This short essay stems from the authors' perceived need to review and update certain aspects of the current code of ethics for Portuguese nutritionists, taking into account the emergence of new premises in the food industry that may affect our professional decisions. In a previous essay , we already addressed some of these issues, namely the funding of higher education institutions and their research, or conflicts of interest. In this second text, we will delve deeper into other areas. Specifically, the issues of "Food Ethics," which introduces the growing importance of considering the impact of food production and consumption on the health of the planet. This concept may include the proper treatment of animals for human consumption, the simultaneous protection of human and planetary health in light of climate change, and the fair treatment of food producers. Living conditions on our planet are changing for the worse, and the speed of change has increased significantly in the last decade. Nutritionists, through their professional practices, can be a powerful force in ensuring that food consumption is aligned with this ethical imperative.
On the other hand, the proximity between the agri-food system and nutritionists has increased and become more visible in recent years. This growing influence of systems, practices, and processes through which commercial agents can affect (for better or for worse) health and equity could be called "commercial determinants of health ." In the food sector, this commercial relationship is increasingly intense and frequent and deserves special reflection from professionals working in the field. The increased complexity of the food system and the need for dialogue with a growing number of actors outside the health system and with different commercial interests at stake, requires ethical reflection on the part of nutritionists, to which we hope to contribute in advance.
Regulation No. 587, published in 2016, which approved the Code of Ethics of the Order of Nutritionists, draws "the attention of nutritionists to the need for an ongoing discussion of ethical issues, which is not exhausted by the Code. In this sense, any code of values is always an incomplete document and in constant improvement." We hereby contribute to this ongoing discussion. Furthermore, ethics as an area of research and reflection within the teaching of nutritional sciences in Portugal is still limited, being a subject scarcely addressed during undergraduate training. We hope that with this document we can contribute to a broader discussion of these topics from an early stage.
The past – The foundations for the construction of the Code of Ethics for Portuguese Nutritionists
The profession of Nutritionist is almost 50 years old in Portugal, having begun with the Bachelor's Degree in Nutrition at the University of Porto through Decree No. 46 on May 31, 1976. Initially, it aimed to "prepare technicians capable of carrying out tasks of guidance and monitoring of rational, normal and dietary nutrition for the general population and in institutions, as a basic factor in promoting health and preventing disease." However, the regulation of the profession in the health field began in 1990, with the integration of graduates in Nutrition Sciences into the career of Senior Health Technician, created in 1981, which included the branch of nutrition. However, it was only years later, in 2004, that the discussion began about the need for this new profession in the health field to have a written code of ethical principles.
The work on creating the first Code of Ethics for Nutritionists in Portugal dates back to 2004. That year, the new Code of Ethics for Brazilian Nutritionists by the Federal Council of Nutritionists, reflecting the growth and diversification of the professional fields of nutritionists in Brazil. Simultaneously, Canadian nutritionists published several documents on best practices, notably the "Professional Standards for Dietitians in Canada," which stimulated discussion around this topic. The New Zealand model of the Code of Ethics , published in 2003, was also of great importance; its simplicity and comprehensiveness served as a structural reference in these early stages of gathering and analyzing the still limited existing legislation on this subject.
In 2004, the Ethics and Professional Conduct Committee was created within the Portuguese Association of Nutritionists (APN). In 2006, this association created a working group, composed of nutritionists, bioethics specialists, and legal experts, to further explore the topic. On July 16, 2007, at the VII National Meeting of Nutritionists in Peniche, a first draft for public discussion entitled "Code of Ethics for Nutritionists" was presented, with the additional contribution of two specialists – Manuel Faria and Miguel Ricou. This first presentation outlined the desired knowledge and skills profile for nutritionists, as well as objectives associated with the existence of a Code of Ethics. Several areas of discussion were defined, such as "Standards of Good Practice," "Personal Development," and "Lifelong Learning." At the time, it was understood that the Code of Ethics should present "a set of expected behaviors in diverse circumstances, enabling prior reflection for judgment and distinction between right and wrong" and that "These norms should reflect a set of values shared by the community and by these professionals, helping to build a certain public credibility in the profession." These foundations remain in place today, as well as some case studies presented that were based on the "ADA/CDR Code of Ethics for the Profession of Nutrition." Dietetics – Trainer's Guide from 2007.
Starting with the VII National Meeting of Nutritionists, on July 16, 2007, a schedule of work was conceived to produce the first guiding principles for professional ethics in the field of Nutritional Sciences in Portugal. Methodologically, it is proposed to: a) Enumerate the most frequent issues where ethical conflicts may exist in the profession; b) propose general principles that, when applied, can resolve these issues; c) to approve principles and establish a continuous improvement process.” To achieve these objectives, a survey was created targeting the profession. Between July 31, 2007, the APN sent emails to all members requesting that they complete the online survey between July and December 2007. The questions addressed attempted to assess the importance of having a Code of Ethics for members and the areas considered most important, as well as the professional characteristics of the respondents. Of the 185 respondents, 97.8% considered the existence of a Code of Ethics important or very important, and the issues that should be included in the formulation of the Code were, according to the colleagues who responded: Professional updating and performance; Commercial practices; Relationships with other professionals; Relationships with employers; and Advertising and communication.
On March 1, 2008, the Ethics and Professional Conduct Committee and the APN Board met and analyzed the results of the survey, defining the main points to be included in the future Code of Ethics. At this stage, the following main areas were considered for the initial construction of the document: Relationships with colleagues; the provision of services; and social and legal responsibilities, which will be further divided in the final document.
Between March and May 2008, a first draft of the Code of Ethics was produced, which was analyzed by jurists and bioethics specialists, and some areas were subsequently refined. For example, according to the jurists consulted, “…the word “Code” presupposes a set of systematized laws that cover a wide spectrum of decisions and that must be well-founded and structured. Given the existence of a general and tentative framework, this should be designated as “Rules of conduct imposed by the exercise of the profession”. Even more so when the Association does not have the legal power to enforce it in case of infractions.” These suggestions will be taken into account in the production of the final document. On July 9, 2008, the proposed Code of Ethics was sent to APN members by email, and a month was given for consultation and suggestions from members. Very few suggestions were received, and the process was finalized. In October 2008, the final document was published. This document will formally organize the initial guiding principles of Ethics and Professional Conduct for nutritionists in Portugal until 2012.
The present – The Code of Ethics of the Order of Nutritionists
The Board of Directors of the Order of Nutritionists took office on April 28, 2012, and is statutorily obligated to present a draft Code of Ethics and have it approved by the General Council within six months of taking office. Based on these assumptions, work will begin on the drafting of the first Code of Ethics for the Order of Nutritionists, the initial proposal of which will be presented by the newly created Jurisdictional Council to the General Council for approval.
The initial proposal for the Code of Ethics for Portuguese nutritionists will be based on the document "Guiding Principles for the Professional Ethics of Nutritionists" published by the APN in 2008, adding other specific provisions for dietitians that were not covered by those "Guiding Principles".
The Code of Ethics of the Order of Nutritionists will encompass the ethical values and principles that typically guide the performance of professionals in the health field and reflect a solid foundation of ethics and professional conduct for professionals registered with the Order, emphasizing the general principles of autonomy, non-maleficence, beneficence, and justice.
The document outlines the commitments of nutritionists and dietitians to their clients, colleagues, and society in general, contributing to building and consolidating the profession's public credibility. It also presents a set of expected behaviors in various circumstances and allows for proactive reflection, judgment, and the distinction between right and wrong.
The model will be based on the Codes of Ethics for Nutritionists in Canada, New Zealand, and Brazil, and on general bioethical issues present in the Codes of Ethics of Portuguese Professional Orders in the health field. Based on this foundation, an initial proposal will be presented, which will then be legally validated and put out for public consultation.
The Code of Ethics of the Order of Nutritionists was published in 2012 through Regulation No. 511/2012 and incorporates the ethical values and principles considered most relevant to the profession, the (general) principles of autonomy, beneficence, non-maleficence and justice, as well as aspects of honesty, integrity and duties of privacy and confidentiality, applying essentially to relationships with clients, colleagues, other professionals and employers.
The conceptual framework of this Code, like others in the health field, focuses on the relationship between the user and the professional, safeguarding the individual (in their personal and social dimensions) and the profession with regard to professional ethics, that is, the obligations, responsibilities, and rights that govern the practice of the profession. However, it is a common understanding that professional practice should not be decontextualized from emerging ethical considerations and that Codes of Ethics should update these concerns in their statements and actions.
In this essay, we argue that issues such as "Food Ethics" or "Ethical Food Consumption" deserve greater attention from nutritionists, as these are topics that are not yet sufficiently reflected upon and developed in the current Code of Ethics for Portuguese Nutritionists, which is based on the biomedical model, similar to other professions in the health field. We intend to launch this discussion and promote reflection on the need to incorporate these topics into future updates of the ethical principles that govern our professional conduct.
The future – Some emerging ethical issues in the professional practice of nutritionists
Food Ethics
Over the last few decades, several activist movements have questioned the globalization of food markets, taking into account values of social justice or environmental sustainability, which are overarching objectives of food ethics. The systemic nature of this global market was vaguely conceptualized (1) by the conglomerate of large international companies responsible for agricultural production factors (seeds, pesticides, etc.) and for the concentration of control over the production, processing, trade, and distribution of food. A more detailed characterization would also include the policies of national and local governments, as well as international organizations that regulate global trade. In the middle would be small farmers, often seen as victims of this system, and also consumers with low levels of food and nutritional literacy and low purchasing power.
These relatively inorganic movements were somehow associated with the emergence of concepts and norms that attempted to counter global hegemonies, such as the concept of “organic food” or “fair trade”. The labeling that accompanied them made these norms effective instruments of transformative change, requiring record keeping and inspection of production practices by third parties to ensure that the specific requirements of the norm were, in fact, met, and were initially developed by non-governmental organizations (NGOs) operating internationally (2).
Despite these attempts to characterize the food chain, only in the last 10-15 years have more developed and interconnected theoretical models emerged to explain the increasing complexity of these relationships. The concept of "food system" is beginning to gain traction to more adequately explain the complexity of structures and actions affecting the global food circuit and the shift in the balance of food systems in recent decades – which have moved from "local systems" with short food chains and minimally processed foods delivered to local markets or consumed by producing households to "global systems" with multiple actors, processes, and circuits. This complex network of activities involves food production, processing, transport, and consumption, and includes the governance and economics of food production, its sustainability, the degree of food waste, how food production affects the environment, and the impact of food on individual and population health. Recently, this vision was embraced by the European Commission in its proposal for a legislative framework for sustainable food systems, one of the flagship initiatives of the Farm to Fork Strategy.
In the area of health and nutrition, it is expected that a better understanding of this intricate set of interrelationships will allow for more successful intervention in the factors that are intensely conditioning the health of populations (in addition to population growth combined with climate change) in order to curb the accelerated growth of obesity and diet-related diseases as well as malnutrition.
The repositioning of food systems, moving beyond the mere supply of food to include concerns about the nutritional value of food, its environmental impact throughout the entire chain, from production to consumption, and the social sustainability of production models, requires comprehensive policy initiatives that go far beyond agriculture and national policies. At this level, the United Nations (UN) will hold its 28th Conference of the Parties – better known as COP – on climate change in 2023, where the impact of the food system will be one of the central themes. The health of citizens, but also the health of the planet and other social, cultural, and economic aspects related to models of food production, processing, storage, transport, and waste raise new ethical questions that will affect the practices of professionals working in these areas.
Ultimately, issues such as the adequacy of ancestral and culturally rooted food practices in the face of new environmental challenges, or the cost of food and the distribution of wealth generated to those who produce it, take on new roles in light of a more transparent food system and also need to be discussed more thoroughly. Until now, there has been the idea that ancestral food models, such as the Mediterranean food pattern or Mediterranean Diet (perhaps the most studied), are capable of balancing the use of existing natural resources in a given geographical area, environmental protection, gastronomic culture, and the health of populations. However, with the acceleration of climate change, new challenges will be posed to this view, and it may be necessary to alter access to certain foods, innovate the traditional way of producing them, or introduce new food combinations into daily life, among other aspects.
Environmental damage caused by production, processing, preservation, or transportation processes may, in certain food products, be incompatible with optimal nutritional choices, potentially creating new and growing ethical dilemmas between nutritional value and environmental protection. If foods are required to use an Ecological Footprint Labeling system, with mandatory stamping, as is already done for nutritional composition, this issue will become even more delicate for our profession.
Currently, there is a heated debate about the future of environmental labeling in the European food industry. The European Union plans to implement legislation to reduce the number of labels available on the market and harmonize them, considering the discrepancy between environmental impact classifications in existing systems. In this regard, a Proposal for a Directive of the European Parliament and of the Council on the substantiation and communication of explicit environmental claims (Eco-claims Directive) was published on March 22, 2023. The WHO/Europe intends to launch a new tool in November 2023 to help policymakers and health professionals conduct Dietary Impact Assessments (DIAs), reconciling population health objectives with environmental sustainability and accessibility. If we add to this the need to value local food cultures and the retention of populations in the territories where food is produced, the level of complexity will increase, as many agricultural practices and traditionally produced food products certainly do not meet the nutritional and environmental targets we would like to achieve today.
Environmental issues will play an increasingly important role in discussions about which foods to choose. But so will simple questions such as who produces the food, under what social and economic conditions it is produced, or even how we treat the animals we consume. “Food ethics” or “ethical food consumption,” defined as “the principles that dictate what should be understood as acceptable treatment of others (human beings, other animals, or the planet) in relation to food,” should prompt reflection within our profession, as these issues may pose obstacles to the current practice of nutritionists, their discourse, and their ethical values.
The commercial determinants of food
From the outset of the drafting of the Code of Ethics for Portuguese nutritionists, the issue of independence, namely the non-compromise of standards of good professional practice with commercial objectives or potential conflicts of interest in situations of commercial relationships, has been considered. We returned to this subject, given the WHO in resuming this debate, and in 2019 in Pensar Nutrição we argued for "the need to identify potential areas where the actions of professionals may be influenced by commercial or other relationships with those who hold economic power, and in these cases, the public disclosure of this relationship is a fundamental step in resolving the conflict, although not sufficient in some cases. For example, when nutritionists hold positions of responsibility that allow them to make decisions that may benefit one of the parties." However, this identification of areas of conflict of interest and their disclosure may not be sufficient.
Recently, the concept of Commercial Determinants of Health (CDoH) has gained renewed public attention. In March 2023, the World Health Organization highlighted the urgency of a global response to address CDoH, and the upcoming WHO Global Report on Commercial Determinants of Health, to be published in 2024, demonstrates this organization's commitment to this issue.
According to the WHO , the commercial determinants of health are the activities of the private sector that have a positive or negative impact on public health, as well as the political and economic systems and norms that enable them. That is, they include all products and services provided by private entities with the aim of obtaining financial profits, as well as market strategies, working conditions, production externalities, and strategic activities with commercial objectives such as disinformation, lobbying, or donations. Some entities and companies also use instrumental, structural, and communicational power to influence public health policies that may threaten their profits. Simultaneously, the private sector is an indispensable partner in the development of vaccines, medicines, and healthcare products, in financing, infrastructure construction, and the provision of health services, contributing to universal health coverage, and in contributing to food security, particularly through innovation and the development of new foods.
In this sense, and according to the WHO, Member States should strive to take advantage of these opportunities for synergy with the private sector, while simultaneously protecting populations from any harm and working together to achieve health for all. It is important not to demonize or create simplistic antagonisms between the private and public sectors, but rather to identify, prevent, and reduce the risks of bad business practices perpetrated by some that can negatively affect the health of populations. To this end, it is necessary to identify and acknowledge that conflicts of interest sometimes exist, and that regulatory, legal, and economic reforms are needed in governance models and policies in these critical areas, including food.
In this utopia, the ideal would be to create societies where public and private actors prioritize environmental sustainability, human rights, basic needs, health, and well-being instead of encouraging consumption patterns that can be harmful to the environment and human health. And public policies should contribute to these objectives, free from commercial interference that could undermine them.
Although there is consensus on these general principles, in practice , the influence of actors with commercial interests is increasingly exerted on investment, production, marketing, and even employment, and on the construction of ideals that shape narratives, norms, and ideologies in the health field and beyond. Currently, there is evidence that these forms of influence are frequently used in the areas of tobacco, soft drinks, alcohol, palm oil, sugar, gambling, fossil fuels, and social media, resulting in restrictions on public health interventions.
According to Tedros Ghebreyesus , Director-General of the WHO, monitoring exposure to these commercial practices should be a central component of national public health surveillance networks and part of global governance efforts for health protection and promotion. The food system that influences food consumption, and where nutritionists work, is heavily determined by commercial interests that can negatively affect the health of populations.
What can be done?
Recently, some authors have considered it desirable to intervene in specific areas to reduce the risk of negative exposure to certain commercial practices in healthcare – in international organizations and governments (for example, establishing clear rules in public-private partnerships and recognizing conflicts of interest); in research and research funding (for example, developing special attention to negative externalities in academic curricula or improving funding for research conducted by public institutions); in the commercial sector (for example, improving regulatory and surveillance systems for negative externalities); and in civil society, for example, by mobilizing independent organizations and healthcare professionals to address the need to prevent these behaviors.
Commercial determinants of health have a significant impact on food choices and public health. Nutritionists need to be aware of these factors and consider them in their practice to promote healthy food choices, identify inappropriate commercial practices, advocate for effective public health policies, and provide evidence-based nutritional guidance
Intervention in these areas, which is very recent, has used three distinct strategies to reduce risk. Research is one of the most common approaches among academics and researchers, aiming to identify the problem and increase knowledge about this phenomenon, which is still unknown to many, highlighting the frequency of these situations and the severity of their effects on health. The second risk reduction strategy uses punishment when an illegal act is detected. However, most actions to influence, condition, and alter positions regarding health and nutrition take place in a grey area where unethical actions are more common than illegal ones. And where there is still some inability to legally define a large set of actions. Here, the fear of punishment is the main deterrent, but for the reasons mentioned, it is still underutilized. The third strategy, called regulatory, makes organizations and their managers co-responsible for preventing and controlling actions that may negatively affect people's health. However, the regulatory approach can be counterproductive, since it gives the impression that, as long as laws and regulations are followed, it is possible to adopt ethical behavior and that anything not prohibited by law is permissible.
Faced with these difficulties, and without neglecting the previous proposals that can be worked on simultaneously, we advocate an additional strategy: integrating the discussion of food ethics and the commercial determinants of food into the ethical principles of our profession. This involves abandoning the idea that people only do what they should when forced to, and encouraging a debate about what is right. It also involves the premise that people are capable of doing what they should because they clearly believe they are doing what is right. We consider it important to introduce these themes into the "case studies" associated with the ethical training of nutritionists and possibly into their Code of Ethics. Specifically, it is necessary to develop the capacity to assess problems in this area, " the ethical implications of decisions , the weighing of alternatives and their impacts on partners, the environment and society in general, and to solve the ethical dilemmas that frequently arise for decision-makers."
As healthcare professionals, nutritionists have an ethical responsibility to prioritize the well-being of the population. This includes providing nutritional guidance that promotes health and is not influenced by other interests, particularly commercial interests. Therefore, knowledge of how commercial practices can negatively influence food choices is an increasingly necessary skill. At the same time, nutritionists must play a critical role in advocating for the use of science to support public health policies and oppose third-party efforts to manipulate or distort science for their own interests. Another dimension to consider is health inequality. The recurring and intense promotion of less healthy products disproportionately affects more vulnerable communities. Nutritionists must be aware of these disparities and work to mitigate their impact by promoting healthy and accessible food choices
“The development of critical moral intelligence is an ongoing process that can be accelerated through reflection, training, debate of ideas, and case analysis.” By providing critical reflection on these issues, nutritionists will be better able to define or improve their own standards, appreciate alternative approaches to identifying and resolving ethical problems, and develop their own skills to deal with complex issues.
In conclusion, the revision of the Code of Ethics for Portuguese Nutritionists is a necessity in light of the significant changes in the food and public health landscape. The growing importance of "Food Ethics" and the "Commercial Determinants of Health" demands that nutritionists be prepared to face complex ethical challenges in their professional practice. This implies recognizing and addressing the impact of inappropriate commercial practices on public health, promoting ethical and accessible food choices, and advocating for effective public health policies. Furthermore, professional associations, such as the Order of Nutritionists, play a fundamental role in promoting updated ethical guidelines, continuing education for professionals, and collaborating with other stakeholders to promote ethical practices in the field of nutrition. This holistic approach is essential to ensure that nutritionists play an effective role in protecting public health and promoting food choices that benefit both people and the planet.
Understanding how the power dynamics work, the existing formats for rebalancing these powers, and the strength that independent actors (nutritionists) can have in this equation could make all the difference. These intervention models could position our profession and its members as leading professionals for society, which could mean a great gain for everyone.
This is a current discussion, and one that we believe is necessary within our professional field.
Abstract
This short essay is based on the need, felt by the authors, to review and update some aspects of the current Code of ethics for Portuguese nutritionists, taking into account the emergence of new premises in the food reality that can affect our professional decisions. In a previous essay, we addressed some of these issues, including the funding of higher education institutions and their research and conflicts of interest. In this second text, we will explore other areas in greater depth. Namely, the issues of “Food Ethics”, which introduces the growing importance of considering the impact of food production and consumption on the health of the planet, which can include the proper treatment of animals for human consumption, the simultaneous protection of the health of people and the planet, taking into account climate change, or the fair treatment of food producers. Living conditions on our planet are changing for the worse and the speed of change has increased greatly in the last decade. Nutritionists, through their professional practices, can be a powerful force in bringing food consumption into line with this ethical imperative.
On the other hand, the proximity between the agri-food system and nutritionists has increased and become more visible in recent years. This growing influence of systems, practices and processes through which commercial agents can affect (for better or worse) health and equity can be called “commercial determinants of health”. In the food sector, this commercial relationship is increasingly intense and regular and should merit special reflection by professionals working in the field. The increased complexity of the food system and the need for dialogue with a growing number of actors outside the health system, with different commercial interests at stake, requires ethical reflection on the part of nutritionists, to which we must be able to contribute in advance.
Regulation no. 587 published in 2016, which approved the Code of Ethics of the Order of Nutritionists, draws “nutritionists' attention to the need for a continuous discussion of ethical issues, which is not exhausted by the Code. In this sense, any code of values is always an incomplete document that is constantly being improved”. Here we make a contribution to this ongoing discussion. We hope that with this document we can contribute to a wider discussion of these issues from an early stage.
- Sandler, R. 2015. Food ethics: the basics. New York: Routledge.
- Belasco, W. 2007. Appetite for change: how the counterculture took on the food industry, 2nd ed. Ithaca: Cornell U. Press.
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
