From Beliefs to Action: Dietitians' Perspectives on Environmental Sustainability and a Pathway to Planetary Health Framework for Food System Change

ABSTRACT

The Pathway to Planetary Health (PPH) is a theoretical framework that supports dietitians to undertake pro‐environmental change within the food system.

Aim

To explore the practical application and impact of the PPH.

Methods

The PPH was workshopped with dietitians and dietetic students (n = 46) using a mixed‐methods case study approach. Data collection was embedded in workshop delivery via a (i) pre–post survey using both Likert scale and free‐text responses, and (ii) qualitative explorations of participants' perspectives via interactive workshop activities. Analysis of quantitative data involved an independent samples t‐test for normally distributed data and a Mann–Whitney U test for non‐normally distributed data. Qualitative data were analysed thematically for survey responses and content analysis for workshop activity responses.

Results

Participants increased their confidence to undertake pro‐environmental change in their personal lives 4.1 ± 0.7 to 4.5 ± 0.8/5, and professional lives 3.6 ± 1.1 to 4.3 ± 0.9/5 (p < 0.05). Three themes were identified as barriers and enablers to pro‐environmental action, including ‘personal’, ‘social and professional’ factors, as well as ‘contextual and environmental’ influences.

Conclusions

The application of the PPH framework was supported by workshop participants who significantly increased their confidence to undertake pro‐environmental food system change.

Key Points/Highlights

• This article evaluates the Pathway to Planetary Health framework, which is a tool to support dietitians in pro‐environmental and food system change.

• The research was conducted in a national conference workshop, and the PPH significantly increased participants' confidence to undertake pro‐environmental changes in their personal and professional lives.

• The participants identified key barriers and enablers to environmental action, which were grouped into ‘personal’, ‘social and professional’ and ‘contextual and environmental’ themes.

• Overall, the PPH was seen as useful for personal and professional pro‐environmental changes and for broader food system change, but participants highlighted the need for other supports, including tools and institutional support.

1. Introduction

Humanity is facing a planetary crisis marked by climate change, global warming, deforestation, biodiversity loss and pollution [1, 2]. Several planetary boundaries, which are the safe operating space for humanity, have been exceeded pushing us into a zone of uncertainty [2, 3, 4]. The Intergovernmental Panel on Climate Change has emphasised the need for transformational change through pro‑environmental action across all sectors of society [1]. A new, broader approach to health and wellbeing is termed ‘planetary health’, which is defined as ‘the health of human civilisation and the state of natural systems on which it depends’ [5].

Food systems contribute significantly to greenhouse gas emissions and environmental degradation, making them key targets for pro‐environmental initiatives aimed at advancing planetary health [6, 7, 8]. Transforming these systems to favour sustainable food production and consumption practices can reduce emissions, protect biodiversity and relieve pressure on planetary boundaries [9]. The United Nations' Sustainable Development Goal (SDG) 12 calls for the global community to ‘ensure sustainable consumption and production patterns’, with targets set to reduce food waste and improve resource efficiency in food systems [10]. Dietitians can contribute to this systemic transformation by promoting healthy and sustainable diets and prioritising policies that support food system change [7, 8]. For example, they can advocate for policy and food system change and to integrate sustainability principles into dietary guidelines, honour Indigenous knowledges of food systems, re‐orient the food environment to prioritise sustainable foods and participate in capacity building for themselves, students and the food system participants that they work with [6, 7, 8, 11].

Dissemination of information, education materials and practical guides that support pro‐environmental change is critical to achieving this transformative action [8, 12]. The previously published ‘Pathway to Personal, Population and Planetary Health’ (Figure 1), developed by dietitian advocates, provides a framework that empowers nutrition and dietetic professionals to support pro‐environmental change, including interventions in the food system [6]. For simplicity hereafter, this framework is referred to as a ‘Pathway to Planetary Health’ (PPH) and nutrition and dietetic professionals will be referred to as Dietitians [5, 6].

Figure 1.

Pathway to Personal, Population and Planetary Health. A non‐sequential, interconnected pathway for dietitians to take pro‐environmental action, guided by the dimensions of Agency, Action, Ascension, Alliance and Allyship, Advocacy and Activism and Alignment.

The PPH describes six dimensions involved in the process of pro‐environmental change for dietitians: Agency, Action, Ascension, Alignment, Alliance and Allyship, Advocacy and Activism [6, 13]. Table 1 presents an overview of the PPH, outlining each dimension with its descriptor and providing an example illustrating how the PPH framework can be applied in dietetic practice and support pro‐environmental change across the food system.

Table 1.

Pathway to Planetary Health overview.

Pathway to Planetary Health dimension	Descriptors	Example
Agency	Vision, self‐belief, confidence, responsibility and strength.	Dietitians can cultivate a clear vision for sustainable practices, build self‐belief and undertake professional development to support pro‐environmental change.
Action	Translate, shift, start, commit and achieve.	Dietitians can use goal setting and take practical steps to integrate environmental sustainability into their daily practice by initiating or joining initiatives in their personal lives, healthcare practice or food system settings.
Ascension	Build, manage, overcome, progress and challenge.	Dietitians are encouraged to overcome barriers, such as food system challenges, limited resources or institutional resistance, by continuous quality improvement and building success and progress.
Alignment	Systems, values, transparency, leadership and diplomacy.	Dietitians should act in line with their values and encourage positive system change through supporting others to address attitude‐behaviour gaps where individuals and organisations are not acting in line with their beliefs or commitments.
Alliance and Allyship	Collaborate, support, represent, community and citizenship.	Dietitians can practice allyship to First Nations Peoples and build supportive networks and collaborations with community members, industry, health professionals and food system colleagues.
Advocacy and Activism	Urgency, transform, disrupt, empower and co‐design.	Dietitians may engage in campaigns for sustainable food systems, practice education or advocacy activities and co‐design pro‐environmental solutions.

Note: Features the dimensions of the Pathway to Planetary Health with their descriptors and examples, which illustrate how dietitians can apply the PPH in their practice.

As a theoretical framework, the authorship team that developed the PPH recognised the importance of proof‐of‐concept work to determine the guide's practical application and impact [6]. The Knowledge to Action Framework describes a widely adopted process for knowledge translation in health research. In this case, it was applied to inform the research design and research questions. This current study focuses on the ‘adapt knowledge to the local context’ stage of the action cycle by exploring participant perspectives on the role of the PPH in guiding pro‐environmental practices among dietitians [14]. To achieve this aim, three key research questions have been addressed (i) What are dietitians' beliefs, existing actions and confidence to engage in pro‐environmental practices? (ii) How do dietitians assess the value, usefulness and appropriateness of the PPH model to guide their practice? (iii) Does a workshop featuring the PPH model enhance dietitians confidence to undertake pro‐environmental behaviours in their personal and professional lives? It is anticipated that this research will help inform and guide future workforce capacity activities, including education and advocacy opportunities, for dietitians to promote pro‐environmental change and contribute to pro‐environmental food system changes.

2. Methods

A mixed‐methods case study approach, grounded in pragmatism, was adopted to address the research questions [15]. Consistent with this pragmatic orientation (i.e., a research design grounded in practice), it integrated multiple research activities rather than adhering to a single established typology [15, 16]. The study was designed with reference to the five interconnected mixed‐methods components described by Maxwell, which provided a coherent structure for linking the research purpose, methods and analytical processes [15]. The five inter‐related components are goals (purposes), conceptual framework, research questions, methods and validity [15]. For example, relating to the component ‘conceptual framework’, the workshop and research were informed by several frameworks, including the PPH, Knowledge to Action Framework and the Behaviour Change Wheel [6, 14, 17]. The Knowledge to Action Framework was broadly applied across the research as it reflects the gap between ‘knowing’ and ‘doing’ in healthcare practice. The PPH is designed to support pro‐environmental action through knowledge acquisition, and the Knowledge to Action Framework informed the exploration of its value, usefulness and appropriateness.

To answer the research questions, concurrent quantitative and qualitative data collection was embedded within workshop delivery at an Australian National Nutrition and Dietetics conference held in July 2023, including (i) a pre–post workshop survey using a Likert scale and free‐text responses, and (ii) written responses generated through workshop activities to qualitatively analyse participating groups' perspectives. Conference delegates were invited to register for the workshop titled ‘Planetary health in diverse settings: Dietitians' power and purpose’. The half‐day workshop was structured to include (i) an introduction to the climate crisis, (ii) Dietitian Australia's Commitment to date, (iii) a Dietitian's PPH, (iv) Dietitians Scope and Influence and (v) Individual and Collective Intentions—defining our power and purpose.

A comprehensive overview of the workshop, including its rationale, learning outcomes, pre‐reading materials and content, is featured in Supporting Information S1: Supplement 1. The workshop and PPH featured many references to food systems. For example, it featured a PowerPoint slide justifying why healthy and sustainable food systems require food system transformation, and the critical role that dietitians can and must play. Additional slides discussed food systems and food systems change as featured within the workshop overview (Supporting Information S1: Supplement 1).

A convenience sample of workshop participants provided consent to participate in the research, with ethical approval via Bond University (ID: 2023/333), Griffith University (ID: 2023/333) and Monash University (ID: 38619).

• (i)Pre‐ and post‐workshop surveys

Data were collected via a survey with a Likert scale and free‐text responses. These were completed before and after the workshop via a quick‐response link to an electronic form using Qualtrics TM. The survey instruments are available in Supporting Information S2: Supplement 2.

The pre‐survey, exploring dietitians beliefs, existing actions and confidence to engage in pro‐environmental practices (research question (i)), featured:

• –Demographic questions: for example, age, gender, residence, location, employment, qualification and membership of a sustainability organisation.
• –Beliefs and actions questions: participants self‐rated their motivation, capability and opportunity for pro‐environmental change on a 6‐point Likert scale, plus a ‘not sure’ option.
• –Barriers and enabler questions: four free‐text responses to describe barriers and enablers to environmental sustainable action in participants' personal and professional lives.

To explore research question (iii) exploring changes in dietitians confidence to undertake pro‐environmental change, the post‐survey featured:

• –Three repeat beliefs and actions ratings: for participants post‐workshop motivation, capability and opportunity to undertake pro‐environmental change on a 6‐point Likert scale, plus a ‘not sure’ option.

The development of the beliefs and actions questions were informed by the COM‐B Behaviour Change Framework, as capability, opportunity and motivation (COM) are recognised as key components of behaviour change (B) [17]. For example, the statement type ‘I am confident’ reflects the COM‐B component capability, the statement ‘I believe there is a movement’ reflects an opportunity, ‘I believe that as a healthcare professional I have a responsibility’ is a motivation and ‘I regularly incorporate’ is a behaviour [17]. The barriers and enablers questions relate to the 3rd stage of the action cycle, in the Knowledge to Action Framework, ‘Assess barriers/enablers to knowledge use’ [14].

Raw data were exported into a Microsoft Excel spreadsheet by the primary researcher K. L. McK. S. For quantitative data exploring pre‐ and post‐workshop ratings, given the potential differences in participant composition (due to different response rates) across the two time points, the two groups were treated as independent entities for data analysis. The 6‐point Likert scale was converted to continuous data for analysis (strongly agree = 5, agree = 4, neutral = 3, disagree = 2, strongly disagree = 1 and not sure = 0).

Statistical analysis was conducted using IBM SPSS Statistics software (Version 28.0.1.0). Participant demographic data (count and percentage) were calculated for all survey sections. The Shapiro–Wilk test assessed the normality of sum scores for pre–post change scores, considering p > 0.05 as indicative of normal distribution. Independent samples t‐test for normally distributed data and Mann–Whitney U test (for non‐normally distributed data) were employed to analyse continuous data. The significance level was set at p < 0.05.

For the qualitative analysis of the free‐text responses of barriers and enablers, two authors (K. L. McK. S. and N. M. S.) led the thematic analysis guided by Braun and Clarke's six steps of thematic analysis [18]. To enable this analysis, survey responses were first exported into a Microsoft Word document verbatim. Both researchers then familiarised themselves with the data and independently coded the data according to the nature of the response. The two authors met, compared codes and collaboratively categorised them into themes [18]. Due to the pre‐existing PPH model, qualitative data were analysed using a predominantly deductive process to answer the research questions [19]. Rather than aspiring to achieve a ‘consensus’, the researchers engaged in peer debriefing discussions to analyse this qualitative data, as encouraged with reflexive analysis. These discussions challenged initial assumptions, explored divergent opinions and refined the theme boundaries and descriptions [18].

• (ii)Written outputs via workshop activities

To explore research question (ii) featuring dietitians' assessments of value, usefulness and appropriateness of the PPH model to guide their practice, participants' perspectives and group written responses to workshop activities were qualitatively analysed. Activities prompted participant contributions in the form of written outputs, that is, worksheets and butcher's paper. In groups, participants discussed and recorded for each PPH guiding principle, its importance, example activities and elements that were clear and fit‐for‐purpose, or required improvement to advance dietetic practice [6]. Qualitative responses from activity worksheets were typed verbatim, and two authors (L. B. and J. M.) led the analysis of the data. Data were analysed deductively via content analysis, guided by the PPH dimensions [6, 20]. Data were synthesised and presented as a narrative summary of workshop task outputs. Preliminary findings were discussed with the broader authorship team [6, 19, 21].

All data (survey and task sheet data) were entered into Microsoft Word and Excel (version 365, Microsoft) and were stored securely electronically at Bond University, and only project researchers had access to the data. For all qualitative data analyses, the authorship team took a reflexive approach, discussing and acknowledging their pre‐existing systems, practice‐based and content knowledge and its interaction with the interpretation of the data. The study reporting was informed by the Good Reporting of a Mixed Methods Study guidelines [22].

To support the validity of the research, relevant frameworks, ethical and governance processes, peer review, and concurrent qualitative and quantitative data collection were embedded within the study design. Drawing upon the workshop facilitators' collective expertise, a reflexive approach was undertaken in the qualitative data collection and interpretation. This paper is authored by four of the five workshop facilitators and three of the co‐authors developed the Pathway to Personal, Population and Planetary Health framework. All authors are Accredited Practising Dietitians, currently in academic roles at universities in three states of Australia. The authorship team have practical experience promoting sustainable food systems in clinical settings, public policy, food service and the food industry, and have drawn upon these experiences to design, implement, interpret and synthesise this study. The decision to adopt a pragmatic approach to this research is grounded in the authors' acute understanding of the need for urgent pro‐environmental, systemic action within the food and health systems.

3. Results

Participant demographics are described in Table 2. Participants were predominantly female dietitians from metropolitan areas, and 35 (83.3%) of responding dietitians reported that they were not a member of a sustainability organisation.

Table 2.

Participant demographics: participant demographics collected at the start of a workshop titled, ‘Planetary health in diverse settings: Dietitians' power and purpose’ via Qualtrics TM survey.

Variable (n)	Description	Frequency (%)
Gender (n = 46)	Female	44 (95.7%)
	Male	2 (4.3%)
	Non‐binary	0 (0.0%)
	Third gender	0 (0.0%)
Location (n = 44)	Rural	11 (25.0%)
	Metropolitan	33 (75.0%)
Australian state/territory (n = 46)	Victoria	18 (39.1%)
	New South Wales	13 (28.3%)
	Queensland	7 (15.2%)
	Northern Territory	2 (4.4%)
	South Australia	2 (4.4%)
	Tasmania	1 (2.2%)
	Western Australia	0 (0.0%)
	Australian Capital Territory	0 (0.0%)
	International/other	3 (6.5%)
Primary employment status (n = 44)	Full‐time	17 (40.5%)
	Part‐time	17 (40.5%)
	Self‐employed	3 (17.1%)
	Contract/sessional	1 (2.4%)
	Student	4 (4.8%)
	Not currently employed/seeking employment	0 (0.0%)
	Other	2 (4.8%)
Predominant occupation/role (n = 43)	Academic/education/research	13 (30.2%)
	Hospital	11 (25.6%)
	Community health/health service	6 (14.0%)
	Food industry	2 (4.7%)
	Private Practice	3 (7.0%)
	Student/not employed	0 (0.0%)
	Other	8 (18.6%)
Highest qualification (n = 43)	PhD/doctorate	10 (23.3%)
	Masters	13 (30.2%)
	Bachelors	16 (37.2%)
	Certificate/diploma	1 (2.3%)
	School	0 (0.0%)
	Other	3 (7.0%)
Member of a sustainability organization (n = 42)	Yes	7 (16.7%)
	No	35 (83.3%)

When analysing dietitians' beliefs, existing actions and confidence to engage in pro‐environmental practices, pre‐ and post‐workshop survey results indicated participants reported increased confidence to undertake pro‐environmental change in their personal 4.1 ± 0.7 to 4.5 ± 0.8/5 and professional lives 3.6 ± 1.1 to 4.3 ± 0.9/5 (p < 0.05) at the conclusion of the workshop. Table 3 features pre‐and post‐workshop beliefs and confidence for pro‐environmental change, with significance.

Table 3.

Pre–post beliefs and confidence for pro‐environmental change.

Question	Time point (n)	Mean ± SD	I'm not sure (0)	Strongly disagree (1)	Disagree (2)	Neutral (3)	Agree (4)	Strongly agree (5)	Significance (p < 0.05)
I believe that globally there is a problem that we need to address by pursuing environmentally friendly/sustainable alternatives (to the status quo).	Pre (42)	4.5 ± 0.9	0 (0.0%)	2 (4.7%)	0 (0.0%)	0 (0.0%)	12 (27.9%)	29 (67.4%)	0.34*
	Post (46)	4.7 ± 0.7	0 (0.0%)	1 (2.2%)	0 (0.0%)	1 (2.2%)	8 (17.4%)	36 (78.3%)
I am confident I can undertake pro‐environmental change (towards sustainability and planetary health) in my personal life.	Pre (42)	4.1 ± 0.7	0 (0.0%)	0 (0.0%)	1 (2.3%)	5 (11.6%)	25 (58.1%)	12 (27.9%)	0.003*
	Post (46)	4.5 ± 0.8	0 (0.0%)	1 (2.2%)	0 (0.0%)	2 (4.4%)	15 (32.6%)	28 (60.9%)
I am confident I can undertake pro‐environmental change (towards sustainability and planetary health) in my professional life.	Pre (42)	3.6 ± 1.1	0 (0.0%)	1 (2.3%)	7 (16.3%)	8 (18.6%)	19 (44.2%)	8 (18.6%)	< 0.001*
	Post (46)	4.3 ± 0.9	0 (0.0%)	1 (2.2%)	0 (0.0%)	7 (15.2%)	14 (30.4%)	24 (52.2%)
I believe as a healthcare professional or professional in training, I have a responsibility to consider planetary health/sustainability in my practice.	Pre (43)	4.5 ± 0.8	0 (0.0%)	1 (2.3%)	0 (0.0%)	1 (2.3%)	16 (37.2%)	25 (58.1%)
I believe there is a movement by consumers and industry to prefer environmentally sustainable options in the health and food sectors.	Pre (43)	4.2 ± 0.7	1 (2.3%)	0 (0.0%)	2 (4.6%)	0 (0.0%)	28 (65.1%)	12 (27.9%)
I regularly incorporate sustainability and environmental responsibility into my personal life.	Pre (43)	4.3 ± 0.7	0 (0.0%)	0 (0.0%)	1 (2.3%)	4 (9.3%)	21 (48.8%)	17 (39.5%)
I regularly incorporate sustainability and environmental responsibility into my professional life.	Pre (43)	3.8 ± 1.0	0 (0.0%)	0 (0.0%)	6 (14.0%)	8 (18.6%)	18 (41.9%)	11 (25.6%)

Note: Measuring pre‐belief and confidence statements, and the impact of the workshop on three environmental belief and the confidence statements on pro‐environmental change in their personal and professional lives.

^*Shapiro–Wilk > 0.05; as a non‐parametric Mann–Whitney U test performed. Sample sizes varied pre‐ and post‐workshop varied due to individual response rates across survey items.

The thematic analysis of survey responses regarding barriers and enablers to pro‐environmental change resulted in three key themes: ‘personal’, ‘social and professional’ and ‘contextual and environmental’ factors, as summarised in Figure 2.

Figure 2.

Factors influencing dietitians' pro‐environmental behaviours.

The theme ‘personal factors’ captured the critical role of an individual's resources, capacity and beliefs in pro‐environmental change. For example, participants described active determinants that influenced their pro‐environmental behaviours, including knowledge, education, motivation, financial resources, time, self‐belief and agency. The data provided specific examples of how these factors could function as either barriers or enablers. For example, a participant responded that the ‘Ability to know if I'm truly supporting organisations that have truly sustainable policies’ (knowledge) was a professional barrier to being more environmentally sustainable. Another participant responded, <the> ‘Attitude of sustainability and having control over my own decisions and how they impact the environment’ as an important enabler.

The theme ‘social and professional factors’ describes the interpersonal influences on pro‐environmental change. The theme encompasses the social and professional environments in which participants were situated, and the role of social and behavioural norms, networks, family, colleagues, peers, professional colleagues and clients as social and professional factors in impacting pro‐environmental behaviours. The theme indicates the importance of these broader factors, including shared understanding, to enable pro‐environmental change. For example, a participant described that ‘Recognition of the problem by everyone’ was an important enabler, while another said that pro‐environmental work as ‘Being seen as soft work’, was a barrier.

The theme ‘contextual and environmental factors’ describes the external physical, structural and political conditions that influence individuals' pro‐environmental actions. It included several systemic elements, including physical location, infrastructure, occupational settings and policies, as well as broader socio‐political and scientific milieu. For example, a participant stated that a ‘Rural location in Nationals <political party area> can make it feel awkward to discuss climate’ was a barrier to being more environmentally sustainable in their professional life, while another participant said ‘Structures and systems in place, for example, recycling services’ was an enabler to environmental sustainability in their personal life.

To answer the second research question, ‘How do dietitians assess the value, usefulness and appropriateness of the PPH to guide their practice?’, a summary of responses is featured in Table 4. The dietitian respondents described that as systems‐thinkers, advocates, activists and change‐makers, dietitians can work with individuals, communities, industries, organisations and institutions, wherever they are in their planetary health journey, to drive change towards a sustainable future. They provided a range of examples of where dietitians are already applying the PPH dimensions in practice, and they emphasised the need for organisational, institutional, governmental and academic support to better integrate these dimensions into practice. Specifically mentioned were Dietitian Australia's (DA) position statement on Healthy and Sustainable Diets [8], and opportunities for professional development, supportive policies and updating of university curricula to include planetary health concepts and education on healthy and sustainable diets.

Table 4.

Importance of PPH dimensions and application.

Dimension and key descriptors	Participants were asked: Why is this dimension important?	Participants were asked: How is this dimension already being applied to practice?
Agency Vision, Self‐belief, Confidence, Strength, Responsibility	It is timely for dietitians as change‐makers and leaders in the community to advocate for climate action and planetary health by working with individuals and communities.	Develop Agency by: upskilling using Dietitian Australia's Position Statement on Health and Sustainable Diets. applying their knowledge and skills to their work. engaging management in change.
Action Start, Shift, Translate, Achieve, Commit	Leverages a dietitian's critical thinking and food skills to influence people and initiate action.	Demonstrate Action through: publication of Dietitian Australia's Position Statement for Health and Sustainable Diets. university curriculum development. conferences including workshops on sustainability.
Ascension Build, Overcome, Manage, Challenge, Progress	Starting small to create change and build ‘on that momentum’ to overcome ‘overwhelm’.	Ascension achieved by: understanding the food system from paddock to plate. sourcing food from local suppliers to reduce food miles. reducing packaging. advocating for appropriate meal portion sizes. having kitchen gardens in schools.
Alignment Leadership, Transparency, Diplomacy, Values, Systems	A sustainable diet is a healthy diet, which closely aligns with affordable eating options, Dietitians need to work together and align with ‘other professions’ to ‘drive change through’ collaboration and strength in numbers, Together, dietitians should work within existing systems to lead change towards healthy and sustainable diets.	Alignment demonstrated through: healthy and more sustainable government procurement policy (Victoria) launched March 2023. supporting local activities, e.g., community gardens. educating schools/children on growing food, reducing waste, etc., and grow interest in where food comes from.
Alliance and Allyship Support, Collaborate, Represent, Community, Citizenship	Dietitians should collaborate and create alliances with other professions to achieve a greater impact globally. Achieve impact through community engagement and empowering the community to take ownership ‘of localised solutions’. Creating alliances will guide dietitians to adopt appropriate language ‘that represents the community’.	Alliance and Allyship can include: partnership and procurement, communities and other food system organisations (e.g., regional co‐operatives, local food suppliers, growers). movement to co‐design. genuine community engagement and be part of the community we want to influence. ‘walking the talk’. finding allies in management and policy. building skills in translation, such as use of language. making information accessible. linking nutrition education, messages and education to those aligned with planetary health. understanding behaviour change. leading by example. creating alliances, e.g., other health services, GPs, health promotion, community health, environmental managers and sustainable living communities.
Advocacy and Activism Disrupt, Co‐design, Transform, Empower, Urgency	Dietitians are well‐placed and have the organisational skills that make them well‐suited to advocacy and activism. To achieve impact, dietitians need to engage in these activities and advocate on behalf of the groups we are working with to influence organisations and institutions.	Advocacy and Activism by: developing new university courses, subjects (e.g., food citizenship, social privilege) and food systems training placements. using DA's position statement for what we can do within our scope of practice. making change via workplace committees, e.g., hospital, university, Dietitians Australia. health program level for students to understand their overall privilege in this area in health and society. organisation policy making. lobbying government, e.g., Dietitians Australia lobbying. education and awareness events, such as workshops.

Note: A summary of each of the dimension of the PPH detailing its importance to dietitians and examples of how it is used in practice.

The information featured within Table 5 highlights participant feedback through workshop activities on the components of the tool that resonate as they are and those that require improvement. Participants found many components resonated as they are, including dietitians as change‐agents, the systems lens, strengths‐based focus, personal responsibility, achievable changes, need for transparency, leadership to inspire action, promotion of collaboration and concept of challenging the status quo as helpful for enabling dietitians to support sustainable and healthy food systems.

Table 5.

Critique of the Pathway to Planetary Health Framework: the components that resonate as they are and areas for improvement for each of the dimensions of the PPH.

Dimensions and key descriptors	Components that resonate as they are	Components that require improvement
Agency Vision, Self‐belief, Confidence, Strength, Responsibility	Participants identified with the strengths‐based focus, the promotion of small changes and collective voices to achieve large transformation and the emphasis on personal responsibility.	Greater emphasis on values‐led practice, exploration of ethical and moral responsibility, the transdisciplinary nature of this field and the need for collective movement.
Action Start, Shift, Translate, Achieve, Commit	The focus on making a start ‘beginning of a better tomorrow’, promotion of smaller and more achievable changes that can be maintained over time, translation of complex ideas into simple, do‐able tasks and action and the link to our profession's commitment (Code of Conduct).	No areas for improvement identified.
Ascension Build, Overcome, Manage, Challenge, Progress	The concept of challenging the status quo resonated with participants, and being able to identify small, feasible opportunities to do this at a local level to achieve global impact.	Participants identified that more tools and resources are required to support the workforce in achieving these changes, together with clearer, specific targets and guidance for action.
Alignment Leadership, Transparency, Diplomacy, Values, Systems	Three components that participants found helpful were (i) the systems lens given that we work within systems and must identify leverage points for change within these systems, (ii) the need for transparency when applying this environmental lens in our work with clients, community members and populations and (iii) leadership to inspire action.	There is need to expand the systems we work within and some examples of the alignment between nutrition and planetary health outcomes of our work within these systems.
Alliance and Allyship Support, Collaborate, Represent, Community, Citizenship	Participants identified two key components to be helpful, including (i) the strengths‐based, inclusive approach in identifying opportunities to learn from the lived experience of others, particularly groups we might not otherwise work with, (ii) promotion of collaboration as a valuable tool, acknowledging that our workforce is ‘in a good position to bring everyone, i.e., different groups together using food as a medium’.	A need to prioritise research that contributes evidence about how alliance and allyship can play a critical role in this path forward. Participants describe this work as an ‘opportunity to better understand how we can support First Nations Peoples' Knowledge and Leadership’, particularly in translating such knowledge into practice in a manner that minimises burden on First Nations' people while celebrating and honouring this knowledge and maximising positive change.
Advocacy and Activism Disrupt, Co‐design, Transform, Empower, Urgency	Participants documented that ‘dietitians are change agents’ resonated with them, and they shared that dietitians already have critical skills in facilitating co‐design (e.g., ‘knowing when to step back’ for other voices), taking a transdisciplinary approach and empowering the public through education. They agreed with the ‘transformational power of university education—empower students as future advocates and activists’. There was mixed response to the idea that dietitians can ‘disrupt’ current systems.	It was identified that dietitians need further skills in (i) talking to people in different professions to enact the transdisciplinary action required in this field (e.g., having the language to work with those in agricultural science), (ii) knowing how to ‘disrupt in a way that fits within our professional scope of practice’ with the request for a guide on how and when to use our voice for advocacy and (iii) translating the principles of ecology especially when teaching our future workforce.

The components to improve the PPH generally focused on skill acquisition to enact the pathway rather than the PPH itself. For example, participants identified the need for more tools and resources; a better understanding of a dietitian's role and their moral and ethical responsibilities; an understanding of how to honour and support First Nations people and minimise the burden placed on them; and a better understanding of the language required to work with other professionals to expand our scope of work within the food system.

4. Discussion

This study explored the feasibility of the PPH to guide pro‐environmental practices amongst dietitians. To achieve this aim, three key research questions were addressed: (i) What are dietitians' beliefs, existing actions and confidence to engage in pro‐environmental practices? (ii) How do dietitians assess the value, usefulness and appropriateness of the PPH model to guide their practice? (iii) Does a workshop featuring the PPH model enhance dietitians confidence to undertake pro‐environmental behaviours in their personal and professional lives?

We found that participating dietitians supported their professional role in facilitating food system change and pro‐environmental action. Importantly, the workshop featuring the PPH was effective in significantly increasing participants' confidence to engage in these practices, which is an essential factor for behaviour and food system change. This finding is important to support dietitians in moving beyond traditional clinical, food service or public health roles, to be able to have the confidence and perceived professional legitimacy to support broader food system changes.

• (i)Dietitians' beliefs, existing actions and confidence

  Before they undertook the workshop, there was strong agreement that dietitians have an important role in pro‐environmental food system change, and further, that there is a movement by consumers and industry across the food sectors to prefer environmentally sustainable options. This is important, as social norms (both for dietitians and within the broader food system) are a key driver of pro‐environmental behaviour, as individuals are more likely to adopt such practices when they are perceived as common, expected or socially approved [23, 24]. This then contributes to collective action and broader food system change.

  When describing barriers and enablers to existing environmental actions, personal, social and professional, and environmental and contextual themes were identified by participants. On reflection, these themes have some similarities to Bandura's Social Cognitive Theory (SCT) which is a behaviour change framework that its author has also related to human agency and confidence for ecological sustainability [25]. However, it is important to note that there were also some differences, including the role of systems, environmental and contextual factors, for example, whether recycling facilities are available in the community or workplace. These are not explicit in SCT but feature in other behaviour change models [17, 26]. The authors recognise that many dietitians are trained in systems thinking, and as this workshop featured many references to systems change and thinking, it follows that dietitians readily consider this issue through a systems lens. However, recognising system complexity does not necessarily translate directly into having the literacy and capacity for promoting food system change. This may be one reason that dietitians have reported barriers to food system changes, despite having a high‐level of awareness of systems thinking.

  Several commonly related barriers, for example, time, cost and peer/social influences, are not new concepts within behaviour and systems change literature. Practical approaches that address these factors may be effective and are also supported by Dietitians Australia's position statement on Healthy and Sustainable Diets [8] which describes incorporating planetary health explicitly into dietitians' job roles or advocating for supportive government and workplace policies. Despite these types of strategies supporting behaviour and systems change, through a clear scope of practice for dietitians or providing institutional supports, these may be undermined if dietitians prioritise individual‐level nutrition over systems‐oriented strategies.

• (ii)Views on the PPH framework

  In the context of this workshop, the PPH was effective in significantly increasing participants' confidence to undertake pro‐environmental change personally and professionally [6]. This is a positive finding because confidence is an important component of behaviour change according to several behaviour change theories, including the COM‐B behaviour change wheel, SCT and the transtheoretical (stage of change) models [17, 27, 28]. In this way, increased confidence could act as a bridge between dietitians' recognising the importance of pro‐environmental action and being able to initiate, sustain or advocate for change within a complex system.

Participants emphasised the importance of applying a systems lens to identify leverage points for change within food, political and workplace systems. While views diverged regarding the disruptive potential of dietitians within these systems, the value of education in empowering future advocates was recognised. Overall, the PPH framework was viewed as useful, though participants called for additional tools and skill‐based resources to translate knowledge into action. Participants reported the useful addition of skill acquisition to enact the PPH rather than the pathway itself—a progression which aligns with the knowledge to action framework at the ‘knowledge tools/products evolving’ stage of the action cycle and supports the progression of the PPH into the implementation phase [14]. This suggests that the PPH was supported as conceptually sound and aligned with the work of the dietetic profession, but the primary challenge is its translation into practice.

Value‐led and strength‐based approaches were highlighted as important in sustaining engagement and addressing barriers such as eco‐anxiety and inaction. Values‐based approaches feature in planetary health education literature, incorporating values like respect, ethics and justice as a progression from knowledge to application [29]. While large, transformational changes to the food and health sectors are required for positive pro‐environmental change [9], achievable and strengths‐based approaches that foster action could potentially be an antidote to eco‐anxiety, helplessness and inaction [30, 31, 32, 33]. Dietitians may be well‐placed to apply these approaches given their training in behaviour change counselling, strength‐based practice and client‐centred communication [7, 34]. Participants also recognised and emphasised that dietitians need to apply PPH planetary health dimensions within their professional decision‐making processes with transparency. This is an important professional discussion that aligns with the ‘transparency’ descriptor within the ‘Alignment’ guiding principle from the PPH [6].

The PPH featured the importance of collaboration and future work with First Nations Peoples—and in Australia, Aboriginal and Torres Strait Islander Peoples—by supporting and collaborating with them on the work they are leading to support planetary health [6]. The participants raised the importance of understanding how to honour and support First Nations people and minimise the burden placed on them. These are important considerations and further emphasise the importance of recognising that the PPH must be applied with an understanding of its scope and that First Nations and Aboriginal and Torres Strait Islander existing knowledge, leadership and resources are central to pro‐environmental progress. For example, it is important to recognise the broader global colonial (colonising) systems within which many food and health systems exist. The participant's responses also indicated an awareness and uncertainty relating to roles and boundaries when working with First Nations Peoples, and potentially the need to co‐design strategies to support pro‐environmental changes across the food and health systems with First Nations Peoples [35, 36, 37].

In interpreting the study findings, strengths and limitations, it is important to note that alongside the PPH, other important information was covered in the workshop, including several determinants of pro‐environmental change related to the dietitian's role, such as problem awareness, ascription of responsibility and self‐efficacy. The workshop presented key causes and consequences of environmental problems and the opportunity to pledge to take some action. The participants who opted to attend the workshop generally reported that they regularly incorporated sustainability and environmental responsibility into their personal and professional lives. As a result, the feedback they provided incorporates perspectives from participants who may be further along in their pro‐environmental development. As a case‐study mixed‐methods approach, further proof‐of‐concept work to demonstrate PPH impact beyond confidence to undertake pro‐environmental change, with specific systems theory or systems science approaches and in other contexts would be useful.

A mixed‐methods design was undertaken to address the study's purposes, conceptual framework(s), research questions, methods and validity considerations as an iterative process [15]. Several strategies were implemented to support the validity of the research. These included the use of established frameworks to guide the development of data‐collection tools, practice‐based implementation to support professional application (though a small sample size and limits in generalisability), expert input and peer review, adherence to ethical and governance requirements, concurrent qualitative and quantitative data collection, and a reflexive approach to data collection and interpretation. The study did not incorporate integration due to the scope and design of the research, but the dual quantitative and qualitative approach illuminated complementary findings, such as the dietitian's confidence to undertake pro‐environmental change.

This research explored dietitians' beliefs, existing actions and confidence to engage in pro‐environmental practices and the value, usefulness and appropriateness of the PPH framework. The PPH has been supported as a useful guide for dietitians that supports pro‐environmental food system change. The research has broad implications for dietitians working across food systems—including policy, community nutrition, industry, food services and broader advocacy—as well placed to support positive food system change. The findings of this study suggest that structured professional development, in this case a workshop featuring the PPH framework, increased confidence and enabled dietitians to support sustainable and healthy food systems.

Importantly, the results also highlighted that motivation alone is not enough to enable dietitians to influence food systems, and other food system factors should be considered, including institutional supports and co‐design approaches, particularly when working with First Nations Peoples. This study recognises that dietitians are important contributors but not the sole agents of pro‐environmental change and also supports a broader body of work suggesting that strengthening organisational, educational and policy‐level approaches, with less focus on individual agency, will enhance the capacity of the dietetics workforce to contribute to sustainable and healthy food systems [38, 39, 40, 41].

Author Contributions

The study design was conceived by Kristen L. MacKenzie‐Shalders in consultation with Jo McCormack, Nicole M. Senior and Liza Barbour. Data analysis and interpretation was completed by all co‐authors, who also reviewed and refined the results. The manuscript was written by Kristen L. MacKenzie‐Shalders with input from all co‐authors. All authors declare that this work has not been previously published.

Funding

The authors have nothing to report.

Ethics Statement

This research was approved by the following ethics committees: Bond University (ID: 2023/333), Griffiths University (ID: 2023/333) and Monash University (ID: 38619).

Consent

Workshop participants provided consent to participate in the research.

Conflicts of Interest

Nicole M. Senior provides freelance consulting services to the food sector and Kristen MacKenzie‐Shalders has started an environmental sustainability consultancy business. All other authors declare no conflicts of interest.

Supporting information

Supporting File 1

Supporting File 2

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.