Professional Documents
Culture Documents
Community Nutrition
For My Parents
No man is an island.
- John Donne
Abstract
Poor quality dietary habits are one of the most pressing public health
concerns of our time. As a society, we are faced with the paradox of
malnutrition and overconsumption existing side-by-side. Many people
in our communities deal with the stark reality of food insecurity coupled
with a reliance on inexpensive, nutrient-poor calories that contribute to
the nationwide prevalence of obesity, type 2 diabetes, heart disease, and
other chronic conditions.
As a resource for both students and practitioners, Public Health and
Community Nutrition provides an overview of how social determinants of
healthsocioeconomic factors that influence a populations or an individuals well-beingcontribute to the existence of health disparities in
the United States. Now more than ever, diet and health experts are needed
to address these 21st-century public health challenges that require specific
professional competencies related to nutritional assessment, knowledge of
food assistance and support options, and nutrition education skills that
are appropriate for targeted audiences.
Keywords
community nutrition, cultural competence, Dietary Guidelines for
Americans, food assistance, food deserts, health disparities, health equity,
health literacy, Healthy People 2020, hunger, NHANES, nutrition
education, public health, SNAP, social determinants of health, WIC
Contents
Prefacexi
Acknowledgmentsxiii
Introduction xv
Chapter 1 Assessing the Nutrition Status of Americans......................1
Chapter 2 Food Insecurity in the United States................................15
Chapter 3 Health Literacy................................................................27
Chapter 4 Cultural Competence......................................................37
Chapter 5 Federal Food and Nutrition Assistance Programs.............51
Chapter 6 Nutrition Education........................................................67
Additional Resources79
Key Terms81
Index85
Preface
Poor quality dietary habits are one of the most pressing public health
concerns of our time. As a society, we are faced with the paradox of malnutrition and overconsumption existing side-by-side. Many people in our
communities deal with the stark reality of food insecurity coupled with
a reliance on inexpensive, nutrient-poor calories that contribute to the
nationwide prevalence of obesity, type 2 diabetes, heart disease, and other
chronic conditions.
In the United States, one-third of adults are obese, while another third
are overweight. At the same time, about 25 percent of the U.S. population participates in at least one federal food and nutrition assistance
program including 47 million people who receive Supplemental Nutrition Assistance Program benefits, and 30 million children who receive
low-cost or free lunches each school day through the National School
Lunch Program.
Nutritional status largely depends on social determinants of health
factors that influence a populations or an individuals well-being such
as income, education, literacy level, language, and cultural perceptions
of health. Today, the U.S. poverty rate is close to 15 percent including
20 million Americans who are coping with extreme poverty, while many
communities find it difficult to procure healthy foods for their households
because of geographical location, inadequate transportation, low income,
and knowledge gaps in sound nutrition practices among other hurdles.
Furthermore, demographic data continues to reflect the diversity of
the nations population with minorities expected to account for more
than 50 percent of the total population by 2043. As the ethnic and racial
makeup of the United States changes, so too does the mix of languages
people speak. Currently, 21 percent of the U.S. population speaks another
language at home, creating linguistic barriers to high-quality health care
and information. Moreover, 20 percent of U.S. adults read at or below a
fifth-grade level, presenting additional issues with access to care for vulnerable segments of the population.
xii Preface
Now more than ever, diet and health experts are needed to address
these 21st-century public health challenges that require specific professional competencies related to nutrition assessment, knowledge of food
assistance and support options, and nutrition education skills that are
appropriate for targeted audiences.
Public Health and Community Nutrition is an excellent introduction
to the key concepts that characterize the nutrition-related problems seen
today in the public health and community setting. As a resource, this
book outlines the socioeconomic factors and other barriers to health
equity that influence nutritional status, and provides information on
tools and resources needed by nutrition experts working to solve these
pervasive problems amid an increasingly complex and diverse population.
Acknowledgments
It takes a village to raise a child, a community to create hope, and a loving
family to write a book. Thank you to my wonderful husband Nicholas,
who was so encouraging every step of the way, and to my beautiful and
ever-patient children Nicole and Benjamin, who put up with a distracted
mother for many months.
To Katie Ferraro and Peggy Williams at Momentum Press, a tremendous thank you for tolerating my changing deadlines, and for contacting
me in the first placeI so enjoyed the opportunity to research and write
this book.
Introduction
Many Americans are not eating as healthfully as they should. For the past
25 years as the countrys prevalence of overweight, obesity, and chronic
disease has increased, the Healthy Eating Index (HEI)an assessment
of how our food habits nutritionally measure up to guidelineshas
remained consistently low (Dietary Advisory Committee Report 2015a).
This mismatch between established science-based dietary standards and
the way Americans actually eat presents an enormous public health
challenge for both policymakers and health care providers.
The problem is a serious one, as poor quality dietary habits as well as
a sedentary lifestyle are associated with preventable chronic diseases such
as obesity, high blood pressure, cardiovascular disease, type 2 diabetes,
certain cancers, and bone problems (Dietary Advisory Committee Report
2015b). In fact, at least six out of the top 10 leading causes of death in
the United States have an etiology that is related to diet and nutrition
(Healthy People 2020).
In order to address these issues, every five years the U.S. government
releases an important set of national guidelines known as The Dietary
Guidelines for Americans, which provides evidence-based recommendations for diet and physical activity to all healthy Americans aged two
years and older. The guidelines are published jointly by the U.S. Department of Health and Human Services (DHSS) and the U.S. Department
of Agriculture (USDA), and is a document that provides the bases for
creating and implementing health promotion and disease prevention
programs for local, state, and national initiatives, as well as private and
nonprofit organizations. It is within these settings that nutrition professionals and other health care providers are best able to assist individuals
and communities in making recommended dietary choices and meeting
physical activity goals for better health (Dietary Advisory Committee
Report 2015a).
xvi Introduction
Disparities
Healthy People 2020 defines a health disparity as
a particular type of health difference that is closely linked with
social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically
experienced greater obstacles to health based on their racial or
ethnic group; religion; socioeconomic status; gender; age; mental
health; cognitive, sensory, or physical disability; sexual orientation
or gender identity; geographic location; or other characteristics
historically linked to discrimination or exclusion (Healthy People
2020).
In response to this problem, the federal government is seeking to
eliminate health disparities and achieve health equity by including the
following new Healthy People 2020 objectives:
Improve the health literacy of the population.
Increase the proportion of persons who report that their
health care provider always gave them easy-to-understand
Introduction
xvii
Source: Healthy People (2020a); Healthy People (2020b); Healthy People (2020c).
xviii Introduction
Canada, the United Kingdom, Australia, and other countries (Accreditation Council for Education in Nutrition and Dietetics [n.d.]).
In contrast, a nutritionist is a nonaccredited title that anybody can
assume whether they have pursued advanced study in nutrition and
dietetics or not, and the term is not legally protected in most countries
so many individuals with different levels of knowledge can call themselves a nutritionist (Accreditation Council for Education in Nutrition
and Dietetics [n.d.]). However, there are indeed qualified nutritionists
who have completed a rigorous course of study, have earned at least a
bachelors degree or a masters degree in nutrition science, and therefore
can serve as reliable experts.
In the United States, many states have regulatory laws that confer
licensure or certification to practitioners who have completed an accredited
curriculum in nutrition and dietetics as well as supervised practiceRDs
automatically meet this criteria, but other nutrition practitioners can as
well based on their education and work experience, and they therefore
can also work as state-licensed dietitian nutritionists (LDNs) or state-
certified dietitian nutritionists (CDNs).
To avoid confusion between those who are dietitians and those who
call themselves nutritionists, CDR now provides the Registered Dietitian
Nutritionist (RDN) credential, which is interchangeable with the RD
credential. Practitioners may use either according to personal preference.
The purpose of this newer version of the credential is to communicate to
the public that based on education and training, all dietitians are nutritionists, but not all nutritionists are dietitians. This book will use the terms
RDN, nutritionist, and dietitian interchangeably.
RDNs who work in public health and community nutrition face
professional challenges associated with nationwide food insecurity, low
health literacy, and the need for cultural competence among health care
providers. The role of public health nutritionists in particular is to focus
on population assessment, program creation and evaluation, and public
policy development. They often work for local, state, and federal departments of health, university extension programs, and other related entities.
Meanwhile, community nutritionists work directly with individuals and
families in community-based settings, participate in program development and nutrition education, and often work closely with social service
agencies (Bruening et al. 2015).
Introduction
xix
References
Accreditation Council for Education in Nutrition and Dietetics. n.d.
Registered Dietitian (RD)ACEND Fact Sheet: Educational and
Professional Requirements. www.eatrightacend.org/ACEND/content.
aspx?id=6442485467
Bruening, M., A.Z. Udarbe, E.Y. Jimenez, P.S. Crowley, D.C. Fredericks, L.A.E.
Hall. 2015. Academy of Nutrition and Dietetics: Standards of Practice and
Standards of Professional Performance for Registered Dietitian Nutritionists
(Competent, Proficient, and Expert) in Public Health and Community
Nutrition. Journal of the Academy of Nutrition and Dietetics 115, no. 10.
Dietary Advisory Committee Report. 2015a. Scientific Report of the 2015
Dietary Guidelines Advisory Committee: Part A. Executive Summary. www.
health.gov/dietaryguidelines/2015-scientific-report/02-executive-summary.
asp (accessed February 27, 2016).
Dietary Advisory Committee Report. 2015b. Scientific Report of the 2015
Dietary Guidelines Advisory Committee: Part B. Chapter 1: Introduction.
www.health.gov/dietaryguidelines/2015-scientific-report/03-introduction.
asp (accessed February 28, 2016).
Healthy People. 2020. Disparities. www.healthypeople.gov/2020/about/
foundation-health-measures/Disparities
Healthy People. 2020a. Social Determinants of Health. www.healthypeople.
gov/2020/topics-objectives/topic/social-determinants-of-health/objectives
Healthy People. 2020b. Communication and Health Information
Technology. www.healthypeople.gov/2020/topics-objectives/topic/healthcommunication-and-health-information-technology/objectives
Healthy People. 2020c. Nutrition and Weight Status. www.healthypeople.
gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives
CHAPTER 1
Fruits
Vegetables
Whole grains
Fat-free or low-fat dairy
Seafood
Legumes
Nuts
Meat
Processed meat
Sugar-sweetened food
Refined grains
vitamin A, and vitamin D, are included as part of the dairy group because
they are similar to milk with respect to nutrient composition. Other products sold as milks but made from plants such as almond, rice, coconut,
and hemp, may contain calcium but are not included as part of the dairy
group because their overall nutritional content is not similar to dairy milk
and fortified soymilk.
In addition to calcium, the dairy group contributes phosphorus,
vitamin A, vitamin D (in products that are fortified with it), riboflavin,
vitamin B12, protein, potassium, zinc, choline, magnesium, and selenium.
Fat-free and low-fat (1 percent) dairy products provide the same
nutrients but less fat (and fewer calories) than higher fat options, such
as 2 percent and whole milk and regular cheese. Fat-free or low-fat milk
and yogurt, in comparison to cheese, contain less saturated fats and
sodium, and have more potassium, vitamin A, and vitamin D. Increasing
consumption of fat-free or low-fat milk or yogurt and lowering the proportion of cheese products would decrease saturated fat and sodium consumption, while increasing potassium, vitamin A, and vitamin D intake.
A Variety of Protein Food
The protein foods group comprises a broad selection of foods from both
animal and plant sources and includes several subgroups: seafood; meats,
poultry, and eggs; nuts, seeds, and soy products; and legumes (beans and
peas), which may also be considered as part of the vegetables group. Protein is also found in some foods from other food categories, such as dairy.
Different types of protein foods contain varying amounts of certain
nutrients. Meats, for example, offer the most zinc, while poultry provides
the most niacin. Meats, poultry, and seafood provide heme iron, which is
a form of iron more bioavailable than the nonheme type found in plant
sources. Seafood provides the most vitamin B12 and vitaminD, inaddition to almost all of the polyunsaturated omega-3 fatty acids, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Eggs contain the
most choline; nuts and seeds provide the most vitamin E; and soy products and legumes are a source of copper, manganese, and iron.
When selecting protein foods, nuts and seeds should be unsalted, and
meats and poultry should be consumed in lean forms. Processed meat
and poultry are sources of salt and saturated fats, and can be eaten as
long as sodium, saturated fats, added sugars, and total calories are within
recommended limits.
Note: Seafood, which includes fish and shellfish, has been shown to
confer health benefits for the general population, as well as for women
who are pregnant or breastfeeding. Strong evidence shows that eating patterns that include seafood are associated with reduced risk of cardiovascular disease, and moderate evidence indicates that these eating patterns are
associated with reduced risk of obesity.
Since mercury is a heavy metal found in the form of methyl mercury
in seafood, in varying levels, seafood choices higher in EPA and DHA but
lower in methyl mercury can include salmon, anchovies, herring, shad,
sardines, Pacific oysters, trout, and Atlantic and Pacific mackerel (not king
mackerel, which is high in methyl mercury). Some canned seafood, such
as anchovies, may be high in sodium. Women who are pregnant or breastfeeding should consume at least 8 and up to 12 ounces of a variety of
seafood per week from choices that are lower in methyl mercury.
Healthy Oils
Although they are not a food group, the Dietary Guidelines emphasizes
oils as part of a healthy eating pattern because these types of lipids are a
major source of essential fatty acids and vitamin E. Oils are fats that are
extracted from plants and are liquid at room temperature. Typical dietary
oils include canola, corn, olive, peanut, safflower, soybean, and sunflower
oils. Oils are also naturally present in nuts, seeds, seafood, olives, and
avocados. The fat in some tropical plants such as coconut oil, palm kernel
oil, and palm oil, are not included in the oils category because they are
significantly higher in saturated fat content. Oils should replace solid fats
rather than being added to the diet.
Less Than 10 Percent of Calories Per Day Should Come from
Added Sugars
When sugars are added to foods and beverages it increases the calorie content without contributing essential nutrients, so consuming these items
can make it difficult to meet nutrient needs while staying within energy
limits. Naturally occurring sugars, such as those in fruit or milk, are not
added sugars. Specific examples of added sugars that can be listed as an
ingredient include brown sugar, corn sweetener, corn syrup, dextrose,
fructose, glucose, high-fructose corn syrup, honey, invert sugar, lactose,
malt syrup, maltose, molasses, raw sugar, sucrose, trehalose, and turbinado sugar.
The recommendation to limit calories from added sugars is consistent with research examining eating patterns and health, where strong
evidence suggest that lower intakes of added sugars are associated with
reduced risk of cardiovascular disease in adults, and moderate evidence
indicates an association with reduced risk of obesity, type 2 diabetes, and
some types of cancer in adults.
Less Than 10 Percent of Calories Per Day Should Come from
Saturated Fats
Saturated fats should be limited to less than 10 percent of calories per day
by replacing them with unsaturated fats, while keeping total dietary fats
within the recommended range appropriate for age (20 to 35 percent of
total calories for adults). Individuals two years and older have no dietary
requirement for saturated fats, which the body can make to meet its physiological needs.
Strong and consistent evidence shows that replacing saturated fats
with unsaturated fats, especially polyunsaturated fats, is associated with
reduced blood levels of total cholesterol and LDL-cholesterol, and is associated with a reduced risk of heart attacks and deaths related to cardiovascular disease.
Some evidence has shown that replacing saturated fats with plant
sources of monounsaturated fats, such as olive oil and nuts, may be
associated with a reduced risk of cardiovascular disease, but the data is
not as strong. Evidence has also shown that replacing saturated fats with
carbohydrates reduces blood levels of total and LDL-cholesterol, but
increases blood levels of triglycerides and reduces high-density lipoproteins (HDL-cholesterol). Replacing total fat or saturated fats with carbohydrates is not associated with reduced risk of cardiovascular disease.
consumed as salt (sodium chloride), and the recommendation for adults and
children ages 14 years and older is to limit sodium intake to less than 2,300
mg per day based on evidence showing a doseresponse relationship between
increased sodium intake and increased blood pressure in adults. In addition,
moderate evidence suggests an association between increased sodium intake
and a higher risk of cardiovascular disease in adults, and individuals with
prehypertension and hypertension should aim for a further reduction in
sodium intake to 1,500 mg per day for even greater blood pressure control.
Alcohol (If Consumed, Should Be in Moderation)
The Dietary Guidelines recommend that individuals who do not drink
alcohol should not start to do so for any reason. If alcohol is consumed,
it should be in moderationup to one drink per day for women and up
to two drinks per day for menand only by adults of legal drinking age.
There are also many circumstances in which individuals should not drink,
such as during pregnancy.
Caffeiness
Caffeine is not a nutrient but a dietary component that functions in the
body as a stimulant. It occurs naturally in plants such as coffee beans, tea
leaves, cocoa beans, kola nuts, and is also added to foods and beverages
such as caffeinated soda and energy drinks. If caffeine is added to a food,
it must be included in the listing of ingredients on the food label. Most
intake of caffeine in the United States comes from coffee, tea, and soda.
Much of the available evidence on caffeine focuses on coffee intake.
Moderate coffee consumption (three to five 8-oz cups per day or providing up to 400 mg per day of caffeine) can be included in a healthy eating
pattern, and is not associated with an increased risk of major chronic
diseases or premature death. However, people who do not consume caffeinated coffee or other caffeinated beverages are not encouraged to start
incorporating them into their diet. Those who choose to drink alcohol
should be cautious about mixing caffeine and alcohol together or consuming them at the same time.
Source: U.S. Department of Health and Human Services and U.S. Department of Agriculture
(2015).
10
on dietary intake, biochemical tests, physical measurements (anthropometric data), and clinical assessments for evidence of nutritional deficiencies (National Center for Health Statistics [n.d.]).
The medical examinations and laboratory tests follow very specific
protocols and are as standard as possible to ensure comparable data across
sites and providers. The survey results are then used to determine the
prevalence of major diseases as well as risk factors for them, and to assess
nutritional status and its association with health promotion and disease prevention. In addition, the findings serve as the basis for national
standards for such measurements as height, weight, and blood pressure
(National Center for Health Statistics [n.d.]).
A total of seven national examination surveys have been conducted
from 1960 to 1994 in distinct cycles encompassing several years, but
since 1999, it has become a continuous annual survey. Data are collected
every year from a representative sample of the civilian, noninstitutionalized U.S. population, newborns and older via in-home personal interviews, and physical examinations in mobile clinics (National Center for
Health Statistics [n.d.]).
What We Eat in America
WWEIA is the dietary intake interview component of NHANES, and represents the integration of two nationwide surveys: the USDAs Continuing
Survey of Food Intakes by Individuals (CSFII) and NHANES. WWEIA
is conducted as a partnership between the USDA and the DHHS. The
latter is responsible for the sample design and data collection, while the
USDA oversees the maintenance of the databases used to code and process the information, and data review. The two surveys were integrated in
2002 with the most recent version covering 2009 to 2010 (United States
Department of Agriculture, Agricultural Research Service [n.d.]).
The Healthy Eating Index
The HEI is a measure of diet quality that assesses how well people adhere
to the Dietary Guidelines, using data that is collected through 24-hour
dietary recalls in national surveys. The original HEI was created by the
Center for Nutrition Policy and Promotion (CNPP) in 1995, and has
12
HEI-2010 dietary
component
(maximum score)
Total
population
2 years
(n = 7,933)
Children
217 years
(n = 2,857)
Older adults
65 years
(n = 1,032)
3.00 (0.11)
3.91 (0.18)
3.84 (0.22)
4.01 (0.17)
4.78 (0.22)
4.99 (0.05)
3.36 (0.08)
2.10 (0.09)
4.16 (0.19)
2.98 (0.15)
0.70 (0.09)
3.58 (0.47)
2.86 (0.13)
2.50 (0.10)
4.23 (0.34)
Dairy (10)
6.44 (0.14)
9.03 (0.22)
5.99 (0.16)
5.00 (0.00)
4.44 (0.13)
5.00 (0.00)
3.74 (0.20)
3.05 (0.17)
4.91 (0.18)
4.66 (0.14)
3.29 (0.18)
5.60 (0.36)
6.19 (0.15)
4.91 (0.16)
7.34 (0.31)
Sodium (10)
4.15 (0.06)
4.85 (0.25)
3.66 (0.26)
12.60 (0.23)
11.50 (0.28)
14.99 (0.44)
59.00 (0.95)
55.07 (0.72)
68.29 (1.76)
Source: United States Department of Agriculture, Center for Nutrition Policy and Promotion
(n.d.).
14
References
Guenther, P.M., K.O. Casavale, S.I. Kirkpatrick, H.A.B. Hiza, K.J. Kuczynski,
L.L. Kahle, and S.M. Krebs-Smith. 2013. Update of the Healthy Eating
Index: HEI-2010. Journal of the Academy of Nutrition and Dietetics 113,
no.4, pp. 56980.
National Center for Health Statistics. n.d. National Health and Nutrition
Examination Survey (NHANES). www.healthindicators.gov/Resources/
DataSources/NHANES_91/Profile
National Collaborative on Childhood Obesity Research. n.d. The Healthy
Eating Index 2010: Fact Sheet. http://nccor.org/downloads/NCCOR_HEIfactsheet_v8.pdf
Snetselaar, L. March 2, 2015. Are American Following the US Dietary Gudielines?
Check thge Healthy Eating Index. www.elsevier.com/connect/are-americansfollowing-us-dietary-guidelines-check-the-healthy-eating-index
United States Department of Agriculture, Center for Nutrition Policy and
Promotion. n.d. Healthy Eating Index. www.cnpp.usda.gov/healthy
eatingindex
U.S. Department of Health and Human Services and U.S. Department of
Agriculture. December 2015. 20152020 Dietary Guidelines for Americans.
8th ed. http://health.gov/dietaryguidelines/2015/guidelines/
U.S. Department of Health and Human Services, Office of Disease Prevention
and Health Promotion. n.d. Scientific Report of the 2015 Dietary Guidelines
Advisory Committee. Appendix E-2.25: Average Healthy Eating Index-2010
Scores for Americans ages 2 years and older (NHANES 20092010). https://
health.gov/dietaryguidelines/2015-scientific-report/data-table-23.asp
United States Department of Agriculture, Agricultural Research Service. n.d.
What We Eat In America. www.ars.usda.gov/News/docs.htm?docid=13793
Index
Agency for Healthcare Research and
Quality, 47
Alcohol, 9
86 Index
saturated fats, 7
sodium, 89
sugars, 67
trans fats, 8
vegetables, 34
Healthy Eating Index (HEI), xv,
1113
Healthy eating patterns
high intake of, 1
less intake of, 2
Mediterranean-style, 3
U.S.-style, 2
vegetarian, 3
Healthy People 2020, xvi
HEI. See Healthy Eating Index
High food security, 18
Households, food insecurity, 1619
ICE. See Industry Collaboration
Effort
Industry Collaboration Effort (ICE),
47
Language, 38
Lets Move!, 7374
Literacy, definition of, 28
Low-fat dairy, 45
Marginal food security, 18
Meals on Wheels, 6364
Mediterranean-style healthy eating
pattern, 3
MyPlate, 7172
National Bureau of Economic
Research, 23
National Center for Cultural
Competence (NCCC), 42,
48
National Center for Health Statistics
(NCHS), 10
National Health and Nutrition
Examination Survey
(NHANES), 1011
National Institutes of Health (NIH)
Plain Language Training, 33
National School Lunch Program
(NSLP), 52, 57
Index 87
88 Index