Nutritionists perform a multidisciplinary activity that extends far beyond the biomedical sciences in which they are involved. The work of these professionals influences food production and consumption, areas where very strong economic interests coexist, with high public visibility and enormous relevance to citizens. In this context, constant ethical and deontological reflection on our actions as nutritionists is extremely important.
This reflection began, in a consolidated way, in 2004, still within the Portuguese Association of Nutritionists (APN), with the perceived need to create a Code of Ethics for Nutritionists, years before the creation of the Order of Nutritionists. In 2006, the APN created a working group, made up of nutritionists, alumni of FCNAUP*, which, after several procedures, namely consulting the members, presented in June 2008, a first draft of this code, and in October of that same year, a basic document entitled “Guiding Principles for the Professional Ethics of Nutritionists” (1). This set of guidelines had as its central objective to draw the attention of the members to the existence of certain generic ethical principles and to the added value of their inclusion in daily professional practice, and also to the need for a continued discussion of deontological and ethical issues within the profession . And that this discussion should not be exhausted in the principles elaborated in that first document. The document was divided into 5 areas of professional interest and activity, namely, professional skills, client relations, relationships with colleagues, service provision, and social and legal responsibilities, which would later give rise to our Code of Ethics , still very similar to this original document today.
Current issues in the field of nutritionists' work that deserve ethical reflection
A Code of Ethics presents a set of expected behaviors in diverse circumstances, enabling prior reflection for judgment and distinction between right and wrong. However, these circumstances are frequently changing, and the perception of their importance depends on each of us. This is therefore a personal reflection by the authors, which may not represent the most frequent ethical problems or even those most anticipated by the profession, but are, in our understanding, emerging areas that are still underdeveloped and deserve in-depth public discussion in the near future.
The issue of keeping knowledge up-to-date in the face of the current rapid pace of scientific evolution in this area
The Code of Ethics reflects the ethical principles of the professional activity of nutritionists. Its objective is to guarantee a professional practice of excellence that contributes to the growth, recognition, and prestige of these professionals. Therefore, the ability of nutritionists to exercise a professional practice based on the most recent scientific evidence is central to our Code. This is expressed in Article 2 – Knowledge of Nutritionists: “Nutritionists integrate, apply, and develop the principles of the basic areas of biology, chemistry, physiology, social and behavioral sciences, and those from the sciences of nutrition, food, management, and communication, to achieve and maintain the best possible health status of individuals, through a scientifically supported professional practice, in light of current knowledge, in constant improvement.” And further on, in the “General Duties,” it is suggested that it is the duty of the Nutritionist to: “Commit to the continuous updating of their scientific, technical, and professional knowledge and skills;”.
This means a high degree of demand for a profession that today encompasses the most diverse areas of activity, each with enormous, almost daily, technical and scientific evolution, and where colleagues are progressively specializing. In other words, it implies the need for constant investment in updating specific areas of practice throughout the professional life cycle and, enormous scientific restraint and humility when addressing areas where one does not work, respecting those who do. Frequent updating of knowledge and continued study as an ethical principle is central to a very young and still-developing profession. Without permanent technical updating in this area, nutritionists will not be able to meet society's expectations. An ethical commitment to continuous learning and updating throughout one's professional life is central. This is an area where we need training and reflection both among younger colleagues and, in particular, among the more experienced ones.
The question of the emergence of an information society and digital media
The nutritionist, as a producer and disseminator of scientific information with increased access to global networks, represents a huge opportunity and, at the same time, a challenge to the reputation of the profession. Specifically, this relatively recent technological capability, with its high public visibility, can be used to promote consumer trends dependent on scientific immediacy and to advance commercial interests below public perception, making them difficult to detect and increasingly susceptible to conflicts of interest.
The emergence of the information society and the possibility for every citizen to become a media actor in the global nutritional and food information arena has encouraged and seduced many actors in the food chain, and beyond, towards constant, easy, and tendentially sensationalist communication in pursuit of the preferences and "tastes" of their readers, thus increasing their public visibility, self-esteem, and commercial value. The writer Ricardo Gavelis (1950-2002) coined the expression "era of dilettantes" for fear of the dominance of aggressive mediocrities, with "their capacity to silence educated and calm men and women of letters who prefer to think twice before saying and doing something." These experiences in an era of continuous sound fragment emissions, “ephemeral things calculated for maximum impact with instant obsolescence” (2) brought the success of “nutrition communicators” on social networks closer to the need for a constant presence in the media space, talking about everything and anything, at all times, seeking the scientific immediacy of the “sound byte” which is hardly compatible with the in-depth study developed in the different areas of activity of our profession.
The emergence of "nutritional influencers," some with weak scientific rigor, in the social media space but with high media success, can also translate into a phenomenon we will call "scientific-media reciprocity," insofar as these communicators/influencers are easy prey for commercial interests. The ability of those with economic power allows them to fuel the influencers' media influence on social networks, and in turn, the influence of these communicators on the global network allows them to advertise the products owned by these companies. These communication formats through influence on social networks and digital communication are now highly funded, becoming, in some cases, the main advertising investment of many large companies. It should also be noted that, in many situations, this commercial relationship, associated with a potential conflict of interest, is not disclosed by either party, remaining invisible to consumers.
Conflict of interest
In the case of nutritionists, the conflict of interest between them and the food industry can go beyond communication issues. Given the increase in reported situations in recent years, in 2017 the WHO conducted an extensive consultation and published various reports on the subject, notably the report " Safeguarding against possible conflicts of interest in nutrition programmes: draft approach for the prevention and management of conflicts of interest in the policy development and implementation of nutrition programmes at country level, " which argues 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. In these cases, public disclosure of this relationship is a fundamental step in resolving the conflict, although it is not sufficient in some instances. For example, when nutritionists hold positions of responsibility that allow them to make decisions that may benefit one of the parties.
Beyond acknowledging the influence this association can have on decision-making and on the good name and reputation of colleagues and institutions, recognizing the conflict of interest does not solve the problems this relationship can cause; it only defines a starting point for its resolution. The goal is to reduce the risk, not just to make it visible.
This is a professional practice that can discredit nutritionists and their good name. Ethical training for future nutritionists on these topics and their public discussion seems essential, especially since the presence of nutritionists throughout the entire food chain is desirable, particularly in nutritional reformulation and improvement in conjunction with the food industry. Nutritionists can be essential in the innovation and development of healthier food products and can also play a decisive role in decision-making in various areas within the food industry and distribution. Transparency in this relationship and the definition of clear guidelines can contribute to a more effective and sustainable partnership for both sides. Therefore, it is important to have a broad discussion about the ways nutritionists interact with the food industry, allowing for the identification of relationship models with a reduced risk of conflict of interest. We will return to this subject in more detail shortly.
The issue of funding for educational and research institutions
Since it is neither possible nor desirable to separate civil society, the business sector, and those who teach and produce science, a serious discussion about this relationship is urgently needed. The lack of clear guidelines in this area opens the door to erratic, case-by-case decision-making, creating a grey, opaque , almost ungovernable space, and above all, a space where it is impossible to identify responsibilities and demand accountability. This ambiguity has been detrimental to everyone, as it accentuates distrust , hinders medium- and long-term business investment, and disconnects educational institutions from the real world. Furthermore, it prevents a serious accounting of where public research is being conducted with private funding and how the State can define a strong research agenda and fund areas of scientific research that can counterbalance areas not funded by private investment. In the area of food, for example, there is chronic underfunding of state-funded research in crucial areas such as the impact of legislation on food consumption or the assessment of the impact of consuming raw, low-value commercial foods on health promotion.
Several guidelines have already been published in this area, which should receive close attention from public institutions and laboratories when defining a strategy for engaging with the private sector. This text presents one possibility, among others. In a first phase, it is suggested that the credibility of partners and the risk associated with the listed proposals be evaluated, particularly by comparing them with pre-established credibility criteria. For example, the American association of nutritionists "Dietitians for Professional Integrity" (DFPI) suggests eliminating from the outset companies related to certain food products. Subsequently, and in another phase, the type and nature of the relationship with these companies should be defined, which could be: a) none; b) a formal dialogue only; c) a non-financial collaboration, for example, the sharing of data or knowledge; or d) a collaboration involving funding. Following this decision, a vast array of other decisions must be made, which may involve jointly defining the type of objectives to be achieved, information ownership, publication models, protocol oversight by external entities, identification of the interests involved and potential conflicts of interest, the diversity of funders, and public participation. This entire process must be monitored and publicized transparently. Finally, consideration must be given to the expected potential results and whether they will contribute to the production and publication of high-quality, independently reviewed science, and whether the results could positively influence the definition of public policies in this area . In the case of scientific production, and according to several authors, it is desirable that funders do not participate in the conduct of scientific work, from the design and definition of the methodology to the interpretation and presentation of data. Public availability of data to other interested . On the other hand, it is increasingly common to ask authors of oral presentations or conference papers to disclose any potential conflicts of interest before their presentations. It's a whole journey to follow, a whole learning process to undertake, and one that has already been done in other areas, such as the pharmaceutical industry, for example.
The issue of conflict between environmental ethics and food and nutritional ethics
One final and central ethical issue that will dominate the discourse of nutritional sciences in the coming years will be the conflict between promoting nutritional well-being and defending the well-being of the planet, as it will not always be possible to reconcile environmental and nutritional perspectives. A recent example of this anticipated dispute is the recommendations to reduce meat consumption due to its impact on water and energy consumption and greenhouse gas emissions, and, on the other hand, the omnivorous tradition of the human species and the nutritional benefits of including a small portion of meat in our diet . Although biomedical ethics has given little attention to this aspect, which is natural, this issue will be central to the decision-making and advice of nutritionists in respecting the lifestyle choices of their clients. In the context of their relationships with clients, nutritionists must "Provide services respecting the dignity of clients, their needs and their personal values, without any type of discrimination". This issue becomes even more complex when we include in this equation respect for animal welfare or the consumption of products with high nutritional value, inexpensive for a disadvantaged population, but with a strong impact on the environment, as they come from distant regions, for example. How to reconcile a compromise, not always possible, between improving the life of a human being or improving the living conditions for the human species?
This reflection will also include the need to more frequently promote, in the discourse of nutritionists with their clients, actions that effectively contribute to reducing the environmental footprint, such as reducing food consumption per se (frugality and not just replacing one food with another, which is the current commercial logic) or making better use of food and reducing waste. These are behavioral suggestions that are still infrequent in the nutritional counseling practice of many colleagues.
In this regard, and since Martinez Alier published his seminal work "The Environmentalism of the Poor" in 2014, much discussion has taken place regarding the fact that environmental concerns may widen the gap between the most disadvantaged, who lack access to food products produced in a way that better protects nature. The critique of the gap that is apparently beginning to exist between the possibility of accessing food that protects producers and local production through environmentally sustainable production models, as opposed to their antithesis—that is, widely available, low-cost, but highly processed and industrially produced foods—should merit a profound debate among nutritionists with these ethical concerns, which we can anticipate from now on. These ethical practices cannot be reduced to arguments about the moral purity of choices. By recognizing that there are various possibilities and concepts of "alternative consumption" as opposed to highly processed food, we will give populations a sense of normalcy, which will greatly benefit public perception of risks and their minimization.
These issues demonstrate the complexity of our field of work and, at the same time, highlight a necessary debate that needs to take place. This text also marks a historic date for FCNAUP and for all nutritionists, as the FCNAUP Ethics Committee began its work this week. FCNAUP will be the first Faculty of Nutrition to have a structure of this kind, which makes us very proud. The Committee, chaired by Professor Sara Rodrigues, is composed of a group of highly regarded individuals who will make an enormous contribution in the coming years to help us improve and think more clearly about these issues. We wish the entire team all the best.
(1) Pedro Graça, Bela Franchini, Alejandro Santos, Maria Palma Lopes, Sandra Lourenço, Guiding Principles for the Professional Ethics of Nutritionists: Portuguese Association of Nutritionists; 2008.
(2) George Steiner – Language and Silence – Gradiva, 2014.
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
