As a health professional, it is important that you are familiar with Canada’s Food Guide 2019. Amidst rapidly changing food trends and evolving fads, the food guide offers health professionals concise and reliable information to inform professional practice. You can find the guide and related documents online at: Canada’s food guide. You will find that there are many resources, some directed at the health professional and some directed at the consumer (i.e., the client/family). A selection of the documents of interest include:

• The food guide snapshot
• Canada’s Dietary Guidelines for Health Professionals and Policy Makers
• Healthy eating recommendations
• Tips for healthy eating
• Recipes

As a health professional, part of your scope of practice is to engage in health promotion and disease prevention discussions with clients as illustrated in Figure 1.1. This engagement transcends primary care, secondary care, and tertiary care across the lifespan. One component of a comprehensive health promotion approach is an active dialogue about eating patterns (sometimes referred to as diet). Nutrition and eating patterns in healthcare often focus on food choices (eating “nutritious” and “not so nutritious” foods) and behaviours (eating “too much” or “too little”). While focusing on eating patterns may be useful for having individual discussions with clients, health professionals also need to be cognizant of the broader social context that informs nutrition and food security, also known as the social determinants of health.

By understanding the social determinants of health, health professionals can have meaningful discussions with clients about nutrition that resonate with their life circumstances. For example, your discussion may extend beyond just “what to eat” to also consider food security, access to fresh foods, ways to store it, and dietary risk which have implications for health and illness. Additionally, culture is an important determinant that influences eating patterns and food choices, and this may not necessarily translate to what is reflected in the food guide. Thus, health professionals should be curious about culture, equipped with skills to help clients better understand how their foods fit within, or even beyond, the food guide, and how their cultural eating practices can lead to healthy food decisions.

Although this resource does not focus specifically on social determinants of health, it seeks to highlight the social framework that surrounds the food guide. As a health professional, you need to be prepared to discuss eating, health, and the food guide with clients and their families across the lifespan. Understanding and interpreting the food guide is important at all stages of life; however, discussion between clients and health professionals are typical during early childhood development, pregnancy, and in the context of illness.

There have been many variations of the food guide over several decades, as illustrated in Figure 1.2. The original food guide emerged in 1942; however, it was referred to as “food rules” at the time (Health Canada, 2019a). As you can imagine, the term “rule” is no longer used because it implies rigid principles with no recognition of social and cultural context. Prior to the 2019 version, the most recent adaptation to the food guide happened in 2007. That iteration included recommendations based on some studies and focused on four food groups: Vegetables and fruit; Grain products; Milk and alternatives; and Meat and alternatives. It also included recommended number of servings in each food group and information about what is considered a serving for different types of food, based on gender and age.

In early 2019, Health Canada released a new food guide with accompanying documents such as “Canada’s Dietary Guidelines for Health Professional and Policy Makers.” The aim of these resources is to support Canadians in patterns of healthy eating and nutritional well-being (Health Canada, 2019b). Alongside evidence-informed healthcare and decision making, it was time for a new food guide, especially since the last one was released over ten years ago. As a healthcare professional and/or a student in a health-related program, you are probably aware that guiding documents and resources should be informed by current evidence, which is typically considered five to ten years.

The new version of Canada’s Food Guide, hereafter referred to as Canada’s Food Guide 2019, has piqued great enthusiasm and interest because this version is based on evidence gathered from scientific reports, particularly systematic reviews, and wide-ranging consultation with health professionals, population and nutrition experts, national Indigenous organizations, and the general population (Health Canada, 2019b). The fact that this food guide is evidence-informed is significant because it aligns with the discourse of evidence-informed decision making in healthcare and the abundance of health benefits and risks related to nutritional intake. Additionally, previous food guides were influenced by the food and beverage industry, which biased the recommendations.

Check out Film Clip 1.1 of an audio podcast by historian Dr. Ian Mosby who talks about the evolution of the food guide and the limitations of the current version.

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/foodguide/?p=44

Film Clip 1.1: Dr. Ian Mosby speaking about the evolution of the food guide

Content in the first paragraph was adapted, with editorial changes, from Nutrition and Labelling for the Canadian Baker by go2HR and is used under a Creative Commons Attribution 4.0 International License.

Most Canadians see the image below (Figure 1.3) when they first attempt to access Canada’s Food Guide 2019 (Health Canada, 2019b). This image is part of the “Food guide snapshot” that is often shared with clients and families as a starting point for discussion.

When scanning the plate in Figure 1.3, you will notice a colourful plate with a diverse mix of foods in which: half the plate is filled with vegetables and fruit; one quarter of the plate has proteins including tofu, legumes, nuts, seeds, yogurt, lean meat/fish and only a small amount of red meat; one quarter of the plate has whole grain foods (e.g., bread, pasta, rice); and, there is a glass of water beside the plate.

The food guide snapshot is now available in 28 languages as illustrated in Figure 1.4.

There are three specific guidelines that inform “Canada’s Dietary Guidelines for Health Professionals and Policy Makers” (Health Canada, 2019b).

As illustrated in Figure 1.5 and outlined in Table 1.1, the first guideline focuses on the integration of nutritious foods to form the foundation of a person’s eating patterns (Health Canada, 2019b). This reproduction (Table 1.1) is a copy in part of the version available at: https://food-guide.canada.ca/static/assets/pdf/CDG-EN-2018.pdf.

Table 1.1: Canada’s Dietary Guidelines: Guideline 1

As illustrated in Figure 1.6 and outlined in Table 1.2, the second guideline focuses on the reduction of foods and beverages that are processed and pre-packaged (Health Canada, 2019b). This reproduction (Table 1.2) is a copy in part of the version available at: https://food-guide.canada.ca/static/assets/pdf/CDG-EN-2018.pdf

Table 1.2: Canada’s Dietary Guidelines: Guideline 2

As illustrated in Figure 1.7 and outlined in Table 1.3, the third guideline focuses on food skills and food literacy to promote healthy eating patterns (Health Canada, 2019b). This reproduction (Table 1.3) is a copy, in part, of the version available at: https://food-guide.canada.ca/static/assets/pdf/CDG-EN-2018.pdf.

Table 1.3: Canada’s Dietary Guidelines: Guideline 3

Attribution Statements

Content related to the three guidelines, reflected in the three tables, was reproduced in part for non-commercial purposes, with editorial changes, from Health Canada (2019), “Canada’s Dietary Guidelines for Health Professional and Policy Makers.”

As with every version of the food guide, there are common critiques, some of which are illustrated in Figure 1.8 and which require a critical and reflective discussion. Some of the critiques that have been common with Canada’s Food Guide 2019 are related to:

In chapter three, you will have the opportunity to critically reflect on how to collaborate with clients and their families to address some of these concerns.

1) What are the main principles of Canada’s Food Guide 2019?

2) In what ways does your own diet follow or not follow Canada’s Food Guide 2019? While reflecting on this question, document a 24-hour food recall of foods and beverages that you have consumed, and use that as a reference. While this only represents one day, it is often used as a snapshot of a person’s eating patterns. It is typical to ask the client if their 24-hour food recall is representative of a usual day for them.

The key takeaways of this chapter are:

• Canada’s Food Guide 2019 is evidence-informed.
• Canada’s Food Guide 2019 is developed for individuals who are two years of age and older and for those who do not have specific dietary requirements.
• The main guidelines note that: nutritious foods are the foundation for healthy eating; processed or prepared foods and beverages that contribute to excess sodium, free sugars, or saturated fat undermine healthy eating and should not be consumed regularly; and, food skills and food literacy are needed to navigate the complex food environment and support healthy eating.

Health Canada (2019a). History of Canada’s food guides from 1942 to 2007. Retrieved from: https://www.canada.ca/en/health-canada/services/canada-food-guide/about/history-food-guide.html

Health Canada (2019b). Canada’s dietary guidelines for health professionals and policy makers. Retrieved from: https://food-guide.canada.ca/static/assets/pdf/CDG-EN-2018.pdf

Nutrition labelling is information included on labels of packaged foods about nutrient content. Considering the health impact of foods and effects related to obesity, cardiovascular diseases, diabetes, and other conditions, there has been a shift in many countries to mandate and regulate nutrition labelling (Viola, Bianchi, Croce, & Ceretti, 2016). The Canadian government has made efforts to create labels that provide necessary information for consumers. However, it is important to be aware that nutrition labelling is often poorly understood by consumers. Health professionals are expected to be knowledgeable about how to read and interpret nutrition labels (including nutrition facts tables [NFT] and the ingredients list). Such knowledge will allow health professionals to help clients read nutrition labels, like that which is illustrated in Figure 2.1, and to make informed choices about healthy and safe eating that meets the dietary needs of each individual.

Health Canada is responsible for constructing policies to meet the standards set by the Food and Drugs Act (FDA). The Food Directorate of Health Canada is responsible for the “development of policies, regulations and standards that relate to the use of health claims on food” (Government of Canada, 2016, 3rd para). Other governing bodies, such as the Canadian Food Inspection Agency (CFIA), have responsibilities for administering and enforcing food labelling policies as well as managing the Consumer Packaging and Labelling Act. Under this legislation, food producers must meet governmental labelling requirements.

Most prepackaged food labels (e.g., can of soup, bag of chips, bag of frozen peas) must include the NFT, a list of ingredients, allergen statements, and best before dates. The NFT is mandatory on prepackaged foods with the exception of some items such as alcoholic beverages and products that have few nutrients (e.g., coffee and spices). The Government of Canada (2019a) does not require nutritional labelling on foods such as fresh fruits and vegetables and foods sold at farmers’ markets. In general, it is mandatory to show both official languages of Canada (French and English) on labels, with some exceptions (e.g., specialty foods, local foods, test market foods, and shipping containers) as long as the products are not resold to consumers.

Attribution statement

Unless otherwise noted, content from this page was adapted, with editorial changes, from Nutrition and Labelling for the Canadian Baker by go2HR and is used under a Creative Commons Attribution 4.0 International License.

Under Government of Canada (2019a) regulations, the NFT must provide information about serving size, calories, percent daily value (% DV) of nutrients, and core nutrients. Currently, the requirements for nutrient information are changing and industry has five years to make changes so that NFT include: fat, saturated fat, trans fat, cholesterol, sodium, carbohydrate, fibre, sugars, protein, potassium, calcium, and iron (Government of Canada, 2019a; Government of Canada, 2017). Figure 2.2 illustrates the new NFT as compared with the original (i.e., the previous version).

The NFT displays the % DV so consumers can determine the amount of a certain nutrient in one serving. For example, the Government of Canada (2019b) indicates that 5% of the DV or less of a nutrient is considered “a little” while 15% of the DV or more of a nutrient is considered “a lot.” You should be aware that the % DV is not used to identify whether a person has had sufficient nutrients in a day, particularly considering that many foods do not require the NFT (Government of Canada, 2019b). Rather, it is best to talk with your clients about using the % DV to compare and make choices between different types of food that are higher in healthy nutrients (e.g., fibre) and lower in nutrients that are not healthy (e.g., sodium and trans fat) (Government of Canada, 2019b).

The list of ingredients (as illustrated in Figure 2.3) is mandatory on most packaged foods that contain more than one ingredient, and ingredients are listed in order of weight. The weight of ingredients listed will be an important aspect of your conversation with a client. You may choose to draw their attention to that aspect of food labelling and discuss with them how it might impact their food choices. In addition, caffeinated energy drinks require that the amount of caffeine is included with a statement that the product is a “high source of caffeine” and “not recommended for children, pregnant/breastfeeding women” (Canadian Food Inspection Agency, 2015).

Attribution statement

Unless otherwise noted, content from this page was adapted, with editorial changes, from Nutrition and Labelling for the Canadian Baker by go2HR and is used under a Creative Commons Attribution 4.0 International License.

Where needed, food labels may also include an “Allergen Declarations and Gluten Sources” statement which captures the top ten priority food allergens. The ten priority allergens are set by Health Canada and include egg, soy, sesame seeds, milk, seafood, tree nuts (including peanuts as per Figure 2.4), sulphites, wheat, and mustard. If any of these priority food allergens are present, they must be listed in the ingredients and/or in a statement that begins with “contains” or “may contain” on a food product label.

It is prudent for any consumer, particularly people with food allergies or those who are purchasing or preparing food for people with allergies, to read food labels. It is important to note that companies can change ingredients without telling consumers; therefore, the responsibility to read labels remains with the consumer. When clients have an allergy, it is meaningful to discuss the importance of letting the host of a social gathering know ahead of time and always talking with the seller or producer of food at farmer’s markets and restaurants.

Attribution statement

Unless otherwise noted, content from this page was adapted with editorial changes from Nutrition and Labelling for the Canadian Baker by go2HR and is used under a Creative Commons Attribution 4.0 International License.

The best before date (or meilleur avant) as illustrated in Figure 2.5 indicates the anticipated amount of time an unopened food product keeps its freshness, taste, nutritional value, or any other qualities claimed by the company, when stored properly. The Canadian Food Inspection Agency (2018) indicates that unopened products “should be of high quality until the specified date.” As soon as the product is opened, the best before date no longer applies. The best before date must appear on packaged foods that have a shelf life of 90 days or less such as milk, yogurt, and bread. Products still can be purchased or eaten after best before dates as these dates are not related to product safety. 

Packaged foods that show an expiration date (as illustrated in Figure 2.6) must be consumed before that date or discarded after the expiry date. The expiry date must not be mistaken for the best before date. Expiration dates are not required on all foods. The Canadian Food Inspection Agency (2018) indicates that foods that have “strict compositional and nutritional specifications” must have expiry dates (e.g., infant formula, meal replacements, nutritional supplements, formulated liquid diets for oral and tube feeding).

Expiration dates and best before dates rely on a consumer’s ability to follow instructions concerning proper food storage. You may need to reinforce with clients the importance of keeping “cold food cold and hot food hot” so that bacteria do not grow (Government of Canada, 2014). The Government of Canada (2014) indicates that refrigerator temperatures should be kept at +4° Celsius and freezer temperatures are to be kept at -18° Celsius. Further information about refrigeration and freezer times for safety and quality can be viewed at: https://www.canada.ca/en/health-canada/services/general-food-safety-tips/safe-food-storage.html

Attribution statement

Unless otherwise noted, content from this page was modified and adapted from Nutrition and Labelling for the Canadian Baker by go2HR, which is licensed under a Creative Commons Attribution 4.0 International License.

Many of the food products sold and consumed in Canada are produced around the world, which is illustrated in Figure 2.7.

If a food product is imported from another country, its country of origin must be on the label. See Film Clip 2.1 of Dr. Lisa Seto Nielsen, a registered nurse, speaking about assumptions concerning food that is produced outside of Canada.

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/foodguide/?p=68

Film Clip 2.1: Dr. Lisa Seto Nielsen speaking about assumptions concerning food that is produced outside of Canada

If products are produced in Canada, they must include the name and address of the responsible company. Food products that say “Product of Canada” must follow specific guidelines. For example, a Product of Canada item must have most (generally 98%) of its food, processes, and labour originating in Canada. This means that Product of Canada foods were grown or raised by Canadian farmers and are prepared and packaged by Canadian food companies.

The claim “Made in Canada” means that the manufacturing or processing of the food occurred in Canada. A claim can be made on a label if the last substantial step in processing a product occurred in Canada, regardless of whether the ingredients are domestic or imported. For example, the processing of cheese, dough, sauce, and other ingredients to create a pizza would be considered a substantial step. If the food product contains some food grown by Canadian farmers, it can use the claim “Made in Canada” with domestic and imported ingredients. If all of the ingredients have been imported, it can use the claim “Made in Canada” from imported ingredients.

Attribution statement

Unless otherwise noted, content from this page was modified and adapted from Nutrition and Labelling for the Canadian Baker by go2HR, which is licensed under a Creative Commons Attribution 4.0 International License.

Part of the health professional’s role is to help clients navigate and understand food nutrition tables. See Table 2.1 about important items to consider.

Table 2.1: NFT items to consider

1. What must be included in the nutrition facts table?
2. What facilitates or hinders the use of nutrition facts tables?

Health professionals play an integral role in helping and empowering clients to better understand nutrition labelling and incorporate it into healthy eating patterns and food choices. As a health professional, it is important that you:

• Understand the legal requirements of nutrition labelling so that you can have informed discussions with clients and advocate when companies do not follow policies.
• Collaborate with clients on identifying and responding to their goals related to NFT, ingredients lists, and other nutrition labelling.

Campos, S., Doxey, J., & Hammond, D. (2011). Nutrition labels on pre-packaged foods: A systematic review. Public Health Nutrition, 14(8), 1496-1506.

Canadian Food Inspection Agency (2018). Date labelling on pre-packaged foods. Retrieved from: http://www.inspection.gc.ca/food/information-for-consumers/fact-sheets-and-infographics/date labelling/eng/1332357469487/1332357545633

Canadian Food Inspection Agency (2015). Transition of caffeinated energy drinks from NHPs to food using temporary market authorization letters (TMAL). Retrieved from: http://www.inspection.gc.ca/food/requirements/labelling/caffeinated-energy-drinks/eng/1377613077840/1377613161282

Dieticians of Canada (2018). Nutrition labelling. Retrieved from: https://www.dietitians.ca/Dietitians-Views/Food-Regulation-and-Labelling/Nutrition-Labelling.aspx

Government of Canada (2019a). Nutrition facts tables. Retrieved from: https://www.canada.ca/en/health-canada/services/understanding-food-labels/nutrition-facts-tables.html#a4

Government of Canada (2019b). Percent daily value. Retrieved from: https://www.canada.ca/en/health-canada/services/understanding-food-labels/percent-daily-value.html

Government of Canada (2019c). Serving size. Retrieved from: https://www.canada.ca/en/health-canada/services/understanding-food-labels/serving-size.html?wbdisable=true

Government of Canada (2017). Food labelling changes. Retrieved from: https://www.canada.ca/en/health-canada/services/food-labelling-changes.html

Government of Canada (2016). Health claims. Retrieved from: https://www.canada.ca/en/health-canada/services/food-nutrition/food-labelling/health-claims.html

Government of Canada (2014). Safe food storage. Retrieved from: https://www.canada.ca/en/health-canada/services/general-food-safety-tips/safe-food-storage.html

Viola, G., Bianchi, F., Croce, E., & Ceretti, E. (2016). Are food labels effective as a means of health prevention? Journal of Public Health Research, 5(768), 139-142. Retrieved from: https://www.jphres.org/index.php/jphres/article/view/768/330

The nursing process (see Figure 3.1) is an important framework to guide you when collaborating with clients and families, especially to help them make sense of Canada’s Food Guide 2019 and healthy eating practices. There are versions of the nursing process, but the iterative steps generally include:

1. Assessment
2. Analysis/Diagnosis
3. Planning
4. Implementation
5. Evaluation

As the first step of the nursing process, a subjective assessment provides data about the client’s eating patterns, social determinants of health, and personal resources. It can be useful to provide a copy of Canada’s Food Guide: Food Guide Snapshot so that they can discuss it with you, ask questions, and reflect on how it might be taken up in the context of their lives. For example, you may initiate a discussion using interview probes with the client such as:

• Tell me what you see when looking at the plate (in the snapshot).
• What questions do you have for me that are important to you?
• In what ways do your eating patterns align with this food plate?
• In what ways do your eating patterns not align with this food plate?

During this phase, you should also assess their personal concerns and goals surrounding their eating patterns and healthy eating. Using a relational approach and            unconditional positive regard, you can focus on what is important to them in terms of eating and nutrition in the context of their own lives.

This baseline data provides an important starting point as you begin to analyze the client’s strengths, areas for improvement, and their own concerns and goals. Some clients and families may have a limited understanding of healthy eating and Canada’s Food Guide while others may have extensive knowledge. You can use a conversational and collaborative approach with the client as you are analyzing their eating patterns, knowledge, and goals before you arrive at a diagnosis.

The next phase is to work collaboratively with the client to develop a plan of care that is created with them as opposed to for them. As part of the planning phase, you help the client identify goals that are relevant and important to them, achievable in a specific time period, and measurable. It is important that you understand the client’s life and what is important to them in order to position the client for success in the implementation phase. During the planning phase, you should also collaborate with the client on developing an evaluation plan. During the evaluation, you will be able to make comparisons with the baseline data.

In addition to assessing the client, you need to assess and reflect on your own values and beliefs about healthy eating and food practices. Like all health professionals, you may hold assumptions about what constitutes “healthy” eating and may place value on certain foods. Eating is a very personal and intimate experience that is informed by a variety of factors, including societal norms, media, trends, culture, family, material resources, the environment, tastes, and memories. How one defines healthy eating is complex and as a health professional, you must be aware of your own assumptions when assisting clients and families to develop goals and outcomes for healthier eating patterns. When you are able to reflect on your own values and assumptions, it facilitates non-judgemental dialogue and demonstrates positive regard for the client’s overall well-being.

Historically, consumption of food has been medicalized,  wherein certain foods have been categorically labelled as “good” or “bad”. This approach to food can perpetuate feelings of shame and silence when clients identify as consuming foods that have been labelled as “bad”. A more accepting and effective approach is to look at healthy eating along a continuum and collaborate with clients to garner a holistic view of their dietary intake and food practices. A holistic view removes a focus on merely what is problematic. Instead, the focus is to identify and emphasize existing healthy eating habits from which you can collaborate with the client to plan and implement nursing interventions. Healthy eating is not just about the physical nourishment of the body, but also encompasses the social and ethical components that inform a client’s decisions around healthy eating.

In evaluating client outcomes, Canada’s Food Guide 2019 also encourages cooking at home more, eating with others, and enjoying food, which you should take into consideration when exploring and determining success. Most importantly, you need to determine what success looks like according to the client. Evaluation should not be on merely whether the client has taken up eating as prescribed by the food guide. Rather, evaluation should focus on:

• Examining where the client lies on the healthy eating continuum as illustrated in Figure 3.2. For example, does the client eat take-out food while working? Are they involved in picking out healthy foods? Are they involved in preparing foods as a family?
• Assessing the strategies that worked and what needs to be modified to move further along the continuum.
• Evaluating or re-evaluating goals in collaboration with the client.

You need to incorporate accessibility into your assessment and planning in order to understand a client’s capacity to acquire and store healthy foods. Accessibility in terms of the food guide refers to the financial and geographical capacity to purchase safe and healthy foods and beverages. There have been several sociological terms to define a community’s access to food, such as: a food desert which has limited access to nutritious and affordable food; a food swamp which has increased access to fast foods; and a food oasis which has access to nutritious options and even less access to unhealthy options (Bridle-Fitzpatrick, 2015). A sample of questions you may ask clients include: “Tell me about the ways that you access or purchase food”; “Do you have any issues accessing or purchasing food?”; “Do you have sufficient income to purchase the food you need?”; “Tell me about your capacity to ensure safe storage of foods?” You may want to probe about nutritious foods specifically, such as fruits and vegetables, protein, and grains.

Incorporation of the above questions into your assessment is important as the answers provide insight into the client’s needs related to accessible and safe foods. Some of the barriers that Canadians encounter are related to limited financial capacity and living in areas where they have limited to no access to reasonably priced foods, fresh fruits and vegetables, clean drinking water, and infrastructure that allows for the safe storage of food and beverages. For some, it might be an economical solution to purchase frozen (versus fresh) fruits and vegetables or dried or bulk legumes. However, this solution does  not recognize the complexity of the issues concerning food safety and accessibility, particularly considering that costs are still high and safe storage can still be an issue.

Many times, eating unhealthy foods is not a choice. Rather, it is influenced or directly impacted by the social determinants of health. Many people have consistently less access to affordable, safe, and nutritious foods. These people may live in rural, remote (including Northern Canadian regions and Indigenous communities) and disadvantaged communities, and they may have limited income, and/or they may be homeless. Even in urban areas, some neighbourhoods do not have easy access to grocery stores or transportation. Access to clean drinking water in Indigenous and remote communities is another example of how the social determinants of health can impact food safety and accessibility. Whelan and colleagues (2018) have indicated that healthy food is more expensive than unhealthy food in rural areas. They have also found that there is variability in quality of food, particularly fruits and vegetables, with limited stock in stores and less diversity in food choices. It has been found that the cost of store-bought food can be drastically higher in rural and remote regions, particularly when these regions are only accessible by air (Randazzo & Robidoux, 2018). For example, it is often estimated that prices can be two to three times higher in Northern communities, as compared to prices in urban centres in Canada.

See Film Clip 3.1 in which Dr. Shelagh McCartney speaks about the complexities of food safety and accessibility in Northern and Indigenous communities.

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/foodguide/?p=207

Film Clip 3.1: Dr. Shelagh McCartney speaking about complexities of food safety and accessibility

In addition to engaging in conversations with clients about their needs, health professionals also have a responsibility to be a social justice advocate by assessing and addressing social determinants of health. Alongside Canadian policymakers, it is vital that health and social professionals respond to the inequities pertaining to financial and geographic access to nutritious and safe foods. Olstad, Campbell, and Raine (2019) indicate that future policies need to move beyond helping Canadians make informed food choices to also include social policies that focus on inequities by addressing the social determinants of health. It is not sufficient to develop a food guide without attention to the social policies and structures that impact a person’s capacity to purchase, store, and benefit from nutritious foods.

The integration of culture across the phases of the nursing process is crucial considering that culture is a part of each person’s life. It is a way of life and not tied just to ethnicity or nationality. In addition, food is culture and culture is food, which means that all individuals have cultural food practices.

Alongside this, Canada is a country of immigrants that has been generously hosted by the Indigenous Peoples including First Nations, Métis, and Inuit. The politics of eating is influenced by the history of colonization because representation and lack of representation of Indigenous Peoples continues to inform national policies. In developing the multiple iterations of Canada’s Food Guide, there was a failure to recognize the meaning and diversity of healthy eating and food practices amongst all Canadians. Subsequently, Health Canada developed a supplementary document for First Nations, Inuit, and Métis peoples in 2007, found at: “Eating Well with Canada’s Food Guide: First Nations, Inuit and Metis.” Although Health Canada (2007) has said that this document can be used in combination with Canada’s Food Guide 2019, it has not been updated to align with the evidence and principles presented in the new edition. However, input was sought from National Indigenous Organizations when developing the new guide, which also incorporates information about the unique histories, social determinants of health, and life circumstances of Indigenous Peoples, challenges they encounter, and the benefits of traditional food.

As part of your practice, you must work closely with clients to develop an intimate understanding of their cultural eating patterns and particularly their traditional and ethnic foods. This is important considering that the image of a plate of food presented in Canada’s Food Guide 2019 mainly includes westernized foods. It does not present what might be recognized as traditional or ethnic foods, i.e., jackfruit, plantain, lamb, caribou, etc. This is problematic because clients may interpret their traditional foods as not being healthy because of lack of representation on the plate.

See Film Clip 3.2 of Yasmin Khatau speaking about her reflection of Canada’s Food Guide 2019 from a cultural perspective.

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/foodguide/?p=214

Film Clip 3.2: Yasmin Khatau reflecting on the Canada’s Food Guide 2019 from a cultural perspective

As a health professional, you can work with clients to validate and support their traditional food choices. You are not expected to know the health implications of all foods and food preparation across Canada. Instead, assessment becomes your tool of inquiry because it allows you to learn about the foods, food practices, and cultural meaning of food directly from the client and family. Consider the difference between learning and supporting healthy eating along the continuum as opposed to making definitive judgements about whether something is healthy or not. Furthermore, co-developing plans of care with clients that prioritize their cultural meaning of foods and food practices will reduce the likelihood that an unwelcome medicalized perspective will be imposed. Rather, this collaborative approach can empower the client to share their cultural food practices, integrate their health knowledge, and facilitate sustainable healthy eating that respects their agency and cultural identity.

The new food guide encourages cooking at home, eating with others, and enjoying food, (Health Canada, 2019) which speaks to the contextual complexities of healthy eating. Eating healthy is not just about consuming nutritious foods. There is acknowledgement that eating is a process that requires time, resources, and knowledge. Many people will tell you that lack of time is a barrier to cooking at home and healthy eating. It may not be possible for families to always cook at home or cook from scratch. Time constraints may mean that cooking at home utilizes more pre-made or easy-to-go ingredients and so it is important for you to work with the client to find balance and substitute more processed options.

During assessment, it is important to obtain a holistic picture of the client’s perceptions of healthy eating, competing priorities, and food skills (e.g., their ability to prepare and cook food). A plan of action may require strategies that do not completely adhere to the recommendations of the food guide. Rather, you may consider what strategies would best maximize healthy eating patterns for the client. You may not have all the answers, and so connecting the client with a registered dietician may be helpful to develop a weekly meal plan. Furthermore, cooking is a skill that some clients, for a variety of reasons, may not have developed. Lack of confidence in cooking skills may contribute to eating more heavily processed foods or eating out more often. An intervention may be to connect clients with cooking classes offered at community centres and encouraging families to cook together so that cooking skills may develop at a very young age.

Canada’s Food Guide 2019 draws attention to social aspects of eating and family meals as an important developmental consideration for growing children. This is a welcomed addition, as the medicalization of food has traditionally focused on what we eat, and not necessarily how we eat. Mealtime is an opportunity for families to connect with each other, establish shared eating patterns, prepare and cook meals together (as illustrated in Figure 3.3), and cultivate enjoyable relationships with food. Mealtime is also a chance to build communication, provide respite from busy lives, and empower children with autonomy and choices which build their self-esteem.

For children two years and older, Canada’s Food Guide 2019 emphasizes a balanced diet with a healthy amount of vegetables and fruit as well as proteins and whole grains. While Canada’s Food Guide 2019 represents an ideal example of eating for children, it is essential for health professionals to recognize that not all children are willing to comply. Many gravitate towards foods such as cereal, pastas, breads, and chicken. Although it is acceptable for children to eat these types of foods, attention must be paid to how to achieve balance and nutrition. Collaborating with parents to understand nutritional needs or gaps in their child’s eating is important for offering a full spectrum of strategies that promote a balanced diet. For example, many parents rely on milk as a source of calcium, vitamin D, protein, and potassium, knowing that their children may not receive sufficient nutrients from other sources. Some critics warn against this practice when high-fat milks, such as 3.25% homogenized milk, satiate children and children refuse other nutrient-rich foods. In addition, high-fat milks contain lactose, which is a known irritant for many children. And of course, animal-based products (particularly red meat) have been critiqued from a health perspective because of a high concentration of saturated fats and from an environmental perspective because of the green-house gas emissions produced through agricultural practices and livestock. It is important that health professionals collaborate with families and understand their context before offering advice. This kind of collaboration establishes a baseline understanding of eating patterns, including sources of nutrients, that will help position children and their parents to identify and reach shared goals.

Canada’s Food Guide 2019 promotes water as the drink of choice, while previous iterations have focused on milk as the drink of choice. This revision is largely in response to more people, particularly children, consuming sugary drinks like juice and pop as their primary drink. Water is encouraged as a substitute to such drinks, and people are advised to limit intake of beverages with a high concentration of sugar. While the new food guide encourages low fat milk products as part of a balanced diet, there is also recognition that not all cultural groups consume milk and water is complimentary to a balanced diet. Additionally, parents may ask whether milk is required for health development in children.

The food guide is intended for persons two years to adulthood, which leaves questions and uncertainties for parents and caregivers seeking guidance for children in their early years (under two). Early childhood nutrition is remarked as one of the most crucial stages of life to consider food because it is foundational to growth and development, it sets the tone for food behaviours, and it also establishes important emotional connections with food. As such, it is important for health professionals to recognize the confusion that may arise for parents about how to maintain nutritious eating for this age cohort. Although not a focus of this book, health professionals may refer parents to these resources for children under two years of age: Infant feeding and healthy term infants. These documents provide recommendations about nutrition for healthy term infants from birth to six months and six to 24 months.

It is unrealistic to expect Canadians to adopt the 2019 food guide without any question or critical examination. As such, as a health professional, you need to think critically and reflexively throughout the phases of the nursing process. This thought pattern involves intentionally examining your own position in the world, and more importantly, the client’s position and social determinants of health. This action is central to the nursing process considering that a person’s positionality influences their identity and experiences, and as a result, their capacity and goals related to eating patterns.

Re-thinking the integration of the food guide into the nursing process using a relational inquiry approach is a beginning step. As an entry-to-practice competency, the College of Nurses of Ontario (2018) has identified relational practice “as the foundation for nursing practice” (p. 4), which is defined by Doane and Varcoe (2015) as assuming each person (including client and nurse) is a relational being who is influenced by those around them, their communities, and social and cultural processes. Health professionals can practice relational inquiry related to the food guide by exploring what is important to the client, as illustrated in Figure 3.4 and demonstrated in Film Clip 3.3.

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/foodguide/?p=224

Film Clip 3.3: Integrating the food guide into the nursing process using a relational inquiry approach

Incorporating a relational inquiry approach to the nursing process can enhance your capacity to think critically and reflexively about your positionality and the client’s positionality. Additionally, this approach promotes iterative discussions with the client about their eating patterns, traditions, and goals. Relational inquiry promotes an active re-positioning of the nursing process so that the client is the driving force of discussions and not the food guide. As such, you collaboratively develop a plan of care with the client that is tailored to their life circumstances and goals.

1. When reflecting on your own eating, what memories and tastes stand out for you that are memorable? For example, you might have memories of food and happiness or celebration, food and trauma, or some other emotion or experience.
2. What are your values concerning healthy eating and how could they unintentionally influence your interactions with clients about the food guide?
3. What factors should you consider when counselling clients on what foods are nutritious?

This chapter has provided you an overview about how to integrate Canada’s Food Guide 2019 into the nursing process. Some key takeaways include:

• Engage in reflexive and critical thinking on your own assumptions about what constitutes “healthy” eating, what values you place on certain foods, and how this could unintentionally influence your interactions with clients.
• Critically reflect on the role of social determinants of health within a client’s life when assessing and co-developing plans of care related to healthy eating.
• Avoid judgmental words such as “good” and “bad” when talking about healthy eating.
• Engage in respectful discussions with the client about their eating patterns.
• Recognize the limitations of the food guide as a prescriptive resource for health professions.
• Use a relational inquiry approach and be curious, open, and inquire about a client’s eating patterns and the cultural meanings.

Bridle-Fitzpatrick, S. (2015). Food deserts or food swamps?: A mixed-methods study of local food environments in a Mexican city. Social Science & Medicine, 14, 202-213.

College of Nurses of Ontario (2018). Entry-to-practice competencies for Registered Nurses. Retrieved from https://www.cno.org/globalassets/docs/reg/41037_entrytopracitic_final.pdf

Doanne, G., & Varcoe, C. (2015). How to nurse: An introduction to relational inquiry in nursing practice. In How to nurse: Relational inquiry with individuals and families in changing health and health care contexts. (pp. 1-23). Philadelphia, PA: Lippincott, Williams & Wilkins.

Health Canada (2007). Eating well with Canada’s food guide: First Nations, Inuit, and Métis. Retrieved from: https://www.canada.ca/en/health-canada/services/food-nutrition/reports-publications/eating-well-canada-food-guide-first-nations-inuit-metis.html

Health Canada (2019). Canada’s Dietary Guidelines for Health Professional and Policy Makers. Retrieved from: https://food-guide.canada.ca/static/assets/pdf/CDG-EN-2018.pdf

Olstad, D., Campbell, N., & Raine, K. (2019). Diet quality in Canada: Policy solutions for equity. Canadian Medical Association Journal, 191(4), E100-2. doi: 10.1503/cmaj.180938

Randazzo, M., & Robidoux, M. (2018). Looking to the land: Local responses to food insecurity in two rural and remote First Nations. The Canadian Journal of Native Studies, 38(1), 103-128.

Whelan, J., Millar, L., Bell, C., Russell, C., Grainger, F., Allender, S., & Love, P. (2018). You can’t find healthy food in the bush: Poor accessibility, availability and adequacy of food in rural Australia. International Journal of Environmental Research and Public Health, 15(10). doi.org/10.3390/ijerph15102316