Future Public Health Workforce Demands and Opportunities

Jamie Stang, PhD, MPH, RDNUniversity of MinnesotaSchool of Public Health

If you think in terms of a year, plant a seed; if in terms of ten years, plant trees; if in terms of 100 years, teach the people.

Confucius

Public Health Nutrition Workforce Development

• Why should we be concerned?– Significant demographic changes are occurring

• Many state leaders are preparing to retire

– Shifting of health care priorities expected• Treatment vs. prevention

– Changes in education and training are underway• Increase in education to become credentialed in

nutrition/dietetics• Limited supervised practice has created a bottle neck

– Upward mobility is expected• Generalist vs. specialist training

ASPHN Members: A Profile

• Training and credentials– 77% are RDNs– 20% have bachelors degree– 63% have masters degree

• Where we work– 78% work in state health department– 6% at university– 2% at local health department– 1% at non-profit– 2% at other state agency

• Our experience– 25.5% have worked in PHN for 26 years or longer– 25.5% plan to retire in next 5 years

• 14.5% not sure2014 ASPHN Member Assessment Survey

Factors in Future Workforce Projections

• 2014 ASPHN needs assessment– Obesity prevention is top responsibility

• Nutrition or health education next• WIC is third (was top in 2012)

– Funding• WIC still funds most positions• State funds• CDC• Few people receive funding from HRSA/MCHB

Select Change Drivers Identified by Academy’s Council on Future Practice

1. Aging population drive opportunities and challenges

2. Population and workforce diversity challenges

3. Workforce education meets job market demands

4. Generalists gain edge over specialists

5. Food industry transforms for public priorities

6. Health care reform

7. Population risk factors and nutrition initiatives

DEMOGRAPHICSA Changing Population

Demographic Trends

• US Census Projections, 2014 – 2060– 319 million people

• Will reach 400 million by 2051

– 1 in 5 Americans will be 65 and older by 2030

– Half of Americans will be from a minority group by 2044

– By 2060, 1 in 5 people will be foreign born• 13% foreign born in 2014• Largest increase expected between 2010 and 2020• 20% of mothers will be foreign-born by 2060

Current Population Reports, Projection of the Size and Composition of the US Population: 2014 to 2060. US Census Bureau

Demographic Trends, 2014 - 2060

• US Census Projections– Population <18 yr will decrease from 23% to 20%

• 8.4% increase among US-born• 30% increase among foreign-born

– 18-64 yr group will decrease from 62% to 57%• Percentage of both US- and foreign-born will remain fairly stable

– >65 yr group will increase from 15% to 24% overall• More pronounced aging among foreign-born groups• 7% increase among US-born older adults

– 15% to 22%• 18% increase among foreign-born older adults

– 14% to 32%

Demographic Trends, 2014 - 2060

• US Census Projections– 44% of Americans will be non-Hispanic white in 2060

• Majority minority crossover expected in 2044

– Multiple race category will grow fastest• 226% increase, from 2.5% to 6.2%

– Asian population 2nd fastest growing category• 143% increase projected, 5.4% to 9.3%

– Hispanic population 3rd fastest growing category• 115% increase, 17% to 29%

– Black population expected to increase by 42%• Will comprise 14% of population by 2060

– American Indian/Alaskan Native and Native Hawaiian and Pacific Islander populations will grow modestly• About 1% of total population, each

Demographic Trends, 2014 - 2060

• US Census Projections for < 18 yr population– US approaching minority majority youth population

• Crossover will occur in 2020

• 2014, 52% of youth are non-Hispanic white– Expected to decrease by 23% by 2060– By 2060, 64% of youth will be non-white

• 24% of youth are Hispanic– 34% will be Hispanic by 2060

– Largest growth for youth will be multiple race category• 2nd largest growth rate will be Asian• 3rd fastest growth rate will be Hispanic• Native American/Alaskan Native and white youth populations will

decrease

How Diverse is ASPHN?

ASPHN Academy RDNs US

White 79.1% 84% 77.7%

Black 5.5% 2% 13.2%

Hispanic 6.4% 3% 17.1%

Asian/Pacific Islander 2.7% 5% 5.5%

American Indian/Alaskan Native 2.7% <1% 1.2%

Other (including > 2 races) NA 1% 2.4%

Male 2.7% 4% 49.2%

How Diverse Will Nutrition and Dietetics Be?

• Dietetics student diversity– 6% black– 11% Hispanic– 7% Asian/Pacific Islander– < 1% Native American/Alaskan Native– 75% white

• Enrollments among most minority groups increasing– +15% Hispanic– +7% Asian/Pacific Islander– +20% American Indian/Alaskan Native– - 1% black

Economic Trends

• 14.5% of Americans live in poverty– 19.9% of youth live in poverty– 13.6% of 18-64 yr old adults live in poverty– 9.5% of older adults live in poverty

– Poverty rate was 22.4% in 1950s– Lowest rate was 11% in 1973– Rose in 1980s to 15.2% (1983)

Economic Trends

• Racial and ethnic differences in poverty– 9.9% white, 12.1% Asian households– 27.4% black and 26.6% Hispanic households

• Poverty rate declined among Hispanics in 2013

• Gender and nativity differences– 31.6% of single female-headed households– 15.8% single male-headed households– 6.2% married-couple households– 14.4% of households headed by US-born adult– 19.9% of households headed by foreign-born adult

Economic Trends

• Bureau of Labor Force Projections 2012 - 2022– 5.5% unemployment rate (May 2015)– In 2012, 63.7% labor force participation rate

• 61.6% by 2022• 2022, 55+ yr 26 % labor force participation rate (currently 21%)

– Average hourly wages $24.96

– Fastest growth in less-skilled, lower paying positions

– Minimum wage will have an effect on poverty rates• Current rate of $7.35 = $15,080 annually• “tipped minimum wage” frozen at $2.13/hr in 1991• Adults 20+ yr make up 88% of minimum wage workers

Food Insecurity• Food insecurity and hunger

– 14.3% of households are food insecure• 5.6% very low food security (hunger)• 8.7% low food security• 47% of homes with food insecurity have incomes > 130% of poverty

line

– 19.5% of households with children are food insecure• 13.9 million children are in food insecure homes• 3.3 million children are in homes that experience hunger• Households with children 2x as likely to experience food insecurity– Children from food insecure homes more likely to have poor

health status, anemia, lead poisoning, behavioral issues

Demographicsof Food

Insecurity

FOOD TRENDSWe Care About Our Food

Consumer Demands for Food

• Organic foods– 4% of all food sales– $35 billion (2014)

– Fruits and vegetables largest category– Dairy is second largest category– Packaged/prepared foods is third

• Conventional stores are the main source of organic foods– 93% sold in conventional/natural food stores– 7% in formers markets– Cost difference is <30% for most foods– Blueberries > 100% premium– Dairy premium was 60% to 110%

Consumer Demands for Food

• Specialty foods– Gluten free

• $1.8 billion market in US• Expected to be $23.9 billion in 2020

– Raw milk• Caused 81 food borne illness outbreaks in 26 states between

2007 and 2012• Campylobacter – 81% of outbreaks• E-coli (shiga toxin-producing) – 17% of outbreaks• Salmonella – 3% of outbreaks• 59% of outbreaks involved children < 5 yr• Sales of some sort legal in 30 states

Consumer Demands for Food

• Sustainable, local foods– US Congress 2008 Food, Conservation and Energy Act

defined “locally or regionally produced agricultural food products” as “< 400 miles from origin or within the State in which it was produced”

– Most consumers disagree with 100 mile radius for produce

– Local foods chosen for freshness (82%), supporting local economy (75%), knowing food source (58%)

– Price was only considered an issue by 16% of consumers• No differences by income, education, race/ethnicity

Trends in Local Foods

• Direct to consumer marketing $1.2 billion in 2007– Was $551 million in 1997– Accounted for almost 1% of agricultural sales in 2007

• 5,274 farmers markets in 2009– Was 2,756 in 1998 and 1,755 in 1994

• 1,144 CSA in 2005– Was 400 in 2001

Local and Regional Food Systems

• 8% of US farms (163,675) marketed foods directly to consumers in 2012– 70% used only CSA or farmers market channels– 17% increase in number, 32% increase in sales 2002-2007

• Local food sales estimated at $6.1 billion in 2012– 85% of local food farms had < $75,000 in gross income in

2012• 13% of food sales

– 5% of local food farms had > $350,000 gross income• accounted for 67% of sales

USDA. Trends in US Local and Regional Food Systems: Report to Congress. Jan 2015

Farm to School• 4,322 School districts (44%)– 23.5 million children

• Local of food– 21% within 50 miles– 13% get foods within 100 miles– 6% within 200 miles– 26% within state

• $385.8 million spent on local foods– 78% fruit– 75% vegetables– 37% milk– 22% baked goods

POPULATION RISK FACTORSHealth Care Reform and Public Health

Snapshot of Health Care

• CVD is leading cause of mortality– 24% of women, 11% men > 65 yr have high cholesterol

• Cancer second leading mortality cause

• Stroke is 3rd leading cause of death– 32% of adults 45-64 yr have hypertension– 51% of adults 65-74 yr have hypertension

• Chronic lower respiratory disorders is #4

• Unintentional injury is #5

• Diabetes is #6– 11% of adults 20+ yr have diabetes– 7% of teens, 26% of adults have pre-diabetes

Snapshot of Health Care

• Limitations of activity affect many people– 9% of youth

• Learning disabilities, neuro-behavioral disorders, neuro-muscular conditions, hearing and vision disorders, speech disorders, intellectual disability

– 25% of adults aged 18-64• Mental illness, diabetes, pulmonary disease, musculoskeletal

disorders, intellectual disability, hearing and vision disorders

– 62% of adults aged 65+ (living at home)• Musculoskeletal disorders, diabetes, dementia, heart

disease, pulmonary disease, hearing and vision loss

Insurance Trends• Patient Protection and Affordable Care Act aka,

“Obamacare” or “the ACA” goals– Provide coverage for uninsured Americans– Improve affordability and stability of insurance for those already

insured– Slow health care cost growth to reduce the federal deficit

• Additional reforms– Shift health care costs from treatment to prevention

• Free, annual wellness checkups• Wellness incentives for reducing weight and cholesterol,

smoking cessation, etc• Increased availability of telemedicine• Increase in community health centers Domestic Policy Council, March 23, 2015

The ACA Five Years Later

• 16.4 million more people have insurance– Uninsured rate decreased 9% among black and 12% among

Latino adults– 40% decline in uninsured young adults through expanded

dependant coverage through age 25

• 129 million people with pre-existing conditions could not be denied coverage– 17 million children

• 105 million people no longer have lifetime cap

• Consumers saved $9 billion– Insurance companies required to spend 80¢ per dollar of

premium cost on careDomestic Policy Council, March 23, 2015

The ACA Five Years Later

• Lowest increase in employer premiums since 1999– $1800 per family in savings for employers

• Hospital Insurance Trust Fund (Medicare) will remain solvent for 13 additional years (until 2030)– Reductions in health care costs

• 424 Accountable Care Organizations serve 7.8 million– 20% Medicare reimbursements linked to health and well-being

of patients

• 9.4 million people on Medicare saved $15 billion on prescription drugs– $1,598/person

Domestic Policy Council, March 23, 2015

Health and Disease Trends

• Overweight and obesity will continue to be major chronic health condition– Co-morbid condition with many chronic conditions– Plateau in obesity a promising sign

• Funding for policy, system, environmental change strategies contingent on evidence of effectiveness– Telling our stories is important for policy and funding

• 75% of health care spending for chronic diseases– 3% is spent on public health and primary prevention– 84% spent on physician-related care

• Medication• Hospitalization• Outpatient surgical procedures

PUBLIC HEALTH AND COMMUNITY NUTRITIONISTS

A Snapshot of the Nutrition Workforce

Definitions: Public Health & Community Nutrition

• Community Nutrition– Community nutrition encompasses individual and inter-

personal level interventions that create changes in knowledge, attitudes, behavior and health outcomes among individuals, families or small, targeted groups within a community setting.

• Community Nutritionist– Professional trained in the delivery of primary, secondary and

tertiary nutrition services within community settings. – Has training in

• Nutrition throughout the lifespan• Nutrition education and counseling• Program development

Definitions: Public Health & Community Nutrition

• Public Health Nutrition– The application of nutrition and public health principles to

design programs, systems, policies, and environments that aim to improve or maintain the optimal health of populations and targeted groups

• Public Health Nutritionist– Professional trained in both nutrition and the core competency

areas of public health• Biostatistics, epidemiology, health behavior, health policy and

management, and environmental science.

– Has advanced didactic and experiential training in public health nutrition or holds advanced degree in public health nutrition or nutrition science

Public Health vs Community NutritionPublic Health Nutrition Community Nutrition

Primary audience Populations (cities, counties, states, regions, countries)

Individuals, families, groups, communities

Levels of prevention Primary, some secondary Secondary and tertiary

Provision of direct services

Limited or no direct service involvement

Primary responsibility

Policy & advocacy roles

Development, evaluation, revision, monitoring

Advocate for change, implement policies

Nutrition program & service roles

Development, evaluation, revision, administration

Assessment, implementation, limited role in other functions

Research & evaluation

Nutrition surveillance, design and analysis, reporting

Data collection, assist with design and reporting

Management responsibilities

Financial, personnel, departmental-level staffing and succession planning

Supervision of program employees, limited other roles

Public Health and Community Nutritionists

• More than half of nutrition and dietetics (RDN) positions are in clinical nutrition– 22% in-patient care– 18% out-patient care– 11% long-term care

– 11% on “community nutrition”– 4% on “other” including public policy and advocacy

Two roads diverged in a wood, and I—I took the one less traveled by, And that has made all the difference.

Robert Frost

Public Health/Community Nutrition Workforce

• 91,889 RDNs– 11% report community nutrition as primary area of

practice– Half of RDNs have a masters/graduate degree

• Median pay for RDN is $28.85/hr• Median pay for community nutrition is $26.06/hr– Lowest of all practice areas– 7% increase in pay between 2011 and 2013 for WIC

nutritionists

• Median pay for PHN is $27.50/hr– 2% increase in pay for public health nutritionists

Commission on Dietetic Registration/Academy, 2013 Compensation and Benefits Study

Hourly Wages of RDNs

Position 25th percentile 50th percentile 75th percentile

Average of All Practice Areas $24.04 $28.85 $34.86

Community Nutrition $21.87 $26.06 $31.25

WIC Nutritionists $19.71 $24.04 $28.21

Public Health Nutritionists $23.08 $27.50 $34.98

Cooperative Extension Educator/Specialist

$20.09 $25.00 $31.45

School/Child Care Nutritionist

$20.83 $28.85 $34.98

Head Start Nutrition Coordinator

$19.91 $25.41 $31.58

Food Bank/Assistance Program Nutritionist

$21.68 $24.04 $29.81

Workforce Supply and Demand

• HRSA Workforce Projection: Dietitians & Nutritionists– Between 2012 and 2025

• Supply expected to increase by 36%• Demand projected to grow by 20%• Projected surplus of 10,400 FTEs by 2025

• Bureau of Labor Statistics Occupational Outlook Handbook– Between 2012-2022

• Demand will increase by 21% (faster than average)

• Commission on Dietetic Registration– Dietetics Supply and Demand: 2010-2020

• Annual growth rate of 1.1%• Only 75% of demand met by 2020• Shortfall of 18,000 FTEs

Professional Attrition Rate

• Nutrition and dietetics has a 2% to 5% attrition rate– Retirement– Extended/permanent leave for family, personal reasons– Continued education into another field– Leave the field for higher paying positions

• 75% of nutrition and dietetics professionals work full time (> 35 hr/week)

• 25% work 20 hr/week or less• Unknown number drop out of the workforce

temporarily for personal/family issues

Uneven Distribution of Professionals

State N = RDN/100,000 population Rank

Top 8

North Dakota 356 55.0 1

New Hampshire 480 36.2 2

Minnesota 1,894 36.0 3

Nebraska 641 35.7 4

Massachusetts 2,287 34.7 5

Vermont 209 33.6 6

Connecticut 1,179 33.5 7

Wisconsin 1,875 33.2 8

Bottom 5

Florida 3,644 19.7 46

Georgia 1,879 19.1 47

South Carolina 870 19.1 48

West Virginia 310 17.0 49

Nevada 422 16.0 50

Bifurcation of the Health Care Workforce

• Greatest growth in lowest education sectors– Community health workers– Home health aids– Assistant or technician roles

• Growth in advanced degree positions uncertain– Administrative or managerial positions– Interprofessional roles

• Stagnation or reduced demand in BS-prepared professionals– Care systems will look for those with lower salaries

and those with advanced, interprofessional skills

Changes in Nutrition and Dietetics Education

• Commission on Dietetic Registration will require a graduate degree to sit for the national RDN registration exam by 2024

• Can be in any field as long as nutrition and dietetics coursework and supervised experience requirements are met

• Does not matter if supervised practice occurs before, during or after graduate degree coursework– BS, internship, graduate degree– BS, coordinated graduate degree program– BS, graduate degree, internship

Nutrition and Dietetics Training

• Currently 575 accredited nutrition and dietetics programs in the US and international settings

ACEND-credited programs N

US Dietetic Technician Programs 42

US Coordinated Programs 57

US Didactic Programs 224

US Dietetic Internships 252

International Coordinated Programs 5

ACEND Proposed Changes in Education and Training for Nutrition and Dietetics

• Move RDN education to masters degree

• Move NDTR education to bachelor’s degree– Pathway III (2556 took exam; 45% of those eligible)

• Create associate-degree credential– Community Nutrition and Health Assistant

• New competencies for each level of education

• Experiential learning integrated into all education

• Career laddering where one degree can be built upon another

• Future exploration of high school and doctoral level programs

ACEND Report Highlights

• Communication skills are an essential and under-developed part of nutrition/dietetics training

• Employers expect strong organizational leadership and project management skills

• Supervised practice is highly valued but the accessibility and quality vary tremendously

Supervised Practice Shortage

• 52% of graduates who apply match with an internship

• Supervised practice spots fiercely competitive– Clinical nutrition is hardest in most areas

• Individualized Supervised Practice Pathways (ISPPs)– Sept 2011 launch, aimed at DPD programs

• DPD graduates who do not match with an internship• Doctoral-degree holders without DPD verification

– Allow 24 months to complete rotations– Most programs have students locate own preceptors– Much less oversight than traditional programs

Broad Education Improves Career Prospects

• Roles specific to nutrition may not be preserved

• Critical skills areas – Program planning and evaluation– Surveillance and monitoring– Program administration and management– Oral and written communication

• Degrees that provide these skills– MPH

• Biostatics, epidemiology, health behavior, healthcare management and administration, environmental health

• Bioethics

– Others ???• MEd, MHA, MS, MPP

College Enrollment

• 24% increase in enrollment between 2002 and 2012– 25% increase in number of females enrolled– 24% increase in number of males enrolled– Enrollment increase similar among those aged 18-25 and 25+

(24%)• 2012 – 2023, a 12% increase among 18-25 yr expected• 20% increase among 25+ yr

• College students – More females than males enroll

• 70% of females born in 1980s• 61% of males born in 1980s

– More females than males complete degree by age 27• 46% of females• 39% males Bureau of Labor Statistics, 2014

College Affordability and Workforce Development

• Average cost of college education is cost prohibitive for many potential nutritionists

• Uncertain value of advanced degreesPublic 2-Yr Public 4-Yr

(In-state)Public 4-Yr (out of State)

Private , non-profit 4-Yr

For-profit

Tuition and Fees $3,347 $9,139 $22,958 $31,231 $15,230

Room and Board $7,705 $9,804 $9,804 $10,824 NA

Total Cost $11,052 $18,943 $32,762 $42,419

National College Board, 2015

Average Debt of Graduating College Students

Demographic Factors in Education & Training

• High school students in 2012– 51% white– 25% Hispanic– 16% black– 8% Asian or Native American

• College students in 2012– 15% Hispanic– 6% Asian/Pacific Islander– 15% black– <1% American Indian/Alaskan Native– 60% white National Center for Education Statistics, 2013

The best time to plant a tree was 20 years ago.

The second best time is now.

Chinese Proverb