Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):24-41.
The 13 Principles of the
Cartagena Declaration
Los 13 Principios de la Declaración de Cartagena
Os 13 Princípios da Declaração de Cartagena
Diana Cardenas1*, Milena Puentes2, Sonia Echeverri3, Angélica Pérez4, Lina López5, Charles Bermúdez6.
Received: September 1, 2019. Accepted: October 1, 2019.
https://doi.org/10.35454/rncm.v2supl1.035
1 Research Institute in Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia.
2 League against cancer, section Bogotá, Bogotá, D.C., Colombia. Treasurer of the Colombian Clinical Nutrition Association (ACNC) 2017 - 2021.
3 Hospital Ethics and Humanism Committee, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia. Vice-president FELANPE Central Region 2019 - 2020.
4 Department of Nutrition and Biochemistry, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia. Executive Secretary ACNC 2017 - 2021.
5 Nutrition support team. Clínica Universitaria Colombia. Bogotá, D.C., Colombia. Vice-president ACNC 2017-2021.
6 Surgery Department, Clínica la Colina y Clínica del Country. Bogotá, D.C., Colombia. President ACNC 2017-2021.
*Corresponding author: Diana Cardenas
dianacardenasbraz@gmail.com
Summary
The Cartagena Declaration recognizes that nutritional care is a human right. To make this human right effective, the Declaration provides a coherent framework of thirteen principles which provide a structure for promoting the development of nutritional care in the clinical setting, allowing all sick people to receive nutritional therapy in dignified conditions. The Declaration, through its principles, may also serve as an instrument to promote, through governments, the formulation of policies and laws in the field of clinical nutrition. The general framework of principles can contribute to raising awareness about the magnitude of this problem and to promote cooperation networks among Latin-American countries.
Thus, the Cartagena Declaration should be considered a framework document whose principles constitute the basis for promoting the development of nutritional care in the clinical field, and raising awareness among public authorities, academic bodies, and the pharmaceutical industry.
This article presents the definition, context, scope, perspective and some key concepts for each of the principles.
Keywords: Cartagena Declaration; Human rights; Principles.
Resumen
La Declaración de Cartagena reconoce que el cuidado nutricional es un derecho humano. Para lograr que este derecho sea efectivo, la Declaración propone trece Principios, los cuales proporcionan un marco de referencia para promover el desarrollo del cuidado nutricional en el ámbito clínico que permita que todas las personas enfermas reciban terapia nutricional en condiciones de dignidad. La Declaración por medio de los principios, podrá servir como un instrumento para que se promuevan, a través de los gobiernos, la formulación de políticas y legislaciones en el campo de la nutrición clínica. También, se pretende que el marco general de principios ayude a crear conciencia acerca de la magnitud de este problema y a forjar redes de cooperación entre los países de la región. Por lo tanto, la Declaración de Cartagena debe considerarse un documento marco cuyos principios constituyen la base para promover el desarrollo de la atención nutricional en el campo clínico, y concientizar a las autoridades públicas, los organismos académicos y la industria farmacéutica.
En este artículo se presenta la definición, el contexto, el alcance, la perspectiva y algunos conceptos clave para cada uno de los Principios.
Palabras clave: Declaración de Cartagena, derechos humanos, principios.
Resumo
A Declaração de Cartagena reconhece que o cuidado nutricional é um direito humano. Para garantir que esse direito seja efetivo, a Declaração propõe treze princípios, que fornecem uma estrutura para promover o desenvolvimento dos cuidados nutricionais no ambiente clínico que permite que todas as pessoas doentes recebam terapia nutricional em condições dignas. A Declaração, por meio dos princípios, também pode servir como instrumento para promover, através dos governos, a formulação de políticas e leis no campo da nutrição clínica. Além disso, pretende-se que a estrutura geral de princípios ajude a aumentar a conscientização sobre a magnitude desse problema e criar redes de cooperação entre os países da região.
Portanto, a Declaração de Cartagena deve ser considerada um documento de estrutura cujos princípios constituem a base para promover o desenvolvimento do cuidado nutricional no campo clínico e conscientizar as autoridades públicas, os órgãos acadêmicos e a indústria farmacêutica.
Este artigo apresenta a definição, contexto, escopo, perspetiva e alguns conceitos-chave para cada um dos princípios
Palavras-chave: Declaração de Cartagena, direitos humanos, princípios.
The principles
Principle # 1
Feed the ill person in conditions of dignity
“The right to nutritional care is recognized as an emerging right that relates to the right to health and the right to food. It is emphasized that the ill person must be fed in conditions of dignity, which implies recognizing during the process of nutritional care the intrinsic value of each human being, as well as respect for integrity, the diversity of moral, social and cultural values. The right to nutritional care includes quantitative, qualitative and cultural acceptability aspects.” (1)
Context
In this principle, it is recognized that nutritional care is a human right and, therefore, ill patients must be fed in conditions that respect their dignity. It must be considered the cornerstone principle of the Declaration. It is the starting point; it is the need to respond to the problem of disease related malnutrition and the undernourishment of the ill person. This problem is still frequent and little progress has been made despite the fact that the science of clinical nutrition has been developed over the last decades and that today we have ample evidence that demonstrates the impact of nutritional therapy, within the framework of an optimal and timely nutritional care, on the prognosis and the outcomes of the patients. Integrating the human-rights-based approach in the field of clinical nutrition is a new perspective that provides the opportunity of engaging different interested parties in a common fight against malnutrition(2).
Scope
Recognizing nutritional care as a human right and promoting the respect for dignity when feeding ill patients has implications that are political, academic-scientific, ethical and legal. Even though the Declaration is not a legally binding instrument, meaning it does not oblige the parties, it does commit them morally. In this context, the scientific societies that have signed the Declaration have committed themselves to recognizing and fostering this right. A first step is to ensure that governments and political authorities look at the problem of malnutrition in the clinical context with inte-rest and promote public policies and legislation on the subject. From the academic point of view, the teaching and recognition of this right as an emerging human right that is deeply related to the right to health and to the right to food, must be promoted. From an ethical perspective, it is possible to recognize that the patient at risk or in a state of malnutrition is a vulnerable person due to the impact on the biological, economic and social aspects. Additionally, it holds us responsible for this problem and forces us to act in favor of nutritional care for all patients.
** Images designed by Milena Puentes in the framework of the promotion program of the Cartagena Declaration
Perspective
The signing of the Declaration of Cartagena on May 3, 2019 is the starting point for common actions in Latin America, but without losing sight of the global perspective of the actions. The Declaration’s implementation program seeks, first of all, to provide the necessary tools that enable the translation of the principles into actions. In other words, the Declaration indicates us “what” must be done and the tools will indicate “how” it must be done. The first principle will be present directly or indirectly in each of the tools.
Key concept
The notion of dignity
Dignity refers to the intrinsic value of each human being for the mere fact of being one. According to Immanuel Kant, dignity implies the fact that the person should never be treated as a means, but rather as an end in itself. In nutritional care, the notion of dignity implies, as stated in the first principle, “recognizing during the process of nutritional care the intrinsic value of each human being, as well as respect for integrity, the diversity of moral, social and cultural values.”
Principle # 2
Nutritional care is a process
“Nutritional care is part of the patient’s overall care, and should therefore be an inherent component of their care. It is conceived as a continuous process consisting of several stages which can be summarized as follows: 1. Screening, 2. Nourish and 3. Watch.
Consequently, health institutions should promote the development of the nutritional care model based on detecting, nourishing and monitoring”. (1)
Context
Principle # 2 recognizes that nutritional care is a process and is closely related to # 1. Principle # 1 of the Cartagena Declaration states that the patient must be fed in conditions that guarantee the respect for human dignity.
How is this achieved? It is possible to guarantee the respect for human dignity if the patient is fed while taking into account the cultural, symbolic and affective or emotional aspects of nutrition, as well as recognizing the risks, benefits and limitations of nutritional therapy. Like any other medical therapy, nutritional therapy must have an indication and must be administered with the patient’s consent. To guarantee the administration of an adequate nutritional therapy, said therapy must be conceived within the framework of a continuous process that starts with the identification of the nutritional risk.
Scope
Recognizing nutritional care as a process has implications mainly on the organization of patient care. Activities must be organized and standardized so that detection, nutritional therapy and nutritional care monitoring are carried out according to the conditions and characteristics of each healthcare system or each institution. Ideally, it must be done from an interdisciplinary perspective (Principle # 4) and with the patient’s involvement (Principle # 3). Principle # 2 recognizes that every person who asks for medical service, at any level of care, has the right to benefit from the nutritional care process. In other words, that once the risk has been identified or the nutritional status has been diagnosed, the person must be fed taking into account the benefits they might have according to the precise medical indication and only after their consent. Principle # 2 also has implications for the academic aspects, since it must be made sure that healthcare professionals acquire the necessary competencies to carry out the three stages of nutritional care.
In this way, the scientific societies that have signed the Declaration have committed themselves to recognizing and promoting nutritional care as a process, and to this end, a first step is to ensure that governments and institutions look at the problem of malnutrition with interest and promote the implementation of the nutritional care model based on three stages and with an interdisciplinary approach. From the academic point of view, the education on the different stages of nutritional care must be promoted.
Perspective
Principle # 2 is key to the development of clinical nutrition and to guaranteeing the respect for the right to nutritional care. The implementation program of the Declaration will have tools that are necessary to define how professionals and institutions set the nutritional care model in motion. The three stages aim to ensure that nutritional care is provided with safety, timeliness, efficiency, efficacy and effectiveness.
Key concepts
Screening
The identification of nutritional risk by means of screening is the first stage, which leads, in the next stage, if the patient is at risk, to the completion of a complete diagnosis of nutritional status, allowing the medical indication of nutritional therapy to be established and the nutritional plan to be carried out. Screening should be systematic for ill patients at any level of health care. Any patient at nutritional risk should benefit from the full nutritional diagnosis.
The nutritional diagnosis allows the identification of nutritional alterations, which can be: a. Malnutrition (synonym of undernutrition), b. Overweight and obesity, c. Micronutrient abnormalities. Malnutrition or undernutrition are defined as the condition resulting from lack of intake, altered nutritional absorption, increased nutrient losses leading to alteration of body composition (decrease in fat-free mass) and body cell mass leading to decreased mental and physical functions and deterioration of clinical outcome. Malnutrition may be the result of fasting, disease or old age (i.e. > 70 years). Each can be presented in isolation or in combination.
Malnutrition may present as: a. Malnutrition without disease, b. Malnutrition associated with inflammatory disease (acute or chronic), c. Disease related malnutrition without inflammation.
It is emphasized that the diagnostic criteria for malnutrition established by consensus should be evaluated in the Latin American context, taking into account the phenotypic characteristics of the population and the socio-economic situation, among others. The detection of nutritional risk should be a priority at all levels of health care.
Nourish
The nutritional plan includes nutritional therapy (or medical nutritional therapy), i.e., with natural foods of ordinary administration and artificial nutrients administered through supplements, enteral and parenteral nutrition. Nutritional therapy is considered to be a medical intervention, requiring a medical-nutritional indication, which has the objective of specific treatment and requires the informed consent of the patient. Like any therapy, nutrition also has side effects, risks and benefits. The biological dimensions (quantitative and qualitative), the symbolic, affective and cultural dimensions associated with feeding are taken into account, even if it is artificial nutritional therapy.
Watch
Nutrition therapy should be monitored and documented. Monitoring seeks to verify that the different dimensions of nutrition therapy are met, as well as preventing side effects. Documentation helps to track and evaluate the continuity of therapy for each patient and to ensure quality. It’s important to be able to start a process of risk management and “insurability” in the clinical setting.
Principle # 3
Patient empowerment as a necessary action to improve nutritional care
“Empowering patients and their families in the fight against malnutrition implies empowering them to think critically about this syndrome and its respective negative consequences, while allowing them to make autonomous and informed decisions, such as demanding nutritional care and complying with the suggested nutritional treatment.” (1)
Context
Principle # 3 of the Declaration of Cartagena recognizes the patient’s central role in the nutritional care process described in Principle # 2. The third principle is defined by the need of moving from a model of paternalistic relation between the patient and the doctor or the healthcare system to a model where decisions are shared. A nutritional care model inspired by empowerment seeks to enhance the patient’s own capacities to manage nutrition in acute or chronic diseases and their capacity to take control of their lives. Empowerment implies that the patient and their support network commit to nutritional therapy, moving from the simple fact of receiving all information passively to active involvement in the decisions. It also implies that the nutritional care professional must transmit certain information so that the patient and their network have the capacity of acting with complete freedom.
Scope
Recognizing that patient empowerment is a necessary action to improve nutritional care and to promote respect for human dignity has implications for organizational, academic-scientific and ethical aspects. From the organizational point of view, the stages of the nutritional care model “Screening, nourish and watch” have to consider educational and awareness actions toward patients. Healthcare professionals have to acquire skills to educate and transmit the information to the patient so that joint decisions can be taken. From the ethical point of view, empowerment implies recognizing the patient’s principle of autonomy (respect for patient’s ability to decide, and their right to have their will respected), the clinical nutrition professionals’ responsibility of feeding the ill person and the principle of equity in health.
The scientific societies that have signed the Declaration have committed themselves to recognizing and promoting nutritional care, and to acknowledging the importance of empowering the patient in decision-making throughout this process.
To this end, a first step is to ensure that governments and institutions look at the problem of malnutrition with interest and promote the implementation of the nutritional care model based on three stages, with an interdisciplinary approach and involving the patient’s empowerment. From the academical perspective, education regarding the different stages of nutritional care and the techniques of therapeutic education and empowerment must be promoted.
Perspective
Principle # 3 is key to the development of clinical nutrition and to guaranteeing the respect for the right to nutritional care. The implementation program of the Declaration will have the tools that are necessary for professionals and institutions to set this principle in motion. Awareness should be raised among the different patient associations in regard to the importance of nutritional care in any disease.
Key concepts
Empowerment is defined as a process and a result. The former is based on the fact that, increasing education improves the ability to think critically and to act autonomously, while the latter (result) is achieved through the sense of self-efficacy.
Empowerment is achieved through education and education implies freedom. In nutritional care, empowering patients means offering them the opportunity to be part of the nutritional process and treatment; consequently, it’s not just about obtaining a voice, but also about sharing knowledge and responsibilities with them and their families. Empowerment seeks to increase the patient’s freedom and autonomy (the ability to take informed decisions) on the role of malnutrition and nutritional therapy in the different stages of the treatment.
Principle # 4
The interdisciplinary approach to nutritional care
“This approach involves the equitable integration of the various disciplines related to nutritional activity. Scientific evidence shows the advantages of this approach in terms of cost-effectiveness, safety and efficiency”(1)
Context
Principle # 4 of the Cartagena Declaration recognizes the importance of interdisciplinarity in the practice of nutritional care. The interdisciplinary approach has been essential to putting into practice the medical and scientifical advances that led to the development of nutritional therapy in the last decades. As nutritional therapy developed, multidisciplinary nutritional support teams were created, progressively migrating to interdisciplinary ones, to optimize the effectiveness and safety of this therapy. It has been demonstrated that the impact of standardization and nutritional care through interdisciplinary groups improve the patient’s results and safety, and have a positive economic impact on health institutions. However, many hospitals don’t have nutritional support teams.
Scope
Recognizing the importance of the interdisciplinary approach in nutritional care has implications that are mainly academic, but also for organizational aspects. It is recommended that nutritional therapy be administered within nutritional support teams where, as a minimum, nutrition, nursing, medicine and pharmacy professionals participate. Additionally, the inclusion of other disciplines such as phono audiology, occupational therapy, physical therapy, rehabilitation, social work and psychology, which increase the effectiveness of nutritional therapy, is advised. Academically, not only should professionals in these disciplines be formed in the field of clinical nutrition, but specific disciplinary competencies should be defined.
The scientific societies that have signed the Declaration have committed themselves to recognizing the importance of the interdisciplinary approach in nutritional care. From the academic perspective, the education of the professionals who make up the interdisciplinary nutritional support teams must be promoted.
Perspective
The creation of the interdisciplinary nutritional support teams and the certification of the currently functioning teams must be promoted through the measurement of their results. Within interdisciplinarity, the different disciplines interact respecting each other’s specific work field. There is cohesion of knowledge, where knowledge is contributed from the disciplinary perspective, responsibility is shared, but the competence of each discipline is maintained. Therefore, it becomes necessary to recognize the limitations and competencies of the different disciplines that interact in nutritional care. In the implementation program, tools that will allow the development of the interdisciplinary approach will be created.
Key concepts
Interdisciplinarity, according to the Royal Academy of the Spanish Language is defined as an activity “That is carried out with the cooperation of several disciplines.” Multidisciplinarity and transdisciplinarity are close and complementary concepts. In Interdisciplinarity the different disciplines interact respecting each other’s specific work field.
Principle # 5
Ethical principles and values in clinical nutrition
“It is recognized that patients at risk or in a state of malnutrition are a group considered ethically vulnerable. Vulnerability is an inescapable dimension of human beings and the configuration of social relations. Considering the vulnerability of the malnourished patient implies recognizing that individuals may at some point lack the capacity and means to feed themselves and, therefore, it is necessary for this need to be met by professionals in clinical nutrition.” (1)
Context
Principle # 5 of the Cartagena Declaration recognizes the need to support the practice of nutritional care in ethical principles and values. Nutritional therapy is considered a great scientific and technological advance that has allowed the ill person to be fed and to improve clinical outcomes, quality of life and impact on health costs. It is recognized that with these advances bioethical issues arise that may have repercussions on individuals, families and groups or communities. Principle # 5 proposes that these issues be analyzed within the framework of the principles set out in UNESCO’s Universal Declaration on Bioethics and Human Rights (DUBDH), particularly the universal principles of equality, justice and equity, non-discrimination and non-stigmatization, nonmaleficence, autonomy, beneficence and respect for human vulnerability and personal integrity(3). Furthermore, this principle recognizes that respect for cultural diversity and pluralism is fundamental to the realization of nutritional care and the debate around ethical questions.
Scope
Principle # 5 establishes the need of giving nutritional care an ethical approach. A key aspect of this approach is recognizing that patients at risk or in a state of malnutrition are a group considered vulnerable. This vulnerability is explained by the impact of malnutrition in the biological, psychological and social aspects (with the risk of losing one’s life and the possibility of losing one’s autonomy) and due to the fact that malnutrition is a commonly overlooked syndrome in the clinical context. Vulnerability is an inescapable dimension of human beings and the configuration of social relations. Considering the vulnerability of the malnourished patient implies recognizing that individuals might at some point lack the capacity and the means to feed themselves and, therefore, it is necessary for this need to be met by clinical nutrition professionals.
The scientific societies that have signed the Declaration have committed themselves to recognizing the importance of the ethical approach in nutritional care. A promotion of the education on ethics, the discussions and spaces for an ethical debate around nutritional care are expected.
Perspective
Nutritional care as a human right implies that every person with or at risk of malnutrition, must have access to nutritional care and in particular to an optimal and timely nutritional therapy. This right must be exercised with an ethical foundation and with professionalism. The ethical foundation establishes the values and principles needed for the practice of nutritional care. These principles will have an impact in the actions and decisions made when feeding the ill person. The goal is for said actions to respect the ill person’s autonomy, take into account the possible benefits and risks, and futile actions to be limited. This principle also has a deontological dimension, since it states that professionalism, honesty, integrity and transparency should be promoted in decision-making, particularly in the declarations of all conflicts of interest and appropriate sharing of knowledge, according to what is stated on article 18 of the DUBDH.
The implementation program of the Cartagena Declaration will develop tools that will allow the creation of programs for ethical formation in nutritional care. These tools will allow the ethical approach to be taken into account in nutritional care and will be essential for promoting the respect for this human right.
Key concepts
Ethics
Ethics is a branch of philosophy whose objective is to carry out an intellectual analysis of the human moral dimension in all its complexity. Ethics deals with principles that allow us to make decisions about what is morally right and wrong. In other words, ethics is the study of what is morally right and what is not.
An ethical dilemma is a situation in which moral obligations demand or seem to demand that a person take one or more alternative but incompatible actions, in a way that the person cannot take all the required actions. In those situations, there exists a conflict or tension between respect for two or more principles which makes it difficult to decide what must be done. Decisions related to futile actions lead to ethical dilemmas.
Principle # 6
The integration of healthcare based on value (economic aspects)
“Economic aspects should be integrated into clinical nutrition exercise, assessment and research. It is proposed to integrate value-based health care into nutritional care. Under this approach, the aim is to reorient health services to improve the satisfaction of patient’s health needs, particularly nutritional care, while maintaining an optimal relationship with costs and outcomes. Generating value implies an emphasis on achieving health outcomes for both patients and organizations and society while maintaining an optimal relationship with costs.” (1)
Context
Principle # 6 of the Cartagena Declaration recognizes the need to integrate the economic aspects mainly in the exercise of clinical nutrition. The need to integrate nutritional care in health systems, guaranteeing efficiency, arises. In other words, health systems and organizations must be able to guarantee nutritional therapy, looking for a health service with the best possible results and maintaining an adequate relation with costs.
Scope
Principle # 6 establishes the need of using a value-based approach and integrating the economic aspects to nutritional care. A key aspect of this approach is the recognition of the need to guarantee, in all health systems, adapted regulatory processes and the reimbursement of nutritional products (supplements, enteral and parenteral nutrition), consultations with specialists, and the integration of the four steps of nutritional care (screening, diagnosing, nourishing, watching).
The scientific societies that have signed the Declaration have committed themselves to recognizing the importance of the integration of healthcare based in value (economic aspects).
Perspective
The ill person has the right to receive safe and high-quality nutritional care, with qualified personnel and seeking cost-effectiveness, based on scientific evidence. Resources should be allocated according to public policies focused on promotion, prevention and nutritional intervention that result in improving the quality of life of patients. For this it is fundamental to implement quality programs which integrate elements of the health economy: cost minimization, cost effectiveness, cost benefit, cost effectiveness and cost utility.
Key concepts
Value in health is defined by an efficient relationship between results and costs, and their beneficiaries: the patient, society and those who finance healthcare services.
Principle # 7
Clinical nutrition research is a pillar for the realization of the right to food in the clinical field and the fight against malnutrition
“The development of clinical nutrition research should be promoted under a new paradigm, which consists of a vision of clinical nutrition that considers that the ill person needs, beyond food and nutrients, an approach to metabolism in the particular context of the disease and a better understanding of its metabolic and nutritional state. For this, it is necessary to develop research to understand the biological-molecular mechanisms associated with the metabolic states of ill patients.” (1)
Context
Principle # 7 of the Cartagena Declaration recognizes the need to promote the development of clinical nutrition research under a new paradigm. It arises from the need to understand that nutritional therapy does not simply imply the administration of nutrients to meet some requirements. Nutritional therapy administration also implies understanding that the ill person shows specific metabolic situations and alterations that could be considered adaptive to the injury or disease. Therefore, nutritional therapy has to be adjusted to the metabolic situation of each patient.
Scope
Principle # 7 establishes the need to promote the development of clinical nutrition research. The goal is to promote research on the mechanisms and physiological and molecular aspects of the injured or ill patient’s metabolic adaptations. A key aspect of this approach is the need to promote research and innovation in nutritional therapy products that allow administering nutrients in a way that adapts to each situation. It is also necessary to develop research so that the molecular, physiological mechanisms that are characteristic of situations like sarcopenia, cachexia and micronutrient deficiencies are known.
Perspective
The scientific societies that have signed the Declaration have committed themselves to promoting research. To that end, a demand for higher investment and support for research in clinical nutrition must be made to government authorities, academic institutions and pharmaceutical companies. The problem of disease related malnutrition and its impact on health systems must have more visibility so that research in this field can be a priority. It is recognized that the interests and welfare of the individual should have priority over the exclusive interest of science or society (pharmaceutical industry, companies, etc.).
The implementation program of the Cartagena Declaration will develop tools that will allow the fulfillment of the following objectives:
a) research on relevant clinical nutrition issues under scientific standards of quality, evidence-based medicine and respecting principles of bioethics; b) developing lines of research that are relevant in the regional (Latin American) context; c) evaluating the advances in science and technology that arise in the field of clinical nutrition; d) supporting the formulation of recommendations, guidelines and consensus of clinical practices based on scientific evidence; e) promoting debate, education and public awareness on clinical nutrition and the problem of malnutrition, as well as participation in respect of the right to food in this field.
Principle # 8
Clinical nutrition education is a fundamental axis for the fulfillment of the right to nutritional care and the fight against malnutrition
“Clinical nutrition education should be created, promoted and supported at the appropriate level and under the new paradigm: a) at the undergraduate level: promote the teaching of clinical nutrition in health careers (medicine, nutrition, nursing, pharmacy, etc.); b) at postgraduate level: recognize clinical nutrition as a clinical specialty and not as a subspecialty or complementary training.” (1)
Context
Principle # 8 of the Declaration of Cartagena recognizes the need to promote clinical nutrition education. This principle emerges from the lack of clinical nutrition education at the undergraduate and postgraduate education levels of healthcare professionals, doctors, nurses and nutritionists, among others. Despite the evidence that doctors have the will, understand the importance of nutritional care and are considered reliable sources of information regarding nutrition, these professionals do not perform nutritional care and cite the lack of knowledge and insufficient training as a barrier. These data align with the evidence of persistent gaps in education and training in medical nutrition in the United States and Europe.
Scope
Principle # 8 establishes the need to promote clinical nutrition education. The goal is to promote the introduction of a basic curriculum in nutrition in the faculties of health careers (medicine, nutrition, nursery, pharmacy, etc.). In postgraduate medicine and other health careers: recognizing clinical nutrition as a clinical specialty and not as a subspecialty or complementary formation.
Perspective
The scientific societies that have signed the Declaration have committed themselves to promoting clinical nutrition education. To that end, a minimum curriculum in nutrition at the undergraduate level and the recognition of clinical nutrition as a specialty must be promoted. Minimum knowledge and competencies should be taught at the undergraduate level of health careers. The corresponding institutions shall accredit specialized formation and foster continuing education in the field of clinical nutrition.
The implementation program of the Declaration of Cartagena will develop tools that will allow the creation, promotion and support, at the appropriate level, and under the new paradigm, of clinical nutrition education. At the undergraduate level: promote the teaching of clinical nutrition in health careers (medicine, nutrition, nursing, pharmacy, etc.). At the postgraduate level: recognize clinical nutrition as a clinical specialty and not as a subspecialty or complementary training. Appropriate institutions: accredit specialized training and promote continuing education in the field of clinical nutrition.
Principle # 9
Strengthening of networks
“Activities, programs and projects shall be created, promoted and supported at the appropriate level for the purpose of: a) promoting in health institutions the development of the nutritional care model based on detecting, nourishing and monitoring; b) strengthening clinical nutrition education programs; c) developing and strengthening lines of research in clinical nutrition; d) promote solidarity and cooperation in the development of programs to promote nutritional care and the fight against malnutrition.” (1)
Context
Principle #9 of the Cartagena Declaration recognizes the need to strengthen clinical nutrition networks. This principle arises from the need to unite efforts among the different scientific societies, academic and hospital institutions, among others, to promote better nutritional care and the fight against malnutrition.
Scope
Principle # 9 establishes the need to develop networks in order to promote nutritional care and, with this, the development of the nutritional care model based on detecting, nurturing, monitoring; strengthening clinical nutrition education programs; developing and strengthening lines of research in clinical nutrition; promoting solidarity and cooperation in the development of programs to promote nutritional care and the fight against malnutrition.
Perspective
The scientific societies that have signed the Declaration have committed themselves to fostering the creation of networks to promote clinical nutrition.
Principle # 10
Creating an institutional culture that values nutritional care
“Activities, programs and projects shall be created, promoted and supported at the appropriate level for the purpose of: a) sensitizing physicians and other health professionals to the importance of clinical nutrition; b) sensitizing the public and institutions to the problems of malnutrition and the right to nutritional care; c) showing the scientific evidence that will make it possible to advance in the institutionalization of the nutritional care model based on detecting, nourishing and monitoring; d) promoting the participation of the public, patients and institutions in the realization of the right to nutritional care; e) promoting fair and equitable nutritional care.” (1)
Context
Principle # 10 of the Cartagena Declaration recognizes the need to create an institutional culture that recognizes the value of nutritional care based on respect for human rights, in particular the human right to nutritional care. This principle arises from the need to raise awareness of disease related malnutrition in the various health care settings and the role of nutritional care.
Scope
Principle #10 establishes the need to foster an institutional culture that recognizes nutritional care as a human right. This implies making society and institutions aware of the problems of malnutrition and the right to nutritional care; showing the scientific evidence that will make it possible to advance in the institutionalization of the nutritional care model based on detecting, nurturing, monitoring; promoting the participation of the community, patients and institutions in the realization of the right to nutritional care; promoting fair and equitable nutritional care.
Perspective
The scientific societies that have signed the Declaration have committed themselves to recognizing the right to nutritional care and to foster the principles and values that are necessary in healthcare institutions at different levels.
Key concept
Institutional culture refers to the values and practices that guide and give meaning to the work of institutions.
Principle # 11
Justice and equity in nutritional care
“A fair and equitable public health agenda should be created, promoted and supported for the purpose of: a) developing mechanisms so that every ill person has availability, and stable, continuous and timely access to nutritional therapy, as well as the correct use of nutritional therapy; b) promoting the integration into health systems of the nutritional care model capable of providing nutritional therapy under dignified conditions; c) promoting the interdisciplinary approach and the creation of nutritional therapy teams; d) valuing the reimbursement and payment of nutritional care services.” (1)
Context
Principle #11 of the Cartagena Declaration recognizes the need to promote justice and equity in nutritional care. This principle arises from the need to promote the idea that that all ill patients receive nutritional care on equal terms and with equal opportunities.
Scope
Principle #11 establishes the need to promote just legislation and public policies in the field of clinical nutrition. This implies promoting the integration within health systems of the nutritional care model capable of providing nutritional therapy in conditions of dignity, justice and equity; promoting the interdisciplinary approach and the creation of nutritional therapy teams; valuing the reimbursement and payment of nutritional care services, among others.
Perspective
The scientific societies that have signed the Declaration have committed themselves to promote legislation and public policies in the field of clinical nutrition that provide access to nutritional care with justice and equity.
We consider that in this way, it is possible to contribute to achieving the goals of United Nations sustainable development goals 2 and 3 (SDG 2 and 3)(4) in particular goals 2.2: “By 2030, end all forms of malnutrition”, and 3.4: “By 2030, reduce by one third premature mortality from non-transmissible diseases through prevention and treatment and promote mental health and well-being.”
Key concept
Equity is the absence of avoidable or remediable differences between different groups of patients, defined by either social, economic, demographic or geographical criteria. Thus, inequity in health goes beyond simple inequities in health determinants, access to resources needed to improve or maintain health, or health outcomes. This lack of equity also results from the impossibility of avoiding or overcoming injustices or non-compliance with human rights.
Principle # 12
Ethical, deontological and transparency principles of the pharmaceutical and nutritional industry (Ph&NI)
“Relationships should be promoted between societies, schools and associations that defend the right to clinical nutrition with the pharmaceutical and nutritional industry (Ph&NI), based on the ethical and transparency policies they demand: Clarity and accountability in the roles of the Ph&NI so that they can demonstrate the highest level of quality of nutritional solutions and products; demonstrate, through Ph&NI independent scientists, that the nutritional solutions created demonstrate objective and scientifically valid clinical benefit; to have education programs promoted by the Ph&NI with the highest scientific value and that are free of any intention of commercialization of the nutritional solutions; that the interaction of the Ph&NI with professional and regulatory organizations is strictly focused on the promotion of the best patient care and constant scientific growth.” (1)
Context
Principle #12 of the Cartagena Declaration recognizes the need to promote relations with the pharmaceutical and nutritional industry based on ethical, deontological and transparency principles. This principle arises from the need to avoid unclear conflicts of interest and to reiterate that the welfare of patient should take priority over the exclusive interest of the pharmaceutical industry.
Scope
Principle # 12 establishes the need to promote relations with Ph&NI based on ethical, deontological and transparency principles.
Perspective
The scientific societies that have signed the Declaration have committed themselves to promoting relations with Ph&NI based on ethical, deontological and transparency principles. To this end, every society, college and association shall establish policies of ethics, integrity and transparency, recognizing that Ph&NI plays an essential role in the creation and commercialization of solutions and nutritional formulas for the patient; and that it contributes to the education of health personnel in the provision of nutrition and in nutritional research.
The declaration’s mandate
Principle # 13
Call to International Action
“FELANPE calls on societies and international organizations to unite in the fight against malnutrition and the respect of the right to nutritional care. The principles set out in this document will serve as a basis for common action.
The FELANPE urges the States and the Human Rights Council of the United Nations to recognize this Declaration and therefore the Right to Nutritional Care as a human right as it guarantees all patients, especially the malnourished ill, access to nutritional care and, in particular, optimal and timely nutritional therapy in order to reduce the high rates of hospital malnutrition and the associated morbidity and mortality.” (1)
Principle # 13 clearly sets out the mandate of the Declaration of Cartagena. It recognizes the right to nutritional care as a human right. It also recognizes that the beneficiaries of that right are patients in any health setting, who may claim access to nutritional care and in particular to optimal and timely nutritional therapy. Those in charge of protecting this right are societies and international organizations that must unite in the fight against malnutrition, and who must reach out to governments and political legislators to create legislation and public policies in the field of clinical nutrition.
Fundig sources
This article was not financed.
Conflict of interests
The authors declare that they have no conflict of interest.
Author’s contributions
DC and MP designed the article. The authors declare that they read and approved the final manuscript.
References
- Cardenas D, Bermúdez CH, Echeverri S, Perez A, Puentes M, Lopez M, et al. DECLARACIÓN DE CARTAGENA. Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición. Nutr Hosp. 2019;36(4):974-98. http://dx.doi.org/10.20960/nh.02701
- Cardenas D, Bermudez CH, Echeverri S. Is nutritional care a human right? Clin Nutr Exp. 2019;26:1-7. https://doi.org/10.1016/j.yclnex.2019.05.002.
- Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura. La Declaración de Bioética y Derechos Humanos. [Internet]. Paris: Unesco; 2005 [consultado el 8 de julio 2019]. Disponible en: http://portal.unesco.org/es/ ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_ SECTION=201.html.
- Organización de las Naciones Unidas. Objetivos de Desarrollo Sostenible. New York: ONU; 2015 [consultado el 8 de Julio 2019]. Disponible en: https://www.un.org/sustainabledevelopment/ es/energy/ [Internet].