Health

Global challenges and opportunities for dietitians

This issue of Nutrition & Dietetics presents a potpourri of research from across the world that highlights the complexity of nutrition as a science and the role of dietitiannutritionists in transforming this science into everyday practicalities.

NUTRITION AS A COMPLEX SCIENCE

Nutrition is a complex science, encompassing not only the biochemistry, physiology, immunology, microbiology and genetics of post-swallowing nutrition but also the myriad of sciences implicated in pre-swallowing events.This complexity has been captured in the eco-nutrition approach to nutrition science.

Eco-nutrition encompasses an ecological approach to food and nutrition where optimal nutrition emerges from the balance between human and environmental health and the food supply mediated by social and economic systems and practices.Disruption in any of the systems, be they biological, environmental, economic or social, leads—via direct (biological) and indirect pathways—to eco-health disorders, affecting every bodily system.

Describing chronic conditions or non-communicable diseases as eco-health disorders makes explicit the overlapping and interdependency of systems across the lifecourse. The manifestation of obesity, for example, is no longer regarded as a simple energy in-energy out equation.

The influences of the in utero environment on the epigenetic response; changes to the food supply that are rendered by high-level agricultural, economic and trade policy; improvements in transport and technology that reduce the impetus for physical activity; increases in environmental pollutants potentially influencing corticohypothalamic responses; and, finally, in a world that never seems to darken, disrupting circadian rhythms all contribute to the aetiology of obesity. One example of these effects is highlighted by the article of Paz-Krumdiek et al, who investigated sedentary behaviour in Peru.Adults spent, on average, nearly 6 hours sitting per day, with nearly one-quarter of the sample sitting for 8 hours or longer per day.

Longer sitting times were associated with increased obesity. The other example in this issue of the journal is the analysis by Wu et al on NHANES data, looking at the associations between unprocessed red meat consumption and the inflammatory response in never, current and past smokers. This article highlights that pollutants could have a profound effect on the body’s physiology and biochemistry, resulting in varying responses to the consumption of the same food.

This systems approach highlights that the narrow review of chronic conditions as the sole responsibility of the individual or his or her failure to comply to guidelines is misdirected. Yet, the language that blames the individual pervades our practice. For example, we talk about individuals managing or changing their “lifestyle” as if it is a simple matter of choosing a different way to live.

A more socially informed approach argues that structural and social processes actively impinge on the capacity to adopt what might be considered an almost elusive ‘healthy lifestyle’. Using ‘personal behaviours’ rather than the politically loaded ‘lifestyle’ in recognition of this is one way to acknowledge these structural and social barriers. In this issue, the challenges associated with changing personal behaviours are highlighted in four articles.

Eykelenboom et al investigated weight loss patterns among Dutch adults who were overweight and obese to investigate psychological and behavioural determinants. The study used two predominant constructs: the ‘Power of Food Scale’ that assesses the psychological impact of the food environment and the second that measured the use of portion control strategies.

Jospe et al have acknowledged that satisfaction with a diet is an important factor to consider for dietary adherence. The short scale they have developed covers not only biological factors but also social (eating at home and away from home), time (meal preparation) and economic factors (diet is affordable).

Adherence is also the focus of the paper by Forslund et al, who explored the experiences of men receiving a nutrition intervention while undergoing radiotherapy for prostate cancer in Sweden. Their results speak to the social dimensions of eating and the importance of involving significant others, of sharing experiences and of tailoring dietary advice to social circumstances. Finally, an article from Sri Lanka explores the availability and composition of weight loss supplements.

This highlights the continual search by those seeking weight loss for a ‘magic bullet’ that will resolve the problem with minimal changes to other facets of their lives. The article is a timely reminder that dietitian-nutritionists need to understand the types of supplements on the market, the claims they are making and the potential for adverse effects. Claims were not monitored, and given their broad availability, strengthening the global regulatory framework around their distribution and marketing needs to be prioritised in order to protect the public.

DIETITIAN-NUTRITIONISTS: PRACTISING THE ART AND SCIENCE OF NUTRITION

It seems you cannot use social media, read a magazine or browse the bestseller list without seeing some reference to what food or diet should be consumed for health. There is a cacophony of nutrition noise, and everybody is an expert. Dietitian-nutritionists, however, are those professionals with training in the science of nutrition, food and the human condition and are best placed to be the translators of science into everyday practice.

Nutrition is also a young science that is constantly evolving. As such,the unravelling of the mysteries of food and its components, as well as the human body and its reactions to food and the environment, across generations means that new discoveries are being made.

These findings have a profound impact on the best available advice that should be delivered to the public. Dietitian-nutritionists therefore need a range of skills and attributes that encompass interpreting and critiquing the science through to those that fall under the umbrella of emotional intelligence.

A combination of these embrace the art and science of nutrition, which are relevant internationally. Essential tools are required to gather the most appropriate and accurate data to apply the science and make recommendations for everyday practice. Several papers in this issue highlight the need for tools that enable practitioners to make the best possible estimates of dietary intake with the least burden to individuals.

These tools need to be tailored to the food supply that is available to individuals at any given time and to different characteristics of target populations. Beck et al, in New Zealand, describe the development and validation of a food frequency questionnaire (FFQ) that takes into consideration changes to the food supply and the applicability of the tool to women from Maori, Pasifika and European backgrounds.

Glabska et al respond to the growing prevalence of a double burden of malnutrition (overweight/obesity and micronutrient deficiencies) in more industrialised nations, using an FFQ to ascertain consumption of magnesium among Polish women. With the rise in the consumption of plant-based diets, Waterplus et al use a plant-based diet index that discerns between healthy and unhealthy sources to monitor changes over a 10-year period and the impact on blood lipids.

Finally, Godois et al look at a particularly time-poor population—athletes—and describe the use of multi-pass 24-hour food recalls to develop a list of foods for an FFQ to explain nutrient variability in Brazilian athletes. At the centre of dietetic practice is person- or community-centred care. The term denotes the building of partnerships with individuals, their families and communities, where health professionals share the power to empower.

Person-centred care is used in lieu of patientcentred care as many individuals with chronic conditions manage these conditions more often outside of the health system than within it. Using ‘patient’ also continues to perpetuate a power imbalance and a subjectivity and identity that may not be welcomed. One of the core skills in enacting person-centred care is empathy.

Yang et al highlight the levels of empathy among dietetic interns in Malaysia, which were self-reported, and from the assessment of the dietetic care recipient.This article also highlights the importance of professionals’ self-care in practice; empathy decreases as burn-out increases, so practitioners need to be mindful of their own physical and emotional health. Empathy is also involved when reflecting on the costs of adhering to specific diets prescribed by dietitians.

Zinn et al in New Zealand identified the costs associated with following a low-carbohydrate, healthy fat diet compared to adhering to the national nutrition guidelines. The cost of following a prescribed diet is a very real consideration for the significant number of people who are anxious about where their next meal is coming from.

Different dietary approaches could be equally effective in improving outcomes, and the role of the dietitian-nutritionist is to marry the science with the needs and responses of individuals to optimise outcomes. For example, the article by Hashemi et al comparing the Dietary Approaches to Stop Hypertension (DASH) diet with the American Diabetes Association nutrition guidelines (both tailored to Iranian food habits) demonstrated that both diets had similar effects on lipid profiles of Iranian patients with type 2 diabetes.

The remaining articles in this issue emphasise the critical role dietitian-nutritionists play in managing malnutrition in the acute care and rehabilitation settings. A team of researchers in Romania has investigated the complex relationship between acute myocardial infarction, inflammation and nutritional status. Their article reports on high rates of malnutrition despite body weights that could be considered overweight or obese. Dietitian-nutritionists have unique capabilities that mean they are best positioned to be the trusted voice of nutrition.

We just need to unlock the potential of the profession as the beacons of evidence-based, pragmatic nutrition practice amidst the growing complexity of an ecologically unstable world. Increasingly, we need to ensure the profession’s mobility across national borders as we optimise the consumption of sustainable, biodiverse diets in the shadow of climate change.

Author: Danielle Gallegos

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