Introduction

The United States Public Health Service (USPHS) celebrated its bicentennial year in 1998. Its mission is to protect, promote and advance the health and safety of the nation. USPHS works toward this by promoting the health of the nation, understanding and preventing disease, assuring safe and effective drugs and devices, delivering health care services, and supplying health expertise in time of national emergencies. Whether serving as either Civil Servants or Commissioned Officers, dietitians and public health nutritionists play an integral part in the mission of this distinguished service.

Beginning

During the late nineteenth century, records indicate that proper nutrition and nourishment of hospitalized patients were regulated under the direction of a hospital steward. By 1902, preparation and food service responsibilities were charged to pharmacists, the only professional personnel other than the medical officers attached to the hospitals. The importance of nutrition and dietetics in the provision of health care quickly became recognized as a required component of hospital care.

The service of dietitians and nutritionists in the PHS dates back to the year 1919. During that year, the first dietetic section was organized in the PHS Division of Hospitals which operated a medical care program for American seamen. These hospitals were primarily located in port cities with in-patient capacities ranging from about 100 to 1,000 beds.

Ms. Hallie Corsette, the first dietitian employed by the PHS, was accorded the title Superintendent of Dietitians. She supervised this newly created dietetic section of the Division of Hospitals. The dietitians were placed under the organizational structure of the medical officer in charge of a facility. Ms. Corsette spent the majority of her time planning dietary departments and recruiting dietitians for the hospitals. By the close of 1919, there were approximately 85 dietitians in the Division of Hospitals; that number doubled over the next two years. During those early years, a dietitian's duties were focused chiefly on the purchase, preparation and delivery of food.

Wartime Efforts

In 1919, the PHS was charged with the responsibility of furnishing medical and hospital care to sick and disabled veterans of World War I. In 1922 the Veterans Bureau was established to provide on-going medical care to war veterans. As a result, the responsibility for supervising many of the Public Health Service Hospitals was transferred to the Veterans Bureau, later known as the Veterans Administration. Over 145 PHS dietitians were transferred to those facilities to care for disabled war veterans. The remaining PHS dietitians were placed under the general direction of the Office of Nursing, Division of Hospitals. Although the dietetic section was abolished as a result of the transfers, dietitians continued with their primary duties of food service administration and took on the additional role of providing patient nutrition education.

During the Second World War, PHS dietitians worked as part of the Civil Defense Mobilization Program. They were responsible for developing recommendations for foods, food storage, equipment and service that could be used if communities suffered bombing attacks.

Programs of The 1940s

The functions and responsibilities of the PHS expanded rapidly during the late 1930s and the early 1940s. Likewise, the role of dietitians within the PHS continued to expand beyond the hospital setting as dietitians were hired by state and local health departments. The creation of the Children's Bureau in 1912 provided states with grant-in-aid for Maternal and Child Health, Crippled Children's Services (Title V) and Child Welfare (Title IV). Subsequently, in 1936 Ms Marjorie M. Heseltine was employed as the first nutrition consultant in the Children's Bureau. Five years later, the Bureau hired a second consultant, Ms Helen Stacey.

In 1942 the PHS established mobile field units to conduct nutrition appraisals in selected states. A medical officer was also assigned to work as a nutrition consultant for public health officials. Nutrition clinics were developed in a few state and local health departments. Today, both the Maternal and Child Health Bureau and the Centers for Disease Control and Prevention still continue to play a vital role in providing nutrition leadership and expertise to the state and local health departments.

As the work of the PHS expanded and the science of public health developed, the need for collaboration between related professionals in the public health field became evident. With the passage of the Public Health Service Act in 1944, a series of laws were passed which significantly affected the nation's medical research, training efforts and increased health services in the United States. The expansion of the PHS required people with additional specialized skills that could be rapidly deployed in response to public health emergencies. The Regular Commissioned Corps was expanded to include dietitians, nurses, veterinarians, scientists, physical therapists, and sanitarians, and other health professionals.

The authority to commission dietitians as PHS officers was granted on July 1, 1944. At that time, the dietetic section of the Division of Hospitals was reestablished. Ms Marjorie Wood, the first commissioned dietitian and the PHS Commissioned Corps' first Chief Dietitian, headed the unit. The section was renamed the Dietetic Branch, Office of Professional Services, and was charged with the responsibility of developing, establishing and maintaining dietetic standards in PHS hospitals; a major emphasis was placed on therapeutic nutrition and teaching programs.

First Dietetic Internship

Ms. Clare Baldauf developed a dietetic internship to provide a teaching program in the field of dietetics. The internship was established in 1945 at the PHS Hospital in Staten Island, New York and approved by the American Dietetic Association (currently known Academy of Nutrition and Dietetics). Twelve interns working under the civil service system were accepted into the first class. Subsequent classes of interns were comprised of PHS Commissioned Officers. The internship provided the first credentialing of PHS dietitians. Miss Baldauf served as the Chief Dietitian and supervised nine classes of interns. This internship served as a mechanism to train new college graduates in the practical aspects of food service administration, therapeutic diet instruction and community nutrition. The PHS used this internship program to train young dietitians to serve in the PHS hospitals. The internship program was discontinued in 1973 with the threat of the PHS hospital closures.

National Institutes of Health Clinical Center

Many of the PHS dietitians that have made significant contributions in nutrition and dietetics have served in some capacity during their career at the world-renowned National Institutes of Health in Bethesda, Maryland.

One was CAPT Edith Jones. CAPT Jones was appointed to the position of Chief Dietitian at the National Institutes for Health in September 1952. She was charged with developing long range plans for creating a department of nutrition for the NIH Clinical Center, a 500 bed research hospital which opened in 1953.

CAPT Jones was a leader in the profession of dietetics at the local, national and international levels. She served as the 38th President of the American Dietetic Association and the ADA Foundation's president in 1972. In addition, she served as Chair of the Fifth International Congress of Dietetics in 1969 and as Chair of the International Dietetic Committee of Dietetic Associations from 1965-69.

The American Dietetic Association recognized CAPT Jones for her vision and courage in pursuit of "professional perfection" in 1971 by awarding her its highest honor, the Marjorie Hulsizer Copher Award. She received the PHS Meritorious Service Medal for her exceptional service and leadership in the field of nutrition and dietetics during her tenure as Chief of the Nutrition Department and Chief Dietitian.

The Edith A. Jones Scholarship Fund, established in 1993, is endowed by the ADA Foundation in honor of CAPT Jones' outstanding accomplishments in the field of dietetics. The recipients of the scholarship are dietetic interns at the NIH Clinical Center.

Noteworthy Contributions to the Category

Jeanne Tillotson served as Assistant Chief of Patient Diet Services also at the inception of the NIH Clinical Center. Later she transferred to the National Heart Lung and Blood Institute (NHLBI) where she worked as a member of a team conducting epidemiology studies, including two of the most famous heart studies: the Framingham Heart Study and the Multiple Risk Factor Intervention Trial (MR FIT). Ms Tillotson was also involved in similar studies being conducted in Puerto Rico and Japan.

As the nutrition expert for these studies, Ms Tillotson created the food composition tables and analyzed the nutrient intake data. Her innovative nutritional contributions to the MR FIT study helped to identify dietary intake as an important variable in heart disease. Ms Tillotson recalls the combined enjoyment and challenge of using computer programs, still in their infancy, to enter and analyze her own preliminary study data. With the assistance of computer programmers, she was able to detect trends and potential problems in the data by using the most current computer technology. Her pioneering nutrition contributions were published in the American Journal of Clinical Nutrition.

CAPT Jeanne Reid worked as a dietitian in the metabolic unit of the National Institute of Digestive, Diabetes and Kidney Diseases at NIH. One of the highlights of her career as a commissioned officer was a detail assignment with the U.S. space program in Houston, Texas. As part of the study team under the direction of Dr Donald Wheedon, CAPT Reid conducted the first studies of the effects of space on minerals, focusing special attention in the area of calcium retention in bones of astronauts.

Nancy Ernst came to the NIH Clinical Center Nutrition Department in August 1966 and became the primary research dietitian for the lipid service headed by Dr Donald Fredrickson and Robert I. Levy. The acceptance of the 1965 lipoprotein typing system precipitated much interest from physicians and dietitians about the diets that provided the therapeutic guidelines for clinical management of these disorders. The experience of the clinical center was translated into the 1969 publication, The Dietary Management of Hyperlipoproteinemia. A Handbook for Physicians and Dietitians. Nancy Ernst - working with Merme Bonnell, then Chief of Patients' Food Service, and Dr. Robert Levy - developed the diet plans into guidance that were transferred into nationally applicable information.

One of the early NIH dissemination activities of their research in the area of cardiovascular nutrition was the 1973 co-authorship by Nancy Ernst and Robert Levy of a chapter titled, Diet, Hyperlipidemia and Atherosclerosis in the fifth edition of Modern Nutrition in Health and Disease, edited by Robert Goodhart, M.D., D.M.S. and Maurice E. Shilis, M.D., Sc.D.

In 1970, Nancy Ernst transferred from the Nutrition Department to the NHLBI Lipid Metabolism Branch assuming the title of Chief Nutritionist. An initial responsibility was the development of the diet protocol for NHLBI Type II Coronary Intervention Study. This trial was one to the earliest studies in the nation to focus on angiographic evidence of coronary artery disease after cholesterol lowering. The 143 patients were randomly assigned to lipid lowering treatment by the drug cholestyramine or placebo. All patients were counseled by Nancy Ernst, and subsequently by Majorie Myrianthopoulos, to follow a cholesterol lowering diet; with dietary intake data collected on all trial participants. The study showed a non-significant trend toward less progression in coronary plaque in the coronary arteries.

In 1970, the NHLBI created the Lipid Research Clinics (LRC) Program. One objective of this program was to determine the prevalence of different types of dyslipoproteineamia and their relationship to diet. The LRCs also conducted the Coronary Primary Prevention Trial (CPPT) to test the effect of cholesterol lowering on the incidence of Chronic Heart Disease (CHD), using the drug cholestyramine. The successful completion of this study indicated that lowering blood cholesterol would lower the risk of CHD and set the stage for major prevention and control programs, such as the National Cholesterol Education Program. Currently, the NHLBI updated their cholesterol guidelines in the Systematic Evidence Review in 2013.

Both Virginia Keating and Barbara Dennis transferred from the Nutrition Department to assume major roles in the Lipid Research Clinics Program. To assure comparability of dietary data collection methods across the 12 LRC programs and also with the Multiple Risk Factor Intervention Study, Ernst and Keating worked with the LRC Nutrition Committee, and NHLBI's Jeanne Tillotson and the Multiple Risk Factor Intervention Study nutritionists to establish: (a) a common dietary intake recall methodology; (b) a training and certification program to establish standard practices for interviewing participants and coding dietary recalls; and (c) a national food and nutrient computer database, that became the foundation of the University of Minnesota's "Nutrition Coordinating Center" and the "Nutrition Data System."

Indian Health Service (IHS)

In 1955, Congress transferred responsibility for American Indian and Alaska Native health care from the Department of the Interior to the PHS. The following year, Miss Bertlyn Bosley, another distinguished PHS dietitian, became the first Chief of Nutrition and Dietetics for the Division of Indian Health (later the Indian Health Service). At the time of her appointment there were dietitians working in approximately 11 of the 56 American Indian reservation hospitals. Ms Bosley was instrumental in incorporating nutrition education into the health, social and educational programs serving American Indians and Alaskan Natives. Ms Bosley was also affiliated with the Pan American Health Organization as a nutrition consultant.

The second Chief of the IHS headquarters Nutrition and Dietetics Branch, Ms Helen G. Olson, recognized a need to train food service supervisors for the forty-eight IHS hospitals. Due to her persistent efforts, in 1969 the IHS Foodservice and Nutrition Training Program opened in Sante Fe, New Mexico. Ms Sallie Mooring, well known professionally for her interest in training, was recruited and appointed its first director. To enhance training activities, Ms Mooring designed and equipped an on-site kitchen laboratory.

A nutrition technician training program was initiated for American Indians to work with public health nutritionists to address nutritional deficiencies in the communities. At a later date, this technician training program was transferred to the IHS Desert Willow Training Center in Tucson and modified to train community health representatives to plan, implement, and evaluate community nutrition programs. In 1978, both training programs were once again consolidated in Sante Fe and continue to evolve to meet the changing needs of American Indians.

Ms Patricia F. Roseleigh, Chief of the Navajo Area Nutrition and Dietetics Branch, established the initial program sites for the WIC Program (Special Supplemental Food Program for Women, Infants and Children) in the Navajo Area. She focused on recruiting and on planning for new dietary departments in Navajo Area hospitals scheduled for construction. In 1977, she transferred to IHS Headquarters as Chief, Nutrition and Dietetics Branch. Ms Roseleigh served as consultant for the revision of the Civil Service Classification Standards for dietitians and nutritionists which positively impacted on PHS's ability to attract qualified candidates, particularly for IHS remote sites.

While serving as a civilian dietitian, Ms Marguerite M. Smith was directly involved in the opening of the Gallup Indian Medical Center in 1961. She was appointed to the PHS Commissioned Corps in October 1962 and joined the Nutrition Department staff at the Clinical Center of NIH. In 1971, she transferred to the Nutrition and Dietetics Branch, IHS Headquarters where she was especially effective in recruiting dietitians and public health nutritionists. CAPT Smith's other accomplishments included chairing the Dietitian-Nutritionist Professional Advisory Committee, reviewing applications for public health nutritionist scholarships, establishing a computerized nutrition and food cost accounting system, revising the PHS recruitment brochures for dietitians and nutritionists, and finally serving as Chief Professional Officer.

Other Directions

In 1958, the Coast Guard Academy became the first military training facility to employ a dietitian. CAPT Jane Davidsaver was detailed to the Academy for nine years where she played a key role in establishing nutritional standards for the cadets. She was also instrumental in the design of four new galleys at the academy.

CAPT Genevieve M. Casalaspro's proudest accomplishment was her appointment as Clinical Director of the PHS Clinic in Miami, Florida. She was the first dietitian to serve as a clinical director in PHS history. CAPT Casalaspro served in Miami from 1977 to 1981. During this time there was an influx of 135,000 Cuban refugees to whom the Miami Clinic provided medical care. In 1981, she moved to Camp Crohm upon the arrival of the Haitian immigrants. There she was responsible for the medical care and feeding programs for 40,000 Haitian refugees. CAPT Casalaspro was awarded the PHS Distinguished Service Medal and two Meritorious Service Medals for outstanding career contributions.

During the late 1970's the National Health Service Corps became an important entry point for public health nutritionists, adding significantly to the number of dietitians serving in the PHS. The majority of these nutritionists worked in poor rural areas of the U.S., including those areas where there were large numbers of migrant workers. In addition, these nutritionists were used to staff remote American Indian reservations. These assignments broadened the public health mission of the dietitian category and focused on strengthening health promotion and disease prevention of underserved populations.

With the closing of the last of the PHS hospitals in 1981, many PHS dietitians and nutritionists branched out into administrative and program positions. These positions created new opportunities for PHS dietitians and nutritionists to serve as food and nutrition experts for many federal agencies, increasing the public health impact of the profession.

The PHS Regional Offices are staffed by numerous health professionals including MCH (Maternal and Child Health) Nutrition Consultants who provide expert consultation to state nutrition programs. Prior to the mid-1980s, nutritionists from state health departments or public health nutrition programs at universities were invited to fill vacancies at the PHS Regional Offices. However, during the 1980s, the administration moved to reduce the number of federal employees, and due to this, Regional Office vacancies could only be filled by nutritionists who were current federal employees.

Mary Egan, longtime MCH nutritionist in the Health Resources and Services Administration, noted that many federal employees did not have the necessary experience to serve as a consultant to state health departments and therefore, were not fully qualified to fill these roles. She developed the MCH Residency Program, which was designed to put federal nutritionists, nurses, and social workers in positions in state health departments for a one year self-planned training program. During this one year assignment, the federal assignees gained needed state-level experience and upon completion of the program, were able to fill vacant consultant positions. The MCH Residency Program was active for three years and 6 nutritionists participated.

Influences of The 1960s - 1970s

During the 1960s, President Johnson's "War on Poverty" led to the creation of many new health programs targeted at low-income, high risk populations. As a result, nutrition and chronic disease prevention programs were created. Nutrition also became an important subject for research and clinical studies. In 1965 the Head Start program was established, as well as the Medicare and Medicaid programs and Community and Migrant Health Centers. In addition, the Framingham Heart Study, the National Diet-Heart Study, the Seven Countries Study and the National Health Examination Surveys were all implemented. The first White House Conference on Food, Nutrition and Health was held in 1969 and established priorities for nutrition programs which would be implemented over the next ten years. As a result, the role of nutrition had been firmly established as an integral part of all public health programs. Meanwhile a gradual shift was taking place away from hospital dietetics as the major place of employment for dietitians, to more diversified roles within all agencies of the PHS.

During the early 1970s, the Centers for Disease Control and Prevention emerged as a leader in health promotion and disease prevention as well as setting a precedent for several landmark surveys of dietary and nutritional status. These surveys included: the Ten State Nutrition Survey (1970), the Total Diet Study, the First National Health and Nutrition Examination Survey (NHANES) in 1971, and the Pediatric and Pregnancy Nutrition Surveillance Systems in the States (1972 & 1979). The Center for Chronic Disease Prevention and Health Promotion was created and provides technical assistance and expertise to state and local health departments. The Center supports local health departments through assembly, analysis and interpretation of data. It also provides guidance on using data to manage and promote nutrition and health education programs.

By the late 1970s, then Surgeon General Julius Richmond conceived a "Second Public Health Revolution" to tackle the agents of contemporary mortality, namely, smoking, drinking, diet, sedentary living and poor safety practices. Dr J. Michael McGinnis was appointed as the Director of the Office of Disease Prevention and Health Promotion in the PHS. The Surgeon General's Report on Health Promotion and Disease Prevention, Healthy People, and Objectives for the Nation which set forth ambitious goals for all Americans to be achieved by the year 1990 were products of Dr. McGinnis' tenure. The Food and Drug Administration also published extensive food labeling regulations, including voluntary nutrition labeling. In 1977 Dietary Goals for the United States was also published, establishing distinct standards for nutrition to be followed by all Americans.

In recent years, great strides have been made in the field of public health nutrition. Several landmark reports have been released and several important pieces of legislation impacting nutrition have been passed by Congress. In 1990 both the Nutrition Labeling and Education Act (FDA) and the National Nutrition Monitoring and Related Research Act (National Center for Health Statistics, CDC) became examples of such legislation. Dietitians and nutritionists in both agencies played an instrumental role in the implementation of these new public health laws on a national scope.

Present

Today PHS dietitians and nutritionists may serve in either the Commissioned Corps or the Civil Service personnel system. Presently there are approximately 100 Commissioned Officers and over 400 Civil Service dietitians and nutritionists serving in the PHS. Regardless of the assignment, their competence and skills are well utilized in advancing the objectives of the organizations they serve.

Dietitians and nutritionists continue to serve in a variety of government agencies such as: Indian Health Service, Food and Drug Administration, National Institutes of Health, Health Resources and Services Administration, Centers for Disease Control and Prevention, Bureau of Prisons, and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration). Dietitians serving in these organizations are involved in a variety of areas including research, clinical nutrition, food service administration, program planning and evaluation, health facility inspections, regulatory oversight and public health nutrition. In addition, dietitians and nutritionists are prepared and are ready to serve in emergency situations, such as the summer Olympic Games in Atlanta, Georgia and Athens, Greece, 911 Terrorist Attack, Anthrax Attack, G-8 Summitt, Rhode Island Fire, Kosovo Refugees, and several Hurricanes. As science continues to substantiate the importance of food and nutrition in relation to health, dietitians will play an even greater role in the continuing history of the profession in the United States Public Health Service.

PHS dietitians and nutritionists have served with distinction, developing and implementing nutrition-related components for the many programs they serve. The dietitians and nutritionists proudly serving under the flag of the United States Public Health Service have made, and continue to make, major contributions to the health of the nation.

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