Competencies for effective public health nutrition practice: a developing consensus

OBJECTIVES: To assess the level of consensus amongst an international panel of public health nutrition leaders regarding the essential competencies required for effective public health nutrition practice. DESIGN: A modified Delphi study involving three rounds of questionnaires. SUBJECTS: A panel of 20 public health nutrition experts from seven countries in the European Union, the USA and Australia. RESULTS: Expert panellists completed three rounds of the study relating to competencies. A literature review conducted as a prelude to the expert panel survey identified common competency units from the fields of public health, health promotion, nutrition and dietetics, and health education. These were categorised into seven competency areas including analytical, socio-cultural and political, public health service, communication, management and leadership, nutrition science and professional competency categories. There was strong initial agreement (> or = 90% of panellists at Round 1) that developing internationally recognised competencies for public health nutrition specialists was a priority. Twenty-six of an initial listing of 52 competency units were rated as essential competencies by > or = 80% of the panellists after Round 1. Iteration rounds resulted in the addition of five extra competency units suggested by panellists after Round 1 and an increase by 13 in the number of competencies rated as essential to consensus levels. From a total of 57 competency units rated after the final survey round, 41 competency units were rated as essential competencies by > or = 80% of the panellists (consensus), with 21 of these unanimously rated as essential competencies. CONCLUSIONS: There is strong international agreement amongst public health nutrition leaders in Europe, the USA and Australia about a range of competencies required for effective public health nutrition practice. Essential competency units identified can be used to develop and review competency standards for public health nutrition.     

Public health nutrition practice in Canada: a situational assessment

OBJECTIVE: Renewed focus on public health has brought about considerable interest in workforce development among public health nutrition professionals in Canada. The present article describes a situational assessment of public health nutrition practice in Canada that will be used to guide future workforce development efforts. METHODS: A situational assessment is a planning approach that considers strengths and opportunities as well as needs and challenges, and emphasizes stakeholder participation. This situational assessment consisted of four components: a systematic review of literature on public health nutrition workforce issues; key informant interviews; a PEEST (political, economic, environmental, social, technological) factor analysis; and a consensus meeting. FINDINGS:Information gathered from these sources identified key nutrition and health concerns of the population; the need to define public health nutrition practice, roles and functions; demand for increased training, education and leadership opportunities; inconsistent qualification requirements across the country; and the desire for a common vision among practitioners. CONCLUSIONS: Findings of the situational assessment were used to create a three-year public health nutrition workforce development strategy. Specific objectives of the strategy are to define public health nutrition practice in Canada, develop competencies, collaborate with other disciplines, and begin to establish a new professional group or leadership structure to promote and enhance public health nutrition practice. The process of conducting the situational assessment not only provided valuable information for planning purposes, but also served as an effective mechanism for engaging stakeholders and building consensus.     

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

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

Tea or coffee? A case study on evidence for dietary advice

The present paper explores the level of evidence required to justify giving dietary advice to the public. There are important practical differences between the development of public health nutrition guidelines and guidelines for clinical practice. While the gold standard for evidence for clinical practice guidelines is a meta-analysis of a number of randomised controlled trials, this is often unrealistic and sometimes unethical for the evaluation of public health nutrition interventions. Hence, epidemiological studies make up the bulk of evidence for nutrition guidelines. Tea and coffee are an interesting case study in relation to this issue. They are two of the most commonly consumed beverages worldwide, yet there is little dietary advice on their use. The evidence for a relationship between coffee or tea consumption and several diseases is discussed. The available studies, predominantly epidemiological, together with animal and in vitro studies, indicate that coffee and tea are both safe beverages. However, tea is the healthier option because it has a possible role in the prevention of several cancers and CVD. While the evidence for such relationships is not strong, the public will continue to drink both tea and coffee, and will continue to ask nutritionists to make recommendations. It is therefore argued that advice should be given on the best available data, as waiting for complete data to become available could have severe consequences for public health.     

Workforce development in South Africa with a focus on public health nutrition

OBJECTIVES: The present paper aims to review and report on the current and predicted future public health nutrition workforce in South Africa. Additionally, it examines ways in which the Department of Health (DOH) is striving to meet the increasing burden of nutrition-related diseases in South Africa. METHODS: The primary sources of data used for the review were reports from the Census office, South African health reviews, mortality and morbidity statistics, and documents from the Health Professions Council of South Africa. RESULTS: There are fewer than 2000 registered dietitians in South Africa and fewer than 600 of them work in the public health sector. Furthermore, professional nurses - who are the backbone of the primary health-care system and deliver the rudiments of basic nutritional care - are not being trained in sufficient numbers to meet population growth; in 2004 there was only one nurse per 4000 persons. This situation is aggravated by the growing burden of conditions associated with both overnutrition and undernutrition, as well as the enormous demands of the HIV/AIDS epidemic. The DOH is striving to meet these increasing needs by means of the Integrated Nutrition Programme as well as a National Human Resources Plan which includes numerous strategies to improve the quantity and quality of health professionals' training, including dietitians and nutritionists. This plan includes the objective of increasing the public health nutrition workforce to more than 250 newly trained dietitians and nutritionists per annum by 2010.     

What is the real cost of our food? Implications for the environment, society and public health nutrition

The current, globalised food system supplies 'cheap' food to a large proportion of the world's population, but with significant social, environmental and health costs that are poorly understood. The present paper examines the nature and extent of these costs for both rural and urban communities, by illustrating the financial pressures on food producers and manufacturers to produce cheap food, the disconnection people experience with how and where their food is produced, and the rise in obesity levels that plague the globe. The paper then proposes that community food systems may play an important role in mitigating the adverse environmental, economic and social effects of the dominant food system, by the use of more sustainable food production methods, the development of local economies and enabling closer connections between farmers and consumers. There are many opportunities for public health nutritionists to contribute to the local food system literature to ascertain whether these systems improve inequities, provide better access to healthy food and help stem the tide of rising global obesity levels. Public health nutritionists can play a key role in supporting people to become food citizens and to advocate for democratic and sustainable food systems.     

Responding to the crisis in sub-Saharan Africa: the role of nutrition

In the chapter dealing with education and health, the report of the influential Commission for Africa prioritises basic health systems, HIV/AIDS, malaria and tuberculosis. In contrast, nutrition is given less than half a page and is reduced to parasite control and micronutrient support. Such neglect of nutrition is hard to understand in the context of increasing hunger and malnutrition across the continent. Sub-Saharan Africa is the only region in the world where the proportion of underweight children has stagnated and the absolute numbers have actually increased in the last decade. It has been pointed out that if current trends continue sub-Saharan Africa will achieve the Millennium Development Goal for child mortality around 2115 - one century after the target date. Quite clearly those concerned with nutrition need to more powerfully advocate the role of nutrition in lifting Africa out of the spiral of poverty. The present paper argues that to achieve this requires an understanding not just of the critical role of nutrition for health and development (both individual and national), but also of how recent global changes are interacting with changes in food production and supply, other determinants of maternal and child health, and the role and capacity of the state to tackle malnutrition in Africa. It concludes by suggesting some responses that nutritionists could now be making.     

Delivery of nutrition services in health systems in sub-Saharan Africa: opportunities in Burkina Faso, Mozambique and Niger

BACKGROUND: In sub-Saharan Africa, underweight and micronutrient deficiencies account for an estimated 25% of the burden of disease. As the coverage of national health systems expands, increased opportunities exist to address the needs of children and women, the most vulnerable to these deficiencies, through high-quality nutrition services. OBJECTIVES: To assess health providers' knowledge and practice with regard to essential nutrition services for women and children in Burkina Faso, Mozambique and Niger, in order to assist the development of a standard guide and tools to assess and monitor the quality of the nutrition services delivered through national health systems. FINDINGS: The three surveys reveal the extent of missed opportunities to deliver nutrition services during routine prenatal, postnatal and child-care consultations for the prevention and treatment of highly prevalent nutritional deficiencies. CONCLUSION: A commitment to improving the quality of facility-based nutrition services is necessary to impact on the health outcomes of women and children 'covered' by national health systems. Rigorous assessment and monitoring of the quality of nutrition services should inform health programme and policy development. Building on the lessons learned in these three assessments, Helen Keller International has developed a standard Guide and Tools to assess the quality of the nutrition services delivered through national health systems. These tools can be adapted to assess ongoing nutrition services in health facilities, provide a framework for nutrition programming, inform the development of pre-service as well as in-service nutrition training curricula for providers, and evaluate the impact of nutrition training on providers' practices.     

Nutrimetabolomic strategies to develop new biomarkers of intake and health effects

Correctly assessing the metabolic status of subjects after consumption of specific diets is an important challenge for modern nutrition. Recently, metabolomics has been proposed as a powerful tool for exploring the complex relationship between nutrition and health. Nutritional metabolomics, through investigating the role that dietary components play in the maintenance of health and development of risk disease, aims to identify new biomarkers that allow the intake of these compounds to be monitored and related to their expected biological effects. This review offers an overview of the application of nutrimetabolomic strategies in the discovery of new biomarkers in human nutritional research, suggesting three main categories: (1) assessment of nutritional and dietary interventions; (2) diet exposure and food consumption monitoring; and (3) health phenotype and metabolic impact of diet. For this purpose, several examples of these applications will be used to provide evidence and to discuss the advantages and drawbacks of these nutrimetabolomic strategies.     

Food-based dietary guidelines and implementation: lessons from four countries--Chile, Germany, New Zealand and South Africa

OBJECTIVE: Food-based dietary guidelines (FBDGs) are globally promoted as an important part of national food and nutrition policies. They are presented within policy as key features of the strategy to educate the public and guide policy-makers and other stakeholders about a healthy diet. This paper examines the implementation of FBDGs in four countries: Chile, Germany, New Zealand and South Africa - diverse countries chosen to explore the realities of the FBDG within policy on public health nutrition. DESIGN: A literature review was carried out, followed by interviews with representatives from the governmental, academic and private sector in all four countries. RESULTS: In all four countries the FBDG is mainly implemented via written/electronic information provided to the public through the health and/or education sector. Data about the impact of FBDGs on policy and consumers' food choice or dietary habits are incomplete; nutrition surveys do not enable assessment of how effective FBDGs are as a factor in dietary or behavioural change. Despite limitations, FBDGs are seen as being valuable by key stakeholders. CONCLUSION: FBDGs are being implemented and there is experience which should be built upon. The policy focus needs to move beyond merely disseminating FBDGs. They should be part of a wider public health nutrition strategy involving multiple sectors and policy levels. Improvements in the implementation of FBDGs are crucial given the present epidemic of chronic, non-communicable diseases.     

Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5 campaign

OBJECTIVE: The Western Australian Health Department's Go for 2&5 campaign aimed to increase adults' awareness of the need to eat more fruit and vegetables and encourage increased consumption of one serving over five years. DESIGN: The multi-strategy fruit and vegetable social marketing campaign, conducted from 2002 to 2005, included mass media advertising (television, radio, press and point-of-sale), public relations events, publications, a website (www.gofor2and5.com), and school and community activities. Campaign development and the evaluation framework were designed using health promotion theory, and assessed values, beliefs, knowledge and behaviour. Two independent telephone surveys evaluated the campaign: the Campaign Tracking Survey interviewed 5032 adults monitoring fruit and vegetable attitudes, beliefs and consumption prior to, during and 12 months after the campaign; and the Health & Wellbeing Surveillance System surveyed 17,993 adults between 2001 and 2006, continuously monitoring consumption. SETTING: Population public health intervention-social marketing campaign in Western Australia, population of 2,010,113 in 2005. SUBJECTS: Adults in the Perth metropolitan area. RESULTS: The campaign reached the target audience, increasing awareness of the recommended servings of fruit and vegetables. There was a population net increase of 0.8 in the mean number of servings of fruit and vegetables per day over three years (0.2 for fruit (1.6 in 2002 to 1.8 in 2005) and 0.6 for vegetables (2.6 in 2002 to 3.2 in 2005), significant at P < 0.05). CONCLUSION: Sustained, well-executed social marketing is effective in improving nutrition knowledge, attitudes and consumption behaviour. The Go for 2&5 campaign provides guidance to future nutrition promotion through social marketing.     

Banning front-of-package food labels: first Amendment constraints on public health policy

In recent months, the FDA has begun a crackdown on misleading nutrition and health claims on the front of food packages by issuing warning letters to manufacturers and promising to develop stricter regulatory standards. Leading nutrition policy experts Marion Nestle and David Ludwig have called for an even tougher approach: a ban on all nutrition and health claims on the front of food packages. Nestle and Ludwig argue that most of these claims are scientifically unsound and misleading to consumers and that eliminating them would 'aid educational efforts to encourage the public to eat whole or minimally processed foods and to read the ingredients list on processed foods'. Nestle and Ludwig are right to raise concerns about consumer protection and public health when it comes to front-of-package food labels, but an outright ban on front-of-package nutrition and health claims would violate the First Amendment. As nutrition policy experts develop efforts to regulate front-of-package nutrition and health claims, they should be mindful of First Amendment constraints on government regulation of commercial speech.     

Coalitions: partnerships to promote agricultural health and safety

Throughout the 1990s, a variety of partnerships and community-based organizations have been formed with the primary mission to promote agricultural safety and health. These groups are altruistic, creative, energetic, and provide critical perspectives for improving the safety and health of the agricultural workforce at the local, regional, and national levels. These coalitions have been created as a result of philanthropic support, public funding, grassroots interest, and personal experiences with agricultural injuries andfatalities. They are playing important roles in collaborating with researchers and in reaching the individual agricultural communities. They have been instrumental in conducting needs assessments and are critical to the development and implementation of successful surveillance programs and interventions. Outreach and dissemination of research findings and other safety and health information to target audiences are strengths of these diverse coalitions. This article will focus on primarily community-based coalitions, providing an overview of the development, foci, membership activities, and contributions or impact of these groups during the 1990s and the challenges in maintaining and sustaining the coalitions. This information should be useful to those seeking to understand the activities of existing coalitions and identify potential partnerships for future activities.     

Introduction to the Food Standards Agency's (FSA) food choice research programmes and to the report of the FSA seminar on peer-led approaches to dietary change held in July 2006

OBJECTIVE: To describe the Food Standards Agency's (FSA) Food Acceptability & Choice and Food Choice Inequalities research programmes and the context for the FSA seminar on peer-led approaches to dietary change held in July 2006. RESULTS: The aims of the FSA's food choice research programmes are to identify the social, psychological and physical barriers to achieving a healthier diet and how they might be addressed. Results of the research provide the scientific basis for some FSA advice on healthy eating. An important element of both programmes is the output of practical tools and resources that can be used by health professionals, nutritionists, teachers and others to encourage people to eat a healthy diet. The FSA held a seminar in July 2006 in order to identify the specific and general learning points from three peer-led intervention studies and to discuss how these could best be communicated to various audiences, including practitioners, researchers and policy-makers. CONCLUSIONS: The seminar provided a useful forum for discussion. The FSA will ensure that lessons learned from these peer-led intervention studies are taken account of in the planning, appraisal and management of future research projects, in the communication of project results and in the dissemination of resources.     

The nutrition and health transition in the North West Province of South Africa: a review of the THUSA (Transition and Health during Urbanisation of South Africans) study

OBJECTIVE: To describe how urbanisation influences the nutrition and health transition in South Africa by using data from the THUSA (Transition and Health during Urbanisation of South Africans) study. DESIGN: The THUSA study was a cross-sectional, comparative, population-based survey. SETTING: The North West Province of South Africa. SUBJECTS: In total, 1854 apparently healthy volunteers, men and women aged 15 years and older, from 37 randomly selected sites. Pregnant and lactating women, those with diagnosed chronic diseases and taking medication, with acute infections or inebriated were excluded but screened for hypertension and diabetes mellitus. Subjects were stratified into five groups representing different levels of urbanisation in rural and urban areas: namely, deep rural, farms, squatter camps, townships and towns/cities. OUTCOME MEASURES AND METHODS: Socio-economic and education profiles, dietary patterns, nutrient intakes, anthropometric and biochemical nutrition status, physical and mental health indicators, and risk factors for non-communicable diseases (NCDs) were measured using questionnaires developed or adapted and validated for this population, as well as appropriate, standardised methods for the biochemical analyses of biological samples. RESULTS: Subjects from the rural groups had lower household incomes, less formal education, were shorter and had lower body mass indices than those in the urban groups. Urban subjects consumed less maize porridge but more fruits, vegetables, animal-derived foods and fats and oils than rural subjects. Comparing women from rural group 1 with the urban group 5, the following shifts in nutrient intakes were observed: % energy from carbohydrates, 67.4 to 57.3; from fats, 23.6 to 31.8; from protein, 11.4 to 13.4 (with an increase in animal protein from 22.2 to 42.6 g day(-1)); dietary fibre, 15.8 to 17.7 g day(-1); calcium, 348 to 512 mg day(-1); iron from 8.4 to 10.4 mg day(-1); vitamin A from 573 to 1246 mug retinol equivalents day(-1); and ascorbic acid from 30 to 83 mg day(-1). Serum total cholesterol, low-density lipoprotein cholesterol and plasma fibrinogen increased significantly across groups; systolic blood pressure >140 mmHg was observed in 10.4-34.8% of subjects in different groups and diabetes mellitus in 0.8-6.0% of subjects. Women in groups 1 to 5 had overweight plus obesity rates of 48, 53, 47, 61 and 61%, showing an increase with urbanisation. Subjects from group 2 (farm dwellers) showed the highest scores of psychopathology and the lowest scores of psychological well-being. The same subjects consistently showed the lowest nutrition status. CONCLUSIONS: Urbanisation of Africans in the North West Province is accompanied by an improvement in micronutrient intakes and status, but also by increases in overweight, obesity and several risk factors for NCDs. It is recommended that intervention programmes to promote nutritional health should aim to improve micronutrient status further without leading to obesity. The role of psychological strengths in preventing the adverse effects of urbanisation on health needs to be examined in more detail.     

Delivering multidisciplinary public health in action - the Cardiff food strategy case study

BACKGROUND: There is an increasing awareness that the provision of healthy food relies on the co-ordinated efforts of a number of diverse disciplines, not merely those traditionally linked with food. This paper documents the development of a food and health strategy, commissioned by the health alliance for the city of Cardiff, and focuses on the areas of sustainability, education and training as well as nutrition, food provision and food safety. OBJECTIVE: The aim of the strategy was to increase the uptake of a healthy, safe and sustainable diet for all those living in Cardiff. METHOD: The methodology included a rapid appraisal of food initiatives operating within the city, establishing a food and health strategy working group and the production of strategy documentation. Multi-agency collaboration and consultation were key components of the approach. RESULTS: As the strategy developed, seven action areas became apparent, including education and training, public sector procurement and rewarding excellence. These action areas were incorporated into seven 'action tables', which constitute the core of the strategy. The food and health strategy document was ratified by the Local Health Alliance board in August 2004. But, far greater benefits were realised as a consequence of setting up the strategy working group. Long before the document was written, the strategy process was operating as 'multidisciplinary public health in action'. CONCLUSION: The network that comprised the food and health strategy working group was already able to commence delivery of a more integrated approach to food and health within Cardiff.     

'The bigger the better'--mothers' social networks and child nutrition in Andhra Pradesh

OBJECTIVE: It is hypothesised that mothers' social networks can positively affect child nutrition through the sharing of health knowledge and other resources. The present study describes the composition of mothers' networks, examines their association with child nutrition, and assesses whether health knowledge is shared within networks. DESIGN AND SETTING: Cross-sectional data for mothers of young children from Andhra Pradesh (south India) were combined with existing data from the Young Lives study, in which the mothers were participating (n = 282). RESULTS: The composition of social networks varied between urban and rural areas, with urban networks being larger, more female, more literate and with a greater proportion of members living outside the household and being non-family. There was a positive association between child's height-for-age Z-score and mother's network size and network literacy rate. The association with network literacy was stronger among the poorest households. Women commonly reported seeking or receiving health advice from network members.CONCLUSION: Big and literate social networks are associated with better child nutrition, especially among the poor. The dissemination of health knowledge between network members is a plausible way in which social networks benefit child nutrition in India. Further research into the underlying mechanisms is necessary to inform the development of interventions that channel health information through word of mouth to the most excluded and vulnerable families.