This section opens with a historical perspective of public health nutrition from the 1800s to the present, and provides a list of the current goals of nutritionists working in the field of public health. The tools used by public health nutritionists vary, and may include geographic information systems (GIS); nutritional epidemiology; survey design, implementation and evaluation; and literature reviews known as meta-analyses. New areas of research in public health nutrition include examining the nutrition transition and learning how diet interacts with genes throughout life, affecting the expression of those genes and, consequently, tissue function and disease risk.
The world faces both old and new public health challenges. The safety of our water and food from unintentional contamination has always challenged us. In fact, the founding event in the science of epidemiology was John Snow’s use in 1854 of a spot map (the forerunner of geographic information systems, GIS) to make the connection between the quality of the source of water and cholera cases. Snow demonstrated an increased incidence of cholera in the households clustered around the Broad Street (London) water pump, which delivered sewage-polluted water. Currently, environmentalists are concerned with the effect on our water supply of hydraulic fracturing (fracking), which may result in water contamination near fracking sites.
Historically, we faced single nutrient deficiency diseases and protein and calorie malnutrition. The presence of severe malnutrition among the poor can render a population more susceptible to infection, as well as impeding their prospects of recovery. The health of the entire population, rich and poor, is undermined because malnutrition among the poor decreases their ability to ward off infectious diseases, which in turn leads to increases in infectious diseases in the population as a whole. Severe malnutrition now exists primarily in developing countries, but with international travel, its effects are seen globally, as infectious diseases are carried by travelers from the developing to the developed parts of the world.
The industrialized nations face the threat of agroterrorism, heart disease, cancer, the health of our increasingly elderly populations, and an obesity epidemic. Paradoxically, obesity is seen predominantly not only among the poor in developed countries but also among the more affluent in developing countries.
Mary C. Egan (a former associate director and chief nutritionist of the Bureau of Maternal and Child Health, Health Resources Administration, Department of Health and Human Services) provides a comprehensive overview of public health nutrition services from the mid-nineteenth through the mid-twentieth century, with special emphasis on mothers, children, and families.1
In the 1800s, efforts were focused on establishing state health departments and voluntary health agencies, initiating early nutrition investigations, and establishing milk stations and school lunch programs in large cities to supplement the diets of poor people and to combat the high rates of morbidity and mortality in infants and children. In 1867 the first state department of health was established in Massachusetts and by 1877 there were 14 state departments of health; in 1872 the American Public Health Association (APHA) was founded. The fields of community and public health nursing and of home economics, established in the 1850s and 1870s, respectively, served as precursors to public health nutrition, which narrowed the focus of both these fields.
Public health nutrition came of age in the early 1900s with the creation of the Children’s Bureau (CB) in 1907, the pasteurization of milk in 1910, and the Massachusetts General Hospital’s hiring in 1917 of its first nutritionist (called a “health instructor in foods”), the CB’s launching of studies of the nutrition status of children, iodization of salt to prevent goiter, and the creation of an experimental food stamp program.
In the 1930s and 1940s, the economic depression, the Second World War and waves of immigration brought new milestones in the delivery of nutrition services to the public. The US government embarked on food and nutrition status surveys, which began focusing attention on groups at nutrition risk, such as infants, children, pregnant and lactating mothers, the elderly, children with developmental disabilities, and racial and ethnic minority groups, and there appeared the first qualifications for nutritionists in public health. These additional landmark events occurred during the maturing years of public health nutrition: the first conference on the role of State Health Departments in nutrition research (1961), passage for the Food Stamp Act (1965), the first White House Conference on Food, Nutrition and Health (1969), which ushered in the Head Start Program, and the first White House Conference on Aging (1971), which led to the establishment of the Nutrition Program for the Elderly.
The 1950s witnessed the founding of the Association of Faculties of Graduate Programs in Public Health Nutrition and the Association of State and Territorial Public Health Nutrition Directors. The War on Poverty in the 1960s called attention to income and health disparities, which resulted in the beginnings of programs in maternal and child health (MCH), migrant health, school lunch and breakfast, all of which employed public health nutrition personnel.
Key figures in the earliest days of public health nutrition include Ellen H. Richards, Lydia Roberts, Frances Stern, Marjorie G. Heseltine. Physicians whose work led to the identification of nutrients responsible for deficiency diseases are Lind (vitamin C and scurvy, 1753) and Goldberger (niacin and pellagra, 1914).
Our current food- and nutrition-related challenges make public health nutrition a multi-disciplinary field that requires expertise in the biological, quantitative, and social sciences. Because preventing disease is at the heart of public health, one must look towards the social sciences to understand health-related behaviors and their societal influences – critical elements in educating and empowering people to make healthier lifestyle choices. In addition to understanding nutrition and food science and the behavioral sciences, public health nutrition professionals are also required to have a background in biostatistics, epidemiology, environmental science, and health policy and management. Working in interdisciplinary teams, public health nutritionists provide evidence-based approaches to solving the population-based health problems, and develop programs and policies to prevent and ameliorate these conditions.
Thus, some of the goals of those working in public health nutrition are to: identify and assess diet-related health problems – of both undernutrition and overnutrition – among diverse population groups in developed and developing countries; identify the social, cultural, economic, environmental, and institutional factors that contribute to the risk of undernutrition and over-nutrition among populations; demonstrate the linkages between agriculture, food, nutrition, and public health; develop educational, institutional, and other population-based intervention strategies to improve food security and reduce obesity; develop policies to reduce barriers to food insecurity and to improve the food and activity choices and nutritional status of diverse population groups; promote policies to ensure the safe production, distribution, and consumption of food; advocate for improved nutrition and physical activity opportunities for diverse population groups; apply population-based research findings to the development and implementation of nutrition policies and programs in the US and abroad; and investigate relationships between diet and disease by using the techniques of nutritional epidemiology.
Because nutrition affects almost every public health challenge, public health nutrition draws on diverse, multidisciplinary teams to find solutions, and in doing so examines the continuum from the cell to the population. Currently, domestic and international research is addressing ways to define and stem the global obesity epidemic, decrease risks of cancer and diabetes through dietary means, supplement women’s diets to improve maternal health, improve materno-fetal, infant, and child nutrition to protect survival and prevent adult onset chronic diseases, assess and prevent micronutrient deficiencies and their health consequences across the life stages, and develop and advocate food and nutrition policies to improve population.
Public health nutrition personnel in managerial and professional titles collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments. Research conducted by public health nutrition professionals may also serve as a resource to assist individuals, other professionals, or the community, and may provide justification for the allocation of resources for health education programs. Personnel in public health nutrition conduct nutrition assessments, design programs, and evaluate nutrition interventions at the individual, community, and national levels. They collect data using dietary assessment tools, qualitative methods, and surveys using local, state, and national data, including surveillance data. They determine how population consumption patterns affect nutrition status, how to evaluate epidemiologic studies on nutrition and health and how to apply findings to practice. They design, implement, and evaluate evidence-based local, state, and national nutrition programs that address the needs of diverse and vulnerable populations.
In terms of obtaining information about an individual’s diet, clinical nutritionists and dietitians use diet histories, 24-hour diet recalls and 72-hour foods records. However, for collection of comprehensive dietary data in large-scale epidemiologic studies, the most practical and economical method is the food frequency questionnaire (FFQ). Several have been developed for use with varying populations and for specific needs – the Willet FFQ (Harvard), and from the National Cancer Institute, the Block Health Habits and History Questionnaire and the Diet History Questionnaire. FFQs ask respondents to report their usual frequency of consumption of each food from a list of foods for a specific time period. Compared with other approaches, such as 24-hour dietary recalls and food records, the FFQ generally collects less detail regarding the foods consumed, cooking methods, and portion size. Therefore, the quantification of intake is not considered as accurate. However, unlike records or recalls, FFQs are designed to capture usual dietary intake. Most are completed independently by a respondent and are relatively inexpensive. Therefore, the FFQ is usually the method of choice in large-scale epidemiologic studies.
The research methodologies used by public health nutrition professionals include secondary analyses of food, nutrition, and health data from the National Center for Health Statistics (NCHS), a unit for the Centers for Disease Control and Health Promotion (CDC). The NCHS maintains literally hundreds of databases with information valuable to public health nutrition professionals. The major surveys used by public health nutrition professionals are: the National Health and Nutrition Examination Survey (NHANES), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Surveillance System (YRBSS), National Health Interview Survey (NHIS). Public health nutrition professionals also contribute to the development and administration of local surveys, such as the New York City Health and Nutrition Examination Survey (NYC HANES). Countries around the world maintain their own health survey data, such as the Canadian Community Health Survey, which includes dietary data, is run by Statistics Canada and Health Canada www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/cchs_guide_escc-eng.php (accessed on March 26, 2012).
In addition to designing and analyzing surveys, public health nutrition professionals conduct research using the standard methodologies of epidemiology. Consider these research study examples, all of which deal with the health effects of consuming sugar-sweetened beverages (SSB): Long-term, randomized, controlled trials have examined the relationship between the consumption of SSB and body weight.2 Prospective, observational studies have examined associations between the consumption of SSB and the risk of type 2 diabetes.3 Meta-analysis demonstrated associations between the intake of SSB and body weight.4 Cross-sectional and longitudinal studies have examined environmental risk factors for overweight children.5
A relatively new tool used in public health, the GIS, includes a set of hardware and software tools that help to visualize and to locate, rather than analyze, the patterns of a phenomenon. Mapping the nutritional terrain is one of the many areas of application of GIS methodologies. GIS presentations have made it easy to visualize where “food deserts” exist and where public health nutrition services should be targeted. A food desert is an urban area with little or no access to nutritious food. Residents living in food deserts are more likely to be overweight and have other diet-related health problems such as diabetes or hypertension. Almost any nutrition survey aiming to define the nutritional status in a certain area (at district, town, province, region, state, nation, or continent level) can be enhanced by a GIS presentation. Early warning systems mapping, poverty mapping, and vulnerability forecasts are examples of applications used by public health planners.
Public health nutrition policy scholars look for successful programs to address the nutritional problems of vulnerable populations, and in this way their work informs and directs policies and programs regarding food and nutrition. Researchers may synthesize existing information in the form of meta-analyses and systematic reviews to provide key information to policymakers on how to deal effectively with public health nutrition problems. They may also examine the impact of policies on important health outcomes, such as policies for obesity prevention and the promotion of physical activity.
Economics poverty and malnutrition are continued challenges in the developing world. The nutrition transition in industrialized nations from a scarcity of calories to a surfeit has led to the development of obesity and nutrition-related non-communicable diseases (NR-NCD), such as cardiovascular diseases, diabetes, and so on. At present, this transition is happening differently in Asia, Africa, the Middle East, Latin America, and Oceana compared to what occurred in the United States, Western Europe, and Japan at a similar stage in their economic development. Understanding the phenomenon of rapid onset of obesity and development of NR-NCDs is important for public health nutritionists and others who are challenged with planning strategies to prevent the continued increase in prevalence of obesity and its complications in the developing world.6
Cutting-edge areas that will be the focus of public health nutrition in the future include epigenetics. Environmental factors interact with genes throughout life, affecting the expression of those genes and, consequently, tissue function and disease risk. One such environmental factor is diet during critical periods of development, such as during prenatal life. Epigenetics, which refers to modifications to the DNA that regulate how much of a gene is produced, has been suggested to underlie these effects. Epigenetics explains why poor diet during pregnancy may compromise the long-term health of the offspring. For example, children born to mothers who consumed an unhealthy diet during pregnancy have an increased risk of type 2 diabetes, a significant contributing factor to heart disease and possibly also to cancer later in life. This knowledge presents new opportunities in cardiovascular and cancer risk reduction using dietary and lifestyle factors, which are goals of public health nutrition.
Some public health nutritionists work in private-sector organizations. Many work at the community level. Those with at least the MPH degree and several years of experience and/or the registered dietitian (RD) credential are employed by public health agencies in government settings.
The functions, duties, and qualifications of public health nutrition personnel have been delineated in Personnel in Public Health Nutrition for the 2000s.7 Those in managerial titles include public health nutrition directors, assistant public health nutrition directors, and public health nutrition supervisors. Those in professional titles include public health nutrition consultants, public health nutritionists, clinical nutritionists, nutritionists, community nutritionists, and nutrition educators. Those providing technical and support services include nutrition technicians (paraprofessionals) and community nutrition workers (who do not require academic preparation).
Personnel in public health nutrition are specialized nutrition professionals and paraprofessionals who provide and/or plan nutrition programs through organizations that reach people living in a designated community. Settings can include federal, state, city, or county government-operated public health departments and contracted services with public or private health centers, hospital ambulatory care clinics, health maintenance organizations, home health organizations, and specialized community health projects. Whether under governmental or non– governmental sponsorship, public/community health organizations generally operate under medical direction. They employ a multidisciplinary staff that includes nutritionists who work with physicians, nurses, social workers, health educators, dentists, epidemiologists, statisticians, health planners, community health workers, and environmental health specialists, among others.
The large number of different competency units identified as essential for effective public health nutrition practice reflects the breadth of skills, knowledge, and applications required to address the myriad problems encountered in public health nutrition practice. As it is unrealistic to expect an individual practitioner to have proficiency in all the competencies identified, this highlights the need for teamwork to ensure the competency mix required for effective work effort.8
One of the difficulties in identifying competencies relevant to public health nutrition relates to whether we are referring to the individual public health nutrition practitioner or the field as a whole. According to a study conducted in 2004,9 many core competencies expected of public health nutritionists are similar to those of nutrition and dietetics, health education, and generic public health practice.10 These competencies are described as analytical (nutrition monitoring and surveillance; assess the evidence and impact of health and health-care interventions, programs, and services and apply these assessments to practice; needs assessment – assessing population needs using various methods; applied research, research and development – appraise, plan, and manage research; interpret research findings and apply in practice; analyze the determinants of nutrition issues using a range of information sources; food monitoring and surveillance; scientific writing and dissemination of research; improve the quality of health and health-care services and interventions through audit and evaluation; and health economics and economic evaluation applications), sociocultural, and political (knowledge and understanding of the psychological, social, and cultural factors that influence food and dietary choices; and policy development); public health services (intervention management: Design, plan, implement, monitor, and evaluate nutrition strategies and programs for promoting health and well-being of the population, reduce inequalities; principles and practice of health education, health promotion theory, behavior change and health promotion policy and programs, public health methods; knowledge of food and nutrition systems and community food needs; provision of preventive nutrition programs; building capacity of the health workforce through training, up-skilling, and mentoring; service and prioritizing programs based on identified needs, their potential impact, as defined by objective measurable criteria; provide nutrition information to diverse audiences; health-care systems knowledge; provision of clinical nutrition services); communication (interpersonal communication and written); management and leadership (financial planning and management skills); and professional (ethics of public health nutrition practice; commitment to continual competency development and lifelong learning; values and participates in peer review; reflective practice to enhance performance).
A masters degree with graduate coursework in advanced nutrition and the core public health areas (biostatistics, epidemiology, health planning/administration, environmental health, health behavior and health education, and cross–cutting competencies) is recommended for managerial positions and public health nutritionist and public health nutrition consultant positions.
In addition to understanding the fundamentals of nutrition and food science, public health nutrition professionals have a background in the five core areas of public health: biostatistics, epidemiology, environmental science, health policy and management, and behavioral science.
Selected schools in the United States and the United Kingdom that offer the Masters of Public Health (MPH) degree, the Master of Science (MS) degree, or the doctorate (PhD, ScD, EdD, DPH) with a concentration in public health nutrition include the City University of New York, School of Public Health at Hunter College (www.cuny.edu/site/sph.html, accessed on March 26, 2012), Harvard University, School of Public Health (www.hsph.harvard.edu/departments/nutrition/prospective-students/public-health-nutrition/index.html, accessed on March 26, 2012), New York University, Steinhardt School of Culture, Education, and Human Development (mph.nyu.edu/academics/concentrations/public-health-nutrition.html, accessed on March 26, 2012), Tufts University, School of Medicine in cooperation with the Gerald J. and Dorothy J. Friedman School of Nutrition Science and Policy (www.tufts.edu/med/education/phpd/mph/concentrations/nutrition/index.html, accessed on March 26, 2012), Johns Hopkins University Bloomberg School of Public Health (www.jhsph.edu/chn/academics accessed on March 26, 2012), University of Massachusetts—Amherst, Department of Nutrition (www.umass.edu/sphhs/nutrition/about/index.html, accessed on March 26, 2012), University of North Carolina, Gillings School of Global Health (www.sph.unc.edu/nutr/degrees, accessed on March 26, 2012), University of Tennessee at Knoxville, College of Education, Health and Human Sciences, Department of Nutrition (nutrition.utk.edu/phn/degree_offering_and_curriculum/dual_ms_mph/index.html, accessed March 26, 2012), and London School of Hygiene and Tropical Medicine (www.lshtm.ac.uk/study/masters/msphn.html, accessed on March 26, 2012).
Other advanced degree programs in nutrition (not all of which offer public health degrees) are listed on the Academy of Nutrition and Dietetics website (www.eatright.org/BecomeanRDorDTR/content.aspx?id=8146, accessed on March 26, 2012).
An alternative qualification would be the RD credential with an undergraduate degree in community nutrition or dietetics, additional public health core coursework, plus three years of increasing or progressively responsible full-time work experience as a nutritionist in a public health organization.
The Academy of Nutrition and Dietetics recognizes programs that train entry-level practitioners in community nutrition. These programs are expected to provide students with the ability to:
In the United States, the major professional associations that represent professionals in public health nutrition include the Academy of Nutrition and Dietetics’ practice groups: Hunger and Environmental Nutrition (www.hendpg.org, accessed on March 26, 2012) and Public Health/Community Nutrition (www.phcnpg.org, accessed on March 26, 2012); the American Public Health Association’s Food and Nutrition section (www.apha.org/membergroups/sections/aphasections/food, accessed on March 26, 2012), and the Association of State and Territorial Public Health Nutrition Directors (ASTPHND) (www.astphnd.org, accessed on March 26, 2012). Globally, see: Nutrition Society (www.nutritionsociety.org, accessed on March 26, 2012) and World Public Health Nutrition Association (www.wphna.org/president_welcome.htm, accessed on March 26, 2012).
1 Egan, Mary C., “Public health nutrition: A historical perspective.” J Am Diet Assoc. 1994, 94: 298–304.
2 James, J., P. Thomas, D. Cavan and D. Kerr, “Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial.” BMJ 2004, 328: 1236; Sichieri, R., Paula Trotte, A., de Souza, R. A., and Veiga, G. V. “School randomised trial on prevention of excessive weight gain by discouraging students from drinking sodas.” Public Health Nutr 2009, 12: 197–202; Ebbeling, C. B., Feldman, H. A., Osganian, S. K., Chomitz, V. R., Ellenbogen, S. J. and Ludwig, D. S. “Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study.” Pediatrics 2006, 117: 673–80; Albala, C., Ebbeling, C.B., Cifuentes, M., Lera, L., Bustos, N. and Ludwig, D. S. “Effects of replacing the habitual consumption of sugar-sweetened beverages with milk in Chilean children.” Am J Clin Nutr 2008, 88: 605–11.
3 Matthias, B., Schulze, P. H., Manson, J. E., Ludwig, D. S., Colditz, G. A., Stampfer, M. J., Willett, W. C., and Hu, F. B. “Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women.” JAMA 2004, 292: 927–34; Montonen, J., Jarvinen, R., Knekt, P., Heliovaara, M. and Reunanen, A. “Consumption of sweetened beverages and intakes of fructose and glucose predict type 2 diabetes occurrence.” J Nutr. 2007, 137: 1447–54; Palmer, J. R., Boggs, D. A., Krishnan, S., Hu, F. B., Singer, M. and Rosenberg, L. “Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women.” Arch Intern Med. 2008, 168: 1487–92.
4 Vartanian, L. R., Schwartz, M. B. and Brownell, K.D. “Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis.” Am J Public Health 2007, 97: 667–75.
5 Gillis, L. J. and Bar-Or, O. “Food away from home, sugar-sweetened drink consumption and juvenile obesity.” J Am Coll Nutr. 2003, 22: 539–45; Ariza, A. J., Chen, E. H., Binns, H. J. and Christoffel, K. K. “Risk factors for overweight in five- to six-year-old Hispanic-American children: a pilot study.” J Urban Health. 2004, 81: 150–61.
6 Popkin, B. M. “Part II. What is unique about the experience in lower- and middle-income less-industrialised countries compared with the very-high-income industrialised countries? The shift in stages of the nutrition transition in the developing world differs from past experiences!” Publ Health Nutr. 2002, 5: 205–14.
7 Dodds, J. M., ed. Personnel in Public Health Nutrition for the 2000s. ASTPHND, 2009. www.astphnd.org/resource_files/105/105_resource_file1.pdf (accessed on April 11, 2012).
8 Hughes, R. “Competencies for effective public health nutrition practice: a developing consensus.” Public Health Nutr. 2004, 7: 683–91.
9 Hughes, R. “Competencies for effective public health nutrition practice: a developing consensus.” Public Health Nutr. 2004, 7: 683–91.
10 Council on Linkages between Academia and Public Health Practice. Core Competencies for Public Health Professionals. Washington, DC: US Department of Health and Human Services, 2002.
Edelstein, Sari, ed. (2011) Nutrition in Public Health: A handbook for developing programs and services, 3rd edition. Washington, DC: American Public Health Association.
Frank, Gail C. (2008) Community Nutrition: Applying Epidemiology to Contemporary Practice, 2nd edition. Sudbury, MA: Jones and Bartlett Publishers.
Gibney, Michael J., Barrie M. Margetts, John M. Kearney, and Lenore Arab, eds. (2004) Public Health Nutrition. Hoboken, NJ: Wiley.
Spark, Arlene (2007) Nutrition in Public Health: Principles, policies, and practice. Boca Raton, FL: CRC Press.
Struble, Marie Boyle and David H. Holben (2006) Community Nutrition in Action: An interdisciplinary approach, 5th edition. Stamford, CT: Thomson/Wadsworth.
Vir, Sheila Chander, ed. (2010) Public Health Nutrition in Developing Countries, Part I. Cambridge: Woodhead Publishers.
Public Health Nutrition: published monthly on behalf of The Nutrition Society to disseminate research and scholarship aimed at understanding the causes of, and approaches and solutions to, nutrition-related public health achievements, situations, and problems around the world. Suitable for epidemiologists and health promotion specialists interested in the role of nutrition in disease prevention; academics and those involved in fieldwork and the application of research to identify practical solutions to important public health problems: www.nutritionsociety.org/publications/nutrition-society-journals/public-health-nutrition (accessed on March 26, 2012).
Occasional articles about public health nutrition in: Journal of the Academy of Nutrition and Dietetics (formerly Journal of the American Dietetic Association), Journal of the American Public Health Association, Journal of Clinical Nutrition, Journal of Nutrition Education and Behavior.
Hunger and Environmental Nutrition www.hendpg.org
Public Health/Community Nutrition www.phcnpg.org
Yale Rudd Center Newsletter www.yaleruddcenter.org/newsletter
Appetite for Profit www.appetiteforprofit.com
Be Active Your Way Blog www.health.gov/paguidelines/blog
Bridging the Health Literacy Gap blogs.cdc.gov/healthliteracy
Food Politics www.foodpolitics.com
Genomics & Health Impact Blog blogs.cdc.gov/genomics
US Food Policy usfoodpolicy.blogspot.com
World Public Health Nutrition Association www.wphna.org/aboutthiswebsite.htm
Yale Rudd Center www.yaleruddcenter.org/blog
Young Public Health Nutrition Network sites.google.com/site/yphnutrition/yphn-blog
Center for Public Health Nutrition, University of Washington depts.washington.edu/uwcphn/about
Rudd Center for Food Policy & Obesity www.yaleruddcenter.org/blog
Principles of Public Health Nutrition (web-based module) www.epi.umn.edu/let/nutri/principles/index.shtm