A Retrospective Analysis of American Dietitian Financial Donations to Political Parties

: Background: Political advocacy surrounding healthcare policy has become increasingly relevant as key platform issues focus on preventive care and the impact of nutrition on health outcomes. Contributions from individuals and political action committees are pivotal in determining the direction of political advocacy. Objective: This study aimed to examine the trends of political contributions of U.S. dietitians from the years 2003-2021.


INTRODUCTION
Approximately three-fourths of all American healthcare costs are spent on chronic disease management [1]. Increasing evidence demonstrates that most of these conditions can be ameliorated with proper nutrition and nutrition counseling, which can also be used as an effective strategy to not only mitigate the impact of these diseases but prevent them altoge-ther. Despite an increased focus on preventative care and increased incentives and reimbursement from payers for these services, little has been agreed upon between the major political parties [2]. Additionally, attempts at healthcare reform in recent decades have left Americans with firm convictions on what the future of healthcare policy should look like. As these sentiments become more polarizing, political agendas have grown to encompass these reforms as key platform issues for candidates. Candidates are now having to make their stances on healthcare clear, as healthcare has become the leading issue for voters, according to a 2020 national poll [3]. As a result, individual contributions to candidates and political action committees have increased and more individuals are making their voices heard through donations [4]. As these issues become more publicized and their consequences more relevant, efforts to understand these trends among different healthcare fields and professionals have increased. Contributions to political action committees within healthcare fields have also steadily risen. Although the impact of political advocacy and contributions from healthcare professionals such as radiologists, neurosurgeons, radiation oncologists, and plastic surgeons have been analyzed, little has been done to better understand the nature of the nutrition and dietetics field and the political contributions of their healthcare workers [5 -8].
In 2003, the American Dietetic Association (ADA) created a nonpartisan political action committee named the American Dietetic Association Political Action Committee (ADAPAC). In 2011, the ADA was renamed to the Academy of Nutrition and Dietetics (AND) to support political candidates who align with the Academy's public policy priorities: disease prevention and treatment, lifecycle nutrition, health food systems and access, quality health care, and health equity [9]. It is currently the only political action committee focused on food, nutrition, and health [10]. Through its member contributions, ANDPAC has had recent successes advocating and influencing key policy issues, including the signing of the School Food Modernization Act of 2021 to upgrade school kitchen infrastructure and equipment. Additionally, ANDPAC was instrumental in reigniting talks around expanding senior access to medical nutrition therapy through the Medical Nutrition Therapy Act of 2021. There have also been strong efforts within the organization to curb obesity and diabetes through public educational programs and expanded access to public resources [11]. We know that these initiatives can be beneficial, as evidenced by Obama's Hunger-Free Kids Act, which was recently shown to improve the dietary quality of free lunches in public schools [12]. With a growing emphasis on healthcare policy and increased evidence of how nutrition impacts health outcomes, gaining a better understanding of where political contributions are directed is critical to understanding their impact and where future funds should be directed. Through the analysis presented herein, we attempt to portray the nature of the political contributions of dietitians to better understand their political involvement and recent trends within the field. Given that these professionals are experts within the nutritional health field, their opinions on ideal public policy could provide meaningful insight into how political parties and their candidates should position themselves within this key voter issue.
Our analysis focused on three main areas. First, we analyzed the overall political contributions of members within the nutrition and dietetics field. This included individual dietitian contributions to political parties and to ADAPAC/ANDPAC, as well as from the ADAPAC/ANDPAC to individual political parties. Second, we analyzed the temporal patterns of these political contributions and how they fluctuated with major elections over the last 18 years. Third, we performed a geographic analysis determining dietitian contributions toward specific political affiliations categorized by state.

Data Source
The United States Federal Election Commission (FEC) database of contributions was created to protect the integrity of the federal campaign finance process by improving transparency, enforcing, and administering federal campaign finance laws. The FEC database is made freely available to the public. Data from 2003 the first year that occupation data were available through 2021 was collected. The database designates information on the contributor's first and last names, the year the donation was made, self-reported occupation, and donation amount. The contributors sent their donations to a specific location with a unique nine-digit number. Each contribution from 2003 through 2010 was made to the American Dietetic Association Political Action Committee (ADAPAC). In 2011, the American Dietetic Association changed its name to the Academy of Nutrition and Dietetics (AND), thereby changing ADAPAC to ANDPAC. From 2011 to 2021, contributions were made to ANDPAC, and each contribution from ANDPAC was donated to a political candidate for federal office.

Data Extraction
To ensure we captured all dietitians included in the FEC database, several occupation lines were required as dietitians may self-identify themselves in various forms. Occupation lines used to filter for dietitians were "registered dietitian nutritionist," "registered dietitian," "rdn," "rd," "dietitian," and "dietetic." Approximately 1,612 entries were formulated through filtering data processed by ANDPAC's committee ID. Donations with a zero or negative value was considered erroneous and was excluded. Any contributions made outside of the United States (e.g., Guam or the Virgin Islands) or missing a location of the contributor were also excluded.

Donation Classification
The FEC database was used to track donations made from the ADAPAC or ANDPAC to Democratic, Republican, or Independent candidates in each congressional election cycle from 2003 to 2021. To designate contributions as either Democratic, Republican, or Independent, the candidate ID number was entered into the FEC database to verify the candidate's political affiliation. Contributions to a candidate with an unknown or absent political affiliation were excluded from the analysis.

Overall Political Involvement
From 2003-2021, a total of 1,612 contributions were made to ADAPAC/ANDPAC by self-identified dietitians, as shown in Fig. (1). The average contribution from the individual to the PAC was roughly $79, with a maximum contribution of $17,500 and a minimum of less than $1. The ADAPAC/ANDPAC then directed these donations, making a total of 1,372 contributions to Democratic (857) or Republican (514) candidates and only 1 donation to an Independent candidate for a total of $1,685,977. The Democratic contribution dollars ($1,088,800) were more than double the Republican contribution dollars ($597,177). The Republicans received more funding than Democrats in 5 instances: 2003, 2005, 2006, 2015, and 2018 (Table 1).

Temporal Patterns
The least number of unique dietetic contributions (3) to ADAPAC/ANDPAC occurred in 2003, whereas 2017 experienced the most unique contributions (181) as shown in Figs. (2 and 3). The number of unique dietetic contributions to the PAC declined from 128 ($19,435) to 68 ($13,836) from 2019 to 2021, respectively. In presidential election years, there was a peak in individual dietetic contributions followed by a lull the following year, except from 2016 to 2017, in which there was an increase in contributions. The least number of the unique dietetic contributions to political parties (excluding ADAPAC/ANDPAC) occurred in 2005 (67; $13,228) while 2020 had the most (48,540; $1,318,764). As shown in Fig. (3), contribution dollars to political parties from the ADAPAC/ANDPAC appeared to strongly favor the Democratic Party.

DISCUSSION
To our knowledge, this is the first analysis of individual dietitians and ADAPAC/ANDPAC political contributions in the United States. As stated by Wright and Doby, the ANDPAC allows dietitians to gain the support of legislators and other elected officials to help the Academy achieve its mission and vision with a dedication to supporting candidates for federal office that are pro-nutrition, food, and health. In 2019 alone, the ANDPAC strengthened political relationships, allowing for a variety of AND goals to be achieved, including: $20 million in additional funding to WIC Breastfeeding Peer Counseling Program, increased reimbursement of dietetic services in diabetes and renal subspecialties, increased member representation in expert panels (i.e., Dietary Guidelines for Americans), and increased support for the Child Nutrition Reauthorization and the Older Americans Act [13].
The ADAPAC/ANDPAC made 1,372 contributions, while individual dietitians made 115,407 contributions between 2003 and 2021. The highest proportion of contributions from both the political action committee and individual dietitians went to committees listed as "Democratic." Democratic support was more widespread across the United States, whereas Republican support was consolidated within a few states. Although Republican support from ANDPAC experienced a rise in contribution dollars in 2018, subsequent years appeared to follow a similar pattern of primarily Democratic contributions. Overall, dietitians have become increasingly engaged in politics over time.
The ANDPAC and individual dietitian contributions have become increasingly politically polarized. This starkly contrasts trends among the general population in the United States. Party affiliation ideologies of the general population can be identified via the Gallup polls, which show relative stability of roughly one-third of the population affiliated with each party (Republicans, Independents, andDemocrats) between 2004-2021 [14]. To better understand this difference in political involvement, it is necessary to acquire a deeper understanding of the special interests of dietitians relative to that of society. According to the Pew Research Center, most Democrats and Independents who lean to the Democratic Party (57%) report an overall positive view of nutrition research scientists, compared to only 43% of Republicans. Similarly, Democrats tend to have more favorable confidence levels in nutrition researchers' competence, concern for the public interest, and accuracy of the information, relative to that of Republicans. While there are no partisan differences in dietitians' views, many dietitians may view their role in society as nutrition research scientists. This is of interest as Democrats are more likely to favor scientific experts in taking political debate positions. The Pew Research report depicted Democrats believing scientific experts as better at making consensus decisions regarding the scientific policy than non-scientific experts. The Democrats may also be more likely than Republicans to believe scientists' decisions are based on facts alone, with little regard for their personal biases [15]. This skewed political party trust in nutrition research scientists may be correlated to dietitian political contributions.
Medical professional involvement has been well documented and is notably increasing over the past several decades [16 -18]. These professionals registered with a political party tend to be skewed toward the Democratic Party; however, the distribution appears to weigh more heavily depending on the medical specialty. Medical specialties that tend to be higher paying, such as surgical specialties and anesthesiology, are generally more Republican-leaning. Lower paying and more preventive care-oriented specialties, such as pediatrics and psychiatry, tend to be more Democratic-leaning [19,20]. These fields align with the role of a dietitian in preventive care services. Additionally, dietitians tend to be paid on the lower end of the spectrum with regard to the healthcare profession. The US Bureau of Labor Statistics shows dietitians and nutritionists earning an annual wage of roughly $65,620, which is lower than nurses ($77,600), occupational therapists ($85,570), speech-language pathologists ($85,820), physical therapists ($95,620), and advanced practice providers (nurse practitioners, $118,040; physician assistants, $119,460) [21].
The increase in political involvement among dietitians has considerably increased since the ADAPAC was initially created, as evidenced by both increases in unique donations and donation amounts. Legislation has a clear impact on dietetic practices and reimbursement rates, indicating a need for political funding. Jortberg et al. investigated changes in reimbursement received from third-party payors between 2013 and 2018, finding that many conditions received an increase in reimbursement amount. This includes conditions such as diabetes, renal disease, gestational diabetes, dyslipidemia, hypertension, prediabetes, gastrointestinal disorders, and eating disorders. Additionally, dramatic increases in healthcare insurance reimbursement from private/commercial health insurance plans for medical nutrition therapy occurred between 2013 to 2018 (from 18.7% to 49.8%) [22]. Therefore, it appears that political involvement allows a more financially sustainable structure mutually beneficial for patients and dietitians. At this time, it is unclear how political leaning or skewed political contributions affects the profession or society as a whole; however, the implications could be immense. For example, in 2020, federal spending on the USDA's food and nutrition assistance programs totaled $122.1 billion. This was an increase of roughly 32% relative to the previous fiscal year [23]. Total annual support for nutrition research based on grants, contracts, and other funding mechanisms has been steadily growing. In 2016, support was estimated at $1.6 billion and increased at nearly $100 million per year until 2020 [24]. Policymakers can have a real impact on addressing public health needs each year, while contributions may influence policymakers in areas of importance to their constituents [25 -29].

LIMITATIONS
Our study did have limitations. The FEC data is a selfreported data collection tool, which raises the possibility of inaccurate results from cases of misreported or unreported occupations, locations, and contribution amounts. Therefore, this analysis may not capture all ADAPAC/ANDPAC funding or donations. The misrepresented contribution amounts may have been due to errors within the FEC database. The entry errors were noted for negative or zero contribution dollars.
These entries represented a small number of potential donations that would likely not have significantly affected our results; however, to further minimize these limitations, these entries were excluded from our data analysis. Dietitians maintain a large array of titles within their profession. To identify the broadest range of titles for dietitians, we attempted to use many titles a dietitian may self-identify as, such as "dietitian," "registered dietitian," or "registered dietitian nutritionist." Some dietitians may have been identified by other titles, such as "nutritionist" or "nutrition scientist" and were not included in our data. We believe the number of missed cases encompasses a small minority of contributions and would not substantially alter the results collected. Lastly, donor selfinterests such as political party preference may be an explanatory variable that was not considered in this analysis.

FUTURE RESEARCH
While we have observed and reported on many impacts on the political contribution landscape among dietitians, further studies must be conducted to better understand how the patterns of contributions fully affect healthcare at the level of the clinician (such as physicians and dietitians) and patients. The field of dietetics encompasses a wide breadth of subspecialties, such as sports dietetics, food-service systems, and medical nutrition therapy. It can also be divided into various sizes, such as private practice or healthcare institutions. Additional research could investigate the correlation of political donations with the various dietitian subspecialties or sizes of practice, as legislation affects dietitians differently depending on their specific practice. It could also be interesting to compare ADAPAC/ANDPAC contribution data into subspecialties from multiple political action committee stakeholders, such as the American Medical Association PAC.
Varying federal contributions towards different specialties can be identified in the National Institutes of Health estimates of funding for various research, conditions, and disease categories. Obesity research and dietary supplement research has seen a downtrend in funding between 2020 to 2021 by roughly $24 million and $34 million, respectively, whereas nutrition as a whole has received an uptick in funding by roughly $18 million in the same period [24]. The political contributions may be correlated with these trends and future research may depict if there is a political divide in beliefs towards these subspecialties. The correlation between a dietitian's income and contribution amount may allow for further insight into political party affiliations. The understanding of how these political party affiliation donations affect public policy will allow insight into whether skewed political contributions are a pragmatic solution to achieving better public health outcomes [30 -34].

CONCLUSION
This extensive analysis of the political contributions of dietitians in the United States has revealed several important trends. First, we revealed that not only is the number of dietetic contributors rising, but the contribution amount by each contributor is also increasing. Second, contributions from the ADAPAC/ANDPAC appear to be heavily skewed towards the Democratic Party. Finally, we have shown an increasingly polarized partisanship among individual dietetic contributors donating directly to political candidates, also skewed towards the Democratic Party. Political contributions remain important for the dietetic field to protect our practices and advance the impact of the field. Advocacy allows for increased empowerment of dietitians to provide high-quality care for their patients and the community. Further research should be conducted to understand the full impact of political contributions on policymakers to determine the impact on public health outcomes.

AUTHORS' CONTRIBUTIONS
SRP developed the study hypotheses, designed the study, and wrote the manuscript. TK aided in writing the first draft of the manuscript and conducted the analysis. HS and LL collected and analyzed the data. All authors critically reviewed and approved the manuscript as submitted.

HUMAN AND ANIMAL RIGHTS
No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION
Not applicable.

AVAILABILITY OF DATA AND MATERIALS
All data was obtained from the Federal Election Commission Database, a publicly available databank of political party donations.

FUNDING
None.