Contemporary issues in dietetics
The coronavirus disease (COVID-19) pandemic has brought the world to its knees in 2020. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has challenged 21st century medicine and wrought havoc on sophisticated and less well-resourced economies alike, touching everyone. It will remain the contemporary issue of the decade and possibly the century.1 As we brace ourselves to ride out the long road in search of a vaccine, health experts are referring back to the 1918 to 1920 Spanish flu pandemic over 100 years ago for insights on how to cope. The COVID-19 pandemic thus reminds us that in contemporary times, many lessons can be learnt from the past.
Three papers in this issue grapple with the COVID-19 epidemic directly. Chapple et al's paper on the nutrition management for critically and acutely unwell hospitalised patients with COVID-19 profiles a joint Australian and New Zealand collaboration between dietitians, nurses, intensivists, epidemiologists and researchers.2 This detailed paper provides essential treatment guidelines for any dietitian managing acute respiratory failure associated with COVID-19. The authors from across four Australian states and New Zealand are all associated with the Australasian Society of Parenteral and Enteral Nutrition, a multidisciplinary body demonstrating the huge benefit of a team approach to a wicked health problem.
Also in this issue, Kelly et al3 have authored the Dietitians Australia position paper on the use of telehealth. Although telehealth in the provision of dietetic services is not new, it has assumed much greater importance during the COVID-19 pandemic as the Australian Government has temporarily included telehealth both by medical practitioners and allied health under Medicare rebates. The paper provides evidence for the benefit of telehealth in delivering nutrition outcomes when compared to traditional methods. The health and economic benefits of using telehealth include its reach to those in remote locations, often unable to access dietetic services easily, if at all. The recommendations to continue the temporary rebate scheme beyond the pandemic is a call to government, providing the evidence of its benefit. Telehealth, alongside traditional methods of delivering dietetic services, is essential especially for those with chronic conditions.
The issue contains several letters that are relevant to contemporary issues in dietetics. The letter by Pelly et al4 highlights how limitations placed on student placements by the pandemic led to opportunities to try an innovative student-led clinic at their university. While again this is not new, the use of telehealth provides insight on how circumstances can fast track new ways of providing student education differently, breaking old moulds. A reflection on the past is evident in two letters by Dr Beverley Wood and colleagues. In the lead up to the 100th anniversary of the nutrition and dietetics profession in Australia, Dr Wood has profiled one of our dietetic pioneers, Dr Ruth English, who was the Chief Nutritionist in the Commonwealth Department of Health from 1979 to 1993.5 In the second letter, the authors have highlighted the role the early American dietitians and the Australians who followed played in the establishment of generalist dietetic training in Australia.6
Dr Ruth English, who was the subject of the 2019 Lecture of Honour at the Dietitians Australia National Conference, embodied the essential characteristics that make the dietetic profession still viable today. She was a trailblazer. Under her leadership, the Commonwealth Department of Health undertook the first national nutrition survey in 44 years, developed recommended dietary intakes and dietary guidelines and modernised and broadened the database for Australian food composition. She demonstrated advocacy and entrepreneurship in bringing many different players to the table to achieve policy outcomes.
The dietetic pioneers in the 1930s, who initiated nutrition, dietetic and food services in the large teaching hospitals of Melbourne and Sydney, also demonstrated leadership, advocacy, business management and entrepreneurship. Mabel Flanley at the Alfred Hospital in Melbourne and Edith Tilton at the Royal Prince Alfred Hospital in Sydney laid the basic tenets for the best practice methods of today. As fearless advocates for good nutrition from a social justice perspective, they set the stage for a bold profession of scientists, critical thinkers and researchers, advocating generalist training for Australian dietitians. Profiling this history remind us that leadership, advocacy, business management and entrepreneurship, complementing the four essential competencies of dietetics—communicating for better care, scientific enquiry, critical thinking and professionalism—remain the focus of today's dietetic education and are still relevant.7
A strong focus on social justice is evident in the research priorities paper by Porter et al,8 where healthy ageing, vulnerable populations and food systems remain important areas of focus. The rise of informatics is a new focus for the 21st century. Using evidence-based practice remains a core tenet of dietetic research and practice and the remaining papers in the issue reflect the importance of using validated tools to screen for and assess malnutrition, and to measure food intake.
Malnutrition continues to be a key challenge. Nishioka et al's retrospective cohort study9 reviewed 113 patients recovering from stroke to investigate the correlation between malnutrition, muscle mass and oral status. Another collaborative study, this time between dietitians, speech therapists, physical therapists and dental hygienists, the study found that reduced muscle mass and poor oral hygiene were independently correlated with oral intake, suggesting a poorer outcome. A cross-sectional study by Lee et al10 of malnourished cardiac patients found 39% of these patients were on restrictive diets, 80% of which were deemed to not be clinically indicated. The study brings into focus past dietary patterns affecting malnourished patients on admission. Botero et al11 undertook an exploratory study of 74 oncology patients to identify if adding malnutrition risk and body mass index (BMI) could predict 12-month mortality. A secondary aim of this study was to evaluate if malnutrition risk and BMI were associated with chemotherapy outcomes. Malnutrition risk was a potential indicator of 12 month mortality for those where chemotherapy was not feasible, although not as an independent risk factor.
Measurement of nutritional intake, an essential tenet of dietetic practice, has embraced newer technologies. Computer applications on smartphones and tablets have resulted in less participant burden in collecting nutrition information; however, nutrition expertise is still required in determining random and systematic error. Lancaster et al12 compared self-reported and dietitian-adjusted dietary intake records among older adults using the Research Food Diary app. Significant errors of up to 8% occurred in some nutrients and food groups between the self-reported and dietitian-assisted records; however, none between the dietitian-assisted and carefully applied dietetic assumptions used independently to adjust the self-reported records. Finally, Hall et al13 reported on a pilot study of the impact of television on nutritional intake of patients with acquired brain injury eating in a communal dining area. Assessment of dietary intake was facilitated by electronic menu analysis via standard portion sizes at meals.
There will be ongoing challenges in managing the health and wellbeing impacts of the COVID-19 pandemic. Critical care will remain an essential part of our practice for those needing nutrition support who are acutely ill. Increasingly though we will witness the economic and mental health impact of the pandemic. It is essential that the focus on social justice and equality of access to services remains a core tenet of dietetic practice and research.
