Comment

Attachment C
Comment from the Academy of Nutrition and Dietetics

December 6, 2016

Summer King
SAMHSA Reports Clearance Officer
5600 Fishers Lane, Room 15E57-B
Rockville, Maryland 20857

Re: Minority AIDS Initiative—Survey of Grantee Project Directors
Dear Ms. King:

The Academy of Nutrition and Dietetics (the “Academy”) appreciates the opportunity to
submit comments to the Substance Abuse and Mental Health Services Administration
(SAMHSA) in response to the information collection published in the October 7, 2016
Federal Register. The Academy is the world’s largest organization of food and nutrition
professionals, with more than 100,000 members comprised of registered dietitian
nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree
nutritionists. We are committed to improving the nation’s health through food and
nutrition and providing medical nutrition therapy (MNT)2 and other nutrition counseling
services to meet the health needs of all citizens, including those with HIV infection. RDNs
are integral components of the coordinated health care team at SAMHSA-funded centers
across the nation at which low-income, uninsured, and under-insured individuals with HIV
infection can get proper medical care. In addition, RDNs can and do play integral roles in
improving the lives and health of people with serious mental illness (SMI) through chronic
care management and preventive services.

The Academy recognizes the important nexus between nutrition and improved
health for people living with HIV/AIDS (PLWHA) and the importance of reducing new
HIV infections among high-risk populations, and we thus support the proposed
collection of information as necessary for the proper performance of the functions of
the agency, particularly given the practical utility resulting from the Minority AIDS
Initiative—Survey of Grantee Project Directors.
A. Utility and Necessity of the Proposed Information Collection
The Project Directors to be surveyed run grantee programs with the goal “to integrate
behavioral health treatment, prevention, and HIV medical care services for racial/ethnic

The Academy recently approved the optional use of the credential “registered dietitian nutritionist (RDN)”
by “registered dietitians (RDs)” to more accurately convey who they are and what they do as the nation’s food
and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
1

Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on
prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic
re-assessment and intervention. [Academy of Nutrition and Dietetics’ Definition of Terms list,
http://www.eatright.org/scope/, accessed 31 June 2012.] The term MNT is sometimes used interchangeably
with, but is sometimes considered different from, nutrition counseling in health insurance plans.
2

minority populations at high risk for behavioral health disorders and at high risk for or
living with HIV.” We support the Project Director Surveys to assess the impact of SAMHSA
funded programs and improve outcomes through judicious use of various program types
and models appropriate for various individuals based upon their particular circumstances
and demographics.

The Academy encourages SAMHSA to ensure the survey includes input not only from the
Program Director, but also from the providers and clinical staff on the grants. These
individuals in the trenches often have answers to questions not available to administrative
staff who have little client or patient contact. The Academy anticipates that SAMHSA will
set measurable goals and success rates as to how many surveys will need returned out of
the 152 program directors surveyed as part of effective data collection and will provide
Program Directors with its estimate of how long the survey is expected to take and the
impact it will have.
Lastly, the Academy encourages SAMHSA to more clearly outline how the following health
indicators will be measured and whether these be quantified or whether experiential and/
or subjective data also be collected:
o Reducing behavioral health disorders and HIV infections;
o Increasing access to substance use disorder (SUD) and mental disorder
treatment and care; and
o Improving behavioral and mental health outcomes; and reducing HIV-related
disparities in four specific grant programs.

B. Importance of Nutrition Services for People with HIV/AIDS
The Academy encourages SAMHSA to continue recognizing the importance of nutrition
services for PLWHA, particularly among low-income and other high-risk populations.
Individuals who are food insecure routinely forego critical medical care – including making
and keeping appointments for primary care and filling medication prescriptions - in order
to pay for food.3 Food insecure PLWHA rely extensively on cheap, highly processed, lownutrient foods.4

For PLWHA, proper nutrition is central to increasing absorption of medications, reducing
side effects, and maintaining a healthy body weight. Research has identified the virus as an
independent risk factor for cardiovascular, liver and kidney disease, cancer, osteoporosis
and stroke. HIV medications can cause nausea and vomiting and may affect lab results
Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study Team. Food and Nutrition Services, HIV
Medical Care, and Health Outcomes. New York State Department of Health: Resources for Ending the
Epidemic, 2014. Available at
https://www.health.ny.gov/diseases/aids/ending_the_epidemic/docs/key_resources/housing_and_supporti
ve_services/chain_factsheet3.pdf.
3

Adaila A, Caban M, Castro C, Cespedes H, Sharma N, Yomogida M. Who Needs Food & Nutrition Services and
Where Do They Go for Help? Available at http://www.nyhiv.org/pdfs/chain/CHAIN%2020132%20Brief%20Report_Food%20Insecurity%20Fact%20Sheet_2.pdf.
4

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testing lipids and kidney and liver function. These compounding health effects, caused by
the virus, its medications, and co-morbidities reinforce the important role a nutrient-rich
diet plays in a patient’s overall care. In addition, providing food and nutrition services
facilitates access and engagement with medical care, especially among vulnerable
populations.
C. Food and Nutrition Services are Essential to Meeting the Goals of the National
HIV/AIDS Strategy

As SAMHSA, the Ryan White program, and the Health Resources & Services Administration
(HRSA) continue to support the implementation of the National HIV/AIDS Strategy (NHAS),
it is important to note that food and nutrition services are critical to the success of the
strategy. In brief, the provision of Food and Nutrition Services (FNS) support the following
goals of the NHAS:
•

•

•

NHAS Goal: Reducing new HIV infections

o PLWHA who are food insecure are less likely to have undetectable viral loads in
a statistically significant way. Undetectable viral loads prevent transmission 96
percent of the time,5 thus, FNS is key to prevention.6

NHAS Goal: Increasing access to care and improving health outcomes for people living
with HIV
o PLWHA who receive effective FNS are more likely to keep scheduled primary
care visits, score higher on health functioning, are at lower risk for inpatient
hospital stays and are more likely to take their medicines.7

NHAS Goal: Reducing HIV-related disparities and health inequities

o By providing FNS to PLWHA who are in need largely because of poverty, we
improve health outcomes, thereby reducing health disparities.8

Palar K, Laraia B, Tsai A, Weiser SD (2013). Food insecurity is associated with sexually transmitted
infections and HIV serostatus among low income adults in the National Health and Nutrition Examination
Survey (NHANES) (1999-2010). Presented at the American Public Health Association 141st Annual Meeting,
Boston, MA, November 5, 2013.
5

Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with
incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San
Francisco. J Gen Internal Med 2009; 24(1):14-20.
6

Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study Team. Food and Nutrition Services, HIV
Medical Care, and Health Outcomes. New York State Department of Health: Resources for Ending the
Epidemic, 2014. Available at
https://www.health.ny.gov/diseases/aids/ending_the_epidemic/docs/key_resources/housing_and_supporti
ve_services/chain_factsheet3.pdf.
7

Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with
incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San
Francisco. J Gen Intern Med. 2009 Jan;24(1):14-20. doi: 10.1007/s11606-008-0824-5. Epub 2008 Oct 25.
8

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D. Conclusion
The Academy appreciates the opportunity to offer comments regarding the Minority AIDS
Initiative—Survey of Grantee Project Directors. We are pleased to offer our assistance and
expertise, including information from our Evidence Analysis Library related to HIV/AIDS
care. Please contact either Jeanne Blankenship at 202-775-8277 ext. 6004 or by email at
[email protected] or Pepin Tuma at 202-775-8277 ext. 6001 or by email at
[email protected] with any questions or requests for additional information.
Sincerely,

Jeanne Blankenship, MS RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

4

Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics