Author: Joshua Clamp / Editors: Shane McAuliffe and Breanna Lepre
Nutrition underpins personal, public, and planetary health and represents a key theme in the sustainable development goals of the United Nations (UN). Globally, 690 million people do not have enough to eat, while 1.9 billion adults are overweight and of these 650 million are obese. This coexistence of undernutrition, overweight, and obesity, known as the double burden of malnutrition, is a primary focus of the UN Decade of Action on Nutrition (2016–2025). If member states are able to implement policies and interventions to address the double burden of malnutrition, this decade will see profound improvements in public health outcomes internationally.
Effective, evidence-based nutrition care plays a vital role in improving individual and population health and is recognised as an essential component of routine health care delivery. Healthcare professionals with the requisite nutrition knowledge, capacity and confidence are perfectly poised to initiate and support nutrition care, facilitating the necessary behavioural and lifestyle changes that can lead to improved health outcomes. Building the capacity of health professionals to provide nutrition care in health care settings is therefore of considerable importance. However, a number of challenges still stand in the way of reaching this potential. For example, whilst it is evident that sufficient training to provide healthcare professionals with this knowledge, capacity and confidence is crucial, medical doctors receive alarmingly insufficient exposure to nutrition training, irrespective of geographical region, setting, or year of training (Macaninch et al., 2020). Understanding these challenges and developing strategies to overcome them is therefore important in strengthening the capacity of the health workforce, and in turn, benefiting population health and reducing the double burden of nutrition.
This scoping review by Lepre et al. (2022) provides an overview of the capacity building efforts in the context of nutrition education for healthcare professionals. It uses a combination of methods, including a review of published literature and interviews with experts, to gather findings and develop a blueprint for the next steps.
Methods
A total of 18 policy documents related to nutrition education and capacity were included and screened for the literature review. Relevant capacity-building efforts in the context of nutrition education for the health workforce were identified and considered for guidance. To complement these findings, semi-structured face-to-face interviews with key personnel from the WHO Nutrition and Food Safety (NFS) were conducted. Members of the NNEdPro Virtual Core, an international, multidisciplinary network of 42 professionals were also engaged, allowing for the consideration of regional implications in countries other than the UK. Three key questions were asked in interviews and surveys, as detailed below. Finally, workshops and presentations with experts, including WHO Chief Scientists, were also conducted to gain further insight into global nutrition capacity.
Key questions:
1. Where do you see a role for medical/healthcare nutrition education within the Nutrition Decade efforts and the work of NFS/WHO?
2. What do you perceive as the main barriers to policy formulation and implementation around medical/healthcare capacity building in this area?
3. Can you identify any current or emerging opportunities to embed medical/healthcare nutrition education into primary and/or secondary prevention initiatives?
Key themes from the literature review, interviews, and workshops
The importance of medical and healthcare professional nutrition education and capacity
One clear message from the reviewed literature was the importance of healthcare professionals and the healthcare system in the promotion of nutrition in the general population, and subsequently improved public health. Furthermore, whilst few countries have the recommended density of nutrition professionals, 96% of countries reported nutrition-focused professionals as regulated health professionals. The healthcare system is the primary delivery channel for nutrition interventions and policy changes, with the education sector coming in second.
Barriers to the application of nutrition in practice
Despite this acknowledgement of the importance of nutrition in healthcare, a number of barriers continue to limit the application of nutrition in practice. Most notably, a lack of healthcare professionals with adequate nutrition skills and knowledge. A lack of specific skills including motivational interviewing techniques and understanding of practical nutrition recommendations in areas such as infant feeding were identified as barriers. Finally, the confines of the current model of care result in limited time with patients, and difficulties in eliciting positive behavioural change.
Barriers to policy formulation and implementation related to medical and healthcare nutrition capacity building
One of the barriers to policy formulation and implementation related to medical and healthcare nutrition capacity building identified by participants was time, namely that long-term efforts are required to develop and implement these policies, which may influence action. Additionally, difficulty in collaboration & coordination between key organisations was identified as a barrier. Finally, issues were also identified relating to the definition of nutrition professionals, and the consistency of this definition across borders.
Five key themes were identified from presentations and other intermediate outputs, which were also used to inform recommendations. These themes confirm the need for a competent and motivated health workforce coupled with scalable nutrition education interventions for sustainable change and indicators to monitor progress in nutrition.
The themes are as follows:
(1) Nutrition capacities | A competent and motivated health workforce is key to progress towards ending the double burden of malnutrition |
(2) Diet quality and food systems | Food systems transformation is key to improvements in nutrition outcomes |
(3) Indicators to monitor progress | The density of nutrition professionals is relevant to the nutrition capacity and progress within countries |
(4) Scalable nutrition education interventions | To drive sustainable change |
(5) The role of voluntary nutrition networks | Voluntary nutrition networks may have a role to play in the dissemination of evidence, such as the NNEdPro Regional Networks |
Recommendations to improve medical and healthcare professional nutrition education and capacity
The analysis of policies included in the literature review, as well as suggestions and comments made during the interview and presentation stages, identified a number of proposed strategies to improve nutrition capacity. A summary of recommendations identified from the literature review and interviews is provided below:
Recommendation | Examples |
Nutrition education and resources – provides training of personnel to improve nutrition behaviour and subsequent nutritional status | Training in nutrition counselling and understanding of referral pathways
Design a rigorous evidence-based medical curriculum |
Nutrition research – to broaden the evidence base of nutrition-based interventions and related policies | To identify and research problems with nutrition care |
Nutrition champions – advocates for nutrition education | Advocacy for increased investment in nutrition |
Government and policy – key role in inter-institutional cooperation on nutrition education and capacity building | Allocation of financial resources for physical infrastructure and facilities |
Governance of nutrition – review and measure ongoing progress | Monitoring progress of nations using objective and validated indicators such as nutrition professionals’ density |
Nutrition education and resources – Enhancing nutrition education for healthcare professionals will improve understanding of diet and the progression and onset of non-communicable disease, leading to improvements in detection, treatment and prevention. Core competencies should extend beyond the basic principles of healthy diets, and include motivational interviewing techniques, onward referral pathways, and leadership skills. Nutrition education for teachers and the incorporation of nutrition education into school curricula, as well the upscaling of community-based programmes can further enhance nutrition capacity. The expansion and dissemination of open access nutrition resources can further facilitate improvements in nutrition capacity. Increased availability of online resources, as well as the leveraging of smart technologies to assist in learning can accelerate improvements faster.
“Accessible, evidence-based public nutrition education is key to empowering individuals and communities to make healthy dietary choices”
Nutrition Research – Innovative nutrition research provides a fundamental evidence base for nutrition education, guidelines and policy development. Increased nutrition research capacity can better support the identification and clarification of problems in nutrition care, delivery and education. Transdisciplinary evidence-based research should also underpin the evaluation of nutrition interventions, and can help understand limitations, feasibility and benefits, as well as measure the impact of programmes in multiple regional and national contexts.
Nutrition champions – Advocates for nutrition education and health improvement can empower others to make healthy choices. Nutrition champions may also play a role in advocating for increased investment in nutrition. Women may have a role as nutrition champions by passing on nutrition knowledge and skills to their community. Identifying and enabling nutitrion champions therefore has the potential to not only improve the nutrition capacity of a community, but to advance equity, equality, and non-discrimination in food systems.
Government and policy – Political entities must commit to a supportive environment for the delivery and implementation of nutrition policy and programmes. For example, pledges from local governments to prioritise nutrition education can support drafting, piloting, and delivery of nutrition education in healthcare professionals. Changes to the policy environment can also improve allocation of financial resources for physical infrastructure and facilities.
Governance in nutrition – It is important that systems are in place to review and measure on-going progress related to established nutrition education and capacity goals. The Nutrition Professionals Density measure is a validated indicator for measuring nutrition capacity. Further clarification on the definition of ‘nutrition professional’, along with the implementation of registration and accreditation systems can ensure quality training and professional competence. Similarly, indicators monitoring the effect of nutrition education on population health status, dietary choices and the food industry should also be developed and strengthened.
3 key recommendations
Establishment of a national curriculum for nutrition education across all healthcare sectors, including the development and expansion of online resources.
Individual and government pledge for adopting nutrition education in community and healthcare as a priority, including establishment of frameworks for best practice.
Improved global data collections mechanisms and validated indicators to assess and measure capacity and progress, such as the nutrition professionals density Indicator.
Conclusion
The importance of building medical and healthcare professional nutrition capacity is clear. Enhanced nutrition capacity at the individual, organisational and systemic levels will facilitate improvements in health outcomes and help to address the double burden of malnutrition. Using a complement of methods, including a review of published literature and interviews with experts, this review synthesises key recommendations to improve nutrition education and capacity. Nutrition data collection, policy, education and implementation of change, along with global nutrition surveillance and monitoring systems, will provide the necessary capacity to eliminate malnutrition in all its forms and allow progression towards the Sustainable Development Goals.
References and further reading
Lepre B, Trigueiro H, Johnsen JT, et al. Global architecture for the nutrition training of health professionals: a scoping review and blueprint for next steps. BMJ Nutrition, Prevention & Health 2022;0:e000354. doi:10.1136/ bmjnph-2021-000354
Macaninch E, Buckner L, Amin P, et al.Time for nutrition in medical education. BMJ Nutrition, Prevention & Health 2020;3:e000049. doi:10.1136/ bmjnph-2019-000049