Chapter 10: Nutrition

Uncertainty in Nutrition

The nutrition profession encompasses a wide variety of practice areas, ranging from nutrition science to dietetics. Nutrition science has traditionally been grounded in biomedical science, dominated by quantitative scientific approaches and a focus on single nutrients (Gingras et al., 2014; Palermo et al., 2021). Dietetics also evolved from a biomedical model; however, dietitians can provide medical nutrition therapy to those affected by health conditions. Common to the whole nutrition profession (including nutrition science and dietetics) is a core competency in public health nutrition, which requires learners to understand the broader food system from which food is produced, processed, distributed, and consumed.

There have been calls for different educational approaches to prepare the nutrition profession to respond to the complex and contextual issues arising from the food system, since the ways in which food is produced and consumed are key drivers of climate change. This chapter therefore focuses on learner preparedness to address unsustainable food systems and climate change. A food system focus requires new ways of framing nutrition research, education, and practice (Barbour et al., 2022; Goodridge et al., 2022). This divergence from traditional and more familiar biomedical approaches to nutrition and dietetics may act as a stimulus of uncertainty within the workforce. Accordingly, the nutrition profession is moving towards embracing uncertainty to prepare learners for more holistic practice that considers social and climate impacts on health.

Emerging scholarship within the nutrition field identifies a need for future leaders to be comfortable with and embrace uncertainty – for example, moving beyond scientific training and accepting that a broad range of determinants (including climate change) influence optimal nutrition (Palermo, 2020). However, health education has been criticised for focusing on such determinants as ‘facts to be known’ rather than ‘conditions to be challenged and changed’ (Sharma et al., 2018, p. 25). A qualitative study identified a change/action focus – that is, addressing growing inequities and disrupting unsustainable food systems practices to reduce the impact of climate change – as crucial for the future nutrition and dietetics workforce in Australia and New Zealand (Boak et al., 2022). The authors identified six new practice areas for the nutrition and dietetics workforce and considered 16 capabilities essential for performing the roles. Common to many of these capabilities was ‘a culture of learning and being comfortable with uncertainty’ (p. 435). However, there is little scholarship about how to prepare and educate nutrition and dietetics learners to accept uncertainty that arises with this fundamental shift in direction.

Priorities to Prepare Learners for Uncertainty in Nutrition

Nutrition practice ranges from a ‘nutrient-focussed’ paradigm to one that is more holistic, which recognises the links between people’s health and the social, ecological, and political determinants of food systems. Educators need to prepare learners for this range of practice, so that those in the nutrient-focussed paradigm also understand the complexities of food systems. To be able to take responsibility for sustaining food systems in their future careers, learners need to be stimulated to apply their scientific understanding of food in becoming ‘systems navigators and food systems activists’ (Boak et al., 2022, p. 427). Educators must support the development of leadership and advocacy skills to generate a sustainable, equitable, and healthy food supply.

The focus on food politics that invariably comes with sustainable food systems education can be met with some resistance, as politics and the functioning of governments have not traditionally been studied in nutrition science or dietetics degrees. This signals a potential disconnect between learners’ perceptions of the profession and the reality that holistic nutrition practice needs to embrace food systems complexity. To this end, educators should be upskilled to support learners to be comfortable with the ‘grey’ and to embrace such complex aspects of practice with flexibility, adaptability, and resilience (Palermo, 2020). Key attributes identified for future nutrition scientists and dietitians include (but are not limited to) curiosity, creativity, empathy, critical thinking, embracing and harnessing diversity, cultural safety, and disrupting expertise (Boak et al., 2022).

Food sits at the nexus between human civilisation and the complex natural systems upon which our global population depends. The ways in which food is produced and consumed within our current food system are promoting poor-quality diets, preventable chronic disease, food insecurity, and malnutrition and are simultaneously depleting natural resources and driving climate change (‘The Bigger Picture of Planetary Health’, 2019; Rockström et al., 2020). The EAT–Lancet Commission brought together 37 of the world’s leading scientists to determine whether it is possible, and if so how, for the food system to nourish a predicted global population of 10 billion people by 2050, without jeopardising the health of future generations. They called for a great transformation of the global food system in order to nourish future generations within planetary boundaries (Willett et al., 2019). Nutrition scientists and dietitians are well positioned to contribute to this systemic transformation, bringing expertise to many elements of the food supply chain. However, this is a somewhat contemporary area of nutrition and dietetic practice, which can create uncertainty among members of the future workforce as they engage in tertiary education, members of the existing workforce, and those involved in training the future workforce. The next section details an example of an undergraduate-level assessment and associated classroom material with potential to moderate learners’ uncertainty towards sustainable food systems practice.

Fostering Uncertainty Tolerance in Nutrition Learners

The activity outlined here, the Local Food System Audit assessment, was designed to provide learners with an opportunity to examine the local food system and identify opportunities for systemic transformation. It replicates the work a nutrition scientist or dietitian might undertake in a local government setting and was designed by both chapter authors, who have a collective four decades of experience working in public health nutrition and sustainable food system practice and education, and who gained expertise in food system sustainability through dedicating doctoral studies to the topic.

The Local Food Systems Audit assessment requires learners to conduct desktop research to map and critique the food system within a local government area of their choice and to present prioritised, evidence-informed recommendations to improve the system to councillors (elected representatives who make decisions on behalf of local government) at a hypothetical council meeting. The assessment aims to challenge learner preconceptions about the breadth of practice in nutrition and dietetics beyond the biomedical model. It builds a diverse range of employability skills (e.g., creativity and innovation, initiative and enterprise, problem identification, and solution generation) and offers learners an experience of navigating complex systems and becoming ‘food systems activists’ (Boak et al., 2022, p. 427), as mentioned previously.

Exemplar Activity: Assessment

Activity Origin

The Local Food Systems Audit was originally designed for nutrition and dietetics learners with knowledge about food systems, planetary health, and environmental sustainability. In the authors’ context, learners were in their third year of a bachelor of nutrition science degree at Monash University, Melbourne, (moderator: high subject proficiency) and were completing a compulsory unit titled ‘Food Sustainability Systems’. This unit was delivered using a flipped classroom approach to engage learners in their weekly interactive workshops: they completed pre-class activities (online) to explore the topic, in-class activities (face-to-face workshops) to apply the concepts, and post-class activities (online) to consolidate their learning. The assessment was submitted in approximately Week 7 of a 12-week semester and required learners to apply the content and concepts learned previously in the unit.

The assessment was introduced to learners in class in the first week of the semester, and shortly afterwards, learners could review a document outlining what was required and the assessment rubric (moderator: scaffolding uncertainty). In approximately Week 4, learners received a video-recorded briefing describing the assessment in a step-by-step manner (moderator: setting clear expectations). At this point, learners were asked to self-select into groups (moderator: diverse teamwork). To support learners as they completed the assessment, several drop-in sessions were offered at the end of the weekly face-to-face workshops, at which learners could receive formative feedback about their progress on the assessment (moderator: expert guidance). The sessions included an online polling option through which learners could remain anonymous as they asked questions (moderator: anonymity).

Sources of Uncertainty

Sources of uncertainty in this activity were identified through experiential observation by facilitating educators and feedback from learners. To learn more about these sources, turn the dialogue cards. The front-side of the cards represents the learner experience, the back-side of the cards is the educator response to build uncertainty tolerance.

Facilitator Guide

Australia’s system of government comprises three levels: federal, state, and local. Local governments sit closest to civil society and are responsible for services such as planning, infrastructure, health and community services, waste management, recreation, and emergency management. With the potential to influence and shape these diverse areas, local government authorities are well positioned to contribute to systemic transformations (Barbour et al., 2022; Carrad et al., 2022; Deakin et al., 2019). Nutrition scientists and dietitians have expertise specific to the food system and can therefore offer local government valuable and unique skills that may contribute to these transformations.

This assessment is completed in groups of four to five learners (moderator: peer teamwork) and aims to develop learners’ ability to do the following:

• utilise a food system scanning and planning tool to conduct a local food system audit
• understand local government policy and decision-making processes to create healthy and sustainable food systems
• prioritise approaches and recommendations to strengthen a local food system based on audit data and other evidence
• apply communication and advocacy skills to convince hypothetical decision-makers to take action.

Activity

In their groups, learners are prompted to select a local government area and an existing framework, model, or tool to assist with guiding their food system audit (moderator: career value). They are provided with example frameworks, such as the Australian-based Environments for Health: Municipal Public Health Planning Framework (Public Health Division, 2001) and the Healthy Food Connect Framework (Prevention and Population Health Branch, 2014) (moderator: scaffolding uncertainty). They are also encouraged to review the literature to identify other frameworks, models, or tools that would be suitable. Using their chosen tool, they complete the mapping process of their chosen local government area by identifying and describing:

• existing local policies and networks of relevance to healthy, sustainable, and equitable food access
• elements of the local food environment, such as the location of healthy food and fresh produce outlets (e.g., greengrocers, bakeries, butchers, supermarkets, delis, fresh food markets) and unhealthy food outlets (e.g., fast food venues)
• opportunities for people experiencing hardship to access food, including community meals programs, food pantries, soup vans, and other emergency food relief options
• food distribution programs that promote shorter supply chains between producer and consumer (e.g., farm gates, farmers markets, fruit and vegetable box schemes)
• existing agriculture or food production activity, including small, medium, and large farms; community gardens; schools with edible gardens; and edible nature strips
• accessibility of the local food supply, including public transport routes, disability access, community transport options, and store opening hours
• any other community food or food sustainability initiatives in the chosen area (e.g., food swaps; food hubs; permaculture groups; food sustainability activities, programs, and events; composting or food waste minimisation schemes).

Learners must map the results of their audit in a visual format – for example, using Google My Maps (moderator: open pedagogy).

Each group is required to prepare two components for submission, which are described below. Each component is assessed using a predefined rubric available to the learners (moderator: scaffolding uncertainty).

Oral Presentation

The first component is a 15-minute oral presentation based on a hypothetical scenario in which the group members have been contracted by their chosen local government authority to research the local food system and present up to three realistic, evidence-informed recommendations to councillors at a council meeting (moderator: uncertainty dress rehearsal). Learners are encouraged to use creative and engaging presentation techniques to detail a convincing call to action to implement their recommendations, drawing upon local demographics, the existing policy landscape, and evidence of feasibility and effectiveness (moderator: flexible assessments). The assessment rubric for this component has three key criteria:

Recommendations The recommended approaches to strengthen the local food system must be realistic, evidence based, and feasible.

Evidence Learners should use multiple sources of high-quality evidence to provide a convincing justification for the recommended actions.

Delivery The presentation should be engaging, creative, and professional, and learners should demonstrate a deep understanding of the local food system in their responses to audience questions.

Written Report

Each group submits a 2000-word report that justifies the three recommendations made in the oral presentation, using relevant demographic data to do so. It should contain the following sections:

Group contribution statement Each group needs to provide a short statement or table outlining the contributions made by each group member.

Background This section should contain a clear, concise description of the context and rationale for conducting an audit of the local food system.

Methods Each group needs to provide a description of their chosen framework, model, or tool and a clearly articulated, evidence-informed account of the reproducible steps taken to apply it.

Results This should report each groups’ findings, presented in a summarised and practical manner, using only relevant data and including images of the maps and associated descriptions.

Discussion Each group should analyse their key findings, exploring the major strengths and weaknesses of the local government area’s food system and the implications of these in terms of health, economic, social justice, and environmental impacts.

Conclusion This should contain a paragraph summarising the key findings and their implications.

Impact

This assessment has been evaluated experientially by educators involved in its facilitation, and their observations and reflections have been used to iteratively improve the learner experience. Learners generally find the task overwhelming initially, as they immerse themselves in new literature to understand the various frameworks, models, and tools available to them and learn a new platform or software to map the relevant food system elements. They are then required to explore a local government website to learn about the existing policy landscape, which can also be overwhelming, as food intersects with policy beyond their familiar scope of nutrition and health – for example, in departments responsible for waste management, environment, urban planning, health, social welfare, economics, and agriculture. Determining which policies are relevant to the local food system requires learners to draw upon knowledge from pre-, in- and post-class activities that have exposed them to the various phases of the food supply chain (stimulus: transferring knowledge). Following this, learners need to determine which elements of the local food system must be mapped in order to identify weaknesses and strengths, and this can be another point of overwhelm.

In the authors’ context, learners undertaking this assessment had not been exposed to systems thinking in class; therefore, the interconnected and complex nature of the food system produced uncertainty around what was relevant to prioritise and the level of detail required. For example, learners must determine how many of the available food retail outlets and which of the public transport routes to each of these they should map. Uncertainty also existed around the oral presentation, as learners often hadn’t experienced a council meeting in real life and therefore were drawing upon hypothetical knowledge about policy-making processes and suitable approaches through which to frame their recommendations (moderator: uncertainty dress rehearsal).

All learners enrolled at Monash University are invited to complete a student evaluation of teaching and units survey. With regard to the Local Food Systems Audit assessment, despite the challenges it posed, previous learners have reflected that it offers an opportunity to apply and reinforce knowledge gained within the classroom in an authentic way. (‘The assessments were helpful in consolidating ideas and putting them into practice in situations that we may face in the future in our careers (i.e. food system audit etc).’) Learners have also reported that the assessment provides a valuable learning opportunity – that is, it is assessment for learning rather than assessment of learning. (‘The assignments are effective in teaching information that is important – food systems audit was a good and practical assignment.’)

Adaptations and Summary

When the Local Food System Audit assessment was first delivered, groups could make an unlimited number of recommendations in their oral presentations to the hypothetical council meeting. This open-ended nature to the task created uncertainty among learners, and some groups presented long lists of recommendations with superficial detail, while others provided in-depth, carefully considered, and evidence-based requests. To address this, we made the assessment expectations clearer and more transparent, with a set of parameters: groups were asked to present up to three prioritised recommendations. Depending on learners’ stage and experience with managing uncertainty pertaining to systems, different approaches in this part of the task could be engaged to grade the challenge of the activity (i.e., learner-determined versus pre-specified numbers of recommendations).

After several years of offering the Local Food System Audit assessment, we decided it would be helpful to show learners a video recording of a council meeting in progress, either in class or as part of the briefing video. This exposed learners to the real-world application of their audit and provided examples of how community members and experts present their recommendations to councillors for consideration (moderator: scaffolding uncertainty).

While aspects of the assessment present significant challenges for learners, they also reflect some of the challenges experienced in real-world practice. Learner feedback suggested that the activity was transformative for some in terms of exposure to a broader, systemic perspective of food, beyond the more traditional nutrient focus in nutrition science. Graduates who have completed the assessment have been sought by employers because of the skills they developed as a result. The assessment has been adapted for and facilitated with secondary school children in several Pacific Island nations and with primary school children in Victoria, Australia, as a mechanism to engage young people with policy decision-making processes. This highlights the authentic, adaptable, and transferable nature of the assessment, beyond nutrition and dietetics. For example, learners could conduct a local system audit to inform recommendations for strengthening social or disability support services (relevant for the social work and occupational therapy professions) or for creating opportunities for physical activity (relevant for the physiotherapy profession). Future adaptations could also include a self-reflection component after completion of the assessment tasks, to prompt learners to articulate what they have learned.

Conclusion

The Local Food System Audit assessment exposes nutrition and dietetics learners to an approach to promoting transformation of the complex, interconnected food system. The task encompasses a holistic paradigm of nutrition and dietetic practice, beyond the traditional biomedical model. This can challenge learners’ preconceived ideas about the breadth of nutrition and dietetic practice, which invariably exposes them to uncertainty. Several moderators can support learners through this by building uncertainty tolerance to help them embrace the challenges of navigating complexity. While the assessment specifically focuses on food systems, which is a highly relevant area of practice for nutrition and dietetics learners, its focus could be broadened to other systems that require transformation to promote planetary health, including the global healthcare system.

References

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