Newfoundland and Labrador Pre-budget Recommendations

Newfoundland and Labrador Pre-budget Recommendations
Newfoundland and Labrador
                                                                         Pre-budget Recommendations
                                                                                               FEBRUARY 2019

Dietitians of Canada (DC) and the Dietitians of Newfoundland and Labrador (DNL) action group are pleased
to provide input to the Government of Newfoundland and Labrador’s 2019/20 pre-budget consultation. Dietitians
play an essential role in health promotion and disease prevention, as well as management of diet-related conditions
including chronic diseases such as diabetes. We are cognizant of the economic pressures facing Newfoundland and
Labrador and have carefully considered our recommendations to ensure that they are fiscally responsible and allow
for efficiencies within the system. Investment in dietitian services and ensuring access to healthy food to improve
health is a cost-effective strategy for Newfoundland and Labrador.

Dietitians of Canada and the Dietitians of Newfoundland and Labrador action group request the following
recommendations be considered when developing the budget for 2019/20:

    1. Enhance access to nutrition services provided by dietitians
        a. Enhance access to dietitian services for continuing care (including long term care and home care)
        b. Enhance access to dietitian services in primary health care settings (including mental health and
        c. Ongoing funding and support for the promotion and operation of the Newfoundland and Labrador Dial-
           a-Dietitian Program
        d. The addition of dietitian services to the Government of Newfoundland and Labrador’s Group Insurance

    2. Ensure appropriate access to Healthy Food for all Newfoundlanders and Labradorians via:
        a. Government policies, programs and initiatives which consider the impact on food security
        b. Ongoing commitment to policies, programs and initiatives that support a healthy eating environment
           in schools, homes and the community
        c. Exploration of the options for a tax on sugar-sweetened beverages

    Detail and discussion regarding each of these recommendations is provided in the following pages.

                    © Dietitians of Canada. 2018. All rights reserved.             DIETITIANS OF CANADA   I   PAGE 1
Newfoundland and Labrador Pre-budget Recommendations
1. Enhance access to nutrition services provided by dietitians

As stated in the Newfoundland Labrador Chronic Disease Action Plan1, “Newfoundland and Labrador continues to have
some of the highest rates of chronic disease in Canada and as the population continues to age the prevalence of chronic
disease is expected to grow. Sixty-three per cent of residents have at least one chronic disease and Newfoundland and
Labrador has the highest rates of diabetes, high blood pressure and obesity across Canadian provinces”. Despite this
recognized burden of nutrition-related conditions such as diabetes and heart disease, current dietitian services are not
meeting needs. Evidence clearly shows that these challenges have a negative impact on health outcomes, result in poorer
quality of life, increase the cost of delivering health care services, and negatively effect economic growth.

DC commends the Government of Newfoundland and Labrador (NL) for the release of the Chronic Disease Action Plan
and the active approach towards supporting citizens. Ensuring adequate dietitian services to support the initiatives
outlined in this plan is essential for successful implementation.

We have identified four specific areas for the Government of NL to invest in dietitian services:

       a. Ensure access to dietitian services for continuing care (including long term care and
          home care)

Long Term Care (LTC)
More than 19 per cent of NL’s population is over the age of 65 and will continue to rise to 27 per cent of the population
within 10 years. As the population ages, the need for residential care facilities will continue to grow. The Government of
NL has taken important first steps towards supporting this population by announcing that the construction and expansion
of three new LTC homes will begin in 2019 which will ease the burden on the acute care system. Ensuring that adequate
dietitian positions are created to support these new homes is very important.

In a recent pan-Canadian scan2, LTC dieitians in NL report that they are caring for increasingly complex and frail residents.
Insufficient dietitian staffing, especially in smaller homes, makes timely and complete assessments and follow-up very
challenging. As well, an inadequate food budget is a barrier to providing residents with the highest quality food and
culturally appropriate meal choices.

Approximately 34% of older adults living in the community are at risk for malnutrition; it is reasonable to assume
that persons admitted to LTC homes would have a higher risk of malnutrition2. Residents’ nutrition status is
recognized as an important contributing factor to health, functional ability, and psychological well-being 3,4. Typical
nutrition-related issues in this population include: decreased food intake, loss of appetite, difficulty chewing or
swallowing, gastrointestinal problems, hypermetabolism, immobility, chronic pain, depression, multiple medications,
social deprivation and loneliness3-7.

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Dietitians’ clinical and management competencies can improve outcomes in LTC. A study conducted in Canada found
significant improvements in weight for residents with dementia living in a special care unit where there was increased
dietitian monitoring and menu enhancements8. The authors concluded that “the professional care of a consistent
dietitian who is allocated sufficient time to assess, treat, monitor, and adjust the diet prescription, while communicating
this plan with staff, is required” to achieve positive outcomes for this group. A study in the United States found significant
improvements in nutritional status in a group of residents where a multidisciplinary review, including the dietitian, was
held weekly 9. A systematic review of mealtime interventions found improvements in nutritional status are associated
with food snacks, increased choice, and improved dining environments, as well as education and training for staff 10;
dietitians working in LTC can effect all these elements, if given appropriate time to do so.

DC and DNL also encourage the Government to continue to support the Provincial Working Group on LTC Nutrition and
Foodservice Standards that is currently revising standards. The 2015 auditor general report (Section 3.6) found several
shortcomings with nutrition services in the two Regional Health Authorities’ LTC facilities that it reviewed. DC’s Best
Practices for Nutrition, Food Service and Dining in LTC Homes was used to compare both the content of the 2005
standards and observations at the homes. Enforceable standards for food and nutrition services, supported by adequate
staffing, in LTC homes helps assure this vulnerable population is provided with the care they deserve.

The high rates of chronic disease and the aging population of NL also places a burden on the Home Care program in the
province. The rural nature of many of NL’s communities makes this support even more difficult. Malnutrition in the
community, as described above, means that there are many citizens with chronic disease living in the community.

NL has fallen behind other provinces with regards to dietitian resources allocated to supporting home care. As members
of home care teams, dietitians assess nutritional needs, develop nutrition care plans, counsel and educate clients, family
members and caregivers, monitor outcomes, consult with colleagues and link clients and family members with nutrition-
related community services and resources. Enhanced dietitian support in home care would decrease malnutrition,
decrease hospital readmission, emergency room visits, wait times for LTC and ultimately enable clients to stay in their
homes longer.

       b. Ensure access to dietitian services in primary health care settings (including rural
          communities and mental health and addictions)

The NL Chronic Disease Action Plan addresses the importance of additional primary health care (PHC) services and key
priorities outlined in The Way Forward. This important plan prioritizes redesigning PHC services and complementing
ongoing healthy living work underway through the Department of Children, Seniors and Social Development.

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Dietitians as core members of PHC teams deliver effective11 and cost-efficient nutrition intervention with a focus on
promoting health and supporting the prevention and treatment of chronic diseases 12. Nutrition counselling has been
shown to effectively prevent and treat chronic disease in the PHC setting. Lifestyle interventions including nutrition
counselling, physical activity and behavior modification can reduce risk of developing type 2 diabetes in at-risk adults by
up to 70% and improve cholesterol levels and blood pressure after 3 months 13.

The Primary Health Care Framework for NL outlines clear goals and objectives to guide health planning and ongoing PHC
reform. Client Health Homes are under development where every citizen will be attached to a PHC provider and team.
High rates of diabetes and obesity in the province increase the need for enhanced dietitian support related to chronic
disease management in PHC. We recommend that the PHC services redesign ensures inclusion of dietitians’ expertise on
the primary care teams. Enhanced dietitian support would also help provide nutrition service to rural communities
throughout NL addressing a primary challenge of providing equitable service to all residents of the province.

Dietitians are essential members of PHC teams delivering cost-effective nutrition intervention with a focus on promoting
health and supporting the prevention and treatment of chronic diseases.

         c. Ongoing funding and support for the promotion and operation of the Dial-a-Dietitian

DC and DNL were very excited about the launch of the NL Dial-a-Dietitian service in April 2018 and the access to dietitian
services that this provided. We have enjoyed working collaboratively with staff from the Department of Health and
Community Services, the Department of Children, Seniors and Social Development as well as the dietitians and leadership
from Fonemed to promote and operationalize this much anticipated program.

It is imperative that the Government ensures adequate resources for the ongoing promotion of this important service,
allowing the dietitians to provide effective support for the citizens of NL. Resources allocated to the evaluation of this
service will also ensure evidence informed decisions are able to be made about promotion and potential expansion of
the service.

Easy access to trusted and consistent advice from dietitians over the phone and via email has enabled residents of NL to
develop the knowledge and personal skills required to achieve desired outcomes. This dietitian phone line has, and will,
assist the Government of NL to achieve the targets in The Way Forward related to increased breastfeeding initiation rates,
decreased obesity rates and an increase in vegetable and fruit consumption.

Telephone counselling provided by a dietitian is an effective component of interventions for reducing chronic diseases,
leading to positive health outcomes such as: improved blood sugar control for people with diabetes, improved blood
pressure, decreased prevalence of metabolic syndrome, reduced hospitalizations and increased quality of life for

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individuals with heart failure. Teledietetics improves client access to evidence-based advice from dietitians for health
promotion and disease prevention, as well as management of diet-related conditions 14.

        d. The addition of dietitian services to the Government of Newfoundland and Labrador’s
        Group Insurance Plan

The Way Forward addresses the importance of examining the structure and roles in the provincial government to create
an efficient workforce. In order to have a healthy and productive workforce the Government of NL has the responsibility
to ensure its employee group insurance plan provides access to reimbursable nutrition counselling services delivered by
registered dietitians.

In addition to improvements in health, consulting with a dietitian can decrease health-related lost productivity by 64%
and decrease disability days by 87% 15 compared to usual medical care. Healthy eating in the workplace can also reduce
employee sick time, rates of injury and disability, prescription drug costs, medical costs and insurance premiums16, which
will result in cost savings to the Government. Such action also emphasizes the value Government places on healthy
eating, nutrition and wellness.

2. Ensure appropriate access to Healthy Food for all Newfoundlanders and Labradorians via:

    a. Government policies, programs and initiatives consider the impact on food security

It is the position of DC that “all Canadians must have food security”17. Recognizing food security as a social determinant
of health, DC and DNL recommend, “[a] population health approach [which] addresses the root cause of individual and
household food insecurity – poverty – through improvements to the social safety net”. Social determinants of health;
such as early childhood development, education, employment, income, environmental quality and safety, as well as
biological factors, account for the major proportion of population health outcomes17. Food insecurity continues to be a
significant problem in NL and is associated with adverse health effects including developmental issues among children,
mental health problems, greater risk for acute illness (often requiring treatment through the health care system) and
greater prevalence of non-communicable diseases 18. Health inequalities (i.e., less health and well-being, more
disease) are particularly prevalent among Canadians with low incomes, people living with mental health challenges and
Canada’s Aboriginal communities.

As the Government of NL moves forward to achieve the target of increasing food self-sufficiency in the province, it will
be important to work closely with Food First NL and consider the results of the data collected by Food First NL in 2016.
The Government of NL must be committed to the development of policies, programs, and initiatives that take into
account all five elements of the food system including food production, distribution, access, consumption and disposal.

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This includes policies on agricultural land preservation, fish quota, fisheries and wildlife conservation, health, food
safety, institutional food procurement and poverty reduction.

    b. Ongoing commitment to polices and initiatives that support healthy eating environments
       in schools, homes and the community

With rates of diet-related chronic conditions, including cancer, diabetes, cardiovascular disease and obesity among the
highest in the country, the Government of NL has collaborated with partners to put a number of strategies, policies and
programs in place to give all Newfoundlanders and Labradorians more opportunities to eat healthy in homes and in
communities. For example, support for the Baby-Friendly Council (action 2.15 in The Way Forward), Eat Great and
Participate, the Carrot Rewards program, and the Regional Health Authorities’ Vegetable and Fruit campaign (action 2.14)
will help build a province where healthy eating and physical activity become part of our daily environment. As well, the
approach to adopt health-in-all-policies, outlined in The Way Forward, as a means to ensure factors such as income,
education and the built environment are identified as key to improving overall health outcomes, is commendable.
Ongoing support for these programs will ensure continued success and improved health outcomes.

The Government of NL must continue to fund and evaluate these strategies, policies and programs to maintain and
increase the current and future health of Newfoundlanders and Labradorians. Resources will also be required to update
these strategies, policies and programs with the Federal Government’s updated Canada’s Food Guide tools that were
released in January 2019 as part of Canada’s Healthy Eating Strategy. These updates will ensure NL policies remain
consistent with other provinces and are based on the most recent literature and evidence.

DC acknowledges the commitment the NL Government has made for school age children and youth as outlined in The
Way Forward. The Healthy School Planner can form the basis of all actions related to school age children including the
Healthy Students Healthy Schools initiative and the Provincial School Food Guidelines. DC applauds the Government of
NL for their continued support of Kids Eat Smart Foundation18 towards achieving their vision “that every school age
child in NL attends school well-nourished to be ready to learn”. In addition, child risk assessments (action 2.17) must
include a healthy eating component and the expertise of a dietitian during its development and implementation to
ensure the development of an evidence-based and appropriate assessment tool (for example, weighing and measuring
children may have long-term detrimental effects). Indicators of healthy behaviours include consumption of vegetables
and fruit, water, whole grains, and plant-based foods. Weight is an outcome that may or may not indicate healthy
behaviours. Healthy eating and nutrition must be a key component to implementing the report from the Premiers Task
Force on Improving Education Outcomes (action 1.33) to ensure children and youth have curriculum related to healthy
eating and are well nourished as they learn in the classroom.

DC suggests that the Department of Education and Early Childhood Development continue to review opportunities for
strengthening the relationship between mental health and nutrition in the K-12 education system. The DC position paper
Promoting Mental Health Through Healthy Eating and Nutritional Care20 describes the relationship between mental health

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and nutrition, including information about the role of dietitians providing services in mental health care, and provides
policymakers with an evidence-based summary of the current literature about the promotion of mental health through
healthy eating and nutritional care.

As discussed in the meeting with the Associate Deputy Minister of Education and Early Childhood Development in 2017,
it is important that the Department of Education and Early Childhood Development work collaborative with the many
initiatives and resources currently underway. Despite the current fiscal challenges, we feel serious consideration should
be given to hiring a dietitian in the Department of Education and Early Childhood Development. This dietitian would be
responsible for bringing an expert food and nutrition lens to the Healthy Students Healthy Schools initiative, the revision
of the Provincial School Food Guidelines, the Expert Advisory Committee for Curriculum Development, and linking the
existing NL initiatives, toolkits and resources with the department.

Breastfeeding Initiation and Duration Rates
NL has one of the lowest rates of breastfeeding in the country. We know from the Feeding Infants in NL study (FiNal study)
21 that infant feeding decisions are determined by individual, organizational and cultural factors. The government of NL

has made breastfeeding a priority in The Way Forward and set a target to increase breastfeeding initiation by 7% by
2025. Breastmilk feeding initiation is 77.2% for NL (vs. 89.9% Nationally) and there is significant regional variation.
Health Canada recommends breastfeeding exclusively for 6 months (with continued breastfeeding up to 2 years and
beyond). Nationally, at 6 months, only about a quarter of the population continues to breastfeed and in NL this rate is
even lower. We were very pleased to see that Labrador West Health Centre in Labrador City, was the first facility in Atlantic
Canada to achieve Baby Friendly Initiative (BFI) designation. To ensure the target in The Way Forward is reached, DC and
DNL suggest:
• Supporting and encouraging the World Health Organization Baby Friendly Initiative (BFI). Evidence shows that
     implementing BFI in hospitals and community health settings will increase breastfeeding rates.
• Having representation on the Breastfeeding Committee for Canada (BCC) as this would be helpful in learning from
     other Provinces/ Territories and having the expertise on hand to help us move towards being a Baby-Friendly
    province. The Baby-Friendly Council is essential to support the Regional Health Authorities in working towards BFI.

Expertise of Provincial Agencies
Newfoundland and Labrador is very fortunate to have several active and successful provincial organizations and
programs supporting the health of Newfoundlanders and Labradorians. Utilizing the expertise of these provincial
agencies and their staff to support food awareness, food skills and healthy eating will create consistency and
efficiencies for all of us in meeting our goals. Many of these agencies have existing toolkits and programs that can be
tapped into and expanded. Such organizations and programs include:
     • Food First NL – provides education and awareness on food security and enhancing food skills
     • Kids Eat Smart Foundation NL- provides nutritious breakfasts to school age children across NL
     • Eat Great and Participate – promotes healthy eating in recreation, sport and community settings

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Health Measurements
Despite increased attention to the obesity epidemic, there remains important work to do to address the bias,
discrimination and harm that children and adults with obesity face every day. The social consequences of obesity include
discrimination in employment, barriers in education, biased attitudes from health care professionals, stereotypes in the
media, and stigma in interpersonal relationships. All these factors reduce quality of life for vast numbers of people with
overweight and obesity and have both immediate and long-term consequences for their emotional and physical health22.
Health is determined by healthy behaviours and DC and DNL urge the Government of NL to be role models for the
residents of their province and beyond by endorsing and permitting policies and benchmarks that are grounded in
science and focus on whole health rather than only weight.

        c. Exploration of the options for a tax on sugar-sweetened beverages

We recommend that the Government of NL explore options to apply a tax to sugar-sweetened beverages sold in NL
either through a provincial tax or through support for the federal government. These products have a negative impact
on the health of Newfoundlanders and Labradorians and the taxation can be a means to reduce consumption. For the
greatest impact, taxation measures should be combined with other policy interventions such as increasing access to
healthy foods while decreasing access to unhealthy foods in schools, day cares, and recreation facilities; restrictions on
the marketing of foods and beverages to children; and effective, long- term educational initiatives.

This position of DC is based on a comprehensive review of the literature23. There is moderate quality evidence linking the
consumption of sugar-sweetened beverages to excess weight, obesity and chronic disease onset in children and adults.
Taxation of sugar-sweetened beverages holds substantiated potential for decreasing its consumption. Based on
economic models and results from recent taxation efforts, an excise tax can lead to a decline in sugar-sweetened
beverage purchase and consumption. Taxation of up to 20% can lead to a consumption decrease by approximately 10%
in the first year of its implementation. Revenue generated from taxation can be used to fund other health promotion
initiatives such as a vegetable and fruit subsidiary, access to clean and safe drinking water within the province.

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Dietitians of Canada and Dietitians of Newfoundland and Labrador are committed to working with the Government of
Newfoundland and Labrador to develop and implement policies, programs and services that will increase access to
safe and healthy foods, evidence-based nutrition information and dietitian services. This work will not only improve
health outcomes and achieve long-term health system savings, but will also be sustainable and effectively meet the
health care needs of everyone in the province. We seek to achieve better health, better care, and better value for all

For more information please contact:

Jackie Spiers, M.Sc., RD                            Lisa Dooley, B.Sc., R.D
Regional Executive Director (NL)                    Chair, DNL Action Group
Dietitians of Canada                                Dietitians of Canada
E-mail:                 E-mail:

                                                                                         DIETITIANS OF CANADA   I   PAGE 9
About Dietitians of Canada and Dietitians of Newfoundland and Labrador

Dietitians of Canada (DC) is the professional organization that represents registered dietitians across Canada, including
members in Newfoundland and Labrador (NL). Our organization is committed to ensuring citizens from NL have access
to the dietitian services they need and educating the public about the importance of nutrition to health. DC works
closely with members and partners to provide resources, tools and best advice to diverse audiences. DC’s vision is to
advance health through food and nutrition; we accomplish this vision by providing trusted nutrition information to
Canadians and advising governments, at all levels, on best practices in nutrition policy and practice. The DC Local
Action Group, the Dietitians of Newfoundland and Labrador, are a group of committed DC members who are passionate
about the health and well-being of citizens in their province.

About Dietitians

In NL, registered dietitians are licensed health professionals, who are uniquely trained to advise on food and nutrition.
Dietitians’ practice is based on evidence-based research and information. Dietitians continue to be the most trusted
source of nutrition information, according to consumer surveys. They must complete rigorous university education and
practical training to be eligible to write the Canadian Dietetic Registration Exam and maintain ongoing competency
requirements through the Newfoundland and Labrador College of Dietitians. Dietitians help people meet their nutritional
needs in health or disease at all stages of the life cycle. They translate the science of nutrition into healthy food choices
and use their expertise in the prevention and treatment of both acute conditions and chronic disease. Dietitians provide
services in many settings throughout the province including community health teams; hospitals; long-term care homes;
public health; health promotion; education; sports and recreation facilities; business, academic and research settings;
and in private practice.

                                                                                          DIETITIANS OF CANADA    I   PAGE 10

1.  The Way Forward. Chronic Disease action plan. Government of Newfoundland and Labrador 2017. Available from
2. Lochs H, Pirlich M. Nutrition in the elderly. Best Practice & Research Clinical Gastroenterology. 2001; 6(15): 869-884.
3. Padala K, Keller P, Potter J. Weight loss treatment in long term care: are outcomes improved with oral supplements and
    appetite stimulants? Journal of Nutrition for the Elderly, 2007; 26(3/4):1-20.
4. Birkemose A, Kofod J. Meals in nursing Homes. Scand J Caring Sci. 2004; 18:128-134.
5. Nowson, C. Nutritional challenges for the elderly. Nutrition and Dietetics, 2007; 64(Suppl 4): S150-S155.
6. Castellanos, V. Food and nutrition in nursing Homes Generations, American Society on Aging. 2004;28(3), 65-71.
7. Salihu H, Bonnema S, Alio P. Obesity: what is an elderly population growing into? Maturitas. 2009;63(1).
8. Keller H, Gibbs A, Boudreau L, Goy R, Pattillo M, Brown H. Prevention of weight loss in dementia with comprehensive
    nutritional treatment. Journal of the American Geriatrics Society 51(7):945-952.
9. Crogan N, Alvine C, Pasvoge A. Improving nutrition care for nursing Home residents using the INRx process. Journal of
    Nutrition for the Elderly. 2006;25 (3/4).
10. Rebecca A. Abbott, Rebecca Whear, Jo Thompson-Coon, Obioha C. Ukoumunne, Morwenna Rogers, Alison Bethel,
    Anthony Hemsley, Ken Stein, Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in
    residential care: A systematic review and meta-analysis, In Ageing Research Reviews, Volume 12, Issue 4, 2013, Pages
    967-981, ISSN 1568-1637,
11. Mitchell LJ, Ball LE, Ross LJ, Barnes KA, Williams LT. Effectiveness of Dietetic Consultations in Primary Health Care: A
    Systematic Review of Randomized Controlled Trials. J Acad Nutr Diet. 2017; 117 (12):1941 – 1962. Available from:
12. Jeejeebhoy K, Dhaliwal R, Heyland DK, Leung R, Day AG, Brauer P, Royall D, Tremblay A, Mutch DM, Pliamm L,
    Rhéaume C, Klein D. Family physician-led, team-based, lifestyle intervention in patients with metabolic syndrome:
    results of a multicentre feasibility project. CMAJ. 2017 Mar; 5 (1): E229-236. Available from
13. Dietitians of Canada. What is the effectiveness of dietary or lifestyle interventions for preventing or treating chronic
    disease in the primary care setting? In: Practice-based Evidence in Nutrition® [PEN]. 2016 Sept 12. Available
    from: The PEN System: an international, online, evidence-based, peer reviewed
    database for nutrition guidance.
 14. Dietitians of Canada, 2018. Dietitians in teledietetics. Available from:
 15. Wolf A, Siadaty MS, Crowther JQ, Nadler J, Wagner D, Cavalieri S, Elward K, Bovnjerg V. Impact of Lifestyle
     Intervention on Lost Productivity and Disability: Improving Control with Activity and Nutrition. Journal of
     occupational and environmental medicine, 2009:51(2):139-145
 16. Ontario Society of Nutrition Professionals in Public Health, 2012. Call to action. Available from:
 17. Dietitians of Canada, 2007. Community Food Security. Position of Dietitians of Canada. Available from:
 18. Seligman HK, Laraia BA, Kushel MB. 2010.Food Insecurity Is Associated with Chronic Disease among Low-Income
     NHANES Participants. J Nutr 140(2): 304-310.

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19. Government of Newfoundland and Labrador. News Release: Department of Children, Seniors and Social
    Development enhances well-being for residents in 2017. Available from:
20. Dietitians of Canada, 2012. Promoting mental health through healthy eating and nutritional care. Available from:
21. Baby Friendly Newfoundland and Labrador. Feeding infants in Newfoundland and Labrador (FiNaL). Summary
    available from:
22. UConn Rudd Center for Food Policy & Obesity:
23. Dietitians of Canada, 2016. Taxation and Sugar-Sweetened Beverages. Position of Dietitians of Canada.

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