Community Nutrition (PDF)

Chapter 1 Community Nutrition and Public Health  Community Nutrition and Public Health Community nutrition is a modern and comprehensive profession that includes, but is not limited to, public health nutrition, dietetics/nutrition, education, and medical nutrition therapy. Community...

Chapter 1 Community Nutrition and Public Health  Community Nutrition and Public Health Community nutrition is a modern and comprehensive profession that includes, but is not limited to, public health nutrition, dietetics/nutrition, education, and medical nutrition therapy. Community nutrition deals with a variety of food and nutrition issues related to individuals, families, and special groups that have a common link such as place of residence, language, culture, or health issues  Community Nutrition and Public Health There is a need to focus on community in health promotion and disease prevention as behavior is highly influenced by the environment in which people live. Local values, norms, and behavior patterns shape an individual’s attitudes and behaviors. Community nutritionists must become more visible and vocal leaders of community health.  The Concept of Community WHO defines community as a social group determined by geographic boundaries and/or common values and interests. Community members – know and interact with one another – function within a particular social structure – show and create norms, values, and social institutions. Suburbs and other areas around city limits are also an integral part of the total community.  The Concept of Community Continued A community is also the demographics such as age, gender, social class, or race. A community can be defined on the basis of a common interest or goal. A collection of people, even if they are scattered geographically, can have a common interest. This is called a common-interest community.  The Concept of Community Continued Examples of common-interest communities: – Members of a national professional organization The Academy of Nutrition and Dietetics, etc. – Members of churches – Disabled individuals scattered throughout a large city – Individuals with specific health conditions Diabetes, hypertension, breast cancer, mental illness, etc. – Teenage mothers – Homebound elderly persons  Public Health and Nutrition Community nutrition and dietetics professionals are members of community and public health agencies responsible for nutrition services that emphasize community health promotion and disease prevention. They deal with needs of individuals in primary, secondary, and tertiary prevention. They establish linkages with other professionals in education and human services such as childcare agencies, social work agencies, services to older persons, high schools, colleges and universities, and community-based epidemiological research.  Public Health and Nutrition Continued Public health is the science and art of preventing disease, prolonging life, and promoting health through organized community effort. Public health has been viewed as the scientific diagnosis and treatment of the community. In this vision, the community, instead of the individual, is seen as the patient. The focus is on the community’s strengths and resilience.  Public Health and Nutrition Continued Community strengths can be physiological, psychological, social, or spiritual. They include such factors as: – Education, coping skills, support systems, knowledge, communication skills, nutrition, coherent belief systems, fitness, ability to develop a supportive environment, and self-care skills. Community strengths can increase the nutrition knowledge of the community members, which can subsequently reduce medical care costs and improve the quality of life.  Public Health and Nutrition Continued Public health nutrition was developed in the United States in response to the prevention of diseases, societal events, and changes of the following situations: – Infant mortality – Access to healthcare – Epidemics of communicable disease – Poor hygiene and sanitation – Malnutrition – Agriculture and food production – Economic depression, wars, and civil rights Public Health and Nutrition Continued – Aging of the population – Behavior-related problems/lifestyle Poor dietary practices, alcohol abuse, inactivity and cigarette smoking – Chronic diseases Obesity, heart disease, diabetes mellitus, mental health, cancer osteoporosis, and hypertension – Poverty and immigration – Preschool/after-school childcare and school-based meals  The Relationship Between Eating Behaviors and Chronic Diseases The relationship between the eating behavior and chronic disease is significant and impacts individuals and communities greatly. Different health agencies have provided comprehensive analyses of the relationship between diet, lifestyle, and major chronic diseases. Table 1-1 shows dietary factors that are linked to some of the most common chronic diseases.  10 Leading Causes of Death United States World 1. Heart disease 1. Ischaemic heart disease 2. Cancer 2. Stroke 3. Stroke 3. Acute lower respiratory 4. Chronic lower respiratory infections disease 4. HIV/AIDS 5. Accidents 5. Chronic obstructive 6. Diabetes Pulmonary disease 7. Pneumonia/influenza 6. Perinatal conditions 7. Diarrheal diseases 8. Alzheimer’s disease 9. Nephritis, nephritic 8. Tuberculosis syndrome, and nephrosis 9. Malaria 10. Septicemia 10. Lung/bronchus/trachea cancer  Reducing Risk Through Prevention Prevention is important in public health as well as community nutrition practice The three important parts of prevention are 1. Personal 2. Community-based 3. Systems-based health  Reducing Risk Through Prevention Continued 1. Personal health prevention is at the individual level Educating and supporting a breastfeeding mother for promoting the health of her infant. 2. Community-based prevention targets groups Public campaigns for low-fat diets to decrease incidences of obesity and/or heart disease. 3. Systems-based prevention deals with changing policies and laws to achieve objectives of prevention practice. Laws regarding childhood immunization, food labels, food safety, and sanitation.  Reducing Risk Through Prevention Continued System-based prevention is also the socioeconomic status that affects health through environmental or behavioral factors. – The socioeconomic model hypothesizes that poor families do not have the economic, social, or community resources needed to be in good health. – The link between socioeconomic status and health related problems is triggered and maintained by two processes. Selection Causative  The selective process: Represented by childhood health, which determines adult health and socioeconomic position. The causative process represents three groups of risk factors – Lifestyle, structural/environmental, and psychosocial stress-related factors – These are intermediaries between socioeconomic position and health problems. Childhood environment, cultural and psychological factors contribute to inequalities in health through selection and causation.  Levels of Prevention Primary prevention – An early intervention focused on controlling risk factors or preventing diseases. Secondary prevention – Identifying disease early (before clinical signs and symptoms manifest) through screening. Tertiary prevention – Intervention to reduce the severity of diagnosed health conditions in order to prevent or delay disability and death.  Health Promotion Proven to be an effective strategy for improving health and preventing chronic health conditions around the world. Health promotion approaches can change lifestyles and have an impact on the social, economic, and environmental conditions that determine health.  Healthy People 2020 A national health agenda that communicates a vision and a strategy for improving the health of the U.S. population and achieving health equity for the next decade. Works promoting and improving the health of every individual in the United States. Designed to make health determinants a primary focus and healthcare a secondary focus Healthy People 2020: Health Determinants The variety of personal, social, economic, and environmental factors that determine the health status of individuals or populations embedded in our social and physical environments. Social determinants – Family, community, income, education, sex, race/ethnicity, geographic location, and access to healthcare Physical determinants – Natural and built environments, exposure to toxins, manmade pollutants, or substandard housing.  Healthy People 2020 Mission Improve health by strengthening policy and practice Identify nationwide health improvement priorities Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress Provide measurable objectives and goals that can be used at the national, state, and local levels Engage multiple sectors to take actions that are driven by the best available evidence and knowledge Identify critical research and data collection needs  Healthy People 2020 HP2020 Vision: A society in which all people live long, healthy lives Overarching goals for HP2020; Eliminate preventable disease, disability, injury, and premature death Achieve health equity and eliminate health disparities Create social and physical environments that promote good health for all Promote healthy development and healthy behaviors at every stage of life  Figure 1-4: Action Model for Achieving Healthy People 2020 Goals Reproduced from: U.S. Department of Health and Human Services.  Knowledge and Skills of Community and Public Health Nutritionists Work as part of an interdisciplinary team – Collaboration among personnel representing different disciplines of public health workers. Community and public health nutritionists diagnose and address the public or community issues by: o Utilizing interventions that promote health and prevent communicable or chronic diseases by managing or controlling the community’s environment.  Knowledge and Skills of Public and Community Nutritionists Continued o Channeling funds and energy to problems that affect the lives of the largest numbers of people in a community. o Seeking out the unserved or underserved populations (due to income, age, ethnicity, heredity, or lifestyle) and those who are vulnerable to disease, hunger, or malnutrition. o Collaborating with the public, consumers, community leaders, legislators, policy makers, administrators, and health and human service professionals in assessing and responding to community needs and consumer demands.  Knowledge and Skills of Public and Community Nutritionists Continued o Monitoring the public or community’s health in relation to public health objectives and continuously address current and future needs. o Planning, organizing, managing, directing, coordinating and evaluating the nutrition component of health agency services. To accomplish the actions listed, public and community nutritionists need to acquire normal and clinical nutrition knowledge and be skilled in educating the public.  Knowledge and Skills of Public and Community Nutritionists Continued Minimum education requirements: – Bachelor’s degree in foods and nutrition or dietetics from an accredited college or university – Master’s in public health with a major in nutrition – Master of Science degree in applied human nutrition with a minor in public health or community health Certification as a Registered Dietitian (RD) may be required (minimum bachelor’s degree from an accredited program plus passing national registration exam) Dietetic Technicians, Registered (DTR) have at least an associate’s degree from an approved educational program.  Knowledge and Skills of Public and Community Nutritionists Continued Understand the epidemiology of health and disease patterns in the population and disease trends. Must be knowledgeable about the principles of health education, program planning, program evaluation, community organization, management, marketing, and policy formation Marketing skills are very important as they help to convey effective nutrition messages using a variety of media format for their audiences. Place of Employment for Public Health and Community Nutritionists Work in official community settings or voluntary agencies to promote health, prevent disease, conduct epidemiological research, and provide both primary and secondary preventive care. State/City/County Levels – Cooperative extension services – Home healthcare agencies – Hospital outpatient nutrition education departments – Native American health services Place of Employment for Public Health and Community Nutritionists Continued – Local public health agencies – Migrant worker health centers – Neighborhood or community health centers – Non-profit and for-profit private health agencies – Universities, colleges, and medical schools – Wellness programs National/Federal/Regional Levels – Food and Drug Administration (FDA) – U.S. Department of Agriculture (USDA) – U.S. Department of Health and Human Services (USDHHS) Place of Employment for Public Health and Community Nutritionists Continued International Level – Food and Agriculture Organization of the United Nations (FAO) – Pan American Health Organization (PAHO) – World Health Organization (WHO) – World Food Agency (WFA) – United Nations Children’s Emergency Fund (UNICEF) – United Nations Organization (UNO)  Ethics and Community Nutrition Professionals Ethics is the study of the nature and justification of principles that guide human behaviors, and are applied when moral problems arise. Community and public health nutritionists must abide by the Academy of Nutrition and Dietetics (AND) ethical code There are 19 principles in the code, which covers the diversity in the dietetic profession  Ethics and Community Nutrition Professionals Have the responsibility to provide accurate and reliable information so their clients can make appropriate choices. They must interpret evidence-based scientific information without bias in order to enable the community or clients to make informed decisions. Moral Virtues of Health Professionals – Integrity – Respect – Compassion  Nutrition Care Process and Model A systematic problem-solving method used to critically evaluate nutrition-related problems and make decisions regarding them. It provides a consistent framework to use when delivering nutrition care Designed for use with patients, clients, groups, and communities of all ages and conditions of health or disease. It contains four separate but interrelated steps.  Figure 1-5: The Nutrition Care Process Model Reproduced from: Nutrition Care Process and Model Part I: The 2008 Update. Writing group of the Nutrition Care Process/Standardized Language Committee. Journal of the American Dietetic Association. 108:7, 2008; page 116 Figure 2.  The Nutrition Care Process Step 1: Nutrition Assessment Utilize critical thinking skills to: Determining appropriate data to collect about your clients Determining the need for additional information for your clients Selecting assessment tools and procedures that match the situation and alternate possibilities Applying assessment tools in valid and reliable ways Distinguishing relevant from irrelevant data Validating the data Table 1-7: The Five Categories of Nutrition Assessment  The Nutrition Care Process Step 2: Nutrition Diagnosis Purpose is to identify and label specific nutrition problems that can be independently resolved or improved through nutrition intervention. The nutrition diagnosis is summarized into a structured sentence called a nutrition diagnosis statement or a problem, etiology, signs/symptoms (PES) statement. The etiology and the signs and symptoms are determined during nutrition assessment. The standard phrases included in a nutrition diagnosis statement are “related to” and “evidenced by.”  PES statements must be clear and concise A group of pregnant high school teenagers in a Midwestern city (target population) are obese and anemic (problem) related to frequent consumption of high fat food and sugary drinks from vending machines plus low iron intake and physical inactivity (etiology) as evidenced by BMI between 27 and 30, hemoglobin level of < 10 g/dl, and spoon-shaped fingernails, as well as vending machines in and around the high school containing high fat chips and sugary soft drinks (signs and symptoms). See Table 1-8 Community/Public Health PES Statements P: Can the nutritionist resolve or improve the nutrition diagnosis for this community/individual, group, or population? E: Can the nutritionist evaluate what was used as the etiology to determine whether it is the root cause that can be addressed with a nutrition intervention to reduce the signs and symptoms? S: Can measuring the signs and symptoms show that the problem is resolved or improved? PES overall: Does the nutrition assessment data support a particular nutrition diagnosis with a typical etiology, signs, and symptoms?  The Nutrition Care Process Step 3: Nutrition Intervention The purpose of the nutrition intervention step of the NCPM is to take specific action that can resolve or improve the identified nutrition problem/ diagnosis through nutrition assessment. The nutrition intervention consists of two components: the planning and the implementation. There are 4 categories of nutrition intervention: – Food and/or nutrient delivery – Nutrition education – Nutrition counseling – Coordination of nutrition care  Planning the Nutrition Intervention Use evidence-based practice – Using the highest quality of available information to make practice decisions. Plan the nutrition prescription – The community or individualized recommended dietary intake of selected foods or nutrients based on current reference standards and dietary guidelines and the client’s or community’s health condition and nutrition diagnosis Drives the selection of nutrition intervention or provides the framework within which the nutrition intervention is implemented  Implementing the Nutrition Intervention The action phase of the nutrition intervention. The purpose of the nutrition implementation is mainly to correct the nutrition diagnosis, remove the etiology, or reduce the signs and symptoms of the problem by: – Communicating the plan of nutrition care or program – Carrying out the plan of nutrition care or the nutrition program – Continuing data collection and modifying the plan of care/program as needed  Quality Implementation (See Table 1-9) Includes: Individualize the interventions to the setting, community, and/or clients Collaborate with colleagues and healthcare professionals such as social workers and the local public health department Follow up and verify that implementation is occurring and needs are being addressed Revise strategies as changes in condition/response occurs  The Nutrition Care Process Step 4: Monitoring and Evaluation Determines whether the goals/expected outcomes were achieved and whether progress was attained in resolving the nutrition problem – Monitor progress – Measure outcomes – Evaluate outcomes See Table 1-10  Nutrition Care Indicators Signs that can be observed and measured and are used to quantify the changes that occurred due to nutrition intervention. The indicators for nutrition monitoring should reflect the community/clients’ nutrition diagnosis, etiology, and signs/ symptoms. Factors That Make A Direct Impact on the Problem Food and nutrient intake; growth and body composition; change in food and nutrition-related knowledge, attitudes, and behaviors; and food access Laboratory values, such as HgbA1c, hematocrit, and serum cholesterol Functional capabilities, such as physical activity Client/community perception of nutrition care and results of nutrition program, such as nutrition quality of life, reduced serum cholesterol, or weight loss  Cooperative Extension System (CES) The Cooperative Extension (CE) System is an agency under the U.S. Department of Agriculture. It provides educational programs that help individuals and families acquire life skills. The Morrill Act of 1862 established land-grant universities to educate citizens in agriculture, home economics, mechanical arts, and other practical professions. In 1914 the Smith-Lever Act established a partnership between the USDA and land-grant universities.  CES Works in Six Major Areas: 4-H Youth Development—helps the youths make life and career choices. At-risk youth participate in school retention and enrichment programs. They learn science, math, social skills using hands-on projects and activities. Agriculture—helps individuals learn new ways to improve their income through research-based management skills, resource management, controlling crop pests. Leadership Development—trains extension professionals and volunteers to serve in leadership roles in the community. Cooperative Extension System Continued – Natural Resources—provides educational programs in water quality, timber management, composting, lawn and waste management, and recycling to landowners and homeowners. – Family and Consumer Sciences—teaches families and individuals nutrition, food preparation skills, positive childcare, family communication, financial management. – Community and Economic Development—helps local governments improve job creation and retention, small and medium-sized business development.  Cooperative Extension System Continued The Expanded Food and Nutrition Education Program (EFNEP) is a federally funded program designed specifically for nutrition education. The county extension home economists provide on-the- job training and supervise paraprofessionals and volunteers who teach low-income families and individuals.  Cooperative Extension Nutrition Program Successful Strategy The Successful Evidence-Based Community Strategies features in this chapter – The Clemson University Cooperative Extension Nutrition Program on Low-Fat Products and Fat Intake – The National Cancer Institute’s Health Promotion Intervention  The National Cancer Institute Health Promotion Intervention’s Successful Strategy The Working Well intervention was based on a conceptual model that incorporated three important elements: 1. The use of participatory strategies operated through a primary worksite contact and an employee advisory board. 2. An ecological approach targeting both individual behavior change and change in environmental and organizational structures. 3. The use of adult education and behavior change strategies in all aspects of intervention planning and delivery. Clemson University Cooperative Extension The successful program focused on the impact of low-fat diets on serum cholesterol utilizing low-fat products and lowering fat in the diet. It incorporated community nutrition classes, grocery store tours, speakers’ bureaus, professional education classes, home study courses, and worksite nutrition education programs. Results showed that this program made a positive impact on the participants  Discussion Topics What is the difference between primary, secondary and tertiary prevention? What is the interrelationship between nutrition and physical activity in promoting health and preventing obesity? What is the relationship between diet and diseases? What are the leading causes of death in the United States and the world?