Sustainability in dietetics means embracing complexity, contributing, and collaborating

Why do we need this issue?
This special issue is intended to respond directly to a barrier that nutrition and dietetics practitioners face globally: finding dietetics-relevant research to help guide practice that contributes to more sustainable food systems and dietary patterns. According to dietitians, sustainable food systems are those which nourish all people, now and into the future, with sufficient, nutritious, affordable, tasty, diverse, culturally appropriate food, and that such food systems support physical and mental health while preserving, promoting, and respecting the integrity of ecological and social systems . But our current food systems are neither sustainable, nor support sustainable dietary patterns. The way we produce and consume food makes substantial contributions to ecological issues such as climate change, which is a major concern facing humans. Our food systems are also contributing to equally important social challenges, such as chronic injustices in access to nourishing food.

To address these challenges, everyone has a part to play through personal choices such as what they eat, or through more collective actions such as advocacy. Those working in nutrition and dietetics have a specific role to play in influencing systems; one common way is through influencing institutions and individuals to adopt more sustainable dietary patterns, which are good for both personal and planetary health. This role has become more obvious in the past few years, as new guidelines focusing not only on human but on planetary health have been introduced, i.e., the EAT Lancet Commission guidelines and well-established dietary patterns, such as the Mediterranean diet, are modified to include and stress the concept of sustainability.

To apply these in practice, nutritionists and dietitians need a good understanding of the relevant evidence and the skills to apply this to their own lives, and to support their families, communities and those making decisions at national and international levels. This JHND special issue brings together evidence to support this and aspires to encourage readers to see examples of potential action alongside evidence.

What are the key messages from this issue?
There are two broad messages that emerge as important for this field. The first is that definitions of sustainable food systems and diets are diverse, and necessarily so. What a sustainable dietary pattern looks like varies by region, and therefore we need research that is regionally specific to help guide dietitians. This is also true at an individual level. The second is that this is a role to be contributed to across diverse practice areas; it is not an area of specialty.

Defining Sustainable Food Systems and Diets
Everitt et al. describe how there are over 10 unique but overlapping definitions being used by dietitians in Canada alone, the most common being Sustainable Diets. This is logical as many, if not most, dietitians work on consumption-focussed activities in the food system (dietary patterns, consumer behaviour, etc.). While there is a recognition that sustainability is a complex, multidimensional topic, in practice Canadian dietitians are struggling to practise in such a multidimensional way; activities of focus tend to focus on 1-2 dimensions of sustainability (such as reducing food waste or greenhouse gas emissions). We see this throughout the literature, including in this issue, and it helps practitioners narrow their work to something less complex and manageable.

We don’t see the multitude of definitions as necessarily a bad thing. Variation in definitions also amplifies that there is no single answer: our collective challenge is that the specifics of sustainable dietary patterns will vary among regions. Coffey et al. examine meat vs. meat alternatives in the UK, with findings supporting the dominant message targeted to the wealthy, industrialised world (for example in the much publicised Eat-Lancet Planetary Health guidelines): meat alternatives are likely to be better for health according to most parameters, and more environmentally, friendly than meat products. However, the higher cost of meat alternatives may be a barrier for some consumers. Sachdeva et al., and Ganpule-Rao et al help us unpack how this message may vary in South Asian countries, highlighting that the focus on meat may not be the most important indicator of sustainable dietary patterns in this region. Ganpule-Rao et al. compared dietary patterns in North and South India to the Eat-Lancet guidelines, finding that the diets of their participants were already mainly plant-based, but that the rural poor fell well short of recommended fruit and vegetable intakes. Diets that provide inadequate nutrient intakes, even if they do have lower greenhouse gas emissions, are not sustainable. Sachdeva et al. examine the data from primarily India on the environmental impacts of increasing food production, emphasising that while livestock (meat production) is problematic, the production of rice and wheat may be a more meaningful dietary pattern to target, and suggest diversification in production (and therefore also consumption) through incorporating coarse cereals such as millets as a way forward. In line with this, 2023 was declared by the FAO as the Year of Millets. While these are only two examples of how contributions to dietary patterns need to be contextually specific, we invite readers to avoid applying sustainable diets data too liberally and to seek regional data where possible.

Gichohi-Wainaina et al., and Vuong et al., add to the discourse through their assertion that the drivers of food choice lie outside of individual choice, in food environments, and these have significant impact on the health and sustainability of dietary patterns. In Kenya, Malawi and Zimbabwe, food prices and food safety concerns are central drivers of dietary diversity (a primary indicator of nutritional adequacy) and food choices among low income consumers. The authors suggest a focus on systemic, policy approaches such as subsidising nutritious foods to lower the cost. Vuong et al. examined food environments in Vietnam, finding that distance to and location of food outlets are also important. Longer distances were associated with higher diet quality, while lower food outlet density increases the odds of underweight (malnutrition) among women. There is significant opportunity for public health approaches to facilitating more sustainable food systems and dietary patterns.

Contributions across all practice areas are needed
While some have made this an area of expertise, contributing to more sustainable food systems and dietary patterns is not a specialised practice area; it is best embedded into diverse practice areas in ways that are logical to the setting and role of the practitioner. Institutional food procurement is one area that is gaining traction. Faulkner et al., and Buller et al., share important reviews of the evidence for more sustainable hospital food services in Australia, exploring organic and local foods respectively. Buller et al., suggest organic foods can increase quality and sustainability of hospital menus. Faulkner et al. emphasise the need for more studies detailing local procurement models, but offer two general types (on-contract, and off-contract). Both studies describe practical barriers, such as cost and supply chains, and highlight opportunities such as institutional support. These studies suggest important avenues for action and further research in this practice setting.

Evidence and practice examples from clinical settings have been slower to come, and this is the practice area where we often hear push-back that sustainability is out-of-scope, or at least de-emphasised in the context of more acute clinical conditions. In this issue, we are very pleased to share first-of-their-kind studies that provide insight into how clinicians can contribute to more sustainable diets. Clay et al, share evidence for a novel therapeutic diet for chronic kidney disease with a lower footprint than the usual renal diet, and the potential to reduce the climate footprint through changing intake of discretionary food and some meats. Furthermore, working with individuals is complicated by the need to consider diets within the context of each person’s specific health needs and lives. Davies et al. suggest personalised dietary approaches to increase acceptability, effectiveness and nutritional adequacy of healthy and sustainable dietary patterns. Hashim et al. have developed a reliable, valid questionnaire that can be used to inform evidence based interventions to increase youth uptake of sustainable diets.

Important to all areas of practice is to consider client-centredness, as they have valuable solutions to contribute. Fleming et al. and Browne et al., whose studies in this issue focussed on young people for whom climate change is especially relevant, point out that young people have good ideas about how to address challenges in food systems. Fleming’s study of 640 children from 18 countries found them to be interested in food issues related to sustainability and that they wanted their voices to be heard to help improve these issues. Similar interest and engagement in food-related sustainability was demonstrated by young people participating in Browne et al.’s school-based audit of food and packaging waste in Ireland, where they proposed achievable solutions to address avoidable waste. Hashim et al., who studied university students, reported good levels of knowledge about sustainable food practices, for example, eating seasonal fruit. However, they identified a mismatch between students’ knowledge and their current dietary practices and their willingness to change towards a more sustainable diet. This mismatch presents a challenge in the drive for more sustainable eating patterns and perhaps this can be addressed through a personalised approach, per Davies et al.

Call to Action: Collaborative Leadership
As guest editors, one of the exciting aspects of this special issue was the response to the call for papers from authors writing about sustainable food systems and dietary practice in nutrition and dietetics practice across the world. The sustainability crisis we are facing is a global concern and being able to include papers with data from 33 countries in five continents demonstrates the widespread engagement and leadership amongst nutrition and dietetic professionals. We hope it enthuses others to read and apply the evidence and adapt our own practice to address challenges such as climate change.

As there are opportunities for practitioners and researchers across practice areas and settings to contribute, we were thrilled to include articles that emphasise the importance of collaborative action and leadership opportunities in dietetics. Pettinger et al., draw attention to opportunities for collaborative leadership among Allied Health Professional leaders in the UK to achieve greater systemic leverage in health care and specific dietetic competencies that are fundamental to this work. Carrad et al. highlight opportunities to collaborate beyond traditional dietetics roles to achieve greater systemic leverage in society. They emphasise the opportunities with civil society organisations that are engaged in education, research and advocacy for food system governance in Australia.

We echo Pettinger et al., and Carrad et al., in their message and invite colleagues to collaborate across practice areas, disciplines and even sectors to contribute to more sustainable food systems and dietary patterns. This is an exciting opportunity for nutrition and dietetics professionals to step into leadership roles for which they are extremely well positioned.