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Trends, challenges, opportunities, and future needs of the dietetic workforce: a systematic scoping review

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Merran Blair, Lana Mitchell, Claire Palermo, Simone Gibson, Trends, challenges, opportunities, and future needs of the dietetic workforce: a systematic scoping review, Nutrition Reviews , Volume 80, Issue 5, May 2022, Pages 1027–1040, https://doi.org/10.1093/nutrit/nuab071

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Issues related to nutrition and health are prominent, yet it is unclear if the dietetics workforce is being used optimally.

Trends, challenges, opportunities, and future needs of the international dietetic workforce are investigated in this review, which was registered with Open Science Framework (10.17605/OSF.IO/DXNWE).

Eight academic and 5 grey-literature databases and the Google search engine were searched from 2010 onward according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Of 2050 articles screened, 184 were eligible for inclusion.

To chart data, a directed content analysis and a constant comparison technique were used.

The following 13 themes were identified: 1) emerging or expanding areas of practice; 2) skill development; 3) economic considerations; 4) nutrition informatics; 5) diversity within the workforce; 6) specific areas of practice; 7) further education; 8) intrapersonal factors; 9) perceptions of the profession; 10) protecting the scope of practice; 11) support systems; 12) employment outcomes; and 13) registration or credentialing.

The dietetics profession is aware of the need to expand into diverse areas of employment. Comprehensive workforce data are necessary to facilitate workforce planning.

A dietitian “is a professional who applies the science of food and nutrition to promote health, prevent and treat disease to optimize the health of individuals, groups, communities and populations.” 1 To use the professional title dietitian in many countries, including the United States, Canada, Australia, New Zealand, and the United Kingdom, requires a minimum of a bachelor’s degree qualification, in addition to a minimum of 500 supervised practice hours. This is in contrast to the title of nutritionist , which is less defined in many countries, with no minimum level of education; however, professional organizations suggest undergraduate degrees in nutrition science are preferred. 2 Dietitians can register with professional bodies in their country of practice, which allows them to treat individuals under various health insurance schemes and in a range of settings. In Australia, dietitians are given the title of Accredited Practicing Dietitian, in the United Kingdom, Canada, and New Zealand, the term is registered dietitian; in the United States, a qualified and registered dietitian is referred to as registered dietitian-nutritionist. For inclusivity, the term dietitian is used in this article.

Current rates of diet-related chronic disease are high, 3 and issues related to sustainable food production 4 and food security 5 , 6 are receiving more attention and requiring strategic action. Dietitians are health professionals who are well placed to address these issues 1 ; however, it is unclear if this workforce is being used optimally. Current dietetic workforce data are limited across the world and there is no objective evidence that gives a clear indication of employment rates of graduates 7 or whether the dietetics workforce is meeting population nutrition needs. 8 In the United Kingdom, approximately two thirds of dietitians work within the publicly funded National Health Service, but employment information is lacking on the one third who do not. 9 In the United States, job growth for dietetics is predicted to be higher than for other professions 10 ; however, some dietitians report leaving the profession for higher pay in alternative fields or being unable to find work. 11 In Australia, workforce supply is perceived to be greater than demand, 12 and anecdotal evidence suggests graduates struggle to find employment.

The goal of workforce development is to ensure that workforce members are able to obtain a sustainable livelihood, in addition to using the labor to achieve organizational goals that meet the needs of society. 13 , 14 Because of the changing nature of healthcare delivery 15 , 16 and consumer needs, 17 , 18 employment opportunities for dietitians are rapidly evolving. It is important that such changes be regularly assessed 19 to ensure the profession remains effective and relevant. The dietetic profession is aware of the need for planning, and comprehensive studies have been completed in both the United States 20–22 and the United Kingdom, 9 with plans underway for similar work in Australia 23 to explore the future of the dietetics profession. Work in the United Kingdom resulted in 16 recommendations for development of a dietetic workforce strategy that included increasing the visibility of the profession and preparing dietitians for more diverse roles through strategic leadership. 9 In the United States, researchers analyzed societal-change drivers and how they might affect the growth of the dietetic profession. 20 , 21 They sketched out 4 possible scenarios of the future the profession may face, depending on how it responds to these change drivers. 22 Although these projects included a systemic review 20 and an environmental scan, 9 which informed subsequent research, no systematic reviews addressing trends within the dietetic workforce have been published.

Our purpose in conducting this systematic scoping review was to investigate trends, challenges, opportunities, and future needs of the global dietetic workforce from a diverse range of literature. This information can be used to inform future workforce development strategies and to guide training priorities for the current and future international workforce. This will help ensure that members of the dietetic workforce are well placed to find employment and effectively improve the nutritional outcomes of our population.

This systematic scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist 24 and with reference to the JBI   Manual for Evidence Synthesis . 25 This review was registered with the Open Science Framework ( 10.17605/OSF.IO/DXNWE ). A scoping review was selected to be conducted in preference to synthesis approaches to capture the depth and breadth of the literature on the broad exploratory research question. 25 Grey literature was included because it has the benefit of contributing contemporary material from a broad range of stakeholders, 26 and publication delays in academic research can mean that results are indicative of past events, rather than current or future.

The following databases were searched on February 6, 2020, in in consultation with the subject specialist research librarian: Ovid MEDLINE, CINAHL Plus, Proquest Social Science Premium Collection, Scopus, and Business Source complete. Searching was also conducted in the following grey-literature databases: Open Grey, Grey Guide, MedlinePlus, Grey Literature Report, and Mednar; and thesis searching was conducted on Trove, Proquest Dissertations & Thesis Global, and Dart Europe E-Theses Portal. All searches were time restricted from January 2010 to February 2020 to capture information about the contemporary workforce from the past decade, rather than historical, outdated data. Only publications in English were included. Inclusion and exclusion criteria were predetermined on the basis of the PICOS model (ie, participants, interventions, comparisons, outcomes, and study design) ( Table 1 ). Search terms ( Table 2 ) were used with appropriate variations according to the functionality of each database. All results were uploaded to Endnote X9 and then to Covidence systematic review software. 27 Title and abstract screening, followed by full-text screening, was completed in duplicate by 2 authors (M.B. and either L.M., S.G., or C.P.). Conflicts were discussed until consensus was reached.

PICOS criteria for inclusion of studies

Abbreviation: CPD, continuing professional development.

Search terms used for the scoping review exploring trends, challenges, opportunities, and future needs of the dietetic workforce

Grey-literature searching, using the search terms listed in Table 2 , was conducted using the Google search engine in February 2020. The first 10 pages of results (ie, the first 100 hits) were screened, initially via the Google search screen, then potentially relevant sites were viewed in full. 26 Reasons for exclusion were noted, and included pages were saved in PDF format for data extraction. Screening of results from the Google search was conducted by 1 researcher (M.B.). Duplicate screening was deemed unnecessary because consensus on eligibility had been reached during database screening and conflict resolution.

Data charting of included papers was completed in a spreadsheet and included year of publication, author, country where the research was conducted or the article was published, type of article, type of study, and, if applicable, research methods, population, and number of participants. In addition, a directed content analysis 28 , 29 was conducted whereby themes were deductively generated under the formative categories of 1) trends (namely, ways the workforce was developing or changing), 2) opportunities (ie, ways to achieve further development), 3) challenges (ie, obstacles to development), and 4) future needs (ie, aspects needed to strengthen the workforce) and recorded in the spreadsheet. This structure was formulated by the researchers with reference to existing research indicating that the dietetic workforce is in a state of flux and in need ofplanning. 9 , 20–22 . For the second stage in the data charting process, we used a constant comparison method 30 whereby common recurring themes were identified, within the formative categories, and these became the results of the review. Data charting was conducted by 1 researcher (M.B) with a subset of 10% (in total) charted by another researcher (either L.M., S.G., or C.P.) and cross-checked for comparison, with no major errors or omissions identified. Critical appraisal of individual sources of evidence was not conducted, as is typical of scoping reviews. 24 The frequency of themes across studies was collated and a visual representation of the frequency of categories was developed on the basis of these data ( Figure 1 ).

Results of the scoping review exploring trends, challenges, opportunities, and future needs of the dietetic workforce, in descending order of commonality. Larger circles indicate the topic was referred to more often; however, this is a graphical representation only and circles are not to scale. Items listed in boxes are subcategories. Linking of circles indicates the path from most commonly to least commonly mentioned topic: emerging or expanding areas of practice (n=52); skill development (n=43); economic considerations (n=31); nutrition informatics (n=23); diversity within the workforce (n=20); specific areas of practice (n=20); additional education (n=17); intrapersonal factors (n=9); perceptions of the profession (n=9); support systems (n=5); protect the scope of practice (n=5); employment outcomes (n=3); registration and credentialing (n=3).

A total of 2050 articles were screened; of these, 184 were included in the scoping review ( Figure 2 ). Characteristics of the included articles are collated in Table 3 , and a comprehensive list of included articles is provided in Table S1 in the Supporting Information online. The following 13 themes were identified and are listed here in descending order of commonality: 1) emerging or expanding areas of practice; 2) skill development; 3) economic considerations; 4) nutrition informatics; 5) diversity within the workforce; 6) specific areas of practice; 7) additional education; 8) intrapersonal factors; 9) perceptions of the profession; 10) protecting the scope of practice; 11) support systems; 12) employment outcomes; and 13) registration or credentialing ( Figure 1 ). Subcategories were also identified under some themes.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of included studies in the systematic scoping review

Characteristics of articles included in the systematic scoping review

Abbreviations: JAND, Journal of the Academy of Nutrition and Dietetics; JADA, Journal of the American Dietetic Association.

Country where the research was conducted, or the article published.

Includes Australia and New Zealand; Australia and United Kingdom; Australia, United Kingdom, and United States; Ireland and United Kingdom; Sweden, Wales, and United States.

Includes China, Ghana, Israel, Italy, Malaysia, South Korea, Sudan.

Includes theses, abstracts, and 2 government reports.

Original research, excluding abstracts or theses.

Includes environmental scan, case study, Delphi survey, policy discourse analysis, nonrandomized controlled trial, prospective cohort.

Emerging or expanding areas of practice

A total of 51 different emerging or expanding areas of practice were identified ( Table S2 in the Supporting Information online). These were highlighted as employment opportunities to expand the scope of the profession 31 , 32 and ways in which dietitians can contribute valuable skills to benefit businesses and individuals. 31 , 33 , 34 Emerging areas were spoken of as a future need, because if dietitians did not fill these roles, they would be filled by other, potentially less qualified, individuals. 35

Skill development

A total of 21 different skills were identified (( Table S2 ) as both opportunities and future needs. Skill development was deemed to be a means by which dietitians would be able to “strengthen their ability to offer food and nutrition solutions in a wide range of situations.” 22 Clinical skills such as integrative and functional medicine 36 and nutritional genomics 37 were noted to be of increasing public interest. Skill development in these areas were suggested in order to meet the changing needs of consumers. 36 , 37 Social media skills were identified as a means to champion evidence-based nutrition information and to advocate for the profession. 38 Areas such as business skills, 22 collaboration, 39 client/customer focus, 40 computer literacy, 40 and financial management 41 were highlighted as skills desired by organizations. Sustainable food systems practices were identified as areas where dietitians can offer solutions to meet the needs of consumers and organizations. 42 It was also suggested that the profession encourage students to have dual degrees to strengthen skills in business and management. 22

Economic considerations

Four subcategories were identified relating to economic considerations: staffing ratios, supply and demand, compensation and benefits, and recruitment and retention.

Staffing ratios.

Inadequate staffing ratios were common 43–49 and described as a challenge because they may result in worse patient outcomes, 45 increased healthcare costs, 44 and increased staff turnover due to burnout. 47 In addition, dietitians were more commonly found in metropolitan areas, 49 which potentially results in lack of equitable access for individuals needing dietetic input. 48

Supply and demand.

Predictions of supply and demand varied between countries and over time. 19 , 20 , 50–53 The US Bureau of Labor Statistics predicted job growth to be “much faster than average” at 11% between 2018 and 2028. 10 Supply and demand were seen as dynamic, requiring ongoing assessment, and fundamental to workforce success. 21 , 22 , 54 An undersupply of dietitians was viewed as an opportunity for the existing workforce, resulting in higher pay rates. 19 Conversely, it was also seen as a challenge that could leave positions open for other professions, which would erode the potential economic advantage. 19 Attrition rates due to retirement were described as a challenge 20 that could result in a lack of qualified dietitians to fill senior positions. 19

Compensation and benefits.

Trends in compensation and benefits varied over time, sometimes keeping up with inflation 55 and sometimes not, 56 and a drop in wages was noted in the United States between 2015 and 2018 from USD 30.62/h to 30.45/h. 11 Higher wages were associated with higher education levels, as were specialty certifications, years of experience, and budgetary responsibility. 11 , 56 Direct client contact was associated with lower rates of pay, and supervisory roles were associated with higher pay rates. 11 , 56 Highest wages were reported in the “areas of food and nutrition management, consultation and business, and education and research.” 11

Some dietitians reported not working in dietetics because they found “a higher paying job outside of the field.” 11 Identified future needs included professional associations supporting members to achieve “recognition, respect and remuneration,” 56 creating job opportunities, 55 and giving members confidence in salary negotiations. 55 , 56

Recruitment and retention.

Opportunities reported to enhance staff retention included the chance for dietitians to specialize or undertake research, 57 opportunities for learning, 58 , 59 positive relationships with others (ie, staff and patients), 58 , 59 a supportive workplace culture, and recognition of the role of the dietitian from other staff members. 59 Factors reported to strengthen recruitment were enhanced job security and closeness of the position to home. 58

Nutrition informatics

Nutrition informatics was seen as a growth area 60–62 offering many opportunities for the dietetics profession. The primary benefit described was the gathering of large data sets that could be used to improve efficiency of interventions and enhance patient outcomes. 62–65 This area also was noted as a challenge because the dietetics profession was not adequately engaged in this field 66 and, at best, was moderately prepared. 63 , 66 It was reported that dietitians need to have greater input into nutritional informatics to ensure the systems developed are of benefit to the profession 62 , 64 and are in line with the Nutrition Care Process. 64 , 65 If dietitians were not involved in the development of nutrition informatics, studies suggested that another profession would fill these roles, 63 and the systems may not be fit for the purpose of dietetics. 64 To enhance dietetic involvement in nutrition informatics, future needs identified were training and professional development, 64 , 66 including certification, 64 leadership, 64 and mentoring. 63

Mobile health apps .

In the literature we reviewed, nutrition apps were seen as a valuable tool to assist in patient care 65 and, if used in conjunction with dietetic counselling, could enhance the client-dietitian relationship. 67 It was reported that dietitians want access to credible, well-designed apps that can be integrated into current practice. 67 However, mobile health apps (aka, mHealth apps) were reported to be poorly designed for collaborative treatment with a dietitian. 68 They were noted to have the potential to increase quality and efficiency of healthcare 68 by gathering real-time, noninvasive data; however, access to these data was reported to be limited. 69

Training, education, and advocacy on the part of dietetic associations were identified as future needs to ensure greater engagement with use of apps by dietitians. 70 In addition, greater collaboration among app designers, dietetic professional associations, and dietitians 67 was identified as necessary to ensure apps are optimal for use in dietetic practice. mHealth app development was identified as a growth industry and it was felt that if dietitians fail to be involved, they may leave these roles open to other, less qualified individuals. 71

Diversity within the workforce

Diversity was described as a challenge, with the dietetics profession being predominately homogenous (female and White) and not representative of the broader population. 72–74 This was reported to create a divide between the profession and the individuals they serve. 72 In addition to sex, gender 73 and race, 74 the need for diversity with reference to age, religion, socioeconomic status, 41 and disability 75 were also identified. Suggested ways to increase diversity included peer mentoring and targeted approaches to recruit more diverse students. 76 , 77

Specific areas of practice

Aspects relating to 7 different areas of practice were described. These included: high staff turnover in rural and remote practice, 78 low patient attendance rates in private practice, 79 the need for interprofessional support in primary health care, 80 the benefits of expanding food-service initiatives within the school setting, 81 and the challenges faced by academic dietetic educators 82 and sports dietitians requiring advocacy for services for college-level athletes. 83

Additional education

Advanced credentialing..

Dietitians were reported to have higher levels of advanced credentialing compared with other professions, 19 with many existing and planned advanced credentials available in the United States. 41 , 84 Opportunities associated with advanced credentialing were identified as expanding an individual dietitian’s scope of practice 84 and recognition of dietitians as leaders in food and nutrition by external stakeholders. 54 Advanced credentialing was also reported to lead to more rewarding job opportunities, 85 particularly in growth areas such as gerontology and chronic disease management. 86 Increased wages were a reported outcome of advanced credentialing, 51 and advanced credentialing was seen as beneficial to the profession because it resulted in more efficient and cost-effective interventions. 85

Challenges identified that are related to advanced credentialing included a previous lack of clearly defined pathways, 87 although many pathways were listed in a more recent article. 84 Residency programs were noted to be an effective method of delivery that incorporated practical learning 85 , 87 , 88 ; however, availability of funding for these was described as inconsistent 87 and sometimes acquired from multiple sources. 83 In addition, the general public were reported to lack understanding of the benefits of advanced credentialing 87 and employers yet to value or demand these credentials. 19

Extended scope of practice.

Extended scope of practice is the recognition of an additional skill that is outside of the defined scope of practice of a healthcare professional. 89 For dietitians, this can include activities such as blood glucose testing, adjusting insulin doses, inserting nasogastric tubes, 89 tube feeding management, 90 , 91 gastroenterologic treatment management, 92 and, depending on local legislation, prescribing of pharmaceuticals. 89 , 93 , 94

Dietitians in extended-scope-of-practice roles were noted to contribute to reduced healthcare costs resulting from streamlining of services and efficient patient-care management. 89–92 , 95 This was identified to be a result of fewer healthcare visits, 89 , 92 , 95 shorter waiting times, 91 and reduced hospital admissions. 90 Opportunities were reported to include an enhanced professional profile, with dietitians in extended-scope roles perceiving increased professional status 90 and recognition. 91 They also reported increased job satisfaction due to working to the full scope of their practice, and sharing the experience with other dietitians through a community of practice. 91 Acknowledgment and appreciation of advanced skills by the healthcare team were thought to result in enhanced working relationships. 90 , 91

The challenges associated with extended-scope roles related to the lack of strategic planning, with these roles reportedly forming out of unfilled vacancies. 90 To assist with more strategic planning, the development of a framework that incorporates the available options for extended scope of practice, 9 in addition to clearly defined learning programs and evaluation strategies, 91 was described as future needs. In 1 instance, it was reported that an extended-scope role caused conflict with nutrition nurse specialists because of the crossing of professional boundaries. 91 Supportive infrastructures were noted as essential for the creation and maintenance of these roles, such as clinical governance and stakeholder engagement. 91

Intrapersonal factors

Job satisfaction..

Trends in job satisfaction indicated that dietitians were moderately 96 or slightly 97 satisfied with their jobs, with dietitians in clinical positions reporting the lowest scores. 98 Age and experience were associated with higher levels of job satisfaction. 99 Key factors reported to enhance job satisfaction included: opportunities for promotion 96 , 97 , 99 , 100 and professional development, 100 flexibility in work hours, 100 a dynamic team environment, 100 a positive work atmosphere, 97 and higher salaries. 97–99 Other elements that were identified as increasing job satisfaction included “reward and recognition” 100 and “autonomy, meaning, recognition and respect.” 98 Issues with the physical environment and access to resources, 100 in addition to “poor perception of professional image,” 99 were reported to have a negative effect on job satisfaction.

Job satisfaction was a challenge, due to the reported costs associated with staff turnover, absenteeism, and reduced productivity 96 that occur when satisfaction levels are low. It was also seen as an opportunity, because increased job satisfaction was reported to lead to improved patient or customer satisfaction. 98

Stress and burnout.

Trends indicated that although dietitians had lower levels of burnout than other health professionals did, they still had moderate levels of emotional exhaustion. 101 In addition, their sense of personal accomplishment was only moderate, although this increased with age and years of experience. 101 The main challenge associated with stress and burnout was the potential for negative health consequences for the individual and decreased job performance, resulting in negative impacts on clients and organisations. 101

Challenges identified that increased stress and burnout were a perceived lack of respect from other healthcare professionals, due to a lack of understanding of the dietitian’s role. 102 In addition, unrealistic expectations as to what dietitians can achieve with limited time and resources and the lack of recognition associated with being a preceptor were reported as challenges. 102 Expectations that dietitians “conform to certain ideals, including thinness” were perceived to increase stress and burnout. 102 Future needs reported included additional training in “resilience, mindfulness and empathy,” as well as interprofessional approaches to combating stress. 102

Preparedness for practice.

Preparedness for practice was perceived as a challenge because of a lack of data on emerging areas of practice, 7 leading to difficulty in tailoring curricula toward employment opportunities. In addition, research specific to the workplace, involving graduates and employers, was identified as lacking. 7 Graduates reported feeling underprepared for new and emerging roles and were overwhelmed by the competition for traditional job opportunities. 103 Future needs identified included comprehensive graduate employment outcome data 7 and a realignment of course curricula to better prepare graduates for emerging roles. 103

Perceptions of the profession

Although the role of the dietitian was thought to have become less confusing to the public, 104 awareness of what a dietitian does was described as low. 105 Dietitians were reportedly seen as simply prescribers of diets, 105 , 106 and the general public had difficulty distinguishing between dietitians and other professions, such as naturopaths. 107 The level of education required to be a dietitian was reported to be poorly understood, 107 and there was an identified lack of clarity of the distinction between dietitians and nutritionists. 9 This was thought to result in a dilution of the credential and confusion regarding the dietitian’s role in healthcare. 9 As a profession, dietitians were reported to desire greater visibility and credibility and a clearer public profile that acknowledges them as experts in nutrition. 9 , 108

Dietitians also wished to be seen as a health professional who should be visited regularly, much like a dentist. 9 , 109 A transformation was reported to be occurring from the dietitian being a provider of information to being a provider of counselling-based treatment. 107 This was identified as an opportunity, because the public perceived treatments involving the transfer of information as requiring only short-term intervention, whereas they viewed a therapeutic, counselling style approach as a long-term strategy. 107 Both the dietetic profession and the public were reportedly struggling to adapt to this change from “information giver” to counsellor. 107

Strong partnerships with physicians provided opportunities, because referrals from them increased the likelihood of patients engaging in ongoing treatment. 107 In addition, physicians acknowledged that their own nutrition education is limited and they had positive opinions of the training and experience of dietitians. 107 Other opportunities identified included the work of special-interest groups with stakeholders relevant to their topic areas and incorporating a broader range of placement opportunities with a broader range of stakeholders. 9

Although dietitians felt they have much to contribute to the healthcare sector, they did not feel they had a voice that can be heard. 9 Professional associations were seen as the key to amplifying the voice of the profession and increasing visibility. 9 Some dietitians expressed concern that their professional association was not fully recognized by consumers or other healthcare practitioners. 110

Because of increasing competition in areas involving nutrition, future needs identified included “clear and compelling communication” with consumers to champion the brand of the dietitian above other potential sources of dietary advice. 105 Although consumers reported unfamiliarity with the credentials and training of dietitians, they did not have negative perceptions, so it was noted as beneficial for professional associations to continue to increase familiarity of the dietitian “brand.” 105 From the reviewed literature, we also identified that research was needed on the public perception of dietitians and nutritionists and to find ways to collaborate to provide enhanced clarity in distinguishing the 2 professions. 9

Support systems

Mentoring or professional support..

Mentoring was reported to offer opportunities in the form of enhanced confidence 111 , 112 and competence 112 , 113 and the chance for reflective practice. 111 , 113 These opportunities were noted to lead to improved productivity for both the mentor and mentee. 111 Other beneficial professional supports included working with another dietitian, peer-support networks, professional supervision, or working as part of a multidisciplinary, multicultural team. 112 Future needs identified included experienced and passionate mentors who create a trusting relationship and provide effective feedback. 113

Communities of practice.

Communities of practice were an effective method of increasing competence 114 and confidence to change practice, resulting in workforce retention 115 and development. 114

Protect the scope of practice

Protecting the scope of practice was described as “the greatest challenge” for the dietetic profession. 116 Competition in providing dietary advice and care was described as coming from other healthcare professionals, 19 , 22 whose expertise may have some nutrition overlap, as well as from individuals without academic training. 19

Opportunities within this area include the development of a workforce that adapts to the changing needs of society and whose value is acknowledged, because this type of workforce has less need to be protective of its scope of practice. 22 In addition, the creation of a more fluid scope of practice among healthcare professionals was noted as a way to enhance interdisciplinary collaboration. 21 A shared code of conduct for nutrition science professionals was suggested as a future need, because this may help define and protect the scope of practice. 117

Employment outcomes

Data related to employment outcomes had significant limitations. A comprehensive report from Australia was based on data from 2011, 118 now a decade out of date. From this report, trends indicated that less than half (45%) of individuals with a dietetic qualification worked as a dietitian, while 41% worked in unrelated occupations. 118 Another article reported on dietitians working in the public sector in a single state of Australia (namely, Victoria), 119 making this information biased toward hospital employment. Results from a study of dietitians who graduated from a single university in Canada indicated that employment may be increasingly difficult to obtain and graduates are having to work in rural or remote areas. 120

Registration or credentialing

Challenges faced in countries that were not members of the International Confederation of Dietetic Associations were distinctly different from those faced in countries where registration and credentialing are well established. In Sudan, professionalism and standards of practice were reported to be poorly defined. 121 In Ghana, an inadequate supply of dietitians in some areas and practitioners lacking formal qualifications were identified. 122 In China, a lack of educational opportunities and a poorly defined credentialing system were reported. 123

The purpose of this review was to investigate trends, challenges, opportunities, and future needs of the international dietetic workforce, from a diverse range of sources. The literature identified is predominantly focused on emerging areas of dietetic practice and skill development to meet current and future health nutrition needs of the population. This finding suggests the profession is aware of the need to adapt its skill set to successfully create jobs and have an impact on the changing food, nutrition, and health environments.

The number and scope of articles we identified demonstrate that the dietetics profession is contemplative of its position within society and how effectively it is serving communities. The profession is aware that healthcare delivery and the food and nutrition environment are changing, and is seeking information on how to adapt to these changes. There is considerable published work designed to understand and guide the future path of the profession, 9 , 20–22 with more underway. 23 Similar to the requirement that individual dietitians reflect on their own practice, 1 the profession as a whole appears to be reflective, questioning the place of dietetics within broader contexts.

The 2 most common themes identified in this scoping review were emerging or expanding areas of practice and skill development. Both of these topics have the potential to significantly enhance workforce development. Expansion of the profession into more diverse areas will lead to greater employment opportunities for dietitians, as well as increased capacity to meet the health and nutrition needs of society. Within the identified literature, emerging roles are most commonly presented as a way to expand the influence of the profession 9 and meeting the needs of society across multiple areas of healthcare and the food system. 20 , 21 The literature does not specify if emerging roles are considered important as a way to enhance employment, such as compensating for a lack of traditional roles (eg, clinical positions). Graduate employment data are lacking globally, resulting in a dearth of information regarding supply and demand for traditional roles.

The results of this review demonstrate that the topic of emerging areas of practice has been under discussion for at least a decade. 124 Despite this, dietetic education programs continue to focus on training students for clinical hospital roles, even though the majority of graduates are unlikely to work in this area. 118 Graduates are aware of the incongruence between training programs and employment opportunities, and they identify an overemphasis on clinical dietetics skills to the detriment of business and private practice skills. 103 Dietetics training programs need to reconsider their curricula to ensure training is reflective of workforce opportunities. To do this, it will be essential first to identify employment outcomes. Once these have been identified, training programs can consider implementing more diverse placement experiences to better prepare graduates for these emerging roles. Because teaching programs must meet accreditation standards, these may also need to be redefined to encourage contemporary placement settings.

Nutrition informatics was identified as an emerging area in this study, particularly relevant in light of the recent COVID-19 global pandemic. Large data sets, which can be gathered through informatics, have been identified as a valuable resource to help rapidly develop effective nutrition treatment strategies in situations such as the COVID-19 pandemic. 125 Well-designed mHealth apps can also compliment remote healthcare (eg, telehealth), as has become common during recent pandemic-associatedlockdowns. 126 Informatics will likely continue to be a rapidly expanding area for the dietetic profession as the world adapts to new healthcare models and global trends in technology.

This review has highlighted a significant lack of published workforce data. Although professional registration bodies generally gather information about their members, not all individuals with a dietetic qualification choose to become members of these organizations. Therefore, this information does not adequately capture individuals who take on nondietetic roles, nontraditional roles, those who remain unemployed. or those who choose not to be members. The US Bureau of Labor Statistics gathers workforce data on individuals who identify as working as dietitians; 10 however, as demonstrated in the Australian context, 118 almost half of individuals with a degree in dietetics work outside of the field. In addition, these data do not capture individuals who may be using the skills acquired during their dietetic degree but do not identify their primary role as “dietitian” (eg, academics teaching in dietetic programs). Comprehensive data that track graduates over time are necessary to identify if and why the profession is losing workforce members. These data are also essential to identify the most contemporary emerging areas as well as the potential impact on health and nutrition of populations. This, in turn, could guide the development of additional education priorities, and identification of specific industries in which advocacy can be targeted to enhance employment opportunities (eg, app developers 70 ).

Although graduate outcomes data will help identify current employment opportunities in the short term, ongoing research will also be needed. To remain relevant to consumer needs, more research should focus on what end users (ie, clients, patients, and the community) require from dietitians. If this area is not addressed, it is likely that other individuals will fill these gaps, as has been the case with unqualified social media “experts” providing nutrition information. 127 In addition, knowledge of the needs of the sectors and disciplines that interplay with the food system is required to identify trends, challenges, and opportunities where dietitians may play a role. It is also worth noting that none of the themes identified within this review has been “solved,” and all areas will require more exploration and development to strengthen the position of the dietetics profession. Leadership by the international dietetics community is needed, both in accreditation and training, to ensure the profession is at the forefront of contemporary developments.

Because food and nutrition have a role to play across many contexts and they affect every individual, the potential employment opportunities for dietitians are vast. Emerging employment areas include such diverse settings as policy development, agriculture, the education sector, 84 and social media. 38 By actively expanding the available fields of employment, the profession is embarking on a journey that appears to be unique to dietitians. Without precedent from other health disciplines, it is difficult to know how best to navigate these changes. What is most important is that the conversation is initiated and work begins in implementing the changes necessary to ensure the dietetic profession remains effective and relevant in the long term.

A strength of this review was that we included an international perspective; however, the restriction in publication language may have resulted in exclusion of perspectives from non–English-speaking countries, and, therefore, their perspectives remain unknown. The scoping review format and the inclusion of grey literature also meant that a broad range of opinions was included. However, this may also be a limitation, because the results were not generated solely from high-level evidence.

The global dietetic workforce is a potentially underused resource but recognizes its own need to adapt to the changing nutrition landscape. To understand this situation better, it is essential that professional bodies gather comprehensive workforce data that track graduates over time. This will assist the profession to stay abreast of emerging roles the workforce can use to expand its reach and effectiveness.

The authors express their gratitude to the unknown reviewers of this manuscript for their generous and constructive feedback.

Author contributions: All authors contributed to conceiving the study and to screening and data analysis. M.B. drafted the manuscript, and C.P., L.M., and S.G. provided critical revision. All authors read and approved the final manuscript. No individual meeting the authorship criteria has been omitted.

Funding . M.B. was supported by a scholarship from the Department of Nutrition, Dietetics and Food, Monash University, to undertake this work.

The funder had no input into the conception, design, performance, or approval of the work.

Declaration of interests. The authors have no conflicts of interest to declare.

Supporting information

The following Supporting Information is available through the online version of this article at the publisher’s website.

Table S1 . A complete list of articles, identified through database searches and the Google search engine, that were included in the systematic scoping review of trends, challenges, opportunities, and future needs of the dietetic workforce.

Table S2 . Extended results of topics identified in the systematic scoping review

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Using realist approaches in nutrition and dietetics research

Gemma jenkins.

1 School of Medical and Health Sciences, Edith Cowan University, Joondalup Western Australia, Australia

Isabella Maugeri

2 Department of Nutrition, Dietetics and Food, Monash University, Melbourne Victoria, Australia

Claire Palermo

3 Monash Centre for Scholarship in Health Education, Monash University, Melbourne Victoria, Australia

Rebecca Hardwick

4 Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth England

The aim of this study was to explore the use and future potential of realist approaches to research in nutrition and dietetics.

A targeted literature review was used to search key journals (n = 7) in nutrition and dietetics to identify existing research using a realist approach. A narrative synthesis was conducted to explore findings in relation to the research aim.

Nine research papers (four realist evaluations, five realist reviews) describing seven nutrition interventions were found, which revealed the application of realist research in nutrition and dietetics has focused on public health interventions. Realist research provided a deeper, more nuanced understanding of varied outcomes including the role of context, and contributed to the development of theory about how and why interventions work. As a theory‐driven research method, realist research was able to assist in overcoming methodological shortcomings to contribute to meaningful, transferable findings.

The results highlight the potential contribution of the realist research in nutrition and dietetics to evaluate interventions and inform future practice.

1. INTRODUCTION

Nutrition and dietetics research spans a wide range of topics across a range of different settings and contexts using a range of different research methodology and methods. With such diversity comes the need for a range of research approaches. Nutrition and dietetics is still dominated by a positivist approach to research, 1 with randomised control trials (RCTs) perceived as the gold standard in terms of methods. 2 RCTs are used to explore the effects of interventions. 3 While there are a number of benefits to RCT implementation, the ability to explore cause and effect relationships through the use of a control group is its main strength. This is suitable for some areas of nutrition and dietetics research; however, the practicalities of achieving this in other areas are markedly different. This is because such research typically takes place in complex settings, where a control group is unfeasible and possibly unethical. In addition, the impact of the human agency element in these interventions introduces confounding variables that can nullify the strengths of the RCT. 4 Nutrition and dietetics research requires approaches that still allow investigators to explore causation but acknowledge complex and social elements of research in this field. Realist methodology offers an alternative approach.

Realist methodology provides one such approach for dealing with the complexity of nutrition interventions. It is grounded in realist philosophy, 5 of which the key tenets include: the belief that social reality is real but only knowable indirectly; complex social interventions can act at all levels of context; and, generative causation— ‘the theoretical and statistical elaboration of an underlying, generative causal process existing in time and space, including also actors who make decisions within social contexts’. 6 Broadly speaking, realist philosophy sits on a spectrum between positivist and constructivist approaches. It shares the ontological perspective of a positivist approach that there is a knowable real world, however, epistemologically it sits closer to constructivism. Positivism maintains that only knowledge that is observable is true, while realism and constructivism posit true knowledge as being indirectly knowable. Realism deviates from a completely constructivist epistemology in that it bases knowledge construction on the interpretation of causation. 7

Realist research is referred to as a ‘theory led’ form of research, whereby the essential premise is that all programs, policies or interventions are ‘theories incarnate’, 8 that is, when resources are provided in a certain way, to a certain group, it produces certain outcomes. 9 , 10 A realist approach has an explanatory focus and is designed to interrogate the ‘program theory’ of an intervention. Such interrogation results in the identification of mechanisms, which are underlying generative causal processes and how they interact with context to contribute to the intended and unintended outcomes of interventions. Statements about the relationship between context, mechanisms and outcomes (referred to as CMO configurations) are developed and contribute to understanding how, under what circumstances and why a complex social intervention may or may not work. 4 In particular, mechanisms allow the researcher to unpack the ‘black box’ of how and why interventions lead to certain outcomes. This is a key difference from non‐realist methodologies and is what makes a realist approach so beneficial.

Pawson and Tilley developed and championed the version of realist methodology discussed in this paper. 9 They translated realist methodology into practical methods to do evaluation 11 , 12 and evidence synthesis. 8 , 13 Realist evaluation usually uses primary data and realist synthesis (or realist review) is a form of systematic literature review 8 that uses mainly secondary data. In both types, researchers focus on theory as the unit of analysis and synthesise findings to develop, test and refine explanatory program theory about how an intervention, or types of interventions, work across different contexts. 14 Researchers can look across similar program theories to explore patterns that can contribute to the theoretical understanding of these interventions. An intention of realist programme theory building and refining is to arrive at a more ‘Middle‐Range’ Theory of the intervention, what Merton, defined as ‘…theories that lie between the minor but necessary working hypotheses that evolve in abundance during day to day research and the all‐inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behaviour, social organization and social change’. 15 The development of middle‐range theory allows for transferability of findings to programs with similar underlying theories.

A realist approach does not prescribe a specific method for evaluating interventions, instead recommending methods which will best fit the study and provide explanatory data. As such, where positivists traditionally focus on quantitative data, realists are avowedly mixed methods and acknowledge the utility of other data in intervention theory building and refining. This is because these data sources are also particularly valuable for providing important contextual information which is important in realist approaches to help describe how the intervention works and in what circumstances. There is potential for realist research to address difficulties in the current state of nutrition and dietetics research, as it acknowledges the complex and social aspects of an intervention in seeking to explain the underlying causes of intervention effects. It also provides opportunity to scaffold existing theory in nutrition and dietetics, particularly in relation to the interplay of human agency and social interactions foundational to behaviour change. 16 It has also been proposed that despite a heavily theoretical underpinning, development of a causal hypothesis can influence policy makers and make a case for the benefits of social interventions 17 (see Table 3 for a glossary of definitions).

Despite the potential for realist research to address the difficulties in the current state of nutrition and dietetics research, there is a paucity of information about how and to what extent realist approaches are used in the discipline, and to what effect. Therefore, the purpose of this review is to find out how realist approaches are used in nutrition and dietetics research and what impact this had on findings, outcome, and research translation. In presenting this synthesis, we aim to inform the future potential of realist approaches in nutrition and dietetic research and evaluation.

In the interest of trying to summarise how realist research could be useful in nutrition and dietetics, this study employed a targeted literature review and narrative synthesis. 18 Key journals in nutrition and dietetics were identified by the authors as Journal of the Academy of Nutrition and Dietetics , Journal of Human Nutrition and Dietetics , British Journal of Nutrition , Canadian Journal of Dietetic Practice and Research , European Journal of Clinical Nutrition , Nutrition Reviews , Nutrition and Dietetics and Public Health Nutrition . The search terms ‘realist’ and ‘realism’ were entered into all of the journal websites in June 2020 by the first authors. No date range or restrictions to language or geographical location were applied. Search results were exported to EndNote 19 and full text retrieved. At this stage, the reference lists of exported full‐text publications were hand‐searched to identify additional relevant publications, which were also exported.

The first authors reviewed all full‐text publications in relation to study aim. Only full‐text publications that described realist research related to nutrition and dietetics were included. Data extraction for included publications was managed using a Microsoft Excel 20 template. One author independently extracted data for included realist evaluation papers and a second author for realist review papers. Extracted data included publication year, location, aim, design, study population, substantive or existing theory about intervention, results (including relevant quotes), how the realist approach impacted the study findings, outcome and research translation and design limitations. The research team then came together to discuss extracted data. During discussions, the research team identified initial impressions on how the approach had been used and what impact the approach had on the study's findings. The first authors then conducted a second review of included papers, with a focus on extending and consolidating the synthesis. Additional data and supportive quotes were extracted in relation to emerging ideas. The final analysis was discussed among the research team who affirmed the findings which are reported below under key headings that summarise the narrative synthesis.

The search identified nine research papers (four evaluations 21 , 22 , 23 , 24 and five reviews 25 , 26 , 27 , 28 , 29 ) describing seven interventions in nutrition and dietetics that applied a realist approach. All were included in the narrative synthesis. Table  1 provides an overview of the key data extracted for the four included evaluations, and Table 2 for the five included reviews. A description of the included interventions is also provided below.

Summary of the included published realist evaluations from nutrition and dietetics specific journals included in narrative synthesis

For all included studies, the majority of research came from the UK (n = 6) 21 , 24 , 25 , 26 , 27 , 29 with two studies from Canada 22 , 23 and one from Australia. 28 All were public health interventions focused on primary prevention, including school food and nutrition (n = 3), 22 , 23 , 27 breastfeeding support (n = 2), 24 , 25 food literacy (n = 2), 28 , 29 and food and nutrition security (n = 2). 21 , 26 Most papers identified existing theory about the intervention and its effects (n = 6), 22 , 23 , 25 , 27 , 28 , 29 including existing formal theory, such as the Health Belief Model 31 and Social Cognitive Theory, 32 or specific intervention theory developed by researchers.

The realist evaluation studies described data collection with diverse participant groups, including the intervention target population/s (n = 4), 21 , 22 , 23 , 24 health professionals and/or other stakeholders involved in intervention delivery (n = 3) 22 , 23 , 24 or a combination of these (n = 3). 22 , 23 , 24 Common research methods were used to gather qualitative data; semi‐structured interviews (n = 4), 21 , 22 , 23 , 24 questionnaires (n = 3), 22 , 23 , 24 observation (n = 3). 22 , 23 , 24 None of the realist evaluation studies reported quantitative data collection. All four realist evaluation studies included data pertaining to refined intervention theory. Limitations described were those commonly reported in research, including small sample size (n = 2), 21 , 24 low response rate (n = 1) 24 or single participant group or geographical setting (n = 3). 21 , 23 , 24

The number of primary studies included in the five realist reviews ranged from 11 28 to 39. 29 Quality appraisal was reported in three of the five studies. 25 , 26 , 28 Four of the five studies reported the identification of formal theories. 25 , 27 , 28 , 29 Four of the five studies alluded to a lack of contextual information that hindered the development of intervention theories. 26 , 27 , 28 , 29

A number of research papers described varied intervention outcomes in existing research, which required further exploration:

‘… little research has elaborated on this in the Canadian context and explored social processes associated with implementation occurring at the level of school districts to help explain how and why district practices may contribute to different levels of policy compliance ’. 23

The realist reviews were able to use existing theory in the development of intervention theory. For example, Greenhalgh et al conducted a realist review on school feeding interventions that explained how and why the findings from a Cochrane review of the same interventions differed across populations, contexts and circumstances. 27

Realist research contributed to understanding how and why diverse intervention outcomes may occur. For some interventions, this was the first study to provide a preliminary understanding.

‘This study is the first to elucidate possible reasons why women may experience these different outcomes’ . 21

For other complex interventions, realist research built on existing theory and research findings to develop a deeper, more nuanced understanding of the mechanisms that contributed to intervention outcomes and the influence of context. One realist evaluation of school food and drink policy provided insight into how stakeholders responded in different ways based on how they viewed the mandatory nature of the policy (a feature of their context), which then led to varied implementation and compliance. These findings were used to scaffold existing intervention theory:

‘Previous studies have found that mandatory nature of policy motivates some school‐level stakeholders towards implementation, however, this study found this is not necessarily the case in practice, as some stakeholders were reported to take limited or no action because of their aversion to the paternalistic nature of mandatory interventions’ . 23

All five of the realist reviews defined context as being more than concepts of ‘geography’ or ‘place’. Ohly et al used the definition for context provided by Pawson 8 in their realist review of the Healthy Start Food Voucher intervention. This definition refers to context as having multiple layers: ‘ individual, interpersonal, institutional and infrastructural ’. While the aim of the review was to identify outcomes linked to contexts at all four levels, insufficient evidence to comment on contexts at the institutional and infrastructural levels was reported. Hence the intervention theories presented by the study focused on how individual and interpersonal contexts influenced why the intervention worked.

In Trickey et al's review of breastfeeding support interventions, three separate contexts were identified: social context, infant feeding context and health service context. 25 Within each of the selected studies, these different contexts were described. For example, a single study analysed for potential intervention theories highlighted that the intervention took place in Scotland, and the context was defined as ‘ high levels of deprivation, very low breastfeeding rates, health professionals ambivalent about breastfeeding… ’ This description allowed the authors to look for similar contextual attributes across the other included cases.

Included realist evaluation studies also highlighted how context is deeper and more nuanced than setting. Ohly et al identified how participants' response to being given food vouchers were influenced by elements of context at the individual and interpersonal level, such as participants' values, beliefs and motivations about healthy eating. 26 In that study, different values, beliefs and motivations about healthy eating shaped how participants used the food vouchers, leading to intended and unintended outcomes.

In a multiple case study approach, Levay et al 22 , 23 purposely selected rural and urban districts to explore how context may influence the implementation of a school food and drink policy. Levay sought data to understand how and why a district being ‘rural’ or ‘urban’, contributed to understanding differences in policy implementation across these settings. They described how vendor availability is a feature of, and varies between, rural and urban implementation settings (context). If procurement of compliant products (the focus of the study) is not possible, then the ability of an area to acquire them is negatively impacted and the area is seen as non‐compliant, despite participants wanting to comply.

In urban contexts there is a high availability of vendors, which can influence availability of compliant products—availability tends to be higher. In rural settings, there are less vendors, therefore procurement of compliant products is more difficult so even where school administrators and volunteers are motivated to implement and comply with the policy, they can be limited by available infrastructure . 23

Each of the selected studies highlighted the benefits of using intervention theory as the unit of analysis. All five of the selected realist reviews emphasised the importance of intervention theory analysis in providing tangible recommendations for policymakers around complex public health interventions. Several authors claimed that the complexity and heterogeneity of these interventions restricts the usefulness of traditional systematic reviews for policy makers.

‘ Simply knowing that feeding programs work is not enough for policymakers to decide on the type of intervention that should be implemented ’. 27

‘ Agency is synonymous with realist mechanisms (the reasoning and reactions of individuals in response to the resources offered by the program), and this review illustrates the contribution of realist methodology to understanding differential impacts of public health interventions or programs’ 26

All four of the realist evaluations also described how the theory‐driven approach provided evidence‐based, plausible explanations for intervention outcomes, which could be transferable to other interventions. Ohly et al, for example, used findings to develop a theoretical model of change, which could be transferable not only to other food voucher interventions, but other interventions where similar mechanisms may occur. 21

‘ Although this model was based on evidence‐based program theories about the Healthy Start program, similar mechanisms relating to prioritisation and reinforced motivation may be transferable to other food voucher programs, and perhaps other types of financial support programs designed to encourage dietary improvement ’. 21

A potential challenge of realist reviews was identified across several papers, which related to a lack of detailed data about interventions in published studies (ie, what was performed, by whom, to whom, for how long) and a lack of information about why the intervention was expected to work (intervention theory).

‘ The attempt to identify intervention theories from the included cases confirms that intervention designs underpinning experimental studies have tended to be undertheorised and highlight heterogeneity among studied interventions. Descriptions of intervention theory were frequently absent from the intervention case materials ’. 25

‘ …we were unable to distinguish between something that was not done and something that was done but not reported on because of the stringent word count constraints of medical journals ’. 27

A number of realist evaluations described a single case study and/or common methodological challenges, such as small sample sizes and challenges with data collection. Levay's study of multiple cases across different geographical settings described inconsistency in the source of data across cases due to variation in how researchers were able to collect data in each school district. 22 However, this did not impact on the quality of the findings, as researchers were able to identify the same mechanisms (theory) across cases.

‘ Regardless of whether it was a principal in one district discussing a particular mechanism or a district office staff in a different district discussing the same mechanism, the mechanisms are the same and conclusions can be inferred as to what contextual factors might actually be influencing the underlying mechanisms across context and across individual stakeholders .’ 22

Similarly, realist reviews defined evidence for inclusion as information relevant to the testing and creating of intervention theory. This helped to overcome limitations in the availability of data on a particular intervention theory from traditional sources or study designs. As Harris et al stated:

‘A method that allows the inclusion of a range of different study designs has considerable merit as each design approach may reveal different elements of the intervention are important in fully understanding the mechanisms, and how they are shaped by context and to what types of outcomes these might lead ’. 29

Indeed, Harris et al went beyond using published data and incorporated stakeholders into the theory development process. The following quote also emphasises how a realist methodology provides much‐needed insight into how, why, for whom and under what circumstances complex interventions succeed or fail:

‘ Consulting with stakeholders became a critical part of the process because studies tended to focus on tangible processes and formally measurable outcomes. Informal or tacit information relating to interpersonal relationships and the subtle contextual conditions that may cause interventions to succeed or fail but were often missing from the papers ’. 29

The transferability of realist review findings were also demonstrated. When analysing the included interventions Harris et al analysed studies individually, then compared them to develop transferable intervention theories. 29 These intervention theories were then scaffolded with formal theories relevant to health literacy. There were no examples across all included studies of interventions where research findings were reported to be translated to practice.

4. DISCUSSION

This manuscript aimed to synthesise how realist approaches have been used in nutrition and dietetics research and what impact this had on findings, outcome and research translation. A targeted search of nutrition and dietetics specific journals identified four realist evaluations and five realist reviews. A narrative synthesis was carried out that described how realist research provided a deeper understanding of varied outcomes and the role of context in how and why interventions work. The findings of this study highlighted the importance of theory driven methods, the need to think differently about study quality and how realist findings could inform practice. In doing so, this study shows the potential value in realist approaches for nutrition and dietetics research.

Realist research is well suited to complex, social interventions and this is reflected where realist research has been used in nutrition and dietetics to date. All manuscripts in this study described public health nutrition interventions, which are typically defined by a focus on understanding and addressing determinants of nutrition and health‐related status in populations. 33 Public health nutrition practice also involves significant complexity as multiple, shifting determinants interact in different ways across diverse populations and contexts. Furthermore, it could also be argued that all areas of nutrition and dietetic practice are intrinsically complex in terms of the science of food and nutrition and the systems which dietetic practice must navigate, including health care and food systems. 34 As such, realist research is well placed as an approach to investigate and develop solutions to issues across all areas of nutrition and dietetic practice.

Food service is arguably an area of practice filled with complexity, as it spans health and food service systems, with multiple actors and competing drivers across sustainability and economics. 35 , 36 , 37 Food service is also key to tackling malnutrition, a long‐standing global issue, across settings including hospital and aged care. 38 Furthermore, malnutrition is complex; determinants of malnutrition are multifactorial and not presently well understood. 39 Traditionally, research in this area has focused on building a common understanding of the aetiology of malnutrition 39 and a recent systematic review concluded the need for more RCTs to provide high‐quality evidence. 40 , 41 However, given the complexities of malnutrition, an understanding of how it occurs across different contexts, and interventions that reflect this, could prove beneficial. Realist research offers such an approach to contribute to the development of effective interventions across food service and other practice areas to address malnutrition in the long term (Table  2 ).

Summary of the included published realist reviews from nutrition and dietetics specific journals included in narrative synthesis

Diverse outcomes of nutrition and dietetic interventions were illustrated in this study, both in realist reviews of existing published evidence and in empirical findings of realist evaluations. This is not surprising; diverse outcomes have been reported across many areas of nutrition and dietetics, including interventions in clinical practice. 42 However, this study highlighted how realist research can make a unique contribution towards understanding how and why interventions outcomes may differ. These findings suggest that realist research can contribute to identify gaps in existing nutrition intervention research, in particular, a lack of information about context. A realist research paradigm anticipates varied outcomes, on the premise that interventions are complex, operating in complex environments, with broader social, political and economic contexts that are multifactorial and diverse. 43 As such, realist researchers focus on understanding how context can influence mechanisms to produce outcomes. All of the included papers in this study gathered and analysed data pertaining to contexts and their interactions with underlying mechanisms. It was also observed that context was interpreted and operationalised in different ways across the studies, including context at multiple levels, similar to the socio‐ecological determinants of health, 44 and defining specific contexts related to the intervention and setting. This reflects the way that realist research can explore context as it is relevant to the intervention theory. Overall, the focus on context in a realist approach facilitated a deeper understanding of how and why interventions work in different ways to produce wholly different outcomes, according to context.

Dietetic practice spans a diverse range of areas, however, as with many disciplines, research and in particular translation of research findings tends to be siloed. As a theory‐driven approach, realist research provides opportunity to connect research across practice areas. Researchers may draw on evidence across different types of interventions, where similar mechanisms may contribute to intervention outcomes. Similarly, there is a level of generalisability of realist research findings, as rich, explanatory theory about how and why interventions work across different contexts can be transferable to other interventions, including similar interventions and those that are somewhat different. 45 This was reflected in this study, for example, as Ohly et al suggested that the theory about how and why women use food vouchers in different ways, based on context, which contributes to both intended and unintended outcomes, could be transferable not only to other food voucher interventions, but also other types of financial support interventions. These findings support the notion that realist research can provide portable theory about interventions and that findings can span across seemingly different interventions or practice areas to provide lessons there. In this way, realist research can support the ongoing accumulation and transfer of knowledge in nutrition and dietetics and break down research siloes.

The focus on theory as the unit of analysis also means that realist research can draw on diverse evidence that may not be captured by other research methods. 46 , 47 Realist evaluations in this study were able to use data that would traditionally be considered lower quality, to contribute to rich theory building. Realist evaluation does not prescribe specific methods. In traditional hierarchies of evidence, whereby RCTs are considered the gold standard, qualitative research is perceived as less rigorous. 8 , 48 , 49 Interestingly, all of the realist evaluations in this study gathered qualitative data and none reported quantitative data collection. Researchers also reported a small sample size, lower response rate and limited case settings. However, realist research was able to aid in overcoming what would traditionally be considered study limitations, as the quality of the data was determined by how it contributed to theory building and testing. Similarly, the use of a realist review, compared to a systematic review, by Harris to investigate community‐based peer support in relation to health literacy allowed researchers to use ‘grey’ evidence gathered through stakeholder consultation. This provided key contextual information, which contributed to refined intervention theory, such as how conditions of disparity can compromise the relevance and uptake of the intervention and subsequent outcomes. These examples demonstrate how realist research requires a shift in thinking about research, focusing on how data contributes towards theory development, rather than only whether it is reproducible. In doing so, diverse data collection methods can be utilised in developing meaningful, transferable findings.

None of the studies included in this narrative study gave in‐depth consideration of implementation of findings and this is an area in need of development in realist research. It has been proposed that realist research can provide practical and tangible recommendations to policy makers, particularly when planning and implementing interventions. 14 However, realist research does not provide simple answers about whether interventions work or not, 14 instead providing rich, explanatory theory of how and why interventions work across different contexts. Therefore, translating realist research to policy involves a different way of thinking about interventions and intervention findings; there is no one‐size‐fits‐all approach. It is acknowledged that knowledge translation is a broad field; one scoping review conducted by Haynes et al. looked at the capacity of policy makers to use research findings, and found that among other factors, the usefulness of research to policy makers is context‐specific and based on more than just academic hierarchies. 43 Therefore, realist research, in common with other forms of research, is subject to the context in which it is conducted, including characteristics of the policy makers, communities, organisations and broader environment. It is important, as with any research, that realist research is presented in a way that is easy for policy makers to understand and translate. 50 It is proposed that the applicability of realist research is that it takes into account context within the research and provides situation‐specific wisdom, 51 developing knowledge that matters locally. However, despite the promise of realist approaches to be more useful to decision makers, it was not a focus of any of the papers in this study and is an area of further research both in nutrition and dietetics but also more broadly, to better understand if and how that occurs (Table  3 ).

Glossary of key ‘realist’ terms

This narrative synthesis of realist research in nutrition and dietetics has described how realist approaches have been used and highlighted future opportunities. Realist research is well placed to deal with the complexities of dietetic practice through a focus on theory about how and why interventions operate in different contexts to contribute to diverse outcomes. Future application of realist approaches could advance researchers’ and practitioners' understanding of complex interventions and inform practice to contribute to meaningful outcomes.

AUTHOR CONTRIBUTIONS

The study was initially conceptualised by CP, an APD with extensive experience in health education research together with GJ and IM, APDs with experience in realist research. The researchers further developed and refined the study aim and strategy collaboratively with RH, who has significant expertise in realist research. GJ and IM were responsible for managing the study. The four researchers met regularly throughout the research and CP and RH provided expert review and input at key stages. All authors have approved this manuscript for submission and have not submitted this manuscript or parts of this manuscript elsewhere.

CONFLICT OF INTEREST

Clare Palermo is an Associate Editor for Nutrition & Dietetics. This manuscript has been managed throughout the review process by the Journal's Editor‐in‐Chief. The Journal operates a blinded peer review process and the peer reviewers for this manuscript were unaware of the authors of the manuscript. This process prevents authors who also hold an editorial role to influence the editorial decisions made. There are no other conflicts of interest to declare.

Jenkins G, Maugeri I, Palermo C, Hardwick R. Using realist approaches in nutrition and dietetics research . Nutrition & Dietetics . 2021; 78 :238–251. 10.1111/1747-0080.12675 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Gemma Jenkins and Isabella Maugeri are joint first authors.

Updates for students, alumni, and supporters

• Upcoming Events

Nutrition & Dietetics Department News, Summer 2024

Save the date for fnce conference alumni reception.

We are excited to have the Food & Nutrition Conference & Expo (FNCE), running October 5-8 th , so close to home this year. We plan to host a UND N&D alumni reception in Minneapolis as an opportunity to reconnect.  

Save the date!   

• Date: Sunday, October 6, from 4:30-6:30 p.m.  
• Venue: Jolliet House at The Marquette Hotel, Curio Collection, 710 S Marquette Ave, Minneapolis, MN 55402  
• We hope that you will save the date to join us! RSVP details will be sent out via email in the coming weeks.   

Join us to reconnect with old friends, meet current faculty, staff, and students, and enjoy light refreshments.

Can’t make it to the event?

Can you help defray the costs for a current UND student to attend? With the conference so close to UND, the department is planning on sending our current students. Costs will include conference fees, travel, and hotel.

If you are interested in supporting a student, you can give a gift securely online or by mail. Just specify “support students at FNCE” in the memo area. If you have questions on this, contact Hailey Huspek at [email protected] or at 701.777.5608.  

Alumni Discount on Graduate Certificate in Health and Wellness Coaching

Unlock a special tuition discount and elevate your career by completing our graduate certificate in health and wellness coaching.

We are excited to offer a 20% tuition discount for any UND alumni on our 9-credit Graduate Certificate in Health and Wellness Coaching! We are accepting students for F all 2024 who are eligible for this special alumni opportunity. >>READ MORE or contact the program director, Anne Bodensteiner, at  [email protected]  or 701-777-3752.

N&D Quick Hits

• Recent UND alum, Sydney Johnson , who just landed a dream job as a renal dietitian, shares about her journey and experience at UND in the CNPD blog .
• The Nutrition & Dietetics department’s students and faculty were highlighted in a UND Today story about the college’s annual research showcase. More than 80 students presented at the event, representing multiple disciplines across the college. Congratulations to Dr. Anne Bodensteiner, who was recognized as one of the Faculty Research and Scholarship Contribution Award recipients. Online student submission recordings are available in the event catalog .
• The Gardening for Healthy Living Grant, spearheaded by Erin Lauckner and Desiree Tande , aims to offer nutrition education through produce gardening, enhancing fruit and vegetable intake among the community. With the ultimate goal of improving food security and reducing chronic disease risks, this initiative has seen remarkable progress since its inception. Several innovative activities have been implemented to bring this project to life: Vegetables in campus flower containers, Scavenger hunt assignments focused on benefits of local produce, GRO.UND Learning Garden Tour, Fall Farmers Market booth, and various Nutrition Education Booths during Earth Day and the NDNC Conference.
• The UND Department of Nutrition & Dietetics announced the awarding of $46,150 in scholarships for the 2024-2025 academic year to Nutrition & Dietetics students. The recipients were recognized at the Spring SAND banquet. The department wishes to extend a thank you to the generous donors for their unwavering support. For more information about our scholarship opportunities and donors, please visit our Scholarship Info page .
• Congratulations to the 2023-2024 Outstanding Student Awards recipients recognized at the Spring banquet: Outstanding Student Leader: Rachel Qualley , Outstanding Student Leader: Claudia PromSchmidt , Outstanding Graduating Senior Award – Human Nutrition: Skylar Thingvold , and Outstanding Graduating Senior Award – Dietetics: Quinn Hilber .
• Danielle Villano , Nutrition & Dietetics faculty, successfully defended her PhD dissertation. “Advancing Nutrition and Dietetics Students’ Preparation for Clinical Practice Through Simulation-based Learning Experiences.”
• Brenna Swanson , Nutrition & Dietetics faculty, successfully defended her PhD dissertation, “An Exploration of Educational Strategies in National Board of Health and Wellness Coaching Programs.”
• UND Dietetics Alum, Rayman Zimmerman, is featured in a video speaking on the use of simulation in Nutrition & Dietetics education. The video was produced as part of UND’s Simulation in Healthcare week celebration week, a collaborative event between the UND School of Medicine & Health Sciences (SMHS) and College of Nursing & Professional Disciplines (CNPD).
• UND alum Jami Rokala was highlighted in a video as part of RDN Day recognition for the college.
• Congratulations to department faculty Brenna Swanson, Danielle Villano , and Erin Lauckner on their promotion to the role of Clinical Assistant Professor.
• N&D students and faculty and the Nutrition lab were included in UND’s latest commercial !
• We appreciate community partners like Dakota TV & Appliance for their long-standing support of supplying equipment for our N&D lab.

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Mediterranean diet tied to one-fifth lower risk of early death in women

Investigators from Brigham and Women's Hospital identified and assessed underlying mechanisms that may explain the Mediterranean diet's 23 percent reduction in all-cause mortality risk for American women

The health benefits of the Mediterranean diet have been reported in multiple studies, but there is limited long-term data of its effects in U.S. women and little understanding about why the diet may reduce risk of death. In a new study that followed more than 25,000 initially healthy U.S. women for up to 25 years, researchers from Brigham and Women's Hospital, a founding member of the Mass General Brigham healthcare system, found that participants who had greater Mediterranean diet intake had up to 23% lower risk of all-cause mortality, with benefits for both cancer mortality and cardiovascular mortality. The researchers found evidence of biological changes that may help explain why: they detected changes in biomarkers of metabolism, inflammation, insulin resistance and more. Results are published in JAMA .

"For women who want to live longer, our study says watch your diet! The good news is that following a Mediterranean dietary pattern could result in about one quarter reduction in risk of death over more than 25 years with benefit for both cancer and cardiovascular mortality, the top causes of death in women (and men) in the US and globally," said senior author Samia Mora, MD, a cardiologist and the director of the Center for Lipid Metabolomics at the Brigham.

The Mediterranean diet is a plant-based diverse diet that is rich in plants (nuts, seeds, fruits, vegetables, whole grains, legumes). The main fat is olive oil (usually extra virgin), and the diet additionally includes moderate intake of fish, poultry, dairy, eggs, and alcohol, and rare consumption of meats, sweets, and processed foods.

The current study investigated the long-term benefit of adherence to a Mediterranean diet in a U.S. population recruited as part of the Women's Health Study, and explored the biological mechanisms that may explain the diet's health benefits. The study investigators evaluated a panel of approximately 40 biomarkers representing various biological pathways and clinical risk factors.

Biomarkers of metabolism and inflammation made the largest contribution, followed by triglyceride-rich lipoproteins, adiposity, insulin resistance. Other biological pathways relate to branched-chain amino acids, high-density lipoproteins, low-density lipoproteins, glycemic measures, and hypertension have smaller contribution.

"Our research provides significant public health insight: even modest changes in established risk factors for metabolic diseases -- particularly those linked to small molecule metabolites, inflammation, triglyceride-rich lipoproteins, obesity, and insulin resistance -- can yield substantial long-term benefits from following a Mediterranean diet. This finding underscores the potential of encouraging healthier dietary habits to reduce the overall risk of mortality," said lead author Shafqat Ahmad, PhD, an associate professor of Epidemiology at Uppsala University Sweden and a researcher in the Center for Lipid Metabolomics and the Division of Preventive Medicine at the Brigham.

The current study identifies important biological pathways that may help explain all-cause mortality risk. However, the authors note some key limitations, including that the study was limited to middle aged and older well-educated female health professionals who were predominantly non-Hispanic and white. The study relied on food-frequency questionnaires and other self-reported measures, such as height, weight and blood pressure. But the study's strengths include its large scale and long follow up period.

The authors also note that as the concept of the Mediterranean diet has gained popularity, the diet has been adapted in different countries and cultures.

"The health benefits of the Mediterranean diet are recognized by medical professionals, and our study offers insights into why the diet may be so beneficial. Public health policies should promote the healthful dietary attributes of the Mediterranean diet and should discourage unhealthy adaptations," said Mora.

• Cholesterol
• Diet and Weight Loss
• Food and Agriculture
• Endangered Plants
• Population dynamics of fisheries
• Mammography
• Head injury
• Cervical cancer
• Appendicitis
• Breast cancer

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Materials provided by Brigham and Women's Hospital . Note: Content may be edited for style and length.

Journal Reference :

• Shafqat Ahmad, M. Vinayaga Moorthy, I-Min Lee, Paul M Ridker, JoAnn E. Manson, Julie E. Buring, Olga V. Demler, Samia Mora. Mediterranean Diet Adherence and Risk of All-Cause Mortality in Women . JAMA Network Open , 2024; 7 (5): e2414322 DOI: 10.1001/jamanetworkopen.2024.14322

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New horizons with the Department of Nutrition

Student ellie goen ’25 charts a medical career, finds her fit in nutrition.

May 21, 2024 - by Mamie Hertel

Ellie Goen ’25 comes from a family deeply rooted in the medical field and Texas A&M University , with both parents being proud Aggies. Her father, an emergency physician, and her mother, a nurse, taught her she could shape her own future with determination and effort.

Goen, hesitant about following in her parents’ footsteps, was unsure about pursuing a medical career or attending Texas A&M. However, her perspective changed during college tours when she discovered that the College of Agriculture and Life Sciences might offer the perfect fit for her.

While exploring potential majors, Goen unexpectedly found herself interested in nutrition.

“I had never considered majoring in nutrition, but something about it resonated with me,” Goen explained. “The heavy emphasis on science in the curriculum intrigued me, despite the challenge I knew it would present. Nutrition intersects with every aspect of our lives, and while I wasn’t certain about my career path, I recognized that it would provide a solid foundation for whatever I chose to pursue.”

Checking emails and career paths

With her newfound focus on nutrition, Goen centered her high school senior thesis on the topic and becoming a dietitian, a common career path for students within the Department of Nutrition . While this project solidified her interest in nutrition, the idea of pursuing the department’s Didactic Program and a career as a dietitian didn’t captivate her.

Toward the end of Goen’s first semester at Texas A&M, she began to question her major, feeling disconnected from the desire to become a dietitian.

“I contemplated changing my major, but the department advisors urged me to stick with it, assuring me there were numerous career avenues I had yet to explore,” Goen recounted.

A few months later, she stumbled upon an undergraduate research opportunity that intrigued her in an unexpected place: her email inbox. She received a message from Heidi Vanden Brink , Ph.D., an assistant professor in the Department of Nutrition who conducts research on endocrinology and the impact of nutrition on polycystic ovary syndrome, PCOS. This was a subject that grabbed Goen’s attention, and seizing the opportunity, she applied for the undergraduate research position.

Now, after four semesters of research, Goen has found her calling in nutrition.

“Continuing my studies in nutrition was undoubtedly the best decision I’ve ever made,” Goen said. “Through my research and coursework, I’ve found a passion for endocrinology. Even if I ultimately decide not to pursue medical school to become an endocrinologist, my experiences as a nutrition major have given me a solid foundation for success.”

Finding a niche in nutrition

Goen is one of many students in the Department of Nutrition who have discovered their calling for a wide range of health care-related careers. Within the department, students aspire to pursue diverse paths, including becoming a registered dietitian nutritionist, as well as medicine, dentistry, nursing, physician assistantship, occupational therapy, optometry, pharmacy, physical therapy and various other health professions including graduate school for biomedical research.

“Nutrition has a substantial influence on health and disease,” said David Threadgill, Ph.D., head of the Department of Nutrition. “It permeates every facet of life, and our department is dedicated to equipping students to successfully compete for admission to professional and graduate schools, as well as dietetic internships.”

The department offers both a human health track and a dietetics track , each providing essential coursework for students interested in health care professions.

In addition to its distinctive curriculum, the department prides itself on intimate class sizes and attentive advising, both of which played pivotal roles in Goen’s journey toward discovering her passion for endocrinology.

Threadgill said while nutrition is often synonymous with dietetics, the department has expanded its scope to offer a comprehensive approach, empowering students to excel in any health-related career.

“I’ve noticed that many common premed majors tend to have large student cohorts, resulting in less personalized instruction and guidance,” Goen said. “I appreciate that within the nutrition program, I don’t feel like just another face in the crowd. I can easily schedule regular meetings with my advisor and the faculty, particularly Dr. Vanden Brink who has provided me with invaluable mentorship. This is a testament to the department’s commitment to helping each student find their niche in the field of nutrition like I have.”

“Students like Ellie exemplify how a degree in nutrition can unlock a plethora of medical opportunities,” Threadgill said.

Find your future in health

The Department of Nutrition offers a wide range of opportunity for students interested in a career within the health professions. Discover your niche via the department’s robust undergraduate degree programs.

Learn about the degree options

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Qualitative research in nutrition and dietetics: getting started

Affiliation.

• 1 Division of Nutritional Sciences, School of Biosciences, The University of Nottingham, Sutton Bonington Campus, Loughborough, Leicestershire, UK. [email protected]
• PMID: 21029212
• DOI: 10.1111/j.1365-277X.2010.01116.x

Qualitative research is well placed to answer complex questions about food-related behaviour because it investigates how and why individuals act in certain ways. The field of qualitative health research is undoubtedly gaining momentum and, increasingly, there is a recognition that it should be a vital part of the decision-making processes that direct the development of health policy and practice. Much of the guidance available, however, is difficult to navigate for those new to 'qualitative research', and there is little discussion of qualitative research issues specifically in relation to nutrition and dietetics. This review, the first in a series, outlines the field of qualitative enquiry, its potential usefulness in nutrition and dietetics, and how to embark upon this type of research. Furthermore, it describes a process to guide high-quality qualitative research in this area that proceeds from the research question(s) and considers the key philosophical assumptions about ontology, epistemology and methodology that underpin the overall design of a study. Other reviews in this series provide an overview of the principal techniques of data collection and sampling, data analysis, and quality assessment of qualitative work, and provide some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.

© 2010 The Authors. Journal compilation © 2010 The British Dietetic Association Ltd.

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Medical school isn't teaching doctors much about nutrition, according to researchers

by Leigh Hataway, University of Georgia

Nutrition is a key determinant of health. But American physicians aren't receiving effective training to counsel patients on the topic, according to a new paper from University of Georgia researchers.

Current medical training focuses on weight and body mass index (BMI), exacerbating anti-obesity bias and increasing the risk of eating disorders, the authors said. And it doesn't give future doctors adequate education on how to encourage healthier eating habits.

"Mainstream medicine is still very focused on linking weight to health," said Kearney Gunsalus, lead author of the paper and an assistant professor at the Augusta University/University of Georgia Medical Partnership.

"Because people with obesity and higher body weights are more likely to have health problems , it's easy to jump to the conclusion that the weight itself is causing those problems. And if you assume that the weight is causing the problems, it seems logical to assume that weight loss is the solution."

Research has shown that being overweight may not mean being unhealthy, the researchers said.

The researchers advocate that small changes to medical education and in how health care providers interact with their patients could have a real impact on some of the greatest health challenges facing the world today.

BMI is not an accurate measure of health, cardiometabolic health is

BMI has long been the standard for sorting individuals into four main categories: underweight, healthy weight, overweight or obese. And it's taught in medical school as a way of gauging a patient's general health.

The problem is it's not accurate, the researchers said. BMI overestimates the number of people who are unhealthy.

Medical education on nutrition should instead focus on objective measures of cardiometabolic health. Cardiometabolic health includes things like blood pressure, insulin resistance, cholesterol levels and more. And it is a much stronger predictor of overall health.

Previous research demonstrated that almost half of Americans deemed overweight by BMI standards are actually metabolically healthy. About one in three whose BMI is in the "healthy" range are actually unhealthy when assessed by more comprehensive measures.

"When you look at some of the newest studies on obesity surgeries and the use of medications like Ozempic and Wegovy, it appears that patients can see health benefits even without weight loss," said Dr. Ellen House, co-author of the publication and an associate professor at the Medical Partnership.

"We really love things that are clear-cut and black and white in medicine. But if the benefits precede and appear to be independent of weight loss, we need to shift the conversations physicians have with their patients to focus more on health and not weight loss."

Anti-fat bias negatively affects patient care

In addition to focusing exclusively on weight loss and BMI, current medical education often neglects to address weight stigma, the researchers said.

Weight stigma connects obesity with moral failures, laziness and gluttony without accounting for the biologic and systemic factors that intersect with weight. These factors include availability of fresh, healthy foods, the ability to afford those foods and access to safe spaces to exercise, among others.

This bias may lead physicians to be less empathetic toward their overweight patients and to provide lower quality care.

"Overweight patients are less likely to get the appropriate screenings or treatments for their medical concerns," said House, who is also a board-certified psychiatrist. "Physicians will miss the asthma, they'll miss the cancer, because they attribute symptoms to weight when weight isn't what's causing the patient's concerns."

Those negative interactions where health concerns are dismissed with a simple "just lose weight" demoralizes patients and can make them less likely to share problems going forward. Shaming patients for their weight can sour patients on the health care system in general, prompting them to stop seeking medical care even when they really need it, the researchers said.

Reframing the conversations between doctor and patient to focus on healthful behaviors, such as moving more and avoiding labeling foods as inherently "good" or "bad," can go a long way in encouraging individuals to move toward health.

"I think doctors are trying to help people be healthier by advising them to lose weight; they're just not aware of the harms that can be done by that advice," Gunsalus said. "If I could wave a magic wand and have doctors do one thing differently when interacting with their patients, it would be to start from the assumption that every patient wants to be and is capable of being healthy."

The findings are published in the journal Medical Science Educator .

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Fats and Cholesterol

When it comes to dietary fat, what matters most is the type of fat you eat. Contrary to past dietary advice promoting low-fat diets , newer research shows that healthy fats are necessary and beneficial for health.

• When food manufacturers reduce fat, they often replace it with carbohydrates from sugar, refined grains, or other starches. Our bodies digest these refined carbohydrates and starches very quickly, affecting blood sugar and insulin levels and possibly resulting in weight gain and disease. ( 1-3 )
• Findings from the Nurses’ Health Study ( 4 ) and the Health Professionals Follow-up Study ( 5 ) show that no link between the overall percentage of calories from fat and any important health outcome, including cancer, heart disease, and weight gain.

Rather than adopting a low-fat diet, it’s more important to focus on eating beneficial “good” fats and avoiding harmful “bad” fats. Fat is an important part of a healthy diet. Choose foods with “good” unsaturated fats, limit foods high in saturated fat, and avoid “bad” trans fat.

• “Good” unsaturated fats — Monounsaturated and polyunsaturated fats — lower disease risk. Foods high in good fats include vegetable oils (such as olive, canola, sunflower, soy, and corn), nuts, seeds, and fish.
• “Bad” fats — trans fats — increase disease risk, even when eaten in small quantities. Foods containing trans fats are primarily in processed foods made with trans fat from partially hydrogenated oil. Fortunately, trans fats have been eliminated from many of these foods.
• Saturated fats , while not as harmful as trans fats, by comparison with unsaturated fats negatively impact health and are best consumed in moderation. Foods containing large amounts of saturated fat include red meat, butter, cheese, and ice cream. Some plant-based fats like coconut oil and palm oil are also rich in saturated fat.
• When you cut back on foods like red meat and butter, replace them with fish, beans, nuts, and healthy oils instead of refined carbohydrates.

Read more about healthy fats in this “Ask the Expert” with HSPH’s Dr. Walter Willett and Amy Myrdal Miller, M.S., R.D., formerly of The Culinary Institute of America

1. Siri-Tarino, P.W., et al., Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients. Curr Atheroscler Rep, 2010. 12(6): p. 384-90.

2. Hu, F.B., Are refined carbohydrates worse than saturated fat? Am J Clin Nutr, 2010. 91(6): p. 1541-2.

3. Jakobsen, M.U., et al., Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index. Am J Clin Nutr, 2010. 91(6): p. 1764-8.

4. Hu, F.B., et al., Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med, 1997. 337(21): p. 1491-9.

5. Ascherio, A., et al., Dietary fat and risk of coronary heart disease in men: cohort follow up study in the United States. BMJ, 1996. 313(7049): p. 84-90.

6. Hu, F.B., J.E. Manson, and W.C. Willett, Types of dietary fat and risk of coronary heart disease: a critical review. J Am Coll Nutr, 2001. 20(1): p. 5-19.

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