Attachment E – Public Comments: Academy of Nutrition and Dietetics

July 6, 2020
Doris Lefkowitz, PhD
Reports Clearance Officer
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services

Re: Agency Information Collection Activities: Medical Expenditure Panel Survey (MEPS) Social and Health
Experiences Self-Administered Questionnaire
Dear Dr. Lefkowitz,
The Academy of Nutrition and Dietetics appreciates the opportunity to comment to the Agency for
Healthcare Research and Quality on the proposed addition of the Social and Health Experiences SelfAdministered Questionnaire to the Medical Expenditure Panel Survey Household Component.
Representing more than 107,000 registered dietitian nutritionists (RDNs), dietetic technicians, registered
(DTRs), and advanced-degree nutritionist researchers, the Academy is the largest association of food
and nutrition professionals in the United States and is committed to improving the nation’s health
through food and nutrition across the lifecycle.
The Academy strongly supports the efforts of AHRQ to integrate this new questionnaire on Social and
Health Experiences into the Medical Expenditure Panel Survey. To better promote health equity, it is
essential to better understand the relationship between social and behavioral determinants of health,
health care costs, health care utilization and health insurance coverage.
The importance of addressing social determinants of health has been widely recognized,1 and is
endorsed by Healthy People 2020,2 the World Health Organization,3 and the National Partnership for
Action to End Health Disparities.4 It is also recognized that behavioral factors, such as physical activity
level, diet quality, alcohol intake, tobacco use contribute substantially to chronic disease risk,
management and outcomes and are also influenced by social determinants of health.5
The domains assessed in the proposed questionnaire align well with screeners that have been used to
assess social determinants of health in clinical settings, covering adverse/trauma/discrimination
experiences, economic stability and food security, neighborhood and built environment, and social
1

Braveman P, Egerter S, Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Public Health.
2011;32:381-98. DOI: 10.1146/annurev-publhealth-031210-101218
2
U.S. Office of Disease Prevention and Health Promotion. “2020 Topics & Objectives: Social Determinants of
Health.” HealthyPeople.gov. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-ofhealth. Accessed June 12, 2020.
3
World Health Organization. “Social Determinants of Health.” WHO.int. https://www.who.int/
social_determinants/. Accessed June 12, 2020.
4
National Partnership for Action to End Health Disparities, U.S. Department of Health and Human Services Office
of Minority Health. National Partnership for Action to End Health Disparities Toolkit for Community Action.
Rockville, M.D.: U.S. Department of Health and Human Services.
https://minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Toolkit.pdf. Accessed June 12, 2020.
5
Schmidt H. Chapter 5 Chronic Disease Prevention and Health Promotion. In Barrett DH, Ortmann LW, Dawson A,
et al., editors. Public Health Ethics: Cases Spanning the Globe. Cham (CH): Springer. 2016.

support, but do not include adverse childhood experiences.6,7,8 Behavioral questions assess physical
activity, stress level, and vaping, but do not evaluate some other important behaviors that may affect
chronic disease risk such as tobacco use, sleep habits, alcohol and drug use or aspects of diet quality
(as ascertained through a validated short-form dietary assessment instrument).9,10 AHRQ should
consider whether additional behaviors or experiences affecting chronic disease risk should be assessed
or justify why these behaviors were not included in the questionnaire.
Lastly, AHRQ should monitor whether adding the potentially sensitive questions on the proposed
Social and Health Experiences questionnaire affects response rates to the survey or the
sociodemographic distribution of the survey respondents. As with all data collected by MEPS, the
continued generalizability of findings from these data are reliant on a large, nationally representative
sample that does not meaningfully differ from the population as a whole based on their willingness to
respond to sensitive survey questions.
Thank you for the opportunity to provide comment on this important survey instrument. Please contact
either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Hannah Martin
at 202-775-8277 ext. 6006 or by email at hmartin@eatright.org with any questions or requests for
additional information.
Sincerely,

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

6

Hannah Martin, MPH, RDN
Director
Legislative & Government Affairs
Academy of Nutrition and Dietetics

O’Brien KH. Social determinants of health: the how, who, and where screenings are occurring; a systematic
review. Social Work in Health Care. 2019, 58(8):719-745. https://doi.org/10.1080/00981389.2019.1645795
7
Sokol R, Austin A, Chandler C, Byrum E, Bousquette J, Lancaster C, Doss G, Dotson A, Urbaeva V, Singichetti B,
Brevard K, Towner Wright S, Lanier P, Shanahan M. Screening children for social determinants of health: a
systematic review. Pediatrics. October 2019, 144 (4) e20191622; DOI: https://doi.org/10.1542/peds.2019-1622
8
Kalmakis KA, Chandler GE. Health consequences of adverse childhood experiences: A systematic review. Journal
of the American Association of Nurse Practitioners(2015)27: 457-465. DOI: 10.1002/2327-6924.
9
National Center for Chronic Disease Prevention and Health Promotion. How you can prevent chronic diseases.
CDC.gov. https://www.cdc.gov/chronicdisease/about/prevent/index.htm. Accessed June 12, 2020.
10
National Cancer Institute Division of Cancer Control & Population Sciences. Dietary Assessment Research
Resources. Epi.grants.cancer.gov. https://epi.grants.cancer.gov/dietary-assessment/resources.html. Accessed July
2, 2020.