Tuesday, 9 May 2017

Why are dietetic courses closing their doors?

This post was originally published on the WeDietitians Facebook page in April 2016

Hello Dietitian Friends,
I hear one of the "dietetics training courses" is closing its doors because the course is deemed "no longer viable". I note comments are headed toward blame of government for "not creating jobs" and/or "not financially making our profession viable".
I'll tackle the "closing of course" first, then "blame", however, the two are intricately related.
Right now today, the food we choose to eat accounts for as much of the burden of disease as tobacco, and, in the absence of effective strategies to change the way we choose, will likely surpass tobacco. This means "demand for a profession effective in halting and reversing this trend" is MASSIVE.
There is much to do, and I've argued previously "there is no better time to be a dietitian".
It seems unfathomable any university would consider ANY food-health professional training "not viable". In fact, the converse is true - a University who has not strategically placed itself to lead in food-health courses and specialities will likely struggle in the competitive environment of "knowledge".
I can hear the argument now though....graduate unemployment, cost to run the course, costs for placements and accreditation upkeep, recruitment and retention of staff.....sure, reasonable to interpret as "no longer viable" on a cost-benefit level. But what do all these [perceived] failures tell us? There is an alternate conclusion.
The course itself, the way we are training dietitians, does not match market demand. We are producing graduates whose expectations are far higher than the reality - they are ill equipped to "hit the ground running". Once in the market, there is a lack of mentors who have sustainable business models with transferable IP. We have little succession planning. We, the profession, have let this next generation down by [inadvertently] maintaining status quo. What I mean is, our profession is based on "historical reasoning" for the way we do things. We have not progressed. And we have not stayed "ahead of the market".
Given Australia's health statistics, it would be reasonable to conclude strategies to date to improve behaviours toward health have not worked. There is certainly economic evidence to demonstrate government spending has remained in the "its the fault of the individual" strategies (dietary guidelines, [ineffective] labelling, knowledge campaigns on what to eat etc).
Along the lines of economic modelling, the evidence there suggests the dietitian-GP partnership is potentially the most cost-effective, long term strategy to manage and reduce the burden of NCDs. The data used for those economic models came mostly from Australian studies - which, by themselves had little impact, but when you look at how HARD it is to get someone to change behaviour, the small gains today, lead to measurable change in the mid and long term.
To date, I do not believe we have exhausted our positions as solid partners by the side of GPs in improving health. I understand from Lauren Ball, and others' work, dietitians, in general, are not viewed as a high-value service by GPs. Is this the fault of government?
Why are dietitians not OUTRAGED?
Why are we not relentlessly writing, campaigning, bringing forth evidence of years of calls-to-action on strategies that "might" work?
Why are dietitians not OUTRAGED about our perpetuated culture of non-discussion on issues such as corporate sponsorship, [inflexible] training programs, systemic bullying, the [bloody] FOOD SUPPLY!!!!
I wrote yesterday in my thesis "we often wait for crisis point before we act; this thesis pre-empts that crisis point - to "be prepared" by understanding the gap between what we think we are doing and what we are actually doing; to document ways to build an evidence-base on HOW we "do dietetics"; what works, what doesn't..." I see this first "closing of doors" as evidence the "writing is on the wall".
Is this the fault of government? Should we be looking to government to "fix" this? Errr, no.
Dietitians have been afforded a sense of protection in being included in the public health insurance scheme - Medicare. We are afforded protection by our inclusion in allied health services across all public and private health sectors. It is possible this sense of protection has led us to "down tools" on self-critique, and serious discussions about our effectiveness. We are a grateful profession, sure, thats nice, but to progress, you need to SPEAK UP, and FIGHT HARDER in your own back yard first.
All of us have a role in this moment of "not viable". All dietitians.
There is much more to say.....however, as many of you are aware, speaking up is a risk - yes, that is me in the "limbo" area of APD land - and is a case in point in the "we've only ourselves to blame" argument. When we shut down discussion, we all lose.
Let's talk. Whenever you are ready.
PS Belinda Carpenter shares my space on the DAA website [ineligible area], however, we've not been able to locate or get in touch with her. If you know her, or have her details, PM/DM.
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Saturday, 11 March 2017

This Australian Paradox

This post discusses potential pitfalls in our translation of "research" to policy and practice.  We can give simple messages, but they need to reflect the context within which the analysis is framed.  Simple messages CAN accurately reflect context.  This post is specifically in response to:  ABC Lateline April 2016: Analysing the Australian Paradox: experts speak out about the role of sugar in our diets.  Available to view online at : http://www.abc.net.au/lateline/content/2015/s4442720.htm

The content of this post is in some way a warning, a friendly "heads up", that our profession, dietetics, does not want to enter a "post-truth" era, and how we can all contribute to keeping it real.  The other end of :post-truth" would naturally be "truth", however, we know there is no absolute truth in "what to eat to achieve health".  So in avoiding "post-truth" this does not imply we must achieve "truth".  What we can aspire to is maybe a "fluid-truth"...we should probably workshop that.  Look up post-truth for yourself too, from a number of sources, because I don't think it means what you think it means.  Inconceivable?  

The case of the "Australian Paradox" has polarised many, and I guess I leverage here what I have learnt from analysing the case, to repackage the learnings into what could be termed: a reminder of our individual and collective responsibility in how we present our research.   

Here, you should watch the ABC program.  Then come back over here.  No CPD points will be allotted.  Soz.
....At its most basic, based on the available evidence, one cannot claim Australia’s high rate of food-related disease IS because of soft drinks, but nor can one claim it IS NOT because of soft drinks.    

The more correct “conclusion” to be stated here is:

“Based on the available evidence on total sugar consumption, and sales of all sugar-sweetened beverages (SSB), it is reasonable to suggest processed foods with added sugar, including SSBs, are likely one of the highest contributors to discretionary intake in Australia.”….this last part itself has not been unequivocally established, and it is unclear across all work on the alleged “Australian Paradox” how far or how close this statement may be “true”.  As a simple message: we do not know which food is the sole cause of food-related disease.  We can say drinking soft drinks is not healthy.  

 Analysis using 2012 “household spending on food” (ABS 2012) reported Australian’s spend 7% of their total food-budget on “drinks” (trolley at-right).  

If we use the Australian Dietary Guidelines (ADG) as the benchmark of “what to eat to be healthy”, which is the purpose of the ADG, the recommended percentage of the food budget to “drinks” should be 0% (trolley at-left).  Note this analysis was completed too in 2012 before the 2013 ADG release (which had been scheduled for 2012). However, the 2013 release did not alter the “scientific evidence” illustrated.

The data presented here in these trolleys is “spend on food” which is different from “contribution of the food to actual intake”.  Given SSBs, and processed foods with added sugar, have the marketing power of price elasticity (which means, are able to “go on special” to “price drop” more frequently, and far more competitively compared with say, vegetables), the 7% spend on drinks could in fact translate to the highest single food-type to total sugar intake per family. 

On alcohol, Australians choose to spend 15% of their food budget on alcohol and the ADG would like to see 0% on alcohol.  As an aside, this statistics is not to be used as a “see alcohol is worse” because alcohol requires its own analyses and public health strategy, a different “public health menace” so-to-speak.

There are many ways to look at “the problem” of what is greatest contributor to food-related disease in the Australian food-supply.  Investigating “one genre of data” (eg total consumption of sugar) is one-part of understanding what is happening.  To draw conclusions based on the “single genre” data source is reasonable, but must be framed in the context of that “single input”.  Or, use a number of sources (triangulation) to build a more robust narrative of what is happening, why, and with what consequences.  Either way, to say with such compulsion “It is NOT soft drinks” and/or “sugar is NOT a problem in Australia” feeds directly into a parallel market (commercial enterprise) at the expense of “healthy people healthy nations”.  To give substance to “see there’s no problem” build a legacy that is very difficult to claw back, as we are currently experiencing in the Australian Paradox case. 

To make statements of what IS and what IS NOT a problem would require a level of evidence we simply do not have, at least retrospectively, that such statement as is/is not can be “unequivocally established”.  When we zoom-out, when we put on our public health lens, and think about the food-supply we want to create that IS compatible with health, it is fair to say, a food-supply with less dominance of SSBs and high-sugar packaged foods on our supermarket shelves, has got to be more compatible with achieving "healthy people, healthy nations".

This is where we can set an objective, and work backward from there.  For example, current spend on SSB is 7% we want to get that down to 2% by 2020?  How are we going to do that? 

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