ADA REPORTS

Health care reform legislative platform:Economic benefits of nutrition servicesIf you are among the two out of three Americans who do notsmoke or drink excessively, your choice of diet can influenceyour long-term health prospects more than any other actionyou might take. Eight out of the ten leading causes of death,including heart disease, stroke, some types of cancer, anddiabetes, are related to diet and alcohol.

- The Surgeon General's Report on Nutrition and Health (1)

he American Dietetic Association, Association of the Facul-ties of Graduate Programs in Public Health Nutrition, Asso-ciation of State and Territorial Public Health Nutrition Direc-

tors, and The Society for Nutrition Education (The Coalition)believe quality health care must be available, accessible, andaffordable to all Americans. Quality health care is defined toinclude nutrition services that are integral to meeting the preven-tive, therapeutic, and rehabilitative health care needs of allsegments of the population. Nutrition services of screening,assessment, education, counseling, and treatment must be in-cluded in health care reform proposals. Nutrition services must becovered as a benefit in the basic benefits package currently beingconsidered by the Administration. Coverage for nutrition servicesmust be provided under Medicare and Medicaid, other publicprograms, and private and corporate insurance programs. Theseservices must be provided by an RD or other qualified profession-als who meet licensing and/or other standards prescribed by theSecretary in regulations.

Any health care reform proposal must include nutrition ser-vices. These cost-effective services must be a component of thebasic benefits package currently being considered by the Admin-istration for the Medicare and Medicaid programs, other publicprograms, and private and corporate insurance programs. Nutri-tion services must be maintained in all comprehensive federal,state, and local programs designed to improve the public's health.

This basic benefits package is fundamental to meeting mini-mum health care needs of all Americans. Nutrition servicesincluded in the basic benefits package are cost-effective, espe-cially for persons at risk for acute and/or chronic medical condi-tions. These services prevent the need for more costly medical orsurgical treatments and reduce costly complications associatedwith disease progression. Nutrition services are an integral part ofhealth care for those at nutrition risk in primary care, acute care,outpatient care, home care, and long-term-care settings; formothers and children; for older Americans; and in preventivecare.

This platform was developed by The American Dietetic Association lastyear and has undergone numerous revisions. Early this year, ADA askedother nutrition organizations to review the platform. Their suggestionswere included and three organizations signed into this version of theplatform.

ADA members and staff who helped draft or review the platforminclude the following.

ADA Members: Ann Coulston, MS, RD (coordinated the platformdevelopment); Ann Gallagher, RD; Pat Splett, PhD, MPH, RD; MaryStory, PhD, RD; and Rebecca Mullis, PhD, RD.

Technical experts: Tina Colaizzo-Anas, MS, RD; Linda Hofmeister, RD;Eleanor Young, PhD, RD; Bert Connell, PhD, RD; Elizabeth Diemand, MS,RD; Janet Levihn, RD; Eleanor Schleinker; Betsey Haughton, MS, RD;Sara Bonam, MS, RD; Leslie Tinker, MS, RD; Linda Newcomb, MS, RD;Harriet Cloud, MS, RD; Elizabeth Leif, RD; Deborah Golden, MS, RD;Patricia McKnight, MS, RD; and Dorothy Marshall, RD.

ADA staff: Michele Mathieu-Harris; Patti Blumer, and Julie Stauss, RD.

Nutrition programs and services that promote health andprevent disease are fundamental to health care reform. Theseprograms and services must foster personal and communityresponsibility for healthy behaviors and life-styles and be deliv-ered in primary care, public health, and community settings. Tomaximize the benefit, these nutrition programs and services mustbe culturally appropriate and meet the needs of the vulnerableand frequently underserved segments of our population and beincluded in preventive care, in maternal and child health care, andin health care services for older Americans.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN ACUTE CARENutrition services in acute care play a vital role in therecovery of the patient. The Coalition supports coverage andindirect reimbursement of nutrition services in the basicbenefits package and under Medicarefor inpatients. Nutri-tion services must be identified as separate and distinctfromadministrative services.

Among hospitalized adults, excess costs for patients with malnu-trition were $5,575 for surgery patients and $2,477 for medicalpatients (2). Adequate nutrition is essential to reduced morbidityand mortality from acute and chronic disease. Well-nourishedindividuals are more resistant to disease and are better able totolerate other therapy and to recover from acute illness, surgicalinterventions, and trauma.

Inadequate nutritional intake can precipitate disease or in-crease its severity. Early detection of nutrition-related problemsand appropriate nutrition treatment are effective in preventingincreased morbidity from many diseases. In other words, nutri-tion treatment can help the patient recover more quickly anddecrease the number of days required in the hospital.

Nutrition services are currently included in the room and boardcharge on an inpatient's bill. Medically necessary nutrition ser-vices in inpatient health care settings must be considered special-ized care and be reimbursed separately, in a manner similar toother services (eg, those of occupational and physical therapists).

This separate coverage is particularly important in light of thefollowing points:* Malnutrition occurs in up to 50% of hospitalized patients (3);a The correlation between malnutrition and disease complica-tions is high;* Advances have been made in nutrition administered by vein ortube;* Evidence indicates that nutrition intervention corrects malnu-trition, prevents disease complications, and speeds rehabilitation;· Evidence shows that nutrition is critical to certain patients'progress (eg, those with diabetes, pressure sores, and cardiovas-cular disease) after acute care.

RDs control costs by ensuring judicious use of costly high-technutrition therapies, including parenteral nutrition (nutrition byvein) (4). When parenteral nutrition is used properly, postopera-tive complications can be reduced by 38% (5). Parenteral nutri-tion administration and monitoring may cost as much as $500 perhospital day. Substantial savings can be realized when enteralfeeding (via tube in the gastrointestinal tract) is substituted forparenteral nutrition. Because nutrition in medical education is inits infancy, it is the RD who has the expertise to make thisdetermination in the acute-care setting. An RD in Philadelphia,Pa, who works with a managed health care company saved her

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firm $60,000 by competent discharge planning and transitionalfeeding planning for a patient receiving parenteral nutrition.

RDs provide an essential role in ensuring the most cost-effective provision of nutrition care. For example, there are morethan 200 nutrient products on the market. Cost savings have beenrealized when RDs manage hospital nutrient solution formularies.One dietitian saved a hospital $40,000 annually by determiningthat a more expensive parenteral formula was not more therapeu-tically beneficial than the standard formula.

The American Dietetic Association has developed validatedpractice guidelines for specific disease states and conditions.These conditions include kidney disease, liver disease, lung dys-function, burns, diabetes, AIDS, cancer, short-bowel syndrome,bone marrow transplantation, solid organ transplantation,parenteral and enteral nutrition treatment, pediatric nutritioncare, and older adult nutrition care. In developing and usingpractice guidelines, dietitians aim to link standardized practice topositive outcomes, thereby ensuring efficiency and effectivenessin the delivery of care. For example, positive outcomes of nutri-tion intervention in burn care include increased survival rates,decreased length of hospital stay, decreased length of stay inintensive care units, decreased complications, and decreasednegative weight changes (6).

Several factors have contributed to an increase in the demandfor nutrition services: the aging of the population, the AIDSepidemic, the higher acuity level of hospitalized patients, and thecoexistence of malnutrition with chronic diseases.

In sum, The Coalition recommends separate reimbursementfor nutrition services in acute-care settings as a clinically effectiveand cost-effective component of health care reform.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN OUTPATIENT CAREAppropriate nuttrit ion services are a cost-effective way to keeppeople healthy and save scarce health care dollars. TheCoalition supports coverage and reimbursementfor nutri-tion assessment and treatment in the basic benefits packageand in Medicare Part B, Medicaid, and other plansfor high-risk patients. The Coalition supports outpatient nutritionservices provided to patients under the care of a physicianwith, de elopnertrd of aplan prescribing the type, amount, andduration of n trit ion senrices.

Because the prospective payment system has decreased thelength of hospital stays, many patients go home requiring furthercare. However, nutrition treatment - previously provided toinpatients who need to follow special diets after discharge- maynot be reimbursed by Medicare as an outpatient service. Becausethese critical follow-up costs may not be paid by Medicare or othersources, many patients do not follow through with the necessarynutrition treatment.

For example, when patients with diabetes are released from thehospital, maintenance of a diet plan can be critical to the stabili-zation of the health of the patient and prevention of rehospitaliza-tion. Diabetes requires daily management - including balancingof food, exercise, and (in some cases) medication - to controlblood glucose, maintain appropriate weight, and prevent or delayserious, permanent damage (blindness, amputation, or death).Appropriate nutrition services are a clinically effective way totreat people with diabetes. The most cost-effective use of nutri-tion services is to keep patients healthybygiving them the trainingthey need to maintain a healthy life-style.

Medically necessary nutrition services in outpatient health caresettings must be considered specialized care and be reimbursedin a mann er similar to care provided by occupational and physicaltherapist s.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN HOME CARECosts of home health care can be reduced by early applicationof nutrition servicesfor nutrition-related diagnosis. Patientswhose care plan includes nutrition treatntent and patientson enteral and parent teral nutrition therapy must be assessedand treated in line with the care plan developed aithl aphysician. The Coalition supports cocrale and indirectreimbursetrument of nutrition assessment (and treatment aspart of the basic benqfits package and ur.er the Medicareprogram.

Because the prospective payment system has decreased thelength of hospital stays, many patients are discharged requiringfurther nutrition treatment. Many of these patients, who cannotbe placed in a nursing facility or make periodic trips to thephysician's office or clinic, receive health care at home. Nutritiontreatment that was previously provided to inpatients who haveserious and complex nutrition treatment needs is not currentlyprovided as a home health care benefit;.

Many patients are discharged when they still require nutritiontherapy by vein (parenteral) or tube feeding (enteral) in thehome. Although home enteral and parenteral nutrition can poten-tially save costs associated with expensive hospitalization, thehome care industry has not been able to respond adequately to thecare needs of home parenteral and enteral nutrition patientsbecause of lack of reimbursement for nutrition treatment. Exces-sive costs for these therapies can be reduced by early mltritionassessment and appropriate nutrition treatment in home caresettings. Home parenteral or enteral nutrition treatment requiresregular follow-up and monitoring by RDs to prevent hospitalreadmission because of complications.

Provision of nutrition services in the home health care settingis a cost-effective way to treat people with diabetes and otherchronic diseases such as kidney failure and AIDS. For example,patients with diabetes are a large population group for whichnutrition treatment can be critical to the stabilization of health andthe prevention of rehospitalization. Diabetes management re-quires daily attention to food intake, exercise, and medication tocontrol blood glucose and prevent or delay disease complications.

Currently, nutrition services are included in administrativecosts and are not separately billable. Home health agencies withlimited administrative funds are often forced to use employeeswho are not trained to assess the nutritional status of patients.This often leads to complications for the patient, more costly care,and increased use of higher cost options for feeding that arereimbursed by Medicare. Dollars can be saved by using theappropriate health professional.

Medically necessary nutrition services in home health caremust be considered specialized care and he reimbursed in amanner similar to care provided by occupational and physicaltherapists.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN LONG-TERM CARENutrition services provided i log-ter7n care ipro?,e thequality of lije, slow the rate of physical deterioration, andprece?/ t further costly hospitalization or the nieef. tir higher'level of care. The Coalition supports coverage ond indirectreimbursemenrt of nutrition assess'rrnt and treatment iilong-termr-carefacilities as part of the basic beneits packagea.n.d nuntder the Medicare programmer.

It is often assumed that daily provision of three nutritious mealsmeets the nutrition needs of nursing home residents. In reality,individualized nutrition services are necessary because an in-

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creasing number of residents require a higher level of acute care.For a variety of psychosocial, economic, and medical reasons,

the elderly in nursing homes are particularly prone to suffer fromprotein-energy malnutrition as well as from certain micronutrientdeficiencies. Appropriate nutrition services can improve qualityof life, slow the rate of physical deterioration, and prevent costlyhospitalization or the need for a higher level of skilled care.

Decubitus ulcers (pressure sores) can be a significant problemin nursing home residents. It is estimated that the averagepressure sore costs $15,000 to treat and frequently involvessurgical treatment (7). Conditions such as anemia, hyperglycemia,dehydration, food-drug interaction, and vitamin/mineral deficien-cies also are indicators of patients at risk for development ofpressure sores. Nutrition treatment delivered to residents withdecubitus ulcers can speed the healing process, and optimalnutrition care can help prevent them from reoccurring. Thedevelopment of pressure sores correlates directly with the inci-dence of protein-energy malnutrition.

Many residents are on enteral or parenteral feedings thatrequire the expertise of an RD to determine the optimum balanceof nutrients and fluid. Consultation by an RD in these situationscan create significant savings for the facility. For example, askilled nursing facility saved $3,000 per month on one patientafter an RD conducted a nutrition assessment and evaluation thatresulted in improved patient acceptance of meals and decreaseduse of a costly supplement.

Federal requirements mandate that nursing facilities employ aqualified dietitian on a full-time, part-time, or consultant basis.Nutrition services are included as a part of the facility's adminis-trative costs, rather than as a separate charge. Financial pressuresin the health care delivery system often force facilities to use aconsultant dietitian for a minimum number of hours per month,and then use less qualified personnel to cover the rest of the time.The increase in acuity level of the residents combined with the fewhours the dietitian has in the facility make it more likely now thatthe nutrition needs of residents are not met. This, in turn, can leadto increased complications and health care costs.

Therefore, The Coalition recommends coverage and indirectreimbursement for nutrition assessment and treatment in long-term-care facilities.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN PREVENTIVE CAREHealth promotion and disease prevention nutrition servicesand programs are necessary, cost-effective, and humanitar-ian measuresfor the prevention of and delay in the progres-sion toward disease. These services and programs must beuniversally available and offered in a variety of settings thatare both traditional and innovative and thatfosterpersonalresponsibility for health behaviors and life-style. To maxi-mize the benefit, nutrition services must be responsive to anindividual's culture, learning capacity, and life situationand must ensure access to a nutritious diet. The Coalitionsupports inclusion of nutrition services and programs inpreventive care.

The goals of preventive care are to keep people healthy in theircommunities, to reduce the incidence and severity of preventablediseases, to improve health and quality of life, and to reduce totalmedical costs, particularly costs for medication, hospitalization,and extended care.

A quality health care system must be available, accessible, andaffordable; contain mechanisms for monitoring and evaluating thepublic's health; ensure that providers of nutrition care programsand services are qualified and have advanced nutrition training/education; use clinical and applied research to improve health

care practice; and maintain a comprehensive federal, state, andlocal public health infrastructure to protect the community'shealth.

A quality health care system that is available, accessible, andaffordable to all Americans must maintain a comprehensivefederal, state, and local infrastructure. The infrastructure must beaccountable for monitoring and evaluating the public's health; forensuring that providers of health care programs and services arequalified and have advanced training/education in nutrition; forensuring accessibility; for applying research to health care prac-tice; and for coordinating the private and public delivery systems.

Eating habits can have a significant impact on the incidence andseverity of many health disorders. A direct relationship clearlyexists between nutrition risk factors and certain key diseases.Consider the following information released in the Surgeon/General's Report (1) in 1988:· Coronary heart disease. Despite the recent sharp decline inthe death rate for coronary heart disease, more than 1.25 millionheart attacks occur each year (two thirds of them in men), andmore than 500,000 people die each year as a result. It still accountsfor the largest number of deaths in the United States. (Today, thecost of treatment is $136 billion.)* Stroke: In 1987, strokes occurred in about 500,000 people,resulting in nearly 150,000 deaths and long-term disability formany more individuals. Approximately 2 million Americans sufferfrom stroke-related disabilities, at an estimated annual medicalcost of more than $11 billion.* High bloodpressure: High blood pressure is a major risk factorfor both heart disease and stroke. Almost 58 million people,including 39 million who are under the age of 65, have high bloodpressure. Occurrence of hypertension increases with age and,with the aging of the population, will become a more prevalentrisk factor.· Cancer: More than 475,000 people died of cancer in the UnitedStates in 1987, making it the second leading cause of death in thiscountry. During the same period, more than 900,000 new cases ofcancer occurred. In 1985, the costs of cancerwere estimated to be$22 billion for direct health care, $9 billion in lost productivitybecause of treatment or disability, and $41 billion in lost produc-tivitybecause of premature mortality, for a total cost of $ 72 billion.· Diabetes Mellitus: Approximately 11 million Americans havediabetes, but almost half of them have not been diagnosed. Inaddition to the nearly 38,000 deaths in 1987 attributed directly tothis condition, diabetes also contributes to an estimated 95,000deaths per year from associated cardiovascular and kidney coni-plications. Diabetes care costs $20 billion per year.* Obesity: In the United States, obesity affects approximate ely 34million adults aged 20 to 74 years; the highest rates are among thepoor and minority groups. Obesity is a risk factor for coronaryheart disease, high blood pressure, diabetes, and possibly sometypes of cancer, as well as for other chronic diseases.

The Surgeon General's Report (1) goes on to state that eatingand drinking habits contribute to heart disease, cancers, strokes,diabetes mellitus, obesity, and other fatal diseases. The linkbetween dietary fat and coronaryheart disease is well established,and now early studies appear to link fat intake to some cancers,specifically breast, colon, and prostate cancers.

In an aging population, a higher-fat, higher-calorie diet and lessphysical activity results in more obesity. The incidence of diabetesis increasing by 6% each year because of the change in theAmerican life-style. Major risk factors include being over 40 yearsold, overweight, and a member of a minority population andhaving a blood-related family member with diabetes.

Nutrition programs and services, the cornerstone of treatment,can prevent, postpone, or mitigate the onset or progression of thisdisease and thus save scarce health care dollars.

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Other benefits of nutrition services include prevention of obe-sity, coronary heart disease, some types of cancer, and otherchronic diseases and their complications; improved recoveryfrom illness; improved physical, social, and mental well-being;reduction in the need for medical services and recurrent hospital-izations because of malnutrition and related problems; mainte-nance of independent living; and costs averted for medical andinstitutional care, surgery, and drug therapy.

Healthy People 2000 (8) states profoundly that a nation'shealthis measured by more than its death rate. Good health comesfrom reducing unnecessary suffering, illness, and disability. Itcomes also from the citizens' improved quality of life and sense ofwell-being. Ilealthy People 2000 acknowledges that this nationhas the means o prevent premature death and disability andachieve the potential for Americans to live healthy lives in theirown communities. We must now implement what we know aboutpromoting health and preventing disease. Personal choices havea powerful influence over one's health prospects. The public musthave the information and guidance necessary to make the wisesthealth choices, and nutrition plays a daily role in those choices.

Health promotion and disease prevention are our best opportu-nities t;o reduce I he ever-increasing portion of our resources spentto treat preventable diseases and functional impairment.

ECONOMIC BENEFITS OF NUTRITION SERVICESIN MATERNAL AND CHILD HEALTHNutrition serm'icesjbrpregnant worren can lead to the propergrow th a xd, developne.nt of th e tus and prevention of low-birth-weight infiml ts and costly complications. Nutrition ser-,ices are (Y'critical importance to promote growth and den)el-opment o!f' inJarnts and children, particularly those withd(i elopienltai disabilities and chronic medical conditions.The?( Coal itio, spl orts family-c(entered nutrition sericesforall pregnant anrd bre.1st-Jeeding women and for infants andchildren a.Ld supports referral to established programs suchaIs he Sperciol Stpplenztnal Food Program for Womtn,hfbn.ts, (td C childrenn (WIC) and EPSDT. Pregnant wondsa1(d ch /ildr(n ide 71iJied at risk, or u with other complications orrcod utio os, should rcce-ive p re motivee, therapeutic, and reha-bililttivc trut tiio? se)!ices.

No period in life is n ore important to good health than the monthsbefore birth. Thle prenatal period may be the starting time for goodhealth or the beginning of a lifetime of illness and shortened lifeexpectancy. Early nutrition intervention can substantially changethe course of e vents to improve pregnancy outcome.

Each year in the United States, nearly 39,000 babies die beforethe age of 1 yea r. Low birth weight, which occurs in 7% of allbirths,is the greatest single hazard to infant health, costing the nation$3.5 to $7.5 billion each year. Medicaid pays almost $19,000 perdelivery of a low-birth-weight infant vs just $ 3,500 per delivery ofa (normal-weight infant (9). Poor nutrition is one of the major riskfactors associated with low birth weight. Women who gain lessthan 21 lb during pregnancy are more than twice as likely todeliver low-birth-weight infants than are those who gain more.Nutrition is also vital to growth and development (including brainfunction development) of infants.

Assessment of nutritional status is an integral part of care at thebeginning of pregnancy and periodically throughout pregnancyand breast-feeding to provide continuing monitoring and recorn-mend appropriate intervention. Nutrition intervention is cost-effective. In 1992. the iS General Accounting Office estimatedthat every $1 spent. on the WIC program for pregnant womenyields up to $4.21 in Medicaid savings.

Specialized professional counseling on feeding should be pro-vidled to parents of low-birth-weight infants, other infants at high

risk, and infants who require special formulas. Parents of childrenwith special health care needs should also receive ongoing profes-sional advice on appropriate diets and feeding methods. Theseinclude children with physical or developmental disabilities orthose with a chronic medical condition caused by or associatedwith genetic/metabolic disorders, birth defects, prematurity,trauma, infection, or perinatal exposure to drugs. These childrenmake up 10% to 15% of the pediatric population, h it the costs oftheir care are disproportionately high (10).

Common nutrition problems among children - obesity, failureto thrive, undernutrition, iron deficiency. and dental caries- canhave significant short-term and long-term consequences. Be-cause eating habits are formed at an early age, the establishmentof healthful eating patterns by children is particularly important.Children need good nutrition during childhood for adequategrowth, development, and maintenance of health to decrease thecost of health care later in life.

Nutrition problems among adolescents include obesity, chronicdieting, eating disorders, hyperlipidemia, and dental caries. OfAmerican children and adolescents, 15% to 27% are obese. Theprevalence of obesity among children in the Urited States hasincreased significantly in the last two decades, an(l these childrenhave an increased risk of adult obesity and its complications. Thepotential cost of these diseases could be prevented or significantlyreduced with nutrition services for youth in priantr care andtlother preventive health care settings.

ECONOMIC BENEFITS OF NUTRITION SERVICESFOR OLDER AMERICANSNutrition assessment and treatn t are essential to dcreas-ing morbidity, mortality, and attendant health care costsfbor

nlu'era(ble older Aericans. The Coalition supports the N?-trition Screen.i ng Initiative recommendati fo l.r the iclu.n-sion of nutrition screening fir this population. I'or thoseidentified as being at nutritional risk, urtriltioo assessmentaoild tr(,atm'nlt mi.st be' covered (1(d l eirdbru)se-dl b! ledicar.

Every day 5,000 people turn 65, and by the year 2030, 21% of thepopulation will be over the age of 65 (11 ). Advancing age bringsincreased dependency and added health care costs. Today, olderAmericans make up almost 12% of the population bui account for36% of health care costs and 30% or more of all hospital stays anddrug prescriptions (11).

The impact of chronic health problems increases with age.Eighty-five percent of the older population has a chroi tic diseasesuch as diabetes, hypertension, or cancer (12). Many of thesediseases are diet related. Cardiovascular disease affects 50% ofpeople over age 70 (13). Decline in nutritional status is not aninevitable part of the aging process; rather it is environmentallydetermined and frequently results from inattention to risk factorsthat can be improved by nutrition screening, assessnenl, edlica-tion, counseling, and treatment.

Nutritional risk is the most important predictor of the totalnumber of physician visits, visits to physicians in emergencyrooms, and the occurrence of hospital episodes, accord:ling to astudy by Wolinsky (14). Twenty-five percent of the "old" oll areadmitted to the hospital with moderate to severe malnutrition(15). In a study of older patients a(ditted to a hospital, those whowere malnourished had actual hospital charges double that ofthose who were not malnourished, and their average length of staywas 5.6 days longer than patients without malnutrition (16).Proper nutrition assessment and treatment for those vvitherableolder persons are essential in decreasing health care costs.

Once older persons have been identified as malnourished,services through public/private partnerships, siich as homne-deliv-eredt meals, should be made available to those who need them.

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Adequately nourished patients have decreased morbidity andmortality and fewer secondary medical complications and dis-eases. Their wounds heal faster, they have fewer infections, andtheir hospitalizations are shorter. These factors all reduce Medi-care, Medicaid, and other third-party payer costs.

Nutrition services are critical because of their direct andimmediate impact on the patient's health or medical condition.Provision of nutrition services decreases costs of medical andinstitutional care, surgery, and drug therapy. Often elderly pa-tients do not seek or follow up on recommended nutrition treat-ment because the cost of such services is not reimbursed to them.

OVERVIEW OF COSTS TO THE AMERICAN PUBLICFOR CHRONIC DISEASENutrition is a daily concern for all Americans. For the past 15 yearsAmericans have become increasingly health conscious. However,disturbing statistics still exist as to the ability of Americans tounderstand and implement the array of messages they receive onnutrition and health.* One third of all Americans are overweight (17).· 1.5 million deaths in 1987 were diet related (1).* More than 250,000 (7%) of US infants have low birth weight,which contributes to the United States being ranked 23rd amongindustrialized countries in infant mortality (18).* Of American children and adolescents, 15% to 27% are obese(19).* The United States spends $2.3 billion daily on health care. In1992, diet-related disease consumed a major portion of the $838.5billion price tag for this nation's health costs (20).* More than $200 billion is spent for treatment of diet-relatedillness affecting 100 million Americans, including heart disease,high blood pressure, cancer, diabetes, and obesity (1).* More than $100 billion is spent for coronary heart disease indirect health care expenditures alone (8).* More than $72 billion is spent for cancer, including productivitylosses (1).* $39.3 billion is spent on obesity (21).* Between $3.5 and $7.5 billion is spent annually on low-birth-weight infants (8, 18).· $302 billion, or 36% of health care costs are spent for olderAmericans, whereas Medicare spent just $102 billion on olderAmericans in fiscal year 1990 (22).· $20 billion is spent annually on diabetes treatment, accordingto figures from the American Diabetes Association.* Another $33 billion is spent annually on illusionary "quick fix"weight loss solutions by 65 million Americans, according toRepresentative Ron Wyden's opening statement before the HouseSubcommittee on Regulation, Business Opportunities, and En-ergy Hearing: Safety and Effectiveness of Weight Loss Programs(May 7, 1990).

The main challenge is no longer to determine what eatingpatterns to recommend to the public (although there is more tobe learned), but how to inform and encourage an entire popula-tion to eat so as to improve its chance for a healthier life, thusdriving down the cost of health care. There is a clear need forcomprehensive, coordinated action to improve Americans' dietand health, as documented in the following federal publications:* Healthy People 2000: National Health Promotion and Dis-ease Prevention Objectives (8);* The Surgeon General's Report onNutrition and Health (1);· Guide to ClinicalPreventiveServices: AnAssessmentoftheEffectiveness of 169 Interventions, issued by the US PreventiveServices Task Force, 1989;· The Dietary GuidelinesforAmericans, 3rd ed, issued by theUS Departments of Agriculture and Health and Human Services,1990;

a Diet and Health, issued by the Institute of Medicine, NationalResearch Council of the National Academy of Sciences, 1989.

In spite of the overwhelming documentation in these reportslinking diet to disease, the United States spends only 3% of itshealth care dollars on preventing disease, according to the Cen-ters for Disease Control.

The nation can no longer afford to ignore its own reports andmust reduce the high cost of disease in this country. Nutritionprograms and services are the cornerstone of cost-effectiveprevention and must occur early in life to help drive down thespiraling cost of health care. More aggressive nutrition interven-tion early in life can have major impact on disease.

References1. The Surgeon General'sReport onNutrition and Health. Washing-ton, DC: US Dept of Health and Human Services; 1988. DHHS publication(PHS) 88-50210.2. ReillyJ, Hull SF, Alert N, Walker A, Bringardener S. Economic impactof malnutrition: a model system for hospitalized patients. .IPEN 1988;88: 371-376.3. Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associ-ated malnutrition: a reevaluation 12 years later. JAm Diet Assoc. 1993:93:27-33.4. Position of The American Dietetic Association: the role of the regis-tered dietitian in enteral and parenteral nutrition support. J Am DietAssoc. 1991; 91:1440-1441.5. The Veterans Affairs Total Parenteral Nutrition Cooperative StudyGroup. Perioperative total parenteral nutrition in surgical patients. NEngl JMed. 1991; 325: 525-532.6. Paulsen LM, Splett PL. Summary document of nutrition interventionin acute illness: burns and surgery. In: Splett PL, director. Effectivenessand Cost Effectiveness of Nutrition Care: A Critical Analysis with Reconm-mendations. JAm Diet Assoc. 1991; 91 (suppl): S15-S19.7. Study Guide: Preventionz and Treatment of Pressure Sores. Evans-ville, Ind: Bristol Myers Co; 1989.8. Healthy People 2000: National Health Promotion and DiseasePrevention Objectives. Washington, DC: US Dept of Health and HumanServices; 1990. DHHS Publication (PHS) 91-50213.9. Schore J. The Savings of Prenatal Costs for Newborns and TheirMothers From Participation in the WIC Program. Washington, l)C:Food and Nutrition Service, UJS Department of Agriculture; 1990.10. Baer M, Farnan S, Mauer A. Children with special health care needs.In: (all to Action: Better Nutrition .for Mothers, Children andFamilies. Washington, DC: National Center for Education in Maternaland Child Health; 1990.11. StatisticalAbstract of the I nited States: 1991 l 1 th ed. Washing-ton, DC: US Bureau of the Census; 1991.12. Roe D. Geriatric Nutrition. Englewood Cliffs, N J: Prentice-Hall;1992.13. Craig L. Nutrition andAginj. Columbus, Ohio: Ross Laboratories;1991.14. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, ChavezNM. Health service utilization among the non-institutionalized elderly. JHealth Soc Behar. 1983; 24; 325-337.15. Agarwal, N. American Society for Clinical Nutrition; conferenceabstract. May 1986.16. Robinson G, Goldstein M, Levine G. Impact of nutritional status onDRG length of stay. JPEN 1987; 11:49-51.17. Forster JL, Jeffrey RW, Schmid TL, Kramer FM. Preventing weightgain in adults: a pound of prevention. Health Psychol. 1988; 7:515-525.18. Early Intervention: Federal Investments Like WIC Can ProduceSavings. Washington, DC: I S General Accounting Office; 1992. Publi-cation No. GAO/HRD-92-18.19. Gortmaker S, Dietz W, Sobol A, Wehler C. Increasing pediatricobesity in the United States. Am J Dis Child. 1987; 141:535-540.20. 1 of Every 7 dollars last year was consumed by health care. Wash-ington Post. January 4, 1993.21. Colditz GA. Economic costs of obesity. An J Clin Ntr 1992; 55:503S-507S.22. Aging America: Trends and Projections. Washington, DC: USDept of Health and Human Services; 1991.DHHS Publication 91-28001.

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