Substitution (health)

Include in Medicare coverage personal food assessments and diet and nutrition counseling from a wide range  of health care settings

Create professional bodies for  health promoters, ones that include food/health promoters

Revamp health professional education to better incorporate food issues

Prescribe food for vulnerable groups

Include in Medicare coverage personal food assessments and diet and nutrition counseling from a wide range  of health care settings

It is well established in the literature that diet counseling can have positive health outcomes.  Although access to diet counseling has slowly improved, it is still underutilized as a strategy (see literature reviewed in the Ontario Food and Nutrition Strategy) especially within a social determinants of health framework (see below).

Publicly-funded medical insurance favours a medical and hospital approach to food and diet assessment and therapy.  This is extremely limiting because: a) it restricts access to these services; b) it places service delivery among those who are not necessarily the best qualified; c) it discourages a whole-person approach to diet therapy.  Essentially, diet counseling needs to be brought to the population, multiple sites and opportunities to help people with their nutritional health.

A consequence of Canada's failure to implement a health promotion system, the value of diet and nutrition therapy and counseling has in many ways  been more fully recognized by some private health insurers in the USA than in Canada's publicly funded system.  Some US private insurance firms have for many years been covering the costs of participating in diet and lifestyle programs aimed at reversing hearth disease.  Mutual of Omaha started such coverage in 1993 because the costs of the Reversal program ($4000/person at the time) saved $58,000US per patient when compared to artery cleaning surgery (Tufts University, 1993).  Many of these reversal programs were operating outside the traditional hospital and doctor's office settings.

It is essential that these services be more widely available, taking advantage of the many professionals who could qualify to provide them (see Revamping Professional Education), in places that are less imposing than the hospital or doctor's office. Dietitians have been added to family health teams in some provinces and their accessibility has sometimes improved with telehealth services and these are typically covered by publicly funded health insurance. Private plans will sometimes cover other services, but many who could benefit will not have coverage and will not be able to afford the out of pocket expense.  Dietitians are clearly at the centre of diet counselling, although their work has sometimes been limited by excessive reliance on nutritionism (Scrinis, 2013), a failure to understand poverty, the role of food system power dynamics in shaping food choices, and limited application of an SDOH framework for their advice.  A more robust system would tailor the level of nutrition expertise to the circumstances of the patient. A wider range of professionals with nutrition training, but not necessarily dietetic certification, could provide basic information for circumstances without an evident clinical condition, in a range of settings.  Dietitians are essential to clinical conditions, such as kidney disease, diabetes, and recovery from heart conditions.

This is strategy is consistent with professional diversification and  a "move away from the gatekeepers approach to health care".  Doctors and other professionals are slowly adjusting to the presence of a wider range of health care deliverers, and so it must be for dietitians as well.  The good news of this transition is that dietetic work will be more targeted but more widely used and respected within traditional health care realms.

Create professional bodies for  health promoters, ones that include food/health promoters

Most provinces/territories have colleges for health professions, and the numbers have been slowly expanding. For example, Nova Scotia has 22 regulated health professions under the aegis of the NS Health Professions Network, Ontario has 28, and Saskatchewan has 27.  With the exception of social workers, sometimes regulated as a health profession, sometimes under Social Service Ministry rules,  those who work as health promoters are largely unregulated.  The advantage is that there's more flexibility in the training and practice, but the disadvantage is that health promoters are less recognized as valued professionals outside of public health units, some NGOs, and community health centres. Many health care and other institutions will only hire social workers for health promotion work because they are more regulated than other fields, and the institutions feel they need the authenticity of a regulated profession.

Becoming a regulated health profession is a challenging process, and not all aspects of it are positive.  The codification of rules and processes can result in a loss of creativity within the profession, significant attachment to institutions unconducive to practice within the field, and the exit of many who decide meeting the new rules are not worth the effort (grandparenting provisions for long-time practitioners can help reduce this outcome).  Once regulated, tensions between new and old professions often remain.

But, on balance, being a regulated profession is a net positive.  The Covid-19 situation provides an example.  Regulated health professions have been allowed to return to practice more rapidly than non-regulated ones.

Revamp health professional education to better incorporate food issues

Professional bodies have requirements for continuing professional development.  Most require that professionals develop a learning plan, approved by the professional body, based on their professional needs, and then implement it.  Practitioners are required to document regularly that they are meeting their learning plans.  Professional bodies often put on workshops and other learning events to help practitioners fulfill their plans, but outside courses/learning events can also qualify.

The challenge is to make food as a social determinant of health more widely understood. Medical education rarely provides the training and skills for such interventions by doctors and while short workshops can help with awareness raising, they are not likely sufficient to develop the skills for interventions later (Hayman et al., 2020). This suggests that it will be important for doctors to know enough that they can bring other professionals with more extensive training into the discussion.

Colleges of Dieticians must be the leads on such changes. Nutrition and dietetics programs at Canadian universities provide a technical background rooted in a biomedical positivist approach to science (see Goal 3 Public Research), but not necessarily one strong in social determinants of health and food system realities, what would be considered part of a Critical Dietetics approach (Gingras et al., 2017; Fraser and Brady, 2019).  Some 30 undergraduate programs exist, but they are attached to multiple places in the universities which affects the program orientation.  Some are connected to narrowly framed agricultural programs, others to medical and kinesiology programs, and some to social services.  Critical approaches are relatively infrequent in core offerings. Many offer electives and elective minors in other fields related to the themes of this site but such courses are often not required and not necessarily framed  for dietitians (Fraser and Brady, 2019).  This reality has historically contributed to a divided profession, one where some graduates work in public health dietetics, but the majority are in very traditional primary care and the food industry. The colleges are part of this problem because they focus on the dominant approaches within the field (what Brady 2019 refers to as hegemonic nutrition) and protecting the employment prospects of their members.

So, there are two phases to implementing this strategy.  First, dietetics programs across Canada must expand SDOH  and the political ecology of food supply chains in undergraduate and graduate curricula. In many ways, this reconnects Dietetics with its roots in the human ecology approach of Home Economics (Gingras et al.,2017).  Many food studies courses, including some in Nutrition schools,  provide such pedagogy, so Dietetics schools will have many examples to draw on.  And many of their members have considerable expertise in these areas which can help inform program changes. Provincial dietetic colleges and Dietitians of Canada must require this change, makes associated changes to their regulations, standards (including expanding social justice requirements in  the Integrated Competencies for Dietetic Education and Practice, see Fraser and Brady, 2019) and the Canadian Dietetics Registration Examination and oversee compliance as they do with all programming.  Changes will also be required to screening and assessment tools, including the electronic Nutrition Care Process Terminology (eNCPT) (Brady, 2019).

The second phase, based on these curricula and regulatory improvements, is to design short, professional development, courses for different health care professionals.  This is timely because many fields have been under pressure to expand member capacity to engage in social justice advocacy (Fraser and Brady, 2019).  This requires integrating critical dietetic pedagogy with another professional field and ensuring that the colleges accept the offerings as part of professional development requirements.  Such courses also need to provide practical training in the use of new screening and assessment tools within a human ecology framework.  Again, the idea here is not to supplant nutritionists/dietitians but rather to create sufficient awareness in other health professions that they can recognize the need for nutrition / dietetic interventions and work with those professionals on patient care.

Prescribe food for vulnerable groups

Supplements are regularly recommended by health professionals, sometimes because they are important to the treatment / healing process, but often because they are the only nutrient sources directly linked to health care processes.  Certain diets are encouraged, but other than advice, the system doesn't support positive eating.  Low income people, and other vulnerable populations, often have difficulty affording and following such recommendations.

A more direct approach is to prescribe food for marginalized and vulnerable populations when warranted, within an SDOH framework. Although there are concerns about practicing nutritionism and the medicalization of food, by this stage in the transition, the SDOH and human ecology framworks are more deeply embedded in primary care practice and policy which mitigates such a result. A team approach to health care facilitates such prescriptions because access to dietitians and health promoters would be more seamless.

Certain previous undertakings can be understood as steps in this direction, including some of the food provision programming at the Montreal Diet Dispensary for women at risk of low - birthweight births (LBW), provincial social assistance programs (cf. BC's program) that allocate additional funds for recognized dietary conditions, and the related campaign to make the special diet allowance of Ontario Works more widely accessible,  supported by some doctors and the Ontario Coalition Against Poverty (OCAP).

Oddly enough, this becomes more logistically feasible with the integration of pharmacy and grocery. All major chains now have pharmacy sections, with evolution of the phenomenon accelerated the last few years with major grocery chain acquisition of major pharmacies (e.g. Loblaws purchasing Shoppers Drug Martin and Metro purchasing Jean Coutu). With a pharmacist overseeing the process in each store, public drug benefit plans can cover food prescribed by a physician.  All provinces (and at least 1 territory) have public drug benefit plans for a range of vulnerable and marginalized groups, including seniors, low income people, and sometimes those with special needs and chronic conditions. Public drug benefit plans would have to create a distinct eligible foods list that operated in parallel to their drug lists.

This measure would serve as a complement to the introduction of a Guaranteed Annual Income (see Goal 1, Income Security Architecture, Substitution).