The Role of the Registered Dietitian

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The Role of the Registered Dietitian
© Adriel Kloppenburg 2015
The Role of the Dietitian
in the Built Environment
Developed by:
The Public Health
Nutritionists of Saskatchewan
The built environment can be planned so healthy
choices are the default choices. Dietitians who
address the built environment go beyond the
traditional approach of nutrition education and act
on external factors that influence the food choices
people make each day. The built environment
can support healthy eating and nutrition through
access to healthy food choices.
September 2015
Introduction
The built environment refers to the human-made surroundings that provide the setting for all
human activity, which include those places where people live, work, eat, learn, rest and play.
These spaces range from rural streets to bustling downtowns and all the places in between.1
The built environment can be planned to enhance an individual’s and a community’s health by
creating places where the default choice is the healthiest option.
A Healthy Built Environment Features: 2-5





A food system that ensures safe, affordable, and equal access to healthy food, protects
and restores the environment, and supports the local economy;
Transportation networks that are safe, accessible, and prioritize active transportation,
such as walking or biking, to destinations for basic amenities such as healthy food,
schools, parks and recreation;
Neighbourhood designs where people can easily access day to day services and which
foster opportunities for social interaction;
Housing that is affordable, accessible and free of environmental and physical hazards;
and
Natural environments which are protected, connected and accessible for all to enjoy.
Healthy Food Systems
There is an important role for dietitians to work towards healthy food systems. The food system
determines what food is accessible and how it is chosen. A healthy food system within the built
environment includes the following three
concepts: 2
Figure 1: The Processes of a Food System
1) Food Environments - access to healthy
food in all neighbourhoods;
2) Community Food Infrastructure - a
system of food facilities, programs, and
social networks such as community
kitchens or gardens that aim to improve a
person’s quality of life; and
3) Sustainable Agriculture - “ … the
efficient production of safe, high quality
agricultural products, in a way that
protects and improves the natural
environment, the social and economic
conditions of farmers, their employees and
local communities, and safeguards the
health and welfare of all farmed species." 6
Source: http://www.slcgov.com/slcgreen/food
2
A healthy food system considers how food is grown, harvested, processed, distributed,
marketed, consumed and disposed of (Figure 1). The economic, ecological and social value of
food extends beyond its nutritional value. This concept is encompassed in the area of civic
dietetics, which is the promotion of a sustainable, just, economically viable, community based
food system.7
As advocates and educators, dietitians have both a role and responsibility in promoting healthy
food systems. Promoting and supporting a healthy food system goes beyond providing
education to improve eating habits but also considers the impact of food choices, programs and
policies on the food system. A healthy food system will ultimately improve the built environment
and community health.
Click here for a printable handout on “What is a Food System?”
www.fhhr.ca/Documents/2013PHNSWG-WhatisafoodsystemupdatedJun12015.pdf
Evidence Summary
1) Food Environments
The food environment can be defined as the food and beverage choices that are accessible to
people while they are in the places they live, work, eat, learn, and play. The product placement,
pricing, marketing and advertising of food and beverages all have a direct impact on food
choices made in the environment.8 Food environments can make healthy choices easy or
difficult.
Most of the evidence in food environment research focuses on geographic food access
(Figure 2) and its link to diet and chronic disease and neighbourhood socio-economic status.
Positive preliminary findings demonstrate that:
Figure 2 : Geographical Food Access to

The most promising evidence for food
environment intervention supports the increase of
accessibility to healthy food within small food retail
stores.9,10

Evidence does not support an increased number
of grocery stores to improve dietary outcomes or
food security. 10-12

There appears to be a link with increased Body
Mass Index (BMI) and obesity with poor access to
healthy food and easy access to corner stores or
fast food outlets. This is especially evident in
children when fast food restaurants are near
schools.13,14
a Supermarket in the City of Regina
Source: Environmental Scan Conventional and Indigenous
Food System and Gaps in Regina Area SK,
http://foodregina.ca/
3
People most affected by the food environments within their neighbourhoods are those without
access to a vehicle or public transportation.15 Even with access to public transportation there
are added challenges for a person to make the healthy choice; some challenges may include
extra time to walk to and from pick up and drop off points, extra time waiting for public
transportation to arrive and depart, carrying the weight of groceries to and from pick up and drop
off points, and the added cost of taking public transportation if they are not within walking
distance. If access to healthy food is not within walking distance, a person without access to a
vehicle or public transportation may have to pay for a more costly form of transportation such as
a taxi service to take them to and from the grocery store.
Low income neighbourhoods tend to have better access to corner stores and fast food outlets
than stores that sell healthier food options.10, 13, 16-18 These neighbourhoods are sometimes
called food swamps. Research suggests that food swamps may have a greater impact on health
than food deserts where little or no healthy food is available.10,13, 16-18
Research Limitations
Food environments are an area of continued and growing
research. Most food environment research has been
completed in the United States or United Kingdom and in an
urban setting.9 Very little research has been completed on
food environments in rural and northern settings. Further,
inconsistent methodologies make it difficult to compare a
study completed in one city with a study completed
elsewhere in Canada. 9
Source: http://cristacarwashandlube.com/crista-chevron-gas-food-mart/
The Canadian literature on food environments is hampered by weak methodologies, resulting in
some studies noting a decreased association between food environments and health outcomes.
There is a stronger association between food environments and health outcomes in studies with
well-designed methodologies.
Dietitians can help improve food environments: 19-21

Collaborate with municipalities, developers, food producers or businesses to
ensure that healthy food is available within schools, recreation facilities, public
spaces and communities. Work to limit the presence of fast food outlets, especially
near schools;

Identify or create spaces to grow food in both rural and urban settings;

Work with developers, city officials, and rural municipalities to encourage healthy
food retail within short distances of where people live;

Complete a food environment assessment. The results can support the adoption of
programs or policies that increase community access to healthy food and
decrease access to less healthy food.

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2) Community Food Infrastructure
There is strong evidence that indicates access to community food infrastructure such as
community kitchens or gardens, improves social skills, social supports, health behaviours and
coping skills.2 However, there is only moderate evidence that indicates food skill and diet quality
improves with access to community food infrastructure.2 There is no conclusive evidence
indicating individual food security is improved through access to community gardens and
kitchens.2
Yara Community Gardens’ Farmer’s Market in Moose Jaw, SK.
Source: www.saltywaffle.com/wpcontent/uploads/2011/08/soup-kitchen.jpg
Dietitians can help improve community food infrastructure:

Identify existing space available for community kitchens or gardening programming. Seek
out partnerships for permission to use and implement programming in the space;

Advocate for spaces in new buildings to support community food infrastructure such as
greenhouses, food storage areas such as root cellars and freezers, commercial kitchens
and outdoor water supplies for gardens;

Build capacity in organizations to deliver programs that incorporate food skills such as the
ability to grow, harvest, cook, preserve and compost food. For example, support school
based educators to incorporate food skills into the current curricula and assist school and
community programs to offer gardening, composting and cooking activities;

Encourage communities to create environments where mothers feel comfortable and
welcome to breastfeed and support organizations in becoming Baby Friendly:
http://breastfeedingcanada.ca/BFI.aspx;

Complete a community food assessment to help map community food infrastructures and
resources in your community. Refer to the following resources to get started:
o
www.sfu.ca/content/dam/sfu/cscd/PDFs/researchprojects_food_security_community
foodassessmentguideforbc.pdf
o www.phsa.ca/Documents/communityfoodassessmentguide.pdf.
5
3) Sustainable Agriculture
There is a lack of research on the effects of sustainable agriculture on health outcomes. This
area is recommended for future research.2 Expert opinions agree that:

Agricultural land, workforce capacity, and supportive
infrastructure such as packing, processing, storage
and distribution systems are essential for a healthy
food system at a local and regional level.2

Small scale urban agricultural activities such as
backyard or community gardens and edible
landscapes (i.e. fruit trees on public property) have
the potential to build a sense of community,
influence food knowledge and preferences, and
contribute to the local food supply.2

Local food systems, including urban agriculture, can
reduce environmental impacts and increase the
resilience of food systems by reducing dependence
on oil. Urban agriculture can make use of city storm
water, wastewater and food waste, and increase
biodiversity in cities.22
A fruit orchard in the Town of Elbow, SK.
Dietitians can help improve sustainable agriculture: 7,20,23

Advocate for control of urban and “town” sprawl to protect availability of
agricultural land by working with town councils and rural municipalities to develop
policies for land use and planning;

Collaborate with partners to create healthy public policies that integrate
sustainability, economic goals and public health. For example partner with tribal
councils to establish productive lands that support indigenous food systems;

Advocate, create and support policies between local producers and food service
departments, schools or other community initiatives, to ensure public availability of
local food;

Create public awareness about sustainable agriculture. Broaden the message of
healthy eating to include a food systems perspective and educate others about
eating in a way that is healthy and sustainable in counseling, presentations and in
general conversation.

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Where to Start
1) Be Informed
Learn more about the built environment and food systems and make it a continuing education
goal. Read the Key Resources listed on page 11 in this paper. Check out universities and
colleges for local or distance courses on food systems. Learn about national and local food
policies that affect the availability of healthy food in your community(s).
Optional Questions to Get Started

Reflect on the nature of your current work in relation to the evidence summarized
in this role paper and Key Resources. How does it relate? How is it unrelated?

What are the individual challenges to working with the built environment and food
systems? What skills or supports do you need? How can you attain those skills or
supports?

What are the organizational challenges to working with the built environment and
food systems? How can you overcome those challenges?
2) Build Partnerships with Key Players
Connect with others. Working in isolation will not improve the built environment or food systems.
Most success is seen when diverse, non-traditional partnerships and collaborations are formed
with various sectors of society, including businesses, various levels of government, school
board officials, rural municipalities, community associations, universities and community
groups.7, 20, 21

Identify and map the assets within your community and explore how you can work
together on shared goals.

Form, or participate on, a policy council or coalition.

Get involved in city and community planning.

Participate in national, provincial and local food and nutrition boards.

Identify community development and food advocacy organizations in your community.
Align the food issues you hope to address with their mission(s) and identify how you can
work together.

Connect with researchers or public health experts to ensure that food policies are
grounded in independent scientific and evidence based knowledge.

Talk with local universities or colleges to complete research and learn about other
research projects. Encourage evaluation of local initiatives that support healthy food
systems.
7
Optional Questions to Get Started

What key messages did the partnership take away from the evidence
summarized in this role paper and/or Key Resources? How can the evidence
guide or support the partnership’s action plan?

How can the partnership support a process to strengthen existing policies so
they are evidence based for the health of the population?

If no policy exists, how can the partnership assist with developing,
implementing, and evaluating the effectiveness of a policy that supports a
healthy built environment and food system?
3) Determine Where Partnerships Can Make an Impact
There are a number of ways to make a positive impact on the built environment and food
systems. Determining the best use of resources and time to implement action is based on a
number of factors including readiness for change, political climate, economic environment,
community needs and interests and the resources and interests of the partnership. Share
evidence based knowledge to help guide the partnership’s actions.
Optional Questions to Get Started

In relation to the built environment and food systems, what assets exist in your
community(s)? What gaps exist?

What organizations or partnerships exist in the community(s) that have a
shared vision, mission and goals and/or may benefit from a partnership with a
dietitian?

What policies exist that impact the built environment and food system? How
do they relate to the evidence summarized in this role paper and Key
Resources? When was it last reviewed? Who are the key stakeholders to
engage to review this existing policy?

If no policy exists, who are the key stakeholders to engage to identify if there is
a need for a policy that supports a healthy built environment and food system?
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Conclusion
Food systems determine food availability and how food choices are made.2 Healthy food
systems can promote access and availability to healthy food for all while supporting a healthy
built environment.
Dietitians have a role in helping all people have access to a healthy food system. Addressing
the built environment pushes beyond a traditional approach to healthy eating and nutrition. It
considers a more holistic approach to food and healthy eating that acknowledges external
factors that influence the food that we eat. Studies have shown that inactive lifestyles,
accessibility to healthy food, food infrastructure, and land use influence population health and
well-being.3-29
It is not sufficient to tell individuals to choose healthy foods; it is necessary to create and support
healthy environments that enable these healthy food choices.14 The knowledge and skills of
dietitians are valued and necessary as part of the movement towards creating a healthy food
system and a healthy built environment for generations to come.
The Public Health Nutritionists of Saskatchewan would like to thank the following
key contributors and reviewers for their efforts in developing this paper:
Key Contributors
Kaylee Michnik, Public Health Nutritionist, Regina Qu’Appelle Health Region
Tracy Sanden, Public Health Nutritionist, Regina Qu’Appelle Health Region
Melanie Warken, Public Health Nutritionist, Five Hills Health Region
Stacey Wiens, Public Health Nutritionist, Prairie North Health Region
Cassandra Touet, Public Health Nutritionist, Prairie North Health Region
Cathryn Abrametz, Public Health Nutritionist, Prince Albert Parkland Health Region
Key Reviewers
Leia M. Minaker, PhD, Scientist, Propel Centre for Population Health Impact
Rachel Engler-Stringer, PhD, Associate Professor, Department of Community Health and
Epidemiology, College of Medicine, University of Saskatchewan
Naomi Shanks, Public Health Nutrition Consultant, Ministry of Health
9
Glossary
Built Environment – the human-made surroundings that provide the setting for all human
activity, which include those places where people live, work, eat, learn, rest and play. These
spaces range from rural streets to bustling downtowns and all the places in between. 1
Civic Dietetics – an area of dietetics involving the promotion of a sustainable, just,
economically viable, community based food system.7
Community Food Infrastructure – a system of food facilities, programs, and social networks,
such as community kitchens or gardens, that aim to improve a person’s quality of life.
Food Desert – a geographic area, such as a community, where there is a lack of access to
affordable, nutritious food. This is largely due to a lack of grocery stores, farmers’ markets, and
healthy food providers.30
Food Environment – the food and beverage choices that are accessible to people while they
are in the places they live, work, eat, learn, and play. The product placement, pricing, marketing
and advertising of food and beverages all have a direct impact on food choices made in the
environment.8
Food Swamp – a geographic area, such as a community, that has better access to corner
stores and fast food outlets versus stores that sell healthier food options, such as a grocery
store or farmer’s market.31
Food Systems – all the processes in feeding a population; how food is grown, harvested,
processed, distributed, marketed, consumed and disposed of.
Sustainable Agriculture – the efficient production of safe, high quality agricultural products, in
a way that protects and improves the natural environment, the social and economic conditions
of farmers, their employees and local communities, and safeguards the health and welfare of all
farmed species. 6
Urban Agriculture – practice of growing, processing, and distributing food in a village, town, or
city.
10
Key Resources
a) Provincial Health Services Authority, BC. (2014). Healthy Built Environment Linkages: A
Toolkit for Design • Planning • Health.
Link: http://www.phsa.ca/Documents/linkagestoolkitrevisedoct16_2014_full.pdf
b) Northern Sydney Central Coast Health Promotion Service. (2009). UP4HEALTH urban
planning 4 health: A Guide for NSCC Population Health.
Link: www.upv.es/contenidos/CAMUNISO/info/U0559153.pdf.
c) NSW Department of Health. (2009). Healthy Urban Development Checklist: A guide for
health services when commenting on development policies, plans and proposals.
Link: http://www.health.nsw.gov.au/urbanhealth/Publications/healthy-urban-dev-check.pdf
d) Gladki Planning Associates in association with Du Toit Allsop Hillier. (2011). The Healthy
Development Index – Recommendations Report – Peel Health.
Link:
http://www.peelregion.ca/health/resources/healthbydesign/pdf/GPA_HDI_Recomendations_
Report_print.pdf.
e) Québec EN FORME. (2012). How the Built Environment Influences Young People’s Food
Choices.
Link: http://www.quebecenforme.org/media/103604/07_research_summary.pdf.
f)
Health Canada. (2013). Measuring the food environment in Canada.
Link: www.hc-sc.gc.ca/fn-an/nutrition/pol/index-eng.php
g) Mah, C.L., Minaker, L.M. (2015) Healthier food environments in city-regions: policy options
and evidence on health outcomes. Summary Report for the National Collaborating Centres
for Environmental Health.
Link: forthcoming.
11
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