uma reflexão crítica à Nutrição pela FCNAUP

This short essay is based on the authors’ perceived need to review and update some aspects of the current Code of ethics for Portuguese nutritionists, considering the emergence of new assumptions in the food reality that can affect our professional decisions.

In a previous essay, we had already addressed some of these issues, namely the funding of higher education institutions and their research or the conflict of interest. In this second text, we will delve into other areas. 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 because of 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 dramatically in the last decade. Through their professional practices, nutritionists can be a powerful force in ensuring that food consumption is in tune 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 becoming increasingly intense and frequent and should be given special consideration by professionals working there. The increasing 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, calls for ethical reflection on the part of nutritionists, to which we hope to be able to contribute in advance.

The 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 a continuous discussion of ethical issues, which does not end with the Code. In this sense, any code of values is always an incomplete and constantly improving the document.” Here, we contribute to this ongoing discussion. We hope that with this document, we can contribute to a broader discussion of these issues 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 started with a Bachelor’s Degree in Nutrition at Porto University through Order no. 46 on 31 May 1976. It was initially intended to “prepare technicians capable of carrying out tasks to guide and monitor the rational, normal and dietary nutrition of the population in general and in institutions, as a basic factor in health promotion and disease prevention. “Meanwhile, regulation of the health profession began in 1990, with graduates in Nutrition Sciences being integrated into the career of Senior Health Technician, created in 1981, and the nutrition branch being included. Only years later, in 2004, discussions began about the need for this new health profession to have a written code of ethical principles.

Work began on the creation of the first Code of Ethics for Nutritionists in Portugal in 2004. That year saw the publication of the new Code of Ethics for Brazilian Nutritionists by the Federal Council of Nutritionists, which reflected the growth and diversification of nutritionists’ fields of professional activity in Brazil. At the same time, Canadian nutritionists were publishing various documents on good practice, namely “Professional Standards For Dietitians In Canada “, which stimulated discussion on this issue. Also of great importance was the New Zealand model Code of Ethics, published in 2003, which for its simplicity and comprehensiveness was a structural reference in these early days of collecting and analysing the still little existing legislation on this subject.

In 2004, the Ethics and Professional Deontology Committee was set up at the Portuguese Association of Nutritionists (APN). In 2006, the association set up a working group of nutritionists, bioethics experts and legal experts to study the issue in greater depth. On 16 July 2007, at the VII National Meeting of Nutritionists in Peniche, a first draft was presented for public discussion entitled “Nutritionist’s Code of Ethics with the additional contribution of two specialists – Manuel Faria and Miguel Ricou. This first presentation outlined the desired profile of knowledge and skills for nutritionists, as well as the objectives associated with the existence of a Code of Ethics. Some areas for discussion were outlined, such as “Standards of Good Practice,” “Personal Development” and “Lifelong Learning.” At the time, it was felt that the Code of Ethics should present “a set of expected behaviours in different circumstances, enabling early reflection in order to judge and distinguish right from wrong” and that “These standards should reflect a set of values shared by the community and by these professionals, helping to build a certain public credibility in the profession”. Bases that still stand today and some case studies presented were based on the “ADA/CDR Code of Ethics for the Profession of Dietetics -Trainer’s Guide” of 2007.

Starting with the VII National Meeting of Nutritionists, on 16 July 2007, a timetable was devised for work leading to the production of the first guiding principles for professional ethics in the area of Nutrition Sciences in Portugal. Methodologically, it is proposed to

• list the most frequent issues where ethical conflicts may exist in the profession;
• propose general principles that, when applied, can resolve these issues;
• approve the principles and establish a continuous process of improvement”.

In order to achieve these objectives, a survey was set up aimed at the profession. Between 31 July 2007, the APN emailed all members asking them to fill in the online survey between July and December 2007. The questions asked sought to assess the importance of the existence of a Code of Ethics for members, the areas that were considered most important to consider, and the professional characterisation of the respondents. Of the 185 respondents, 97.8 percent considered the existence of a Code of Ethics to be 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; relations with other professionals; relations with employers and publicity and communication.

On 1 March 2008, the Ethics and Professional Deontology Committee and the APN Board met and analysed 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.

A first draft of the Code of Ethics was produced between March and May 2008, which legal experts and bioethics specialists analysed, and then some areas were refined. For example, the lawyers consulted said, “…the word ‘Code’ presupposes a set of systematised laws that cover a wide range of decisions and must be well-founded and structured. Since this was a generalised and tentative framework, it should be called “Rules of conduct imposed by the exercise of the profession.” All the more so when the Association has no legal power to enforce it in the event of infringements.” These suggestions will be taken into account when the final document is produced.

On 9 July 2008, the draft Code of Ethics was sent to APN members by email and members were given a month to consult and make suggestions. Very few suggestions were received and the process was finalised. The final document was published in October 2008. This will be the document that will formally organise the first guiding principles of Ethics and Professional Deontology for nutritionists in Portugal until 2012.

The present – The Code of Ethics of the Order of Nutritionists

The Board of the Order of Nutritionists took office on 28 April 2012 and is statutorily obliged to present a draft Code of Ethics and have it approved by the General Council by the end of its sixth month in office. It was on this basis that work began on drawing up the first Code of Ethics for the Order of Nutritionists, the initial proposal for 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, with the addition of other provisions specific to dietitians that were not included in those “Guiding Principles”.

The Code of Ethics of the Order of Nutritionists will encompass the ethical values and principles that usually guide the performance of health professionals and reflect a solid basis of ethics and deontology for professionals registered with the Order, emphasising the general principles of autonomy, non-maleficence, beneficence and justice.

The document presents the nutritionist’s and dietitian’s commitments to clients, colleagues and society in general, which contribute to building and consolidating the profession’s public credibility. The document also presents a set of expected behaviours in different circumstances and enables early reflection on judgement 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 the general bioethical issues present in the Codes of Ethics of the Portuguese Professional Orders in the area of health. On this basis, 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 511/2012 and incorporates the values and ethical 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, essentially applying to relations with clients, colleagues, other professionals and employers.

The conceptual framework of this Code, like others in the health area, focuses on the relationship between the user and the professional, looking after the person (in their personal and social dimension) and the profession in terms of professional deontology, i.e. the obligations, responsibilities and rights that regulate the exercise of the profession. However, it is a common understanding that professional practice should not be decontextualised from emerging ethical considerations and that Codes of Ethics should update these concerns in their wording and actions.

In this essay, we argue that issues such as “Food Ethics” or “Ethical Food Consumption” should be given greater attention by nutritionists, as they are topics that are not yet sufficiently reflected and developed in the current Code of Ethics for Portuguese Nutritionists, which is based on the biomedical model, like other health professions. We intend to launch this discussion and promote reflection on the need to incorporate these issues into future updates of the ethical principles that govern our professional conduct.

Curiously, one of the objectives we are now considering was already addressed in the speech given by the President of the ON’s Jurisdictional Council in 2012, which we quote – “But beyond ethical issues, our profession cannot be far removed from the great ethical issues that should distinguish us as Nutrition and Food specialists, bridging the gap between food production and consumption. Food (I’m talking here about the production, transport and consumption of food) is probably the human activity on the face of the earth that most influences life on the planet. The way we eat, the way we choose our food, is the biggest determinant of water consumption and one of the main, if not the main, contributor to carbon emissions into the atmosphere. The choice of food, as well as decisively influencing our health, has extraordinary impacts on life on our planet, its biodiversity and what we want to leave our children. This is one ethical challenge, among many, that we must embrace today.” Despite this warning and the interest in having this discussion, to this day this reflection has not been taken up again, nor has it had any effect on the changes that have been made to the Code of Ethics in the meantime.

The future – Some emerging ethical issues in the professional practice of nutritionists
Food Ethics

Over the last few decades, several activist movements have challenged the globalisation 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 conceptualised (andler, R. 2015. Food ethics: the basics. New York: Routledge.) by the conglomeration of large international companies responsible for agricultural production factors (seeds, pesticides…) and the concentration of control over food production, processing, trade and distribution. A more detailed characterisation would also include the policies of national and local governments, as well as the international organisations that regulate global trade. In between would be small farmers, often seen as victims of this system, as well as 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 standards that tried to counter global hegemonies, such as the concept of “organically produced food” or “fair trade”. The labelling that accompanied them made these standards effective instruments of transformative change, requiring record-keeping and third party inspection of production practices to ensure that the specific requirements of the standard were in fact met, and were initially developed by non-governmental organisations (NGOs) operating at international level.

Despite these attempts to characterise the food chain, it is only in the last 10-15 years that more developed and interconnected theoretical models have emerged to explain the growing complexity of these relationships. The concept of “food system” is beginning to take hold in order to more adequately explain the complexity of structures and actions that affect the global food circuit and the change in the balance of food systems in recent decades – which have gone from “local systems” with short food chains and minimally processed food delivered to local markets or consumed by producer families 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 complex and networked vision was taken up by the European Commission in the proposal for a legislative framework for sustainable food systems, which is one of the flagship initiatives of the Farm to Fork Strategy.

In the area of health and nutrition, it is hoped that a better understanding of this intricate set of interrelationships will make it possible to intervene more successfully in the factors that are intensely conditioning the health of populations (in addition to demographic growth combined with climate change) in order to halt the accelerated growth of obesity and food-related diseases, as well as malnutrition.

The repositioning of food systems, which is no longer limited to the supply of food but includes concerns about the nutritional value of food, its environmental impact throughout the chain from production to consumption and the social sustainability of production models, requires comprehensive political initiatives that go far beyond agriculture and national policies. At this level, in 2023 the United Nations Organisation (UN) will hold its 28th Conference of the Parties – better known as COP – on climate change, where the impact of the food system will be one of the central themes. The health of the citizen, but also the health of the planet and other social, cultural and economic aspects related to the models of production, processing, storage, transport and food waste raise new questions, which are ethical questions, and which will affect the practices of the professionals who carry out their work in these areas.

Ultimately, issues such as the suitability of ancestral and culturally-rooted food practices in the face of new environmental challenges, or the cost of food and distribution of the wealth generated to those who produce it, take on new roles in the light of a more transparent food system and also need to be discussed more. 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 natural resources in a given geographical space, environmental protection, gastronomic culture and the health of populations. However, with the acceleration of climate change, new challenges will be posed to this vision, and it may be necessary to change access to certain foods, innovate the traditional format of production or introduce new food combinations into everyday life, among other aspects.

The environmental damage caused by production, processing, conservation or transport processes may not be compatible with the best nutritional choices for certain food products, and could create new and growing ethical dilemmas between nutritional value and environmental protection. If foodstuffs are obliged to use a Footprint Labelling System, with a compulsory stamp, as is already done for the nutritional composition of foodstuffs, this issue will be even more sensitive for our profession.

There is a heated discussion about the future of environmental labelling in the European food industry. The European Union plans to implement legislation to reduce the number of labels available on the market and harmonise them, considering the discrepancy between environmental impact classifications in existing systems. To this end, a Proposal for a European Parliament and Council Directive on the substantiation and communication of explicit environmental claims (Green Claims Directive) was published on 22 March 2023. Also, WHO/Europe intends to launch a new tool in November 2023 to help policy makers and health professionals carry out Food Standards Impact Assessments (FSAs), reconciling population health objectives with environmental sustainability and accessibility.

Suppose we add to this the need to value local food cultures and the settlement of populations in the territories where the food is produced. In that case, the level of complexity will increase, as many agricultural practices and traditionally produced food products certainly do not fulfil the nutritional and environmental goals we would like to achieve today. Environmental issues will play an increasingly important role in the discussion about which foods to choose. But also simple questions such as who produces the food, under what social and economic conditions it is made or 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 give rise to reflection on the part of our profession, as these issues could pose obstacles to the current practice of nutritionists, their discourse and their ethical values.

The commercial determinants of food

Since the beginning of the construction 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 possible conflicts of interest in commercial relationship situations, has been considered. We returned to this subject concerning WHO‘s interest in resuming this debate. In 2019 at “Pensar Nutrição” we argued “the need to identify potential areas where the work of professionals may be influenced by commercial or other relationships with those who hold economic power, and in these cases publicising this relationship is a fundamental step towards resolving the conflict, although not sufficient in some cases. For example, when nutritionists hold positions of responsibility that allow them to make decisions that could benefit one of the parties.” However, identifying areas of conflict of interest and publicising them may not be enough.

Recently, the concept of Commercial Determinants of Health (CDoH) has gained renewed public attention. In March 2023, the World Health Organisation highlighted the urgency of a global response to address CDoH and the next WHO Global Report on the Commercial Determinants of Health, which will be published in 2024, demonstrates the organisation’s commitment to this issue.

According to 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. In other words, they include all the products and services provided by private entities to make a financial profit, as well as market strategies, working conditions, production externalities and strategic activities with commercial objectives such as disinformation, lobbying or donations. Some organisations and companies also use instrumental, structural and communicational power to influence public health policies that could threaten their profits. At the same time, the private sector is an indispensable partner in the development of vaccines, medicines and health care products, in the financing, construction of infrastructure and provision of health services, contributing to universal health coverage and being able to contribute to achieving food safety, mainly through innovation and the development of new foods.

According to the WHO, Member States should endeavour to take advantage of these opportunities for synergy with the private sector while protecting populations from harm and working together to achieve health for all. It is important not to demonise or create simplified antagonisms between the private and public sectors but rather to identify, prevent and reduce the risks of bad business practices produced by some that can negatively affect people’s health. To do this, it is necessary to identify and recognise that there are sometimes conflicts of interest and that regulatory, legal, and economic reforms are needed in governance and policy models in these critical areas, including food.

What can be done?

In this utopia, the ideal would be to create societies where public and private actors prioritise environmental sustainability, human rights, basic needs, health, and well-being instead of encouraging consumption models that can harm the environment and human health. Public policies should contribute to these goals, free from commercial interference that could affect these objectives.

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 health and beyond. Now, 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 must be a central component of public health surveillance networks at the national level and form part of global governance efforts to protect and promote health. The food system, which influences food consumption and where nutritionists carry out their work, is strongly determined by commercial interests that can negatively affect the health of populations.

Recently, some authors have considered it desirable to intervene in specific areas to reduce the risk of negative exposure to certain commercial practices in health – In international organisations and governments (for example, by establishing clear rules for public-private partnerships and recognising conflicts of interest); In research and research funding (for example, by developing special attention to CDoH in academic curricula or improving funding for research carried out by public institutions); In the commercial sector (for example, by improving systems for regulating and monitoring negative externalities) and in Civil Society, for example, by mobilising independent organisations and health professionals on the need to prevent these behaviours.

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 work 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 different strategies to reduce the risk. Research is one of the most common approaches among academics and researchers, with the aim of identifying the problem and increasing knowledge about this phenomenon, which is still unknown to many, alerting people to the frequency of these situations and the seriousness 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 change positions on health and food take place in a grey area where unethical actions are more common than illegal ones. And where there is still some inability to legally delimit a large set of actions. Here, fear of punishment is the main deterrent, but for the reasons mentioned, it is still little used. The third strategy, called regulatory, makes organisations and their managers responsible for preventing and controlling actions that could negatively affect people’s health. However, the regulatory approach can be counterproductive, as it gives the idea that as long as you comply with the laws and regulations, you can adopt ethical behaviour and that everything that the laws don’t prohibit can be done.

Faced with these difficulties and without neglecting the previous proposals that can be worked on simultaneously, we advocate or add a different strategy, which is to integrate the discussion of food ethics and the commercial determinants of food into the ethical principles of our profession. Abandoning the idea that people only do what they have to do when they have to, and encouraging a debate about what is right. And on the assumption that people can do what they should because they believe they are doing the right thing. We think it’s 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 ability to assess problems in this area “the ethical implications of decisions, to weigh up alternatives and their impact on partners, the environment and society in general, and to resolve the ethical dilemmas that often confront decision-makers.”

As health professionals, nutritionists are ethically responsible for putting the population’s well-being first. This includes providing nutritional guidance that promotes health and is not influenced by other interests, namely commercial interests. Thus, knowledge about how commercial practices can negatively affect food choices is an increasingly necessary skill.t the same time, nutritionists must play a critical role and defend the use of science to support public health policies and oppose third-party efforts to manipulate or distort science in favor of their own interests. Another dimension to take into account is health inequality. The recurrent 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, debating ideas and analyzing cases.” By providing a critical reflection on these issues, nutritionists will be better able to define or refine their own standards, appreciate alternative approaches to identifying and resolving ethical problems, and develop their own competencies for dealing with complex issues.

In conclusion, revising the Code of Ethics for Portuguese Nutritionists is an urgent 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 requires nutritionists to be prepared to face complex ethical challenges in their professional practice. This involves recognizing and addressing the impact of inappropriate commercial practices on public health, promoting ethical and affordable food choices, and advocating for effective public health policies. In addition, professional associations, such as the Order of Nutritionists, play a key role in promoting up-to-date ethical guidelines, continuing education for professionals, and collaborating with other stakeholders to promote ethical practices in nutrition. This holistic approach is essential to ensure that nutritionists play an influential role in protecting public health and promoting food choices that benefit both people and the planet.

Understanding how the game of influences works, the existing formats for rebalancing these powers, and the strength independent actors in this equation (nutritionists) can have could make a difference. These intervention models position our profession and its members as professionals of reference for society, which could greatly benefit everyone.

We think this is a necessary discussion in our professional class.