Dietitians Australia position statement on healthy and sustainable diets

A cross-sectional survey exploring knowledge, beliefs and barriers to whole food plant-based diets amongst registered dietitians in the United Kingdom and Ireland

BACKGROUND

Plant-based diets (PBDs) have gained popularity in recent years due to their co-benefits for human and planetary health. Although clinical guidelines now recommend well-balanced PBDs, it remains unclear how dietitians in the United Kingdom (UK) and Republic of Ireland (ROI) view such diets and their implementation in practice. This study aimed to evaluate the perspectives of registered dietitians (RDs) on the role of a whole food plant-based diet (WFPBD) in clinical practice.

METHODS

A cross-sectional online survey was conducted amongst RDs in the UK and ROI between September and November 2023.

RESULTS

A total of 335 RDs participated in the survey. Most RDs (76%) agree that a well-planned WFPBD is suitable for all stages of life, with some (48%) expressing concerns over the risk of malnutrition and micronutrient deficiencies. Three-quarters of RDs (75%) incorrectly thought that plant protein is incomplete, necessitating protein combining. A WFPBD was on average ranked fourth out of 14 dietary strategies for managing some of the leading non-communicable diseases. Excluding dairy and eggs was the primary reason preventing RDs from personally adopting a WFPBD, whereas meal preparation and cost were the main barriers for their clients. The majority of RDs (79%) feel they did not receive sufficient education on WFPBDs, with 58% agreeing there are insufficient evidence-based resources available in their field. Only 33% feel supported when advocating for a WFPBD in their workplace.

CONCLUSIONS

Although many RDs view WFPBDs as viable and clinically relevant, significant barriers to their implementation exist, underscoring the need for enhanced education and support.

Supporting those experiencing food insecurity: A scoping review of the role of a dietitian

BACKGROUND

Increasing levels of food insecurity in the United Kingdom (UK) suggest an imperative to consider the role of dietitians in supporting people who may have insufficient access to safe and nutritious food.

OBJECTIVE

To explore the available evidence on the (i) role of a dietitian, (ii) impact of support and (iii) training needs of dietitians to support those with inadequate access to food.

METHODS AND DESIGN

Scoping review methodology was used to identify qualitative, quantitative and grey literature on the role of dietitians in supporting those with/or at risk of food insecurity. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to report the evidence reviewed for this study. Methods included multiple literature searches, charting of data extracted, and content analysis. The data of interest included the country of study, study methodology, the population of interest, the role of a dietitian, the measures, tools or guidance used and a summary of key findings.

RESULTS

In total, 466 studies were identified, following the removal of duplicate records, 243 records were screened for inclusion; the full text of 95 articles was reviewed for eligibility, and 19 were included in the review. Articles were summarised descriptively using tables and synthesised to identify emerging themes. Overarching themes of dietitians' role included, (i) identification and screening of food insecurity, (ii) facilitating community interventions and (iii) policy development.

CONCLUSIONS

Dietitians hold a range of roles to support people at risk of or experiencing food insecurity. However, there are considerable gaps in current training programmes, and a paucity of evidence describing the impact dietitians have on improving nutrition outcomes for those individuals at risk of or experiencing food insecurity.

Integrating the sustainable development goals into health professions' curricula: using the nominal group technique to guide their contextualisation

BACKGROUND

To embed the Sustainable Development Goals in health profession education, educators must contextualise them to their profession and geographical region. This study used the nominal group technique to contextualise the SDGs for Australian nutrition and dietetics tertiary education programs by determining the specific knowledge, skills, and values required for graduating dietitians to practise sustainably.

METHODS

In 2022, 23 experts in food and sustainability attended a group session that employed the nominal group technique to discuss the Sustainable Development Goals knowledge, skills, and values Australian dietetic students should develop. After the group session, participants ranked the Sustainable Development Goals according to their perceived level of importance for student dietitians. These data were analysed using multi-methods, including a summation of the rankings, directed qualitative content analysis and reflexive thematic analysis.

RESULTS

The three highest-priority Sustainable Development Goals identified were (1) Zero Hunger, (2) Good Health and Well-Being, and (3) Responsible Consumption and Production, which were then considered with the qualitative findings. The main categories that were generated from the content analysis reflected the broad knowledge, skills, and values student dietitians should develop. The preliminary codes provided specific details for each of the main categories. The thematic analysis generated two additional themes: the importance of Indigenous ways of knowing, being and doing, and authentic experiential learning activities.

CONCLUSIONS

The method employed for this study provides a useful framework for health professions to contextualise the Sustainable Development Goals to their profession and geographical region. For this study, the ranking process and the qualitative data analysis enabled the Sustainable Development Goals to be reframed in a way that would be meaningful for dietetic educators and students and demonstrate the interrelatedness of the goals. The direct qualitative content analysis and reflexive thematic analysis identified the knowledge, skills, and values student dietitians should develop.

Sustainability-informed dietetics education: key messages for educators and national dietetics associations

BACKGROUND

Dietetics curricula currently fail to meet the educational needs of the future dietetic workforce to contribute expertise in sustainable, healthy food systems in the settings in which dietitians work. A 'Global Networking Event on Sustainable Food Systems in Nutrition and Dietetics Education' was held in June 2023 with the goals of building relationships among international stakeholders and informing the development of shared curricula.

METHODS

Plenary lectures, panels and roundtable discussions were held over 2 days, designed to provide the background required to generate informed actions. Topics included recent research from practice and education, competency standards and relevant policy documents, examples from the field, 'big questions' about scope and student perspectives. Key messages were summarised thematically to inform educators and national dietetics associations.

RESULTS

Fifty-five delegates attended from 11 nations representing education, research, dietetic associations, industry and diverse practice backgrounds. Key priorities identified for educators included co-development of curricular frameworks and pedagogical theory, practical training supports and solutions to limited time and expertise. Key recommendations for national dietetics associations included strategic promotion of sustainable food systems in dietetic roles and practical supports.

CONCLUSIONS

Outcomes are anticipated to stimulate ongoing discussion, collaboration and actions on sustainable food systems education within the dietetics profession leading to shared curricular models and supports.

Diverting Food Waste From Landfill in Exemplar Hospital Foodservices: A Qualitative Study

BACKGROUND

The US Environmental Protection Agency Food Recovery Hierarchy suggests methods for diverting food waste from landfill. Knowledge of how hospital foodservices implement food waste management strategies could help modernize food waste practices.

OBJECTIVE

The aim of this study was to explore hospital staff members' experiences of implementing a food waste management strategy to divert food waste from landfill in their hospital foodservice, including the journey, challenges, and facilitators of this practice change.

DESIGN

A qualitative study was conducted in 2022-2023 using semi-structured interviews.

PARTICIPANTS/SETTING

Eighteen participants were staff members with knowledge of the food waste management strategy from 14 exemplar hospitals in United States, Spain, Scotland, and Australia using strategies to divert food waste from landfill within the last 10 years.

ANALYSES PERFORMED

Mapping and thematic analysis were undertaken to code and identify themes from the interviews that described staff members' experiences of the journey to implement the strategy.

RESULTS

Six hospitals donated food, 1 transferred food waste for animal feed, 4 used an industrial solution, and 3 sent food waste for composting. A common journey pathway for successful implementation was identified from participants' experiences. It features the following 6 phases: idea, preparation, roll out, maintenance, established practice, and evolution. Facilitators included legislation, enthusiastic staff members, executive support, and "luck." Challenges were smells, occasions when food waste was not collected, equipment breakage, and funding depletion.

CONCLUSIONS

This study identified a common journey pathway for implementing a food waste management strategy in hospital foodservices that can be used to anticipate and prepare for the steps in the implementation process.

Canadian farmers' perceptions of social sustainability in agriculture

Sustainable food production is an important part of dietetic education and training; however, the focus in the dietetic sphere is often on the environmental aspect. Understanding the multi-dimensional nature of sustainability can enhance dietetic students' sustainability competences-such as empathy and change of perspective, systems thinking, and critical thinking and analysis-to help them in their future careers and strengthen their position in society as trusted and knowledgeable food and nutrition professionals. Enhancing public understanding of sustainable food production is imperative as populations become more urban, are less connected to agriculture, and have expectations for sustainably grown/raised food, often without knowing current food production practices or the multiple aspects of sustainability that must be in place for farmers to meet those demands. The goal of this research was to understand Canadian farmers' perceptions of environmental, economic, and social aspects of sustainable food production. Employing a descriptive qualitative approach and constant comparative analysis, four food and nutrition researchers analyzed interviews from 52 farmers from across Canada. Participants had to be English-speaking, produce food through farming on land, and own or rent the land on which they farm. Telephone/video interviews revealed five overarching social themes: (1) the importance of community and social capital, (2) public perception and social license to operate, (3) lack of infrastructure, and (4) deep connections to personal lives. The final theme, mental health issues (5), reflected the consequences of the multiple sources of stress that can undermine the social sustainability of farmers, farm communities, and food production. These findings may help various audiences appreciate the multiple dimensions of sustainable food production; reflect on their values, perceptions, and actions with regard to agriculture; and enhance their compassion and empathy for all farmers.

Forgetting how we ate: personalised nutrition and the strategic uses of history

Personalised nutrition (PN) has emerged over the past twenty years as a promising area of research in the postgenomic era and has been popularized as the new big thing out of molecular biology. Advocates of PN claim that previous approaches to nutrition sought general and universal guidance that applied to all people. In contrast, they contend that PN operates with the principle that "one size does not fit all" when it comes to dietary guidance. While the molecular mechanisms studied within PN are new, the notion of a personal dietary regime guided by medical advice has a much longer history that can be traced back to Galen's "On Food and Diet" or Ibn Sina's (westernized as Avicenna) "Canon of Medicine". Yet this history is either wholly ignored or misleadingly appropriated by PN proponents. This (mis)use of history, we argue helps to sustain the hype of the novelty of the proposed field and potential commodification of molecular advice that undermines longer histories of food management in premodern and non-Western cultures. Moreover, it elides how the longer history of nutritional advice always happened in a heavily moralized, gendered, and racialized context deeply entwined with collective technologies of power, not just individual advice. This article aims at offering a wider appreciation of this longer history to nuance the hype and exceptionalism surrounding contemporary claims.

Nutrition quality and food and packaging waste associated with the school food system: A pilot, citizen science study in an Irish secondary school

BACKGROUND

School is an important setting for creating healthy and sustainable food environments. Using participatory methods, this pilot study examined food and packaging waste and nutrition quality within the school food system.

METHODS

One secondary school in Ireland participated in a waste audit. Eleven male students (15-17 years) participated as citizen scientists. Students collected waste over 1 day and documented data on waste categories. Nutrition labels were photographed for analysis. Students created a video and participated in a focus group. Quantitative data were summarised using descriptive frequencies. A Nutrient Profile Model was applied to summarise nutrition quality. The focus group discussion was analysed using content analysis.

RESULTS

Highest weights of waste were organic waste (14.2 kg), paper and cardboard (5.0 kg), and hard plastics (4.1 kg). Materials banned by the European Union Single Use Plastics Directive were found. Recycling bins were contaminated with food waste. Nutrition labels from 132 food packages were analysed, of which 115 items (87%) were low-nutrient, energy dense foods. Confectionary, energy bars and desserts and savoury snacks were the most common packaged food groups. Students were not surprised by the unhealthy food choices; however, they were shocked and saddened at the waste practices. Their proposed solutions mapped across individual, community and organisational levels.

CONCLUSIONS

The methodologies allowed successful engagement with students on this topic. The use of unnecessary plastics to serve food, poor waste separation practices, and the production of avoidable waste from low-nutrient, energy-dense products were key issues identified. Students proposed solutions that are achievable in the short-term.

The role of Australian civil society organisations in food system governance: Opportunities for collaboration in dietetics practice

BACKGROUND

Civil society organisations (CSOs) are increasingly participating in food system governance in ways that challenge the dominant industrialised profit-driven system.

METHODS

An online survey of Australian CSOs that self-identified as being involved in food system governance was conducted to identify their objectives and activities and the enablers of, and barriers to, their participation in food system governance. Respondents were nongovernment organisations/registered charities, social enterprises, businesses and collaborative research initiatives involved in food system governance in Australia (n = 43).

RESULTS

Organisations undertook activities across all dimensions of the food system (food growing/production, distribution, sale, marketing, access and consumption) and had diverse goals related to health, sustainability and social and economic development. They engaged in food system governance via activities such as advocacy and lobbying for policy and legislative change and guiding policy development. Key enablers of this engagement included funding, internal capacity, external supports and collaborations, and inclusive consultation processes and, when not present, were considered barriers.

CONCLUSIONS

CSOs play an important role in food system governance in Australia, including by influencing policy outcomes, contributing to more inclusive and democratic forms of governance and leading community-based food system policies. For CSOs to play a more central role, provision of longer-term funding; creation of dedicated food and nutrition policies at local, state and federal government levels; and governance processes that are inclusive, accessible and minimise power differentials are required. This study's findings can be used to identify many opportunities for dietitians to engage with CSOs in education, research and advocacy roles for food system transformation.

Conceptualising sustainability in Canadian dietetic practice: A scoping review

BACKGROUND

Dietitians (RDs) are well-positioned to promote sustainable food systems and diets. This research aims to review the literature for how RDs in Canada define sustainability and determine the types of relevant activities that exist in practice as described in published literature.

METHODS

Using standardised scoping review methods, researchers searched CINAHL, ACASP, PubMed and ENVCOM databases to identify peer-reviewed articles and conducted a grey literature search to locate other publications related to sustainability in Canadian dietetic practice. Qualitative, thematic coding methods were used to examine definitions and existing practice. The PRISMA extension for scoping reviews guided reporting.

RESULTS

The search resulted in 1059 documents and, after screening, 11 peer-reviewed and 16 grey literature documents remained. Ten unique definitions were used, the most common being Sustainable Diets. Definitions were multidimensional, including environmental, social, economic and health dimensions, and 31 unique subtopics. However, existing practice activities appear to reduce actions to one to two dimensions. Existing practice areas well-reflected include Food and Nutrition Expertise, Management and Leadership, Food Provision and Population Health Promotion. Notable gaps include action in Professionalism and Ethics and Nutrition Care.

CONCLUSIONS

No single definition supports all professional contexts, and agency in choice of language to define the work is helpful for contextual clarity. Strengthening practitioners' ability to analyse issues using systems thinking and applying this in practice will help to address challenges and reduce risks of trade-offs. Updates to competency standards that reflect the breadth of existing activities, as well as curricular supports or practice standards, are needed.

Benefits, limitations and implementation issues for integrating organic foods into hospital foodservices: a systematic review

BACKGROUND

Public institutions have the opportunity to implement environmental sustainability policies through leveraging their buying potential. Given the role of hospitals within the food system, the implementation of sustainable initiatives into hospital foodservices is a priority. Compared to conventional agricultural methods, organic food production uses more sustainable practices and warrants consideration for utilisation in hospitals. This systematic review aimed to synthesise the published literature to identify benefits, limitations and implementation issues regarding the use of organic foods in hospital foodservice settings.

METHODS

The review protocol was prospectively published (PROSPERO registration CRD42022322245) and reported consistent with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of four databases was undertaken for papers published from January 2000 to March 2022; key outcome data were extracted and synthesised. Study quality was assessed using the Quality Criteria Checklist for Primary Research or the Critical Appraisal Skills Programme checklist.

RESULTS

After review of 4102 titles/abstracts and 113 full-text papers, the final library comprised 10 papers of moderate to high quality. The implementation of organic foods increased quality in addition to environmental sustainability improvements. The price premium, additional production requirements, change to kitchen routines and concerns with food quality and security of supply were reported as barriers. Government targets for increasing organic food, organisational support, and staff knowledge and training supported implementation.

CONCLUSIONS

This review identified opportunities for the implementation of organic foods into hospital foodservices, but there are numerous barriers to be overcome through strategies including organisational support and staff training.

European dietitians as key agents of the green transition: An exploratory study of their knowledge, attitudes, practices, and training

Introduction

How food systems are currently provisioning food to the population is a matter of debate worldwide. Food systems, driven by widespread and increasing adherence to a westernized dietary pattern, are failing to meet people's basic needs and are draining natural resources. There is a push to make food systems more healthy, fair, and sustainable. To this end, action from all players is needed to meet the international agenda. In this regard, dietitians play a crucial role, as they can provide advice and promote actions that foster the adoption of more sustainable dietary patterns (SDP) as well as the promotion of sustainable food systems. As an emerging requirement in their training, it is crucial to know what dietitians know about SDP as well as their attitudes and current practices in this field in order to strengthen their competences and be key agents for the green transition. For this reason, the aim of the present study is to explore the knowledge, attitudes, practices, and training (KAPT) of European dietitians on SDP by administering an online survey.

Methods

Cross-sectional survey administered between April-August 2021 to dietitians based in the European countries with National Dietetic Associations or Education Associate Members affiliated to the European Federation of Associations of Dietitians (EFAD). Results were analyzed based on European region of professional practice (Northern/Southern/Western/South-East Europe), area of expertise and years of experience.

Results

Responses from 2211 dietitians from 25 countries were received, although the analysis was based on those that responded at least 90% of the survey (n=208). European dietitians are lacking training on SDP but are willing to learn more about it. Most dietitians perceive themselves as able to define an SDP, although aspects concerning social and economic sustainability were underestimated. Dietitians concur that barriers exist to the promotion of SDP, such as the lack of updated national food-based dietary guidelines and the absence of support from peers and managers. The country of professional activity seemed to be key to influencing dietitians' KAPT.

Discussion

These results emphasize the need to strengthen European dietitians' training in SDP and increase public/private commitment to consider dietitians as key professionals for the transition towards SDP.

Australian Consumers' Attitudes towards Sustainable Diet Practices Regarding Food Waste, Food Processing, and the Health Aspects of Diet: A Cross Sectional Survey

Environmentally sustainable diets are increasingly aspired to in food-based dietary guidelines across the world. However, little is known about consumer attitudes toward these diets when making food decisions. This study aimed to identify the demographic characteristics of Australian adults based on the level of attention they paid to the healthfulness of their diet, their consideration of the level of food processing, and their concern about household food waste and sustainable packaging disposal. Adults aged from 18 to over 75 years (n = 540) were surveyed online. Thirty-seven percent were concerned about sustainable food waste, 28% considered the level of food processing when making food decisions, and 23% paid attention to the healthfulness of the food they ate. Adults who had higher educational attainment (above Year 12) were twice as likely to be concerned about food waste and sustainable packaging disposal (odds ratio (OR) = 2.10, 95% confidence interval (CI) 1.29-3.4), and processing levels (OR = 2.04, 95% CI 1.23-3.42) (controlling for age and gender). Those earning an income over AUD$100,000 were twice as likely to pay attention to the healthfulness of their food choices than those earning less than AUD$50,000 (OR = 2.19, 95% CI 1.28-3.74). Only 9% percent were concerned about or paid attention to all three of the components of healthy sustainable diets investigated, and 45% paid no attention and were not concerned about all three components. These findings suggest there is a need to educate the public to raise awareness of and concern for healthy, minimally processed, and sustainable food choices.

Quantifying waste and its costs in hospital foodservices

AIM

To measure the amount of different types of food and food packaging waste produced in hospital foodservice and estimate the cost associated with its disposal to landfill.

METHOD

A foodservice waste audit was conducted over 14 days in the kitchens of three hospitals (15 wards, 10 wards, 1 ward) operating a cook-chill or cook-freeze model with food made offsite. The amount (kg) of plate waste, trayline waste and packaging waste (rubbish and recycling) was weighed using scales and the number of spare trays and the food items on them were counted. Waste haulage fees ($AU0.18/kg) and price per spare tray item were used to calculate costs associated with waste.

RESULTS

On average there was 502.1 kg/day of foodservice waste, consisting of 227.7 kg (45%) plate waste, 99.6 kg (20%) trayline waste and 174.8 kg (35%) packaging waste. The median number of spare trays was 171/day, with 224 items/day on them worth $214.10/day. Only 12% (20.4 kg/day) of packaging waste was recycled and the remaining 88% (154.4 kg/day) was sent to landfill along with food waste at two hospitals. Overall 347.3 kg/day was sent to landfill costing $62.51/day on waste haulage fees, amounting to 126.8 tonnes and $22 816.15 annually.

CONCLUSION

A substantial amount of waste is generated in hospital foodservices, and sending waste to landfill is usual practice. Australia has a target to halve food waste by 2030 and to achieve this hospital foodservices must invest in systems proven to reduce waste, solutions recommended by policy advisors (e.g., waste auditing) and waste diversion strategies.

'Nutritional Footprint' in the Food, Meals and HoReCa Sectors: A Review

Nowadays, the food industry is integrating environmental, social, and health parameters to increase its sustainable impact. To do this, they are using new tools to calculate the potential efficiency of nutritional products with lower levels of environmental impact. One of these tools is called the 'nutritional footprint', created by Wuppertal Institute for Climate, Environment and Energy GmbH. This study aims to review this concept and clarify its historical development, its use in several sectors of the food industry, and its transformation from a manual to an online tool. Results reflected that it is a suitable indicator that integrates nutritional, environmental, and social-economic dimensions to help the decision-making process in the procurement of more sustainable products and, although it is limited to Germany due to the use of the national standard nutritional intakes of Germany, its importance lies in the fact that is a promising instrument to promote environmental sustainability in the context of food, meals, and the hotel, restaurant and catering (HoReCa) sectors.

Innovation in Healthy and Sustainable Food Product Development for Health and Aged Care: A Scoping Review

Population ageing and climate change are issues of global concern. Subsequently, the need for healthy and sustainable food systems to meet the increasing demands for health and aged care is evident. This review aimed to systematically identify studies reporting new or innovative foods, drinks and snack products in health and aged care, and describe health and environmental sustainability considerations where reported. Methods were guided by the Joanna Briggs Institute guidelines for scoping reviews and reported against the PRISMA-ScR guidelines. Eligible studies were conducted in an inpatient healthcare setting or aged care facility where a new or innovative food, drink or snack product was evaluated with outcomes of product use, acceptability, cost, appropriateness for the population, and clinical or environmental sustainability outcomes in the last decade. Three databases were searched using a replicable strategy, with five publications of four studies included in the final library. Product innovations were led at the facility level and included testing dewaxed brown rice, talbinah, and an apple/pear juice fibre solution. Results suggest that food industry suppliers are operating in parallel with foodservices within hospital and aged care. Future intersection would be transformative for both industry sectors.