Training Public Health Nutritionists: Competencies for Complacency or Future Concerns Today the public perceives that sound nutrition is essential to good health and that an adequate diet is necessary to achieve sound nutrition. This represents a change for consumers, who, traditionally have only considered cost, convenience, and family taste preferences in their food choices. Increasing concerns about the quality, safety, and impact of diet on health has become evident in recent years.' Twothirds of American adults now believe they would be healthier if they made certain changes in their diet-such as decreasing consumption of foods high in refined carbohydrates, salt and animal fat, and increasing consumption of fruits, vegetables and whole grain products.2 Available evidence suggests that many American adults have not changed their dietary behavior to match their stated beliefs. 1-4 This is of interest in view of findings reported by Sims in the current issue of the Journal.5 In a survey of educators and public health nutritionists designed to elicit the essential competencies of "entry-level" nutritionists, communication, counseling clients, and interpreting scientific data in lay language were given high ratings by both groups. What has limited the effectiveness of nutritionists and other associated health personnel in achieving behavior change: lack of scientific evidence of health benefits, lack of skill in interpreting the scientific information to the public, or an inability to effectively motivate consumers to change? Lack of scientific evidence of health benefits is a troublesome issue when the public health nutritionist must respond to specific questions posed by clients. It was easier to evaluate the benefits of change in dietary behavior which helped to eliminate specific nutritional deficiencies since there were clearer cause and effect relationships, e.g., use of cod-liver oil and vitamin D fortification eliminated vitamin D deficiency rickets in our population. Today, the role of nutrition in health and disease is a more complex one; we are dealing with diseases which are multifactorial in etiology, and where inappropriate intake of calories or of certain nutrients represents only one contributing component. There are those who feel that our present health care system has failed to reduce the burden of disease and that prevention is the only answer to rising medical care costs. Yet in many cases, the data to substantiate the role of nutrition in chronic disease prevention are at best anecdotal. It is our belief that the general public subscribes to such dietary goals as reducing consumption of animal fats. Yet, the scientific community is embroiled in a controversy about whether such goals will produce the expected benefit-less coronary disease.8 The reality of these dilemmas is that the public health nutritionist and the consumer must jointly make decisions based on the best information available. This leads to the second issue in educating public health nutritionists-attaining the skills to interpret scientific information. These skills differentiate qualified public health nutritionists and clinical dietitians from perpetrators of misinformation. Their nourishment requires an atmosphere that encourages scientific thinking and the ability to analyze and critically evaluate available data. The third issue-motivation of consumers to changerequires another set of competencies. As the experimental 1096

design is the ultimate in scientific endeavors, skills of planning and evaluating are the tools needed to effect changes in a client of consumer. Change is not likely to occur unless the practitioner can define the client's current behavior, develop realistic objectives in consort with the client, employ strategies that will assist the client to comply, and assess the effectiveness of the efforts made.9-11 Sims' paper represents an important effort to document competencies required by entry-level public health nutritionists; it provides more information than has heretofore been available. Communication and effective counseling require that valid scientific information be assessed and reliably interpreted. If these two elements are not available, skillful communication will serve only to delude the nutritionist and mislead the consumer. Based on the assumption that the public health nutritionist has the scientific information as well as the ability to interpret information and communicate it effectively to clients, the final step is to document behavior change. In the past, evaluations of educational efforts have been minimal and have consisted largely of testing the client's nutrition knowledge. If all the reasoning holds, evaluation of patient outcome as determined by change in health status is what is really needed. If we are going to develop competencies to deal with future concerns, all of these elements must be taken into consideration or we are merely developing competencies for complacency.

ANITA L. OWEN GEORGE M. OWEN, MD Address reprint requests to Dr. George M. Owen, Professor of Nutrition and of Pediatrics, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109.

REFERENCES 1. Yankelovich, Skelly and White, Inc., A Summary Report on

U.S. Consumer Knowledge, Attitudes and Practices about Nutrition. General Mills, Inc., Minneapolis, MN, p. 24, 1978-79. 2. Harris, Louis and Associates, Inc. Health Maintenance. Pacific Mutual Life Insurance Co., p. 32, Nov., 1978. 3. Evans RI and Hall Y: Social psychology in changing eating behavior. J of American Dietetic Association 72:378-383, 1978. 4. Mahoney MJ and Caggiula AW: Behavioral methods in nutrition counseling. J of American Dietetic Association 72:372-377, 1978. 5. Sims LS: Identification and evaluation of competencies of public health nutritionists. Am J Public Health 69:1099-1105, 1979. 6. Holtzman NA: Hyperlipidemia screening: a search for heffalumps? Pediatrics 64:270-271, 1979. 7. Harper AE: Dietary goals: a skeptical view. Am J Clin Nutr 31:310, 1978. 8. Hegsted DM: Dietary goals: a progressive view. Am J Clin Nutr 31:1504, 1978. 9. Frankle RT, and Owen AY: Nutrition in the Community: The Art of Delivering Services. St. Louis, MO: C.V. Mosby Co., pp. 148-158, 1978. 10. Owen AY: Community Nutrition in Preventive Health Care Services: A Critical Review of the Literature. DHEW Publication No. (HRA) 78-14017. U.S. Govt Printing Office, Washington, DC, pp. 35-48, May, 1978. 11. Guide for Developing Services in Community Health Programs. DHEW Publication No. (HSA) 78-5103, Rockville, MD, pp. 1230, 1978. AJPH November 1979, Vol. 69, No. 11