Include in Medicare coverage personal food assessments and diet and nutrition counseling from a wide range of health care settings
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). Sustainable diet promotion is relatively weak (Alberdi and Begiristain-Zubillaga, 2021). 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. Only a limited number of programs and studies of their effectiveness exist, but there is some evidence that they can increase fruit and vegetable consumption, and reduce BMIs and blood sugar (Bhat et al., 2021).
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).
Integrate the sustainable diet with health care transformation (adapted from MacRae et al., 2014)
A key element of strategies at this stage is integrating the sustainable diet with health care. As discussed under Goal 2, Demand-supply co-ordination, Substitution, our understanding of the sustainable diet in Canada and it's nutritional parameters is at the early stages. We do have some non-definitive evidence, however, from organic foods that suggests the possibility that a sustainable diet will be superior due to some combination of reduced contaminants (particularly pesticides) and improved nutritional profiles, and that the costs will be reasonable (see Goal 2, Demand-supply co-ordination, Financing the Transition).
Almost all pesticides believed to have potentially significant negative health impacts on humans are not permitted in organic production. Consequently, dietary residues of production pesticides are almost always lower in organic foods (FAO 2000; Bourn and Prescott 2002; Magkos et al. 2006; Lu et al. 2006; Tasiopoulou et al. 2007; Lairon 2010). Globally, fruit, vegetables and cereals have been most commonly examined for residues in organic vs. conventional food studies (Hansen et al. 2002). One study found that the organic foods examined had residues on 23% of samples, while the conventional foods had residues on 75% of samples. In both types of food, most detected residues lay below established safety limits (Baker et al. 2002). Using data over a 14-year period from the USDA pesticide residue testing programme, Benbrook (2008) reported that non – organic fruits and vegetables were 3.2 and 3.5 times more likely to contain a pesticide residue than organic fruits and vegetables. Baby foods may sometimes be an exception, where residues are often similar in both systems, in part because of higher quality control measures applied by conventional baby food manufacturers. For example, Michigan - based Gerber has invested heavily in IPM and pesticide residue control amongst its contract growers. A Michigan study found no residue differences, consequently, between the production systems (Moore et al. 2000). Lairon (2010), in reviews conducted for the French Agency for Food Safety, found that 94-100% of organic samples did not contain pesticide residues. At least two studies have found significantly lower levels of organophosphate pesticide metabolites in the urine of children fed a predominantly organic diet (Curl et al. 2003; Lu et al. 2006). Not all pesticides have been assessed, however, and studies examining fungicides and herbicides and pesticide cocktails are particularly lacking (Oates and Cohen 2011).
Organic food is not residue free since organic farmers are unable to control atmospheric deposition of airborne pollutants and the 3-year conversion period may not always be sufficient to eliminate soil contaminants from conventional production (Woese et al. 1997; Magkos et al. 2006). However, in organic milk, there is some evidence of lower levels of synthetic chemicals associated with airborne transport, including chlorinated hydrocarbons, PCBs, DDT and lindane (Stockdale et al. 2001). Other possible reasons for the presence of residues in organic foods include processing contamination, inadvertent or intentional mixing of organic and non-organic ingredients in the distribution chain, and fraud (Lo and Matthews 2002).
Ultimately, the issue is whether these differences are biologically meaningful (Magkos et al. 2006; Mie et al., 2017), a complex subject beyond the scope of our review as it addresses the levels at which various contaminants have significant impacts on the human body. Certainly, many studies now suggest that dietary exposure can be significant (Oates and Cohen 2011) and some substances used in agriculture are active at lower doses than previously thought (cf. Colborn et al. 1996). Fortunately, in general, dietary pesticide risks are falling as pesticide registration systems focus more on low risk products. Organic appears to represent the lowest risk systems approach, as some studies have shown that dietary residue levels shift risks out of uncertainty ranges to negligible ones (e.g., Curl et al. 2003), however no studies currently document that organic diets reduce pesticide-related diseases and conditions (Oates and Cohen 2011).
For at least 90 years, scientists have known that soil conditions affect some nutritional parameters of foods[i]. This knowledge led to refinements in such things as fertilization strategies to improve wheat milling quality or to lengthen the storage period of many foods. Because organic farmers employ fundamentally different soil management practices compared to conventional farmers, organic foods may have a more optimal nutritional profile than conventional foods, in particular those constituents that may have a more subtle impact on health than deficiencies of protein and carbohydrates. Although some argue such questions are irrelevant, given the amount of food available to Canadians, data from historic nutrient files in Canada, the US and the UK suggest that levels of some micronutrients have fallen significantly in the past 50 years (Bergner 1197:46-75; Haliwell 2007; Mayer 1997)[ii]. Given that the Canadian population has only scored in the 2000s between 54 and 65%, depending on age and sex, on Health Canada's Healthy Eating Index (Canadian Community Health Survey – Nutrition 2004), and some 10% of Canadians have previously reported being deprived sporadically of sufficient food due largely to poverty (Che and Chen 2001), it is possible that such nutrient losses could have an impact on the health of many.
Results of studies looking at organic vs. conventional plant foods, mostly vegetables, are highly variable, with some showing no difference, some showing organic to be superior in certain parameters, and some showing conventional to be superior. At this point, the official position of most health authorities is that evidence is insufficient to support a claim that organic is nutritionally superior. Review studies, where authors have examined a wide range of results, have also been divided in their assessments, some concluding that differences are minimal or non-existent (Bourn and Prescott 2002: Dangour et al. 2010), others determining that organic is superior, quite consistently, in a number of constituents (Worthington 2001; Benbrook et al. 2008). Even where there are nutritional differences favouring organic foods, authors have concluded that they are of minimal significance for human health (Williamson 2007; Dangour et al. 2010).
Most studies examine particular nutrients (e.g., vitamins, minerals) in organic vs. conventional foods and these have typically produced mixed results. The most consistent (but not definitive) results pertain to lower quantity but higher quality grain protein, and lower nitrate and higher vitamin C levels in many organic foods (Woese et al. 1997; Worthington 2001; Benbrook et al. 2008; Lester and Saftner 2011). The reason for the conflicting results in other components appears to be that nutrient levels are affected by a whole host of factors, including the type of soil, fertilization, tillage, the variety of plant, the particular micro-climate, planting and harvesting dates, harvesting and handling techniques, and post-harvest handling. Managing all these variables to identify the organic vs. conventional comparison is very difficult, and many studies have not managed it well, making their conclusions suspect. Additionally, it may be the wrong comparison. The specific nutrient content may be less important for nutritional health than the ratios of nutrients. In other words, the body’s ability to utilize nutrients may, within a specified range, be less related to absolute levels of a particular nutrient and more connected to the relationships between numerous nutrients. Consequently, studies that focus on comparing absolute levels of a small range of nutrients may not be particularly helpful.
A bit more consistency is found in studies where test animals are fed an organic vs. conventional diet. In these studies, the researchers look at wider-angle health indicators, for example, the health and fertility status of the animal. In these studies, animals on an organic diet tend to perform better in fertility and infant morbidity parameters than those on a conventional diet (Plochberger 1989; Woese et al. 1997). However, the reasons for this result are not clear, although a recent study, using fruit flies as the test organism, fed extracts from organic vs. conventional foods purchased at retail. It found for most diets higher longevity and fertility with the organic diets, and the authors concluded this result was due to higher levels of nutrients and more balanced nutrient profiles (Chhabra et al. 2013). Other studies, however, have not been able to determine whether their results were related to nutritional parameters or possibly lower levels of pesticide residues found on organic foods (see discussion above), The limited number of studies on humans consuming organic vs. conventional diets have produced mixed results, some showing fertility advantages for those on primarily an organic diet, others showing no significant differences (Kouba 2003; Smith-Spangler et al. 2012). Vigar et al. (2019) found, though not yet definitively, that "significant positive outcomes were seen in longitudinal studies where increased organic intake was associated with reduced incidence of infertility, birth defects, allergic sensitisation, otitis media, pre-eclampsia, metabolic syndrome, high BMI, and non-Hodgkin lymphoma."
Plant studies have increasingly focused on food components other than minerals and vitamins. In a number of comparative studies, higher levels of some nutritionally significant phyto-nutrients (including antioxidants) have been reported in organic foods (Baranski et al., 2014; Baxter et al. 2001; Brandt and Mølgaard 2001; Asami et al. 2003; Grinder-Pedersen et al. 2003; Benbrook et al. 2008; Lairon 2010; Hallman 2012; Hallmann and Rembiolkowska 2012; Koh et al. 2013; ), and this may prove to be an interesting research area in the future as there is some indication consumption of such antioxidants is beneficial for human health (Chhabra et al. 2013). An emerging approach is to examine the effects of consumption of organic foods on immune system function. One recent study concluded that organic carrots had a greater stimulating effect on immune function in rats, than conventional carrots (Roselli et al. 2012).
The nutritional quality of animal products is even less well studied than plants. Comparisons are complicated by additional factors - different growth rates, different feed, different breeds, limited micronutrient supplementation, and free range husbandry. Extensive vs. intensive rearing practices (rather than organic vs. conventional) may be the biggest factor determining differences in quality (Stockdale et al. 2001). Lairon (2010) concluded, however, that organic animal products contain more polyunsaturated fatty acids, than conventional ones. A meta analysis of 29 studies conducted by Palupi et al. (2012) concluded that organic dairy products contain significantly higher protein, total omega-3 fatty acid and other essential fatty acids than conventional dairy products. Also observed was a significantly higher omega-3 to omega-6 ratio in organic dairy. Benbrook et al., (2010) arrived at similar conclusions from their literature review and modelling, confirmed later by Benbrook et al. (2018), although they found that grass-fed dairy was superior to both organic and conventional production. Kuczyriska et al. (2012), however, reported more variable results, with some quality parameters favouring organic and many favouring conventional. Length of pasturing was a confounding factor that made the organic/conventional comparison more complicated to assess.
In summary, the evidence is encouraging regarding contaminant reduction and nutritional benefits of organic food, but would not yet qualify as definitive. Part of the difficulty is the different ways studies define significant health effects. Those employing a disease reduction framework are more likely to conclude there are no effects or no significance for human health than those with a broader and more dynamic interpretation of what creates health (Huber et al. 2012).
Given that the sustainable diet has elements beyond just the organic vs. conventional comparison, there is more work to be done, but there remains the strong possibility that the sustainable diet could also advance the health promotion agenda.
[i] See Commonwealth Agricultural Bureau annotated bibliographies on soil conditions and food quality.
[ii] In Canada, CTV News and the Globe and Mail national newspaper reported extensively on the Canadian results in June 2002; There is some debate about whether these differences are a result of changes in measurement techniques over time.