Integrating sustainable nutrition into health-related institutions: a systematic review of the literature

Citation: Guillaumie, L., Boiral, O., Baghdadli, A. et al. Integrating sustainable nutrition into health-related institutions: a systematic review of the literature. Can J Public Health 111, 845–861 (2020). https://doi-org.ezproxy.acadiau.ca:9443/10.17269/s41997-020-00394-3 

Relevant to: 

Dietitians-Nutritionists working in health-related institutions.  

Question: 

This systematic review of 20 studies identified factors that influence health professionals’ practice of integrating sustainable nutrition into their work. Most studies (70%) focused on dietitians and were conducted in “Western” countries; systematic reviews or position papers were not included. The terms “sustainable nutrition” and “sustainable diets” are used interchangeably in the study. 

Bottom line for nutrition practice: 

Twenty-five factors influencing the integration of sustainable nutrition into professional practice were reported. Factors most reported include (n= # studies where identified): perceived knowledge of sustainable nutrition (n = 16); perceiving environmental issues to be part of one’s professional role (n = 13); awareness of environmental issues (n = 11); and perceived skills and self-efficacy (9). Respondents also recommended:  the need to promote sustainable diets among the general population (e.g., public health campaigns) (n = 11); the need to provide operational guidelines on sustainable nutrition and lobby for improved labelling laws (n = 10); and the importance of informing patients and educating the general population (n = 10). Overall, respondents emphasized that their place of practice prioritized health promotion, and while they saw them as important, environmental issues were a lower priority. 

The authors discussed a need to “institutionalize professional practices surrounding sustainable nutrition”,  

noting that study participants expressed the need for public organizations and decision-makers to prioritize and legitimize sustainable nutrition and develop policies and guidelines related to it.  

In addition to health-related institutions, they suggest that influencing factors also need to be addressed at the societal level (e.g., awareness campaigns), the political level (e.g., government policies), the industrial level (e.g., marketing), the organizational level (e.g., policies and procedures), and the educational level (e.g., universities). 

Abstract:

Objectives 
Sustainable nutrition is increasingly important, as the food system contributes one third of greenhouse gas emissions. Sustainable nutrition, or sustainable diet, refers to diets with low environmental impacts that contribute to food security and health. This systematic review aimed to identify factors that influence whether professionals in health-related institutions integrate sustainable nutrition into their practice. 
Methods 
A mixed-methods systematic review was conducted using the MEDLINE, Embase, PsycINFO, and CINAHL databases. To be included, the studies had to document perspectives on sustainable nutrition from health professionals, including dietitians, students and educators in health sciences, public health officers, and hospital food service managers. Data extraction focused on perceived barriers, facilitating factors, and top recommendations for promoting sustainable nutrition. 
Synthesis 
Twenty studies were included, most of which focused on dietitians. Data analysis revealed that 25 factors influenced the integration of sustainable nutrition into professional practice. The factors most reported in the included studies were perceived knowledge of sustainable nutrition, self-efficacy, awareness of environmental issues, and perceiving the promotion of sustainable nutrition to be part of one’s professional role. Increasing societal support through awareness campaigns and increasing institutional support through guidelines, information tools, and financial support were also frequently mentioned. 
Conclusion 
Sustainable nutrition is a multifaceted concept; integrating it into already complex professional practices is therefore challenging. At the present time, dietitians seem to be the health professionals predominantly researched regarding their views on sustainable nutrition. Many concrete avenues to promote sustainable nutrition were identified through this review. 

Details of results: 

Data from each study were categorized into four main categories of factors influencing the integration of sustainable nutrition: social and demographic characteristics of professionals; knowledge, attitudes, and values of professionals; skills and professional practices; and health system characteristics and practice settings. (n= # studies where factor was cited).  

 1. Social and demographic characteristics of professionals: 
Current or past vegetarianism or veganism influenced knowledge and integration of sustainable nutrition principles (n = 5). Dietitians who had been practicing longer reported a lesser intent to include sustainable nutrition into their practice (n = 5), however, this may be less valid for urban Dietitians and those with higher levels of education.  

2. Knowledge, attitudes, and values of professionals:  
Professionals’ knowledge was the most frequently cited factor (n = 16), and it was described as a prerequisite for integrating sustainable nutrition. The need for more knowledge was reported, and very few reported that sustainable nutrition had been part of their dietetic curriculum.  

Most respondents saw environmental issues as part of their professional role (n = 13), and saw that educating clients on sustainable nutrition as important (n = 10), however, reported that priority is given to health and food security issues. Professionals’ awareness of environmental issues (n = 11) was also frequently reported, and they noted that professional and personal beliefs could not be separated.  

3. Skills and professional practices  
While factors in this category were noted less frequently than others, several are of note. First, “having access to evidence-based facts and information” (n = 8); Dietitians reported the need for client tools and a uniform message regarding sustainable nutrition. Whether priority is given to environmental issues at their place of practice was noted as a factor (n = 8); where low priority was reported, this was noted as a barrier. Related to this, Dietitians working in educational or community situations were more positive about integrating sustainability issues. Facilitating factors included: Dietitians that had experience in advocating for sustainable nutrition (n = 8), practicing in a setting committed to environmental issues (n = 8), attending events focused on sustainable nutrition (n = 7), access to training (n = 6), managerial support (n = 5), and involvement in networks (n = 5).  

4. Health system characteristics and practice settings:  
The need to promote sustainable nutrition with the general population was frequently reported (n = 11). The authors note that this would help to shift societal perspectives and practices and thus increase the legitimacy of incorporating sustainable nutrition.  Respondents also frequently reported the need for operational guidelines on sustainable nutrition tools to translate it into practice, and improved labelling laws (n = 10).  Regarding the latter, respondents noted the need for consistent information for consumers to be able to identify products consistent with sustainability principles. Lack of financial support was noted as a barrier (n = 6) in relation to training, food costs, research and program development.  

Overall, the authors suggest that the results underscore previous studies showing that for implementation by organizations and individuals, sustainable nutrition practices must be institutionalized (e.g., policies, certifications, guidelines). The literature also shows that even when practices are adopted, they can be superficial or symbolic, instead of changing internal practices through managerial support, resources, the development of competencies, planned integration, setting practice expectations and providing indicators for monitoring progress.  

 Of additional interest: 

Of the studies not focusing on Dietitians, two studies were conducted with food service managers, and one with public health officers. Hospital food service managers suggested that due to a low consumer awareness of sustainable nutrition, much more attention was focused on human health. They also reported a need for clearer labelling and more available and accurate product information. Due to cost constraints, they often focused on specific aspects of sustainable nutrition (e.g., purchasing local products). This may be a way to slowly integrate sustainability, but could be problematic if it leads to complacency and more systems-based steps are not taken. Finally, they identified the need to identify key targets and specific indicators for monitoring sustainable nutrition advancement in hospitals. The study with public health officers also noted the need to systematically monitor changes at the local food system level using common metrics such as the percentage of sustainably or locally sourced foods.  

The authors noted that context is crucial to consider in the promotion of sustainable nutrition. For example, for some Indigenous residents in Northern Canada, hunting for meat is likely more environmentally sustainable and culturally appropriate than produce flown into communities.  

Editor’s comment:  

A table of definitions for each factor was not included in the article. 

Open access link to article: 

N/A 

Conflict of interest/ Funding: 

N/A  

External relevant links: 

N/A 

Transparency | Diversity | Dynamism | Evidence-based |

AdministrationCommunityFoodserviceNutrition carePublic Health
EducationMenu ChangePersonal Knowledge DevelopmentProgramming
AmericasOceania