HNFE 4984 (undergraduate) / HNFE 5984 (graduate) Course Syllabus

U.S. Food and Nutrition Policy (3 credit hours)

Department of Human Nutrition, Foods and Exercise (HNFE)

College of Agriculture & Life Sciences, Virginia Tech, Blacksburg, VA

Fall 2015

 

Time:              Monday & Wednesday from 11:00 am–12:15 pm

Location:        332 Wallace Hall

Instructor:      Vivica Kraak, PhD, RD, Assistant Professor

Office:             223 Wallace Hall         Phone: (540) 231-9638           Email: vivica51@vt.edu

Office hours are by appointment. Email is the best way to contact me to make an appointment.

Pre-req:          HNFE 5604 (public health nutrition) and a course in political science are suggested but not required. Designed for senior undergraduate and graduate students. Other interested participants may take the course with permission of the instructor.

 

Course Description

This course will introduce students to a range of food and nutrition policy concepts, institutions, stakeholders and pertinent issues in the United States. Topics covered will include: definitions of a healthy diet, healthy food environments, food security, and sustainable food systems.                     The course will provide an overview of the roles and interests of federal agencies, private-sector firms, business-interest organizations, public-interest non-governmental organizations, and the media relevant to U.S. food and policy. This course will examine food policy development drawing on examples from the U.S. Farm Bill 2014 and Dietary Guidelines for Americans; food policy implementation using examples from the federal food and nutrition programs administered by the U.S. Department of Agriculture (USDA), the Smart Snack Standards for schools, packaged foods and menu labeling, and consumer nutrition education programs; and food policy monitoring and evaluation using examples from the National Health and Nutrition Examination Survey (NHANES) and U.S. Department of Health and Human Services’ Healthy People 2020. Class discussions will explore the connections among national, state and local food and nutrition policies; as well as evolving policy issues such as the Food and Drug Administration’s revision of the Nutrition Facts panel, nutrition and health claims, food biotechnology, managing food waste, and food advocacy and activism to promote healthy food environments. Finally, the course will compare and contrast international perspectives on food and nutrition policies and programs used to support global nutrition, health promotion and wellness goals.

 

Learning Objectives

Having successfully completed this course, students will be able to:

1. Discuss the economic, political, social and cultural factors that influence U.S. food and nutrition policies and impact national food systems and population health.
2. Describe major processes and players involved in U.S. food policy development, implementation, monitoring and evaluation.
3. Compare and contrast the 15 federal food and nutrition programs administered by USDA.
4. Conduct an in-depth analysis of a specific food and nutrition policy issue through the stages of development, implementation, and monitoring and evaluation.
5. Describe six federal agencies that are involved in food policy development, implementation, monitoring and/or regulation.
6. Specify three evolving and emerging food policy issues and why these are important to the U.S. context.

 

This course will be taught using the new online learning platform called Canvas. 

Please see Student Getting Started with Canvas Guide Links to an external site.. The guide includes helpful tips for students such as the login web URL, instructions on how to set up notifications, how to get the Canvas app for mobile devices, as well as how to get help with Canvas questions available at https://vt4help.service-now.com/kb_view.do?sysparm_article=KB0010590 Links to an external site..

Students can get information and support by going to the Torgersen Bridge on Wednesdays and Thursdays from 6-8 p.m. during the first month of classes. The Canvas video guides are also helpful and are available online at https://community.canvaslms.com/docs/DOC-3891 Links to an external site..

Canvas will be used for assignments, readings, notes, announcements, grade posting and any other relevant information about this course. Students are responsible for materials and information posted to Canvas and for checking the site often as course materials and important announcements will be posted frequently. Assignments may be emailed directly to the instructor (vivica51@vt.edu) or submitted through Canvas via a laptop computer and not a mobile device.

 

Required Readings

Neff R, ed. Introduction to the Food System. Public Health, Environment, and Equity. The Johns Hopkins Center for a Livable Future. San Francisco, CA: Jossey-Bass, Wiley & Sons, 2014. 

http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-a-livable-future/news-room/our-stories/2014/textbook-US-food-system.html Links to an external site.

Supplemental required readings will be provided to enrolled students or other participants.

 

Course Criteria and Expectations

Academic integrity policy

The instructor requires that each student adhere to the Virginia Tech Honor Code at http://www.honorsystem.vt.edu/. This Code is a university-wide expectation that written work submitted by every student in this course either for academic credit or auditing purposes will be the participant’s own work. While students are allowed to explore a relevant topic in greater depth that has been researched in another course, they should not submit a similar or exact assignment that has been previously used and graded. For full information about what activities constitute academic misconduct (e.g., cheating, plagiarism and falsification), please visit and familiarize yourself with the content of the website above.

 

Written work guidelines

The reference style required for this policy course is that of the U.S. National Library of Medicine based on the International Committee of Medical Journal Editors (ICMJE) Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals: Sample References. Sample citations are at: http://www.nlm.nih.gov/bsd/uniform_requirements.html Links to an external site.. Please include the weblink for the document identification (doi) where available. Example:

• Brownson RC, Royer C, Ewing R, McBride TD. Researchers and policymakers: travelers in parallel universes. Am J Prev Med. 2006;30(2):164–72. http:// Links to an external site.doi.org/10.1016/j.amepre.2005.10.004 Links to an external site.

Please note that this is different from other courses that may require the American Psychological Association’s (APA) Publication Manual (6th edition) style. Papers and written assignments with minor grammar errors will be marked accordingly. Written work will be checked for plagiarism. As part of Virginia Tech’s Principles of Community, participants should avoid using sexist, gender-exclusive, racially prejudiced, and other forms of discriminatory language in all course work.   

Attendance and class preparation

The course instructor’s expectation is that all students will be prepared each week to actively engage in and contribute to an in-depth discussion based on the readings and assignments. It is expected that all students with actively participate in the class discussions and activities while showing mutual respect for other class participants. Students should demonstrate courtesy by silencing their mobile phones and arriving to class on time. Absences from class may be excused in the event of medical illness or immediate family emergency.  In the event of a planned absence, such as a professional obligation or religious holiday, participants are expected to inform the instructor or graduate teaching assistant. More than three absences may result in a significant participation grade deduction by the instructor.  

 

 

 

Special learning needs

Any course participants with special needs are encouraged to consult with the instructor as soon as possible so that we can work together to provide the necessary accommodations. Anything you discuss with me will be kept confidential. Additional information about assistance for special learning needs for all Virginia Tech students can be located at the office of Services for Students with Disabilities (SSD), 250 S. Main Street, Suite 300; Mail Code (0185); 231-0858  (V); 231-0853 (TTY); www.ssd.vt.edu.

 

Course Assignments and Grading

• 20%: Class participation and engagement based on preparation of the assigned readings.
• 30%: Students will prepare a written and oral presentation of a stakeholder’s position for an in-class debate that will address a specific U.S. food and nutrition policy issue. HNFE 5984 course will be asked to coordinate and facilitate the group work for the stakeholders’ debate. Potential topics that students may select include: revision of the U.S. Nutrition Facts label, implementation of restaurant menu labelling legislation, strengthening industry self-regulation and government oversight for industry food marketing practices targeting children and teens, review of USDA’s Supplemental Nutrition Assistance Program (SNAP) to address hunger and food insecurity, enacting legislation in cities or states to pass a sugar-sweetened beverages or a ‘junk food’ tax, or enacting a local zoning ordinance to ban fast food restaurants from locating in certain areas of cities with high obesity and type 2 diabetes rates.
• 50%: HNFE 4984 students will write and submit one analytic essay drawing from the material covered and supplemented by external research secondary conducted during the course to analyze a specific U.S. food and nutrition policy issue through the stages of policy development, implementation, monitoring and evaluation and regulation. HNFE 5984 students will write and submit two analytic essays on different policy topics, each worth 25% of this grade component. The first essay will adhere to the criteria described above. The second analytic essay will be based on a policy topic related to your graduate research after consultation with the instructor during the semester.

 

The evaluation criteria of course work comprises accuracy, depth, and comprehensiveness; logic and organization of thought and writing; and clarity of writing and presentation. In all written work submitted, course participants must present convincing arguments supported by appropriate research and published literature. Late assignments will receive point deductions by 10 points each day after submitted beyond the deadline. Course incompletes are available only for students with special circumstances, such as medical emergencies (either personal or family), and must be cleared by the instructor.  

 

Course evaluation and grading guidelines

Assignment	Points	Grading Scale
Prepare weekly readings for class participation and engagement (20%)	80	A	100-93.0	C	76.9-73.0
Prepare a written and oral presentation for an in-class stakeholder debate that will address a relevant U.S. food and nutrition policy issue (30%)	120	A-	92.9-90.0	C-	72.9-70.0
Analytic essay analyzing a specific food and nutrition policy issue through stages of policy development, implementation, monitoring and evaluation (50%) *One essay for HNFE 4984 students and two essays for HNFE 5984 students	200	B+	89.9-87.0	D+	69.9-67.0
Total Points	400	B	86.9-83.0	D	66.9-63.0
		B-	82.9-80.0	D-	62.9-60.0
		C+	79.9-77.0	F	˂ 60.0
The assignment guidelines and assessment criteria will be posted on Canvas. Assignments MUST be submitted through Canvas via a laptop computer and not a mobile device. Final grades will be based upon a percentage of total possible points out of students’ actual points. Assignments are submitted electronically prior to class on the date due stated on the calendar unless otherwise announced. In some cases, hard copy versions will be required.

U.S. Food and Nutrition Policy Course Detailed Course Syllabus

HNFE 4984 (undergraduate) / HNFE 5984 (graduate)

Fall 2015

Department of Human Nutrition, Foods and Exercise (HNFE)

College of Agriculture & Life Sciences, Virginia Tech, Blacksburg, VA

                       

Week & Date	Topics	Readings & Assignments
Week 1 Aug 24 and 26	Introduction to U.S. Food and Nutrition Policy Course Course overview and expectations of the instructor and students Overview of the policy process and policy concepts	Read course syllabus Brownson et al., 2006
Week 2 Aug 31 and Sept 2	Definitions and Policy Concepts Defining the nature and extent of diet-related challenges in U.S. Perspectives on stakeholders, settings, sectors and policy analysis tools and approaches to promote healthy food environments	Neff (Intro & Chapter 1) O’Connor, 2015; Bryson et al., 2011; and IDS, 2013
Sept 7	No class – Labor Day	Prepare week 3 readings below
Week 3 Sept 9	Disciplinary Perspectives Public health, economic, systems science and policy sciences frameworks and perspectives on causes of and solutions for obesity and strategies to promote healthy food environments	Neff (Chapters 2 & 4) and Johnston et al., 2014 DUE: Sept 9, 2015 Class will select 3-4 policy issues and identify working groups for the in-class stakeholders’ debate
Week 4 Sept 14 and 16	U.S. Food and Nutrition Policy Development History and evolution of the Dietary Guidelines for Americans,  National Nutrition Monitoring Act and U.S. Farm Bill	Neff (Chapter 8) Rahavi et al., 2015; Altman et al., 2015; Dietary Guidelines Advisory Committee Report Executive Summary, 2015; Slavin, 2015; and Oppenheimer & Benrubi, 2014   DUE: Sept 16, 2015 Email course instructor the nutrition policy topic you have selected for your analytic essay. *Graduate students (5984) send a second analytic essay topic related to your graduate research.
Week 5 Sept 21 and 23	U.S. Food and Nutrition Policy Development Influence of the Dietary Reference Intakes (DRIs) on U.S. food and nutrition policies and programs Development of Physical Activity Guidelines for Americans and U.S. Obesity Prevention Policies	Otten et al., 2006 and IOM, 2015
Week 6 Sept 28 and 30	U.S. Food and Nutrition Policy Implementation FDA’s oversight of food safety, Nutrition Facts panel, front-of-package food labeling, and restaurant menu labeling	Neff (Chapter 13) Kessler, 2014
Week 7 Oct 5 and 7	U.S. Food and Nutrition Policy Implementation Federal, private-sector and community-level strategies to address health disparities, promote health equity, and food well-being   Federal response: USDA’s administration of 15 federal food and nutrition programs and the Smart Snack School Standards	Neff (Chapters 5-6) USDA, 2014 and 2015   DUE: Oct 7, 2015 Submit your draft stakeholder position statement for the policy issue debate maximum word limit = 5 pages, 1-1/2 spaced plus references in the NLM style
Week 8 Oct 12 and 14	U.S. Food and Nutrition Policy Implementation (continued) Federal agency oversight for sustainable and eco-food labeling (e.g., fair trade, organic, non-GMO food labels), nutrition and health claims A primer on how Congress and the Virginia state legislature operate	Neff (Chapter 13)
Week 9 Oct 19 and 21	U.S. Food and Nutrition Policy Monitoring and Evaluation Concepts related to poverty, income inequality, food insecurity and health disparities and government, private-sector and community responses to these complex issues National Health and Nutrition Examination Surveys (NHANES), What We Eat in America and Healthy People 2020	Neff (Chapters 15)       Slining et al., 2015 and Miller et al., 2015
Week 10 Oct 26 and 28	Food Industry and Corporate Marketing Practices Business goals, shifting marketing practices to support a healthy diet and food marketing to children Assessing stakeholders’ responsibility and accountability for Healthy food environments	Neff (Chapters 10) Kraak et al., 2012 and Healthy Eating Research, 2015   Kraak et al., 2014
Week 11 Nov 2 and 4	U.S. Food and Nutrition Policy Implementation, Monitoring and Evaluation Consumer education; health, food and nutrition literacy Regulation of dietary supplements	Ratner and Riis, 2014 and Wansink and Pope, 2015 and   Finley et al., 2014 DUE: Nov 4, 2015 250-word written abstract describing your policy issue for analytic essays 1 and 2 including  development, implementation, monitoring and evaluation of the issue, and the federal agency with regulatory oversight
Week 12 Nov 9 and 11	Evolving and Emerging U.S. Food and Nutrition Policy Issues Special Health Affairs issue on food and health, November 2015	Select one article in the special issue and be prepared to provide a 5-10 minute discussion for the class and how it relates to material we have covered
Week 13 Nov 16 and 18	Evolving and Emerging U.S. Food and Nutrition Policy Issues Legal approaches to advance food and nutrition policy issues Food advocacy and activism to promote healthy food environments	Mermin & Graff, 2010, Rutkow et al., 2015 Chapman, 2015 and Cardello, 2014
Week 14 Nov 23 and 25	Thanksgiving Break	Enjoy your holiday
Week 15 Nov 30 and Dec 2	Global Food and Nutrition Policies, Institutions and Structures United Nations (UN) System institutions involved in oversight for international food trade, cross-border food safety, global food security and governance for health Review of course objectives and students’ evaluation	Horton et al., 2014; Burkle et al., Kahn et al., and Schuftan et al. 2014; Griggs et al., 2013; United Nations, 2015; and Brinsden and Lang, 2015
Week 16 Dec 7 and 9	Work on your policy analysis and preparation for the class debate	No readings assigned DUE: Dec 9, 2015 Submit your food and nutrition policy essays maximum word limit = 10 pages, 1-1/2 spaced plus references in the NLM style
Final Exam Dec 14 to 16 (Date TBD)	In-class debate of stakeholders’ positions for the selected U.S. food and nutrition policy issue	DUE: Dec 14, 2015 Submit your written policy analysis and stakeholder position statement before the in-class policy debate

Supplemental Readings

 

Week 1: Introduction to U.S. Food and Nutrition Policy

Brownson RC, Royer C, Ewing R, McBride TD. Researchers and policymakers: travelers in parallel universes. Am J Prev Med. 2006;30(2):164–72. http://dx.doi.org/10.1016/j.amepre.2005.10.004 Links to an external site.

 

Week 2: Policy Concepts, Issues, Institutions and Players

O’Connor A. Coca-Cola funds scientists who shift blame for obesity away from bad diets Links to an external site.. The New York Times. August 9, 2015.

Bryson JM, Patton MQ, Bowman RA. Working with evaluation stakeholders: a rationale, step-wise approach and toolkit.

Eval Program Plann. 2011;34(1):1–12. http://www.sciencedirect.com/science/article/pii/S0149718910000637 Links to an external site.

 

Institute of Development Studies. Introduction to Stakeholder Engagement. August 2013.

http://www.researchtoaction.org/wp-content/uploads/2014/02/Introduction-to-Stakeholder-Engagement.pdf Links to an external site. 

 

Week 3: Definitions and Disciplinary Perspectives

Johnston LM, Matteson CL, Finegood DT. Systems science and obesity policy: a novel framework for analyzing and rethinking population-level planning. Am J Public Health.  2014;104(7):1270–78. http://dx.doi.org/10.2105/AJPH.2014.301884 Links to an external site.

 

Week 4: U.S. Food and Nutrition Policy Development

Rahavi E, Stoody EE, Rihane C, Casavale KO, Olson R. Updating the dietary guidelines for Americans: status and looking ahead.

J Acad Nutr Diet. 2015;115(2):180–2. http://dx.doi.org/10.1016/j.jand.2014.11.022 Links to an external site.

 

Altman J, Spahn J, Stoody EE, Rihane C, Casavale KO, Olson R. Laying the foundation for expanding the Dietary Guidelines for Americans to address children from birth to 24 months and women who are pregnant. J Acad Nutr Diet. 2015;115(5):693–794. http://dx.doi.org/10.1016/j.jand.2015.03.008 Links to an external site.

 

Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Executive Summary. 2015.  http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/02-executive-summary.pdf Links to an external site.

 

Slavin J. The challenges of nutrition policymaking. Nutrition Journal. 2015;14:15. http://dx.doi.org/10.1186/s12937-015-0001-8 Links to an external site.  

 

Oppenheimer GM, Benrubi ID. McGovern's Senate Select Committee on Nutrition and Human Needs versus the meat industry on the diet-heart question (1976-1977). Am J Public Health. 2014;104(1):59–69. http://dx.doi.org/10.2105/AJPH.2013.301464 Links to an external site.

 

Week 5: U.S. Food and Nutrition Policy Development

Otten JJ, Hellwig JP, Meyers LD, eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC:

The National Academies Press, 2006.

http://www.nap.edu/catalog/11537/dietary-reference-intakes-the-essential-guide-to-nutrient-requirements Links to an external site.

 

Institute of Medicine. Infographic. Dietary Reference Intakes. 2015.

http://iom.nationalacademies.org/About-IOM/Leadership-Staff/Boards/~/media/Files/Infographics/2014/DRIs.pdf Links to an external site.

 

Week 6: U.S. Food Labeling (part 1)

Kessler DA. Toward more comprehensive food labeling. New Eng J Med. 2014;371(3):193–5. http://dx.doi.org/10.1056/NEJMp1402971 Links to an external site.

 

12-minute interview with Professor David Kessler on more comprehensive food labeling. Suppl to N Eng J Med. 2014;371(3):193–5. www.nejm.org/action/showMediaPlayer?doi=10.1056/NEJMp1402971&aid=NEJMp1402971_attach_1 Links to an external site.

 

Week 7: U.S. Food and Nutrition Policy Implementation

Food and Nutrition Service. U.S. Department of Agriculture. Programs and Services. 2014.

http://www.fns.usda.gov/programs-and-services Links to an external site.

 

U.S. Department of Agriculture. Smart Snacks in School Standards. 2015. http://www.fns.usda.gov/sites/default/files/allfoods_flyer.pdf Links to an external site.

 

Pomeranz JL, Chriqui JF. The Supplemental Nutrition Assistance Program: analysis of program administration and food law definitions. Am J Prev Med. 2015;49(3):428–36. http://dx.doi.org/10.1016/j.amepre.2015.02.027 Links to an external site.

 

Week 8: Food Labeling (part 2)

Finley JW, Finley JW, Ellwood K, Hoadley J. Launching a new food product or dietary supplement in the United States: industrial, regulatory, and nutritional considerations. Annu Rev Nutr. 2014;34:421–47. http://dx.doi.org/10.1146/annurev-nutr-071813-105817 Links to an external site. 

 

 

Week 9: U.S. Food and Nutrition Policy Monitoring and Evaluation

Slining MM, Yoon EF, Davis J, Hollingsworth B, Miles D, Ng SW. An approach to monitor food and nutrition from "factory to fork".

J Acad Nutr Diet. 2015;115(1):40–9. http://dx.doi.org/10.1016/j.jand.2014.09.002 Links to an external site.

Miller PE, Reedy J, Kirkpatrick SI, Krebs-Smith SM. The United States food supply is not consistent with dietary guidance: evidence from an evaluation using the Healthy Eating Index-2010. J Acad Nutr Diet. 2015;115(1):95–100. http://dx.doi.org/10.1016/j.jand.2014.08.030 Links to an external site.

 

Week 10: Food Industry and Corporate Marketing Practices and Accountability

Kraak VI, Story M, Wartella EA, Ginter J. Industry progress to market a healthful diet to American children and adolescents.

Am J Prev Med. 2011;41(3):322–33. http://dx.doi.org/10.1016/j.amepre.2011.05.029 Links to an external site.

 

Healthy Eating Research. Recommendations for Responsible Food Marketing to Children. Minneapolis, MN: Healthy Eating Research, 2015. http://healthyeatingresearch.org/wp-content/uploads/2015/01/HER_Food-Marketing-Recomm_1-2015.pdf Links to an external site.

 

Kraak VI, Swinburn B, Lawrence M, Harrison P. An accountability framework to promote healthy food environments. Pub Health Nutr. 2014;17(11):2467–83. http://dx.doi.org/10.1017/S1368980014000093 Links to an external site.

 

Week 11: Evolving and Emerging U.S. Food and Nutrition Policy Issues

Ratner RK, Riis J. Communicating science-based recommendations with memorable and actionable guidelines. Proc Natl Acad Sci U S A. 2014 Sep 16;111 Suppl 4:13634–41. http://www.pnas.org/content/111/Supplement_4/13634.long Links to an external site.

Wansink B, Pope L. When do gain-framed health messages work better than fear appeals? Links to an external site. Nutr Rev. 2015;73(1):4–11. http://dx.doi.org/10.1093/nutrit/nuu010 Links to an external site.

 

Week 12: Evolving and Emerging U.S. Food and Nutrition Policy Issues

Health Affairs special issue on food and health, November 2015: http://content.healthaffairs.org/content/34/11.toc Links to an external site.

 

Week 13: Evolving and Emerging U.S. Food and Nutrition Policy Issues

Mermin SE, Graff SK. A legal primer for the obesity prevention movement. Am J Public Health. 2009;99(10):1799–1805. http://dx.doi.org/doi:10.2105/AJPH.2008.151183 Links to an external site. 

Rutkow L, Vernick JS, Edwards DM, Rodman SO, Barry CL. Legal action against health claims on foods and beverages marketed to youth. Am J Public Health. 2015;105(3):450–6. http://dx.doi.org/10.2105/AJPH.2014.302376 Links to an external site.

Chapman S. Reflections on a 38-year career in public health advocacy: 10 pieces of advice to early career researchers and advocates. Public Health Research & Practice. 2015;25(2):e2521514. http://dx.doi.org/10.17061/phrp2521514 Links to an external site. Links to an external site.

Cardello H. How Big Food’s attackers are undermining their cause. Forbes Magazine. January 28, 2014. http://www.forbes.com/sites/forbesleadershipforum/2014/01/28/how-big-foods-attckers-are-undermining-their-cause/ Links to an external site.

 

Week 15: Global Food and Nutrition Policies, Institutions and Structures

Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto.

Lancet. 2014;383(9920):847. http://dx.doi.org/10.1016/S0140-6736(14)60409-8 Links to an external site.

 

Burkle et al., Kahn et al., and Schuftan et al. A manifesto for planetary health. Lancet. 2014;383(9920):1459–60. http://www.thelancet.com/pdfs/journals/lancet/PIIS0140673614607108.pdf Links to an external site.

Griggs D, Stafford-Smith M, Gaffney O et al. Policy: Sustainable development goals for people and planet. Nature.

2013;495(7441):305–7. http://dx.doi.org/10.1038/495305a Links to an external site.

 

United Nations. Highlights of the UN Sustainable Development Summit. September 2015.

http://www.un.org/sustainabledevelopment/blog/2015/09/highlights-of-the-un-sustainable-development-summit/ Links to an external site. and http://www.un.org/sustainabledevelopment/sustainable-development-goals/ Links to an external site.

 

Brinsden H, Lang T. Reflecting on the ICN2: was it a game changer? Archives Public Health. 2015;73:42. http://www.archpublichealth.com/content/73/1/42 Links to an external site.

 

Links to an external site.