce, such as home health aides lated in the Patient Protection and Afford- from the Bureau of Labor Statistics for (50.0%), personal and home care aides able Care Act and projections about the 2008 to 2018 are for substantial growth in (46.0%), recreation and fitness workers future health care workforce have impli- the “frontline workforce” of health care (21.2%), and health educators (18.1%) cations for the dietetics profession over personnel with a bachelor’s degree or less (79). These projections suggest an impor- the long-term. As noted previously, the and who will have extensive direct pa- tant role for dietetics practitioners, who health care reform bill has three goals: tient contact [(78-80) (and American Di- will remain providers of patient-care ser- • health insurance coverage for etetic Association. Report to the House of vices, but also might assume increased re- the uninsured; Delegates: Final Report of the Phase 2 Future sponsibilities as consultants and manag- • improved affordability and sta- Practice and Education Task Force. July 15, ers of those in the frontline workforce, bility of coverage for those with 2008, unpublished; Gilbride J, Parks S, who will have more extensive and ex- health insurance; and • Dowling R. Framework for analyzing sup- panded direct-care contact. slow growth of health care costs ply and demand for the dietetics profes- Related to growth of the frontline work- (38). sion, 2011, unpublished), such as home force is bifurcation of the health care Implementation will shift from a fee-for- health aides and personal and home care workforce (78), as the proportions of per- service payment model to preventive, pa- aides. As health care costs increase, indi- sonnel with lower levels of education (as- tient-centered approaches, including the viduals also will seek lower-cost alterna- sociate’s degree or less) and those with patient-centered medical home and ac- tives. For example, elderly adults may higher levels of education (graduate de- countable care organization models, and a seek home-based care instead of long- gree) increase, but the proportion of staff reformed delivery system with more pri- term, institutionalized care. Others may with bachelor’s degrees decreases. The mary care providers, medical homes, and seek services offered by health educators tension of employers trying to control community-based health centers (39). or fitness trainers and aerobics instructors personnel costs and professional associa- While future dietetics practitioners will to help them change their diet and be- tions trying to advance their professions continue to have a role in tertiary preven- come more physically active. This grow- will only continue. It will be important for tion, particularly related to chronic disease ing trend of the frontline workforce has the Academy of Nutrition and Dietetics management, they clearly have the poten- been noted within the public health nutri- and CDR to consider what level of educa- tial for expanded roles in primary and section workforce through enumeration sur- tion and training is appropriate in relation ondary prevention in individual- and inter- veys conducted by the Association of State to how much employers are willing to pay personal-level interventions. As members and Territorial Public Health Nutrition Di- (78,82,83). What qualifications are required of specialized and integrated care teams, directors since 1985. For example, data for future dietetics positions and what will etetics practitioners will play an important from 1999-2000 and 2006-2007 enumer- the market bear for quality, nutrition-re- role, but they will need to position them- ations suggest a considerable increase in lated health outcomes? Currently, survey selves to other team members and to health the proportion of breastfeeding peer findings range from 34% of RDs having an insurers as recognized providers of nutri- counselors (0.4% vs 12.6%) working with advanced degree in dietetics, food, nutrition, tion and dietetics services. the WIC program (81). Whereas the Bu- or a related field (74,75) to up to half of all RDs At the same time that health care re- reau of Labor Statistics projects that RD having any advanced degree (85), whereas form is implemented, health care employ- and DTR positions will grow at rates of only 1% of DTRs having an advanced degree

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Table 2. State-speciﬁc ratios of dietetics practitioners per 100,000 population, United States

Population Ratio RDsa DTRsb State n RD per 100,000c Rank State n DTR per 100,000c Rank

North Dakota 356 55.0 1 Maine 105 8.0 1 New Hampshire 480 36.2 2 Ohio 721 6.2 2 Minnesota 1,894 36.0 3 Wisconsin 226 4.0 3 Nebraska 641 35.7 4 Connecticut 107 3.0 4 Massachusetts 2,287 34.7 5 Minnesota 144 2.7 5 Vermont 209 33.6 6 New York 526 2.7 6 Connecticut 1,179 33.5 7 Pennsylvania 230 1.8 7 Wisconsin 1,875 33.2 8 New Hampshire 23 1.7 8 Rhode Island 341 32.4 9 Nebraska 31 1.7 9 Ohio 3,728 32.3 10 New Jersey 143 1.6 10

South Dakota 261 32.1 11 Florida 265 1.4 11 Colorado 1,574 31.3 12 North Dakota 8 1.2 12 Kansas 871 30.9 13 Washington 82 1.2 13 Iowa 925 30.8 14 Missouri 70 1.2 14 Pennsylvania 3,749 29.7 15 Indiana 73 1.1 15 Maryland 1,692 29.7 16 Arizona 74 1.1 16 Washington 1,970 29.6 17 California 405 1.1 17 Montana 283 29.0 18 Illinois 129 1.0 18 New York 5,578 28.5 19 Colorado 47 0.9 19 Idaho 441 28.5 20 Oregon 35 0.9 20 New Jersey 2,437 28.0 21 Massachusetts 56 0.8 21 Delaware 246 27.8 22 Arkansas 24 0.8 22 Michigan 2,738 27.5 23 Virginia 64 0.8 23 Utah 747 26.8 24 Maryland 46 0.8 24 Kentucky 1,150 26.7 25 Vermont 5 0.8 25 Illinois 3,435 26.6 26 Louisiana 30 0.7 26 Maine 349 26.5 27 West Virginia 12 0.7 27 Missouri 1,579 26.4 28 South Dakota 5 0.6 28 Louisiana 1,184 26.4 29 Tennessee 37 0.6 29 North Carolina 2,460 26.2 30 Idaho 9 0.6 30 Hawaii 336 25.9 31 Michigan 57 0.6 31 District of Columbia 153 25.5 32 Rhode Island 6 0.6 32 Tennessee 1,584 25.2 33 North Carolina 47 0.5 33 Alaska 175 25.1 34 Kentucky 21 0.5 34 Indiana 1,600 24.9 35 Texas 119 0.5 35 Oklahoma 911 24.7 36 Nevada 12 0.5 36 Virginia 1,923 24.4 37 Delaware 4 0.5 37 Alabama 1,140 24.2 38 South Carolina 18 0.4 38 Oregon 911 23.8 39 Alabama 17 0.4 39

(continued on following page)

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Table 2. State-speciﬁc ratios of dietetics practitioners per 100,000 population, United States (continued)

Population Ratio RDsa DTRsb State n RD per 100,000c Rank State n DTR per 100,000c Rank

Mississippi 698 23.6 40 Kansas 10 0.4 40 Arkansas 679 23.5 41 Oklahoma 13 0.4 41

California 8,416 22.8 42 District of Columbia 2 0.3 42 Wyoming 120 22.0 43 Montana 3 0.3 43 Texas 5,136 20.7 44 Iowa 9 0.3 44 Arizona 1,304 19.8 45 New Mexico 5 0.2 45 New Mexico 397 19.8 46 Georgia 24 0.2 46 Florida 3,644 19.7 46 Mississippi 7 0.2 47 Georgia 1,879 19.1 48 Wyoming 1 0.2 48 South Carolina 870 19.1 49 Alaska 1 0.1 49 West Virginia 310 17.0 50 Utah 3 0.1 50 Nevada 422 16.0 51 Hawaii 1 0.1 51

Puerto Rico 202 5.1 52 Puerto Rico 1 0.0 52

aRDϭregistered dietitian. bDTRϭdietetic technician, registered. cBased on personal communication (with Chris Reidy, RD, September 2010) and Readex Research (74).

(74,75). What level of education and creden- are located; whether they practice at the tion, October 2010). The state-specific ra- tial is required to address individual and pop- primary, secondary, or tertiary preven- tios (expressed per 100,000 people) range ulation needs (84)? Training a qualified and tion levels; and how they practice across from 55.0 in North Dakota to 16.0 in Ne- marketable workforce will require educa- the lifespan and across the levels of the vada—so, in contrast to Nevada, where tional institutions and programs to have goals social-ecological model. Moreover, there there are only 16 RDs for every 100,000 and curricula aligned with workforce and are few staffing ratio recommendations residents, North Dakota, representing the population needs (82). available to interpret the number of peo- best ratio of RDs per person, has 55 RDs for ple served by dietetics practitioners in every 100,000 people in need of primary, Location of the Dietetics these different capacities. The staffing secondary, and tertiary prevention, across Workforce in Relation to recommendation used for public health the lifespan, and for interventions across dietetics practitioners with population/ the social-ecological model. These data Population Need system responsibilities in support of core demonstrate important state-specific dif- The location of dietetics practitioners geo- public health functions is 1:50,000 (88), ferences in available RDs per population graphically and within communities can but this recommendation dates to 1978 and suggest considerable differences in affect availability, access, and delivery of and its validity has not been tested. the availability of RDs for needed services, Currently, the Academy of Nutrition services, which raises additional ques- technical assistance/consultation, super- and Dietetics Research Committee and tions about the dietetics workforce. Are vision, and management. Clinical Nutrition Management Dietetic there areas where there are shortages in Table 2 reveals some additional points Practice Group is developing inpatient dietetics services? Within communities worth noting: and within facilities and agencies, how staffing models for RDs (89). The WIC pro- • Among the 10 states with the well do the types and numbers of dietetics gram also has been involved in research to best ratio of RDs per 100,000 practitioners match the needs of individ- develop professional staffing require- people, five are in the New Eng- uals and populations served? Answers to ments for local WIC agencies (90). How- ever, even with staffing ratio recommen- land region of the United States. these questions relate to health equity • and quality of care. For example, medi- dations, it is difficult to determine The ratios of DTRs per 100,000 cally underserved, minority, and rural workforce shortages and needs because are even lower than that for populations typically have more limited the distribution of personnel differs RDs, ranging from the best ra- access to health care and higher rates of across and within states and within com- tios of 8 DTRs per 100,000 in chronic disease (86). Shortages of primary munities and facilities (91). Maine to 0.1 DTRs per 100,000 care health professionals have been iden- A gross view of the overall dietetics in Hawaii. tified in Ͼ75% of rural counties; many of workforce across the United States is re- • Among the top 10 states for the these counties have no primary care pro- vealing in this regard. Table 2 shows the best ratios of RDs per population, vider (87). Similarly, RD shortages in rural number of RDs and of DTRs per 100,000 six states—New Hampshire, Min- communities also exist (39). population, based on 2009 state popula- nesota, Nebraska, Connecticut, There are limited data and research tions and data from CDR (Chris Reidy, CDR Wisconsin, and Ohio—also have available on where dietetics practitioners Executive Director, personal communica- the best ratios for DTRs.

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AUTHOR INFORMATION B. Haughton is a professor, Department of Nutrition, The University of Tennessee, Knoxville. J. Stang is an associate professor, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis. Address correspondence to: Jamie Stang, PhD, MPH, RD, LN, Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Suite 300 West Bank Office Building, 1300 South 2nd St, Minneapolis, MN 55454. E-mail: [email protected] STATEMENT OF POTENTIAL CONFLICT OF INTEREST: No potential conflict of interest was reported by the authors. FUNDING/SUPPORT: Publication of this article was supported by the Commission on Dietetic Registration as part of the Dietetics Workforce Demand Study. ACKNOWLEDGEMENTS: The authors wish to acknowledge Shannon Looney, MPH, RD, for her significant contributions to this manuscript, including thoughtful reviews, discourse, and edits to drafts and identification of foundation literature. In particular, her visual conceptualization of how the dietetics workforce relates to life-course interventions across all levels of the social-ecological model and for all groups is very much appreciated. At the time of this work, Looney was a doctoral student at The University of Tennessee, Knoxville, and a trainee in maternal and child health nutrition.

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