This learning activity is relevant to the Nursing Council of New Zealand competencies: 1.2, 2.4 and 4.3.
Reading and reflecting on this article will enable you to:
- Demonstrate the ability to apply the principles of the Treaty of Waitangi Te Tiriti o Waitangi to nursing practice.
- Ensure the health consumer has adequate explanation of the effects, consequences and alternatives of proposed treatment options.
- Participate in quality improvement activities to monitor and improve standards of nursing.
In January 2019 more than 35 experts published Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems, a new way of looking at food that is both healthy for people and sustainable within planetary boundaries (2019).
Radical changes dubbed ‘The Great Intergenerational Food Transformation’ are required to feed around 10 billion people by 2050 and limit harmful pollution and greenhouse gases (GHG). Presently around 820 million people are hungry and undernourished, while more than 2 billion adults are overweight and obese and suffer the consequences of diets high in fat, salt and sugar, such as heart disease, cancer and type 2 diabetes.
A third of New Zealand children are either overweight or obese, and rates are higher amongst Māori and Pasifika children (Health Navigator, 2019), leading to further inequalities in health. In 2017, more than 96,000 children had teeth extracted due to dental decay. We also have one of the highest cancer rates in the world.
The World Health Organization (WHO) states that climate change is the biggest threat to global health in the 21st century. According to Patricia Espinosa, Executive Secretary of the United Nations Framework Convention on Climate Change, “we can no longer afford incremental progress when tackling climate change – we need deep, transformational and systemic change throughout society, which is crucial for a low-emissions, highly resilient and more sustainable future” (Espinosa, 2019).
The Intergovernmental Panel on Climate Change (IPCC) has given stark warnings to drop our emissions to net zero by 2050 so that the Earth’s temperature rises no more than 2°C, or better still, 1.5°C.
For this to be achievable, we need to halve our emissions over the next decade requiring unprecedented support from government, corporations, communities and households.
We are currently tracking towards a 4°C temperature rise if we continue with ‘business as usual’, meaning that half the world’s coastal cities will be gone, displacing 100 million people. This is also a social justice issue, as the countries that contribute least to greenhouse gas emissions are often less-developed nations that will be the most affected by climate change. In New Zealand, Māori health will be disproportionately affected by climate change, further engendering inequity (Bennet et al., 2014).
The effects of climate change are already being felt and will continue to lead to an increase in extreme weather events, water and food insecurity, rising sea levels, mass migrations, species extinction and increased conflict. These effects impact directly on the basic determinants of health, such as clean air and water, healthy food and a safe environment. We must transition quickly from our reliance on fossil fuels like oil and coal to renewable energy sources.
What is New Zealand’s role in this? The government has ratified the Paris Agreement of 2016 and is aiming to reduce our emissions to net zero by 2050 through the Climate Change Response (Zero Carbon) Amendment Bill.
This bill will do four key things:
- Set a new greenhouse gas emissions reduction target to:
- reduce all greenhouse gases (except biogenic methane) to net zero by 2050
- reduce emissions of biogenic methane within the range of 24–47 per cent below 2017 levels by 2050 including to 10 per cent below 2017 levels by 2030.
- Set a series of emissions budgets to act as stepping stones towards the long-term target.
- Require the government to develop and implement policies for climate change adaptation and mitigation.
- Establish a new, independent Climate Change Commission to provide expert advice and monitoring to help keep successive governments on track to meeting long-term goals.
The recent School Strike 4 Climate NZ student protests inspired by Swedish teenager Greta Thunberg, in which New Zealand school students in their tens of thousands took part, and the global Extinction Rebellion movement, show that the public is demanding more action on climate change. This has also been supported by the recent BBC series One Planet and the documentary Climate Change – The Facts narrated by Sir David Attenborough, further increasing the public’s awareness of climate change.
Almost half of our GHG emissions are from agriculture (dairy, sheep, beef and other). Cows produce methane, which, although it has a shorter life span, is much more potent than carbon. Energy use makes up around another 40 percent, half of which is from transport.
Food production is responsible for up to 30 percent of GHG emissions in New Zealand. Our native forests have been cleared, with our largest land cover now being pasture. We are currently using masses of nitrogen fertiliser to enable productive crop yields; however, this fertiliser is a finite resource and is also harming water quality in New Zealand.
According to the government’s Environment Aotearoa 2019, water quality is a concern for many people in New Zealand as many of our rivers and lakes are no longer safe to swim in or drink from. There is growing public concern around the use of plastic and the impacts of climate change (Colmar Brunton Better Futures Report, 2019). How do we transform these concerns into meaningful action at the scale required?
The three global pandemics of climate change, malnutrition and obesity are all linked (Eat–Lancet, 2019a). Changes to our food system are urgently needed and have the potential to both improve people’s health and promote environmental sustainability, which is termed a ‘co-benefit’. Dr Rhys Jones, co-convenor of OraTaiao: The New Zealand Climate and Health Council, states that “healthy and sustainable diets are a win-win for people and the planet”.
How does this affect our practice as registered nurses?
The International Council of Nurses (ICN) acknowledges the risks of climate change to health and has called for increased leadership within nursing to combat the effects of climate change on health. In alignment with the EAT–Lancet report, the American Nurses Association has included sustainability as part of their core nursing competencies, while the British Dietetic Association has released the ‘One Blue Dot’ summary and the Canadian government has recently updated their national dietary guidelines.
Nurses make up the largest health workforce in New Zealand and are highly regarded by the public. With over 56,000 of us in New Zealand, we are in a key position to talk to our patients about the link between dietary choices and health and are well placed to offer evidence-based lifestyle information.
The Ministry of Health has this year updated its online healthy food guidelines. The traditional ‘food pyramid’ is out, with the new focus being on enjoying a variety of nutritious foods, split into four main categories:
- Plenty of vegetables and fruit.
- Grain foods, mostly whole grain and those naturally high in fibre.
- Some milk and milk products, mostly low and reduced-fat/plant-based milk.
- Some legumes, nuts, seeds, fish and other seafood, eggs or poultry, and red meat with the fat removed.
So how does this compare with the new Planetary Health Diet? Let’s take a look. There are many popular diets and EAT–Lancet has taken the best evidence for a healthy, balanced human diet that is achievable within planetary limits. Guidance is provided on the healthy range of foods that can be eaten; this is flexible to allow for varying dietary patterns, health needs and cultural preferences.
The Planetary Health Diet
The Planetary Health Diet over one day could look like this
Visually, in one meal this looks like half a plate of fruit and vegetables (not including potato). Around 50g of potato or kumara is considered a serve. Recent dietary advice has concluded that six hot chips is considered a serving size, which is much less than a typical ‘scoop’ served as part of the Kiwi classic, fish ’n’ chips.
Whole grains include rice, wheat and corn. This is important to note for anyone currently following a low-carb or keto diet, as they may be missing out on essential nutrients from this food group. Vegetables should include a mix of dark green leafy vegetables and a variety of colours. At least two serves of fruit a day is recommended, so overall, we can still promote the commonly used advice of ‘5+ a day’.
Although dairy has long been encouraged for bone health, and specifically fracture reduction, in fact WHO notes that countries with low dairy consumption actually have lower fracture rates.
Low calcium intake is only one of the contributors to fracture risk, and people regularly underestimate other factors, such as physical inactivity, low fruit and vegetable intake, smoking, alcohol intake and vitamin D status.
The reference diet states that dairy can come from either animal or plant-based sources. It recommends that fish, which is high in omega-3 fatty acids, should come from sustainable sources; however, certain types should be avoided by pregnant or breastfeeding women due to high levels of mercury.
The recommendation for eggs is about one and a half a week; however, low-income populations with poor diet quality, it states, would benefit nutritionally from a higher intake. Nuts and seeds are a powerhouse of energy and should be encouraged.
According to The Lancet, the intake of almost all healthy foods and nutrients around the world in 2017 was less than recommended, while the intake of unhealthy foods was too high, particularly sugar-sweetened beverages, processed meats and sodium (The Lancet, 2019b). Eating ‘treat’ foods every day sets taste preferences for those foods and makes healthier choices less favourable.
We need to focus on eating more fruit and vegetables, nuts, legumes (beans, peas, chickpeas, soy beans) and wholegrains. For some, this will also mean a shift towards eating less red meat and fewer dairy products, not only for health reasons but also because these have the highest GHG emissions.
People may still include small amounts of animal protein; however, it is no longer considered a necessity. For example, those choosing to eat a steak can still do so, but should think of this more as a once-a-month food. There are also many benefits from a diet that is higher in fibre, such as a reduced incidence of constipation, heart disease, stroke, type 2 diabetes and bowel cancer.
Some people will already be following certain dietary patterns, so it pays to be familiar with them. These are:
- Omnivore – meat and plants.
- Pescatarian – plants and no meat, except some fish and seafood.
- Vegetarian – plants and no meat.
- Vegan – plants, no animal products (meat, cheese, milk, honey, eggs, gelatine etc…).
- Whole food plant-based – plants, no animal products, with an emphasis on healthy, unprocessed food.
Veganism and whole food plant-based eating are already on the rise globally, with around one in 10 New Zealanders going mostly meat-free in 2018 (Colmar Brunton Better Futures Report, 2019).
Well-planned, plant-based diets can meet nutritional requirements with some possible considerations for pregnant women, children and adolescents and those with chronic medical conditions.
It is recognised by the Academy of Nutrition and Dietetics in the US that“appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases. Well-planned vegetarian diets are appropriate for individuals during all stages of the life cycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes” (2009).
A focus on eating more plant-based foods and reducing meat and dairy consumption linked to personal health and sustainability is likely to be more acceptable than suggesting a shift towards a vegetarian or vegan diet.
Care needs to be taken with vegan diets as they can still be high in fat, salt and sugar. Note that supplementing with Vitamin B12 is essential for those following a vegan diet, although many who do eat animal products are also lacking in Vitamin B12.
What should we be doing?
As renowned author Michael Pollen states, “vote with your fork”. We know that consumer-driven shifts in dietary choices are met through the market, as we have already seen an increase in vegetarian and plant-based options hitting mainstream supermarket shelves. There is already a vast amount of knowledge in this area due to our being such a multicultural and globally connected society.
How we grow food, what we choose to grow and how we transport it all need to be considered. Other key messages are to avoid food wastage, as this contributes significantly to unnecessary GHG emissions.
Plan meals ahead and cook more at home. Also, buy locally grown, seasonal foods and grow your own food if you can. Less food waste saves money and reduces wastage. This is supported by the Ministry of Health’s Sustainability and the Health Sector guideline (2019), which includes six key action points around food, of which reducing food wastage is one. The ministry also supports reducing meat and dairy and encouraging more plant-based diets.
Nurses must incorporate Tiriti O Waitangi principles into their practice.
Knowledge about caring for the environment and the interconnection of health and wellbeing is not new. For Māori, as tangata whenua, there is a key link between health and care for Papatūānuku (the land), Rangi-nui (the sky) and Rongo-mā-Tāne (cultivated vegetables) among others.
Sir Mason Durie, renowned for Te Whare Tapa Whā, a holistic model of health in Aotearoa, has recently developed a further model based on the Matariki constellation that is broader and includes the links between the rights of indigenous peoples, families, communities and the whole environment.
One rising young entrepreneur, Raniera Rewiri, also known as ‘The Plant-based Māori’ on social media, is sharing the plant-based message from a Māori perspective. His work encourages others to be more mindful of their food choices. The change is coming, with Aotearoa’s largest marae, Ngaruawahia’s Turangawaewae marae, already serving vegan meals to improve people’s health.
Time for brave conversations
As we talk to patients about lifestyle choices, it means having brave conversations about the new Planetary Health Diet.
Nurses have a moral and ethical duty of care to act in the best interests of health. People will have different incentives for making changes in eating habits – personal health, environmental concern or animal welfare – but creating a space in which healthy and sustainable diets are normalised helps people move towards them.
Focusing on encouragement, rather than what must be reduced, is more likely to have a positive effect. Already in Norway over the past year, one in five people have reduced their meat intake and almost half have reduced their food waste, because of concern about climate change.
Nurses have a key role in supporting the great food transformation, in their work with clients, the workplace, their own lives, with their family and local communities.
The changes required over the next decade are immense. Rather than feel overwhelmed by the task ahead, focus on what we can do, which is what nurses are already so good at.
When there is an emergency, nurses don’t sit down and feel the problem is too big; they prioritise, roll their sleeves up and jump to action.
Prime Minister Jacinda Ardern has said that climate change is our nuclear-free movement. Nurses getting behind the cause and supporting change around what we eat, and why, can have a huge impact on reducing our GHG emissions and enhancing people’s health, for the wellbeing of future generations and, indeed, our planet.
About the Author
Rebecca Sinclair, RN PgDip SCPHN is a Public Health Nurse, member of the College of Nurses Aotearoa and of OraTaiao: The New Zealand Climate and Health Council.
This article was peer reviewed by
- Dr Chloe Corbett, BBiomedSci MBChB DCH
- Rose Cairns-Morrison, Public Health Nurse, Child & Family North, Waitematā DHB
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