CHAPTER 20 Nutrition and dietetics: promoting health for all Australians
Almost all of us are interested in food to some degree. We may enjoy selecting food, cooking favourite dishes and sharing foods with family and friends. Many of us also have definite ideas about the types of foods we consider important in our lives and, as such, food can play an important role in defining who we are. Food however, plays a much broader role in our lives than the social and cultural practices evident in everyday life. Food provides our bodies with nutrients essential for normal functioning and is one of the key influences on our state of health or illness.
Dietitians are health professionals who are trained to understand the myriad of functions and roles played by food in our lives and in our communities. Dietitians use this understanding to enhance the nutritional health of individuals, groups and entire populations through promoting health-enhancing changes to food practices and to the food environment.
Dietitians are allied health professionals who are experts in both the clinical management of disease using medical nutrition therapy, and in the prevention of ill health through advocating healthy eating practices. The clinical management of patients is essentially what distinguishes the dietitian from a generically trained nutritionist. A nutritionist may be trained in human nutrition but will not be expert in the nutritional treatment and management of diseases in a clinical and individualised setting. In community settings you may find dietitians who call themselves nutritionists because they have only limited engagement in clinical practice in their work. You may also find generically trained nutritionists who are also engaged primarily in health promotion and community education roles.
Dietetics is a relatively new profession in Australia. It is considered to have its roots in the early 1930s when hospitals began to employ dietitians and to offer internship training programs for dietitians (Nash 1989). The first professional association for dietitians, The Dietetic Association, Victoria, was established in 1935 with 13 people registered as members (Nash 1989).
Since that time, the number of practising dietitians has been increasing steadily. A 50% increase in workforce numbers was observed between 1991 and 2001, with an estimate of almost 2000 dietitians in the workforce throughout Australia in 2001 (Brown, Capra & Williams 2006). The Dietician’s Association of Australia (DAA) is the peak professional body for dietitians. Membership of DAA is thought to account for at least 85% of dietitians in the workforce (Brown, Capra & Williams 2006). In 2006, DAA had 2560 members currently practising in the workforce and over 400 student members (DAA 2006).
Like many other allied health professions, dietetics is a female-dominated profession with approximately 10% of males in the workforce in 2001 (Australian Institute of Health and Welfare [AIHW] 2001b). Despite the clear growth of dietetics in Australia, it remains a relatively small allied health profession, comparable in numbers to podiatrists and chiropractors (AIHW 2001b).
Dietetic training was initially organised as hospital-based internships, however, in 1963 university-based dietetic training was established through the University of Sydney (Nash 1989). Today, dietitians must graduate from a DAA accredited university program to practise as a dietitian. There are currently nine universities Australia wide that offer accredited training programs for dietitians, with offerings including both undergraduate (4 years duration) and postgraduate (1–2 years duration) programs. All nutrition and dietetics programs ensure a strong background in basic science including biochemistry and physiology. Specialist subject areas within dietetic programs include food and nutritional science, medical nutrition therapy, community and public health nutrition practice, research skills, communication skills, management, food service and sociology of food and nutrition.
Dietitians who have completed a DAA accredited university program in Australia are eligible to become Accredited Practicing Dietitians (APDs) with DAA after the completion of a defined and ongoing professional development program. APDs are committed to the DAA Code of Professional Conduct and to undertaking continuing professional development. Dietitians who have completed a DAA accredited university program in Australia find their qualification is accepted in many international settings, including the UK, Asia and the Middle East, and in 2007 discussions are underway for mutual recognition of qualifications with New Zealand.
Dietetic training programs are reviewed regularly by DAA to ensure training meets the DAA ‘National competency standards for entry level dietitians’ (DAA 1993). These standards outline all areas of competency new graduates need to demonstrate and include clinical management of nutritional disorders, communication skills, teamwork, management of community-based nutrition programs, management of food service systems, research and professional ethics and practice.
In 2007 a new category of accreditation for ‘Accredited Nutritionists’ was established by DAA for graduates of university nutrition programs who do not have a clinical dietetic qualification but have substantial training in human nutrition. This change allows for a broader range of trained professionals to be appropriately recognised for their expertise in nutrition and reflects the changing workforce in the nutrition arena.
Pause for reflection
Much of the work done by dietitians and generically trained nutritionists may be similar. Can you foresee any potential difficulties emerging due to these professional similarities? How might these issues be resolved?
Dietetic professionals can be found in a broad range of workplace settings, with approximately 60% employed within the government or public sector, and the rest employed in a range of private sector settings (Australian Health Workforce Advisory Committee 2004).
Almost 50% of the dietetic workforce is employed in a primarily clinical or acute care setting within hospitals or aged care facilities (Brown, Capra & Williams 2006). Clinical dietetics usually involves the day-to-day management of clinical disorders such as diabetes, heart disease and other disorders using medical nutrition therapy consistent with the biomedical model of care. Dietitians work within the acute health care team with doctors, nurses, speech pathologists, social workers, psychologists, occupational therapists and others. They prescribe individualised and specific dietary regimes, dietary supplements or even specific nutrients that will assist in improving the health of the patient. They consider the type, amount and consistency of foods in dietary prescriptions and may provide additional supplements to ensure nutritional needs are met. Clinical dietitians often specialise in a particular disorder (i.e. diabetes, renal diseases, liver diseases). They may also become specialists in the management of acute care food service systems ensuring quality and efficiency of delivery of both normal and therapeutic diets.
Almost 20% of dietitians are employed in the community sector (Brown, Capra & Williams 2006). The work of dietitians within this sector may range from clinical one-to-one services and localised group education to broader policy development and involvement in state, territory or national nutrition campaigns. Community-based dieticians generally work within a primary health care or a social model of health. There is a need from the acute health care system for community dietitians to be involved in clinical care pathways to assist individual patients re-entering the community from acute care settings.
There is also a need for community dietitians to focus on public health nutrition issues which affect whole populations of Australians, such as the obesity epidemic, or nutritional issues impacting on vulnerable subgroups of Australians, such as homeless people, low income earners and Indigenous peoples. Hughes (2004) draws our attention to key national agendas mandating for public health nutrition issues to be central to community nutrition practice and identifies the level of community nutrition workforce capacity lost to clinical services. In a health environment with limited funding and resources, competition for resources between interest groups representing the dominant medically oriented clinical services and broader public health groups continues to be a feature of the health system. The case study for this chapter outlines an example of work done by community-based dietitians and nutritionists. The questions at the end of the case study ask you to consider how dietitians might best work towards creating healthy public policy and health-promoting environments.
Dianne is a dietitian working in community health. In her local area the incidence of childhood obesity is higher than the national average and her organisation has planned initiatives which aim to address this issue. Dianne has set up two clinics a week to see children and their families for individual appointments, and is currently arranging for these families to be followed up in group education sessions which will cover healthy eating practices and will encourage behavioural change. These initiatives have been well received by her organisation, which is now able to demonstrate the numbers of children and families who are being assisted with weight issues. Local general practitioners (GPs) have also expressed their satisfaction that they now have a reliable source of referral in their bid to support these children with their weight issues.
Dianne decides to contact the local primary school and discuss potential strategies with the teachers. They are keen to assist and feel that including nutrition information in the children’s curriculum would be useful as currently very little time is devoted to teaching the children about healthy eating. They invite Dianne to work with them to develop and teach these classes. Dianne notices while she is at the school that many of the teachers are eating high fat and takeaway food for lunch from the nearby deli. The school currently has no food and nutrition policy and the school canteen sells only limited foods on some days.
On the way back to the office, Dianne hears a health minister on the radio saying that they will not be supporting a ban on food advertising during children’s prime time TV and that it is the parents’ responsibility to monitor children’s TV watching and food intakes. Dianne has a 3-year-old child and understands first-hand the ‘pester-power’ generated by advertising. The last time Dianne went shopping with her toddler there were tantrums in the aisle and demands for a high sugar cereal with her child’s favourite TV cartoon character on the front.
Using your knowledge from previous chapters on models of health such as health promotion, primary care and primary health care, reflect on the effectiveness of the approach Dianne and the school intend to take.