Bermúdez C, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):82-86.
Implementation of the International Declaration on the right to nutritional care in the clinical setting and the fight against malnutrition
Implementación de la Declaración Internacional sobre el derecho al cuidado nutricional en el ámbito clínico y la lucha contra la malnutrición
Implementação da Declaração Internacional sobre o direito ao cuidado nutricional no contexto clínico e o combate à desnutrição
Charles Bermúdez*1, Angélica Pérez2, Milena Puentes3, Lina López4, Mery Guerrero5, Eloísa García Velasquez6, Serrana Tihista7, Gertrudis Baptista8, Paula Sanchez9, Haydee Elena Villafana Medina10, Lázaro Alfonso11,
Tania Palafox12, Sonia Echeverri13, Diana Cardenas14
Received: September 1, 2019. Accepted: October 15, 2019.
https://doi.org/10.35454/rncm.v2supl1.033
1 Surgery Department, Clínica la Colina y Clínica del Country. Bogotá, D.C., Colombia. President of the Colombian Clinical Nutrition Association (ACNC) 2017-2021.
2 Department of Nutrition and Biochemistry, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia. Executive Secretary ACNC 2017 - 2021.
3 League against cancer, section Bogotá, Bogotá, D.C., Colombia. Treasurer ACNC 2017 - 2021.
4 Nutrition support team. Clínica Universitaria Colombia. Bogotá, D.C., Colombia. Vice-president ACNC 2017-2021.
5 Clinical nutrition and dietetics unit, Cancer figth Society, Guayaquil, Ecuador. President of the Ecuadorian Society of Parenteral and Enteral Nutrition, ASENPE.
6 Nutritional support and nutrition department, Hospital Clínica San Francisco. Guayaquil, Ecuador. Secretary of FELANPE
7 Nutrition department, Centro Nacional de Quemados, Montevideo, Uruguay.
8 Universidad Central de Venezuela. Nutrition Support Unit, Hospital Universitario de Caracas, FASPEN.
9 Nutrition Unit, Hospital Dr. Rafael Ángel Calderón Guardia. Caja Costarricense de Seguro Social. San José, Costa Rica.
10 Hospital regional docente de Trujillo, Universidad Nacional de Trujillo, Perú. Past president ASPETEN.
11 Hospital Pediátrico Universitario William Soler Ledea, La Habana. Cuba, President of the Cuban Society of Clinical Nutrition and Metabolism. Miembro Consejo Fiscal FELANPE 2018-2020.
12 Clinical Nutrition, Centro Médico Dalinde, Ciudad de México, México. Mexican College of Clinical Nutrition and Nutrition Therapy.
13 Hospital Ethics and Humanism Committee, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia. Vice-president FELANPE Central Region 2019 - 2020.
14 Research Institute in Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia.
*Corresponding author: Charles Bermúdez
chebermud@yahoo.com
Summary
Considering the high prevalence of disease-related malnutrition and the need to advance education and research in clinical nutrition, the Cartagena Declaration was signed in May 2019. This is the International Declaration on the right to nutritional care which is addressed to societies, colleges and associations affiliated with FELANPE, and to any organization or institution that promotes the fight against malnutrition.
The Declaration provides a coherent framework of 13 Principles which can serve as a guide in the development of action plans. In addition, it will serve as an instrument for states to formulate policies and legislate in the field of clinical nutrition. We believe that the general framework of principles proposed by the Declaration can contribute to raising awareness about the magnitude of this problem and forging cooperation networks between the countries of the region, and why not, the world. It will be, then, contributing to achieving the United Nations Sustainable Development Goals that seek, by 2030, to end all forms of malnutrition.
The Colombian Association of Clinical Nutrition and FELANPE propose a program which aims to implement actions aimed at promoting and putting into practice each of its 13 Principles.
Keywords: Human rights; Malnutrition; Principles.
Resumen
Frente a la alta prevalencia de malnutrición asociada a la enfermedad y la necesidad de avanzar en la educación e investigación en nutrición clínica, se firmó en mayo de 2019 la Declaración de Cartagena. Se trata de la Declaración Internacional sobre el derecho al cuidado nutricional la cual va dirigida a las sociedades, colegios y asociaciones afiliadas a la FELANPE, y a toda organización o institución que promueva la lucha contra la malnutrición.
La Declaración proporciona un marco coherente de 13 Principios los cuales podrán servir de guía en el desarrollo de los planes de acción. Además, servirá como un instrumento para que los Estados formulen políticas y legislen en el campo de la nutrición clínica. Consideramos que el marco general de principios propuesto por la Declaración puede contribuir a crear conciencia acerca de la magnitud de este problema y a forjar redes de cooperación entre los países de la región, y por qué no del mundo. Se estará, entonces, contribuyendo a alcanzar los Objetivos de Desarrollo Sostenible de Naciones Unidas que buscan, para 2030, poner fin a todas las formas de malnutrición.
La Asociación Colombiana de Nutrición Clínica y la FELANPE proponen un programa de implementación el cual tiene como finalidad poner en marcha acciones encaminadas a promover y a poner en práctica cada uno de sus 13 Principios.
Palabras clave: derechos humanos, malnutrición, Principios.
Resumo
Face á alta prevalência de desnutrição associada à doença e a necessidade de avançar na educação e pesquisa em nutrição clínica, se assinou em maio de 2019 a Declaração de Cartagena. Esta é a Declaração Internacional sobre o direito ao cuidado nutricional, dirigida a sociedades, faculdades e associações afiliadas na FELANPE e a qualquer organização ou instituição que promova o combate à desnutrição.
A Declaração fornece uma estrutura coerente de 13 Princípios que podem servir como um guia no desenvolvimento de planos de ação. Além disso, servirá como um instrumento para os estados formularem políticas e legislem no campo da nutrição clínica. Acreditamos que o quadro geral dos princípios propostos pela Declaração pode contribuir para a criação de uma consciencia sobre a magnitude deste problema e criar redes de cooperação entre os países da região, e porque não do mundo. Contribuirá, então, para alcançar os Objetivos de Desenvolvimento Sustentável das Nações Unidas que buscam, até 2030, acabar com todas as formas de desnutrição.
A Associação Colombiana de Nutrição Clínica e a FELANPE propõem um programa de implementação que tem como propósito promover ações e colocar em prática cada um de seus ١٣ princípios.
Palavras-chave: direitos humanos, desnutrição, Princípios.
The Cartagena Declaration should be considered as a starting point for the development of actions that seek to promote the right to nutritional care and the fight against malnutrition. The principles established therein must be transformed into concrete actions. To this end, an implementation program is proposed, the purpose of which is to implement actions aimed at promoting each of its 13 principles (Figure 1).
Figure 1. Steps of the Cartagena Declaration.
The program for the implementation of the Cartagena Declaration is justified, first, by the need to promote better nutritional care and the fight against disease related malnutrition. Its foundation is the recognition of nutritional care as an emerging human right that implies that the right of everyone to benefit from the stages of nutritional care that lead to adequate nutritional therapy (supplements, therapeutic diet, enteral and parenteral nutrition, etc.) should be respected, protected and fulfilled(1). This means that the patient has the right to benefit from the stages of nutritional care by a team of experts, and the government should be able to guarantee this. This human right is inseparable from the right to health and the right to food. We are convinced that promoting this right from the level of primary care to highly complex hospital institutions is a mechanism that will make it possible to combat the problem of malnutrition and to promote nutritional therapy in conditions of dignity for all(1).
Second, the need to advance clinical nutrition education and research. The lack of education and training of health professionals (doctors, nutritionists, nurses and pharmacists, among others) in the field of clinical nutrition is alarming(2). This is in addition to the lack of awareness of these professionals about the importance of addressing nutritional problems with patients in an appropriate manner. The integration of content and a sufficient number of hours of nutrition education into undergraduate curriculums is a priority. In addition, the recognition of clinical nutrition as a specialty is essential in order to promote its teaching in postgraduate and continuing education programs. Providing high quality nutrition education to physicians and other health professionals is a mechanism that contributes to building healthier populations. Hand in hand with education, research will promote and ensure the development of the discipline. The development of research lines on the most frequent problems in this field is a priority. In particular, efforts should be directed to the understanding of the physiopathology of malnutrition, metabolic and nutritional alterations and adaptations through innovative technology (for example, metabolomics) which will be important to optimize treatment and develop new strategies to obtain better results.
Third, the need for tools to address bioethical questions and dilemmas. The possibility of feeding all the sick people who require it thanks to advances in science and technology entails bioethical questions and dilemmas. We believe that the exercise of clinical nutrition should be carried out within the framework of a set of ethical principles and values which should be based on respect for human dignity. The UNESCO Declaration on Bioethics and Human Rights, promulgated on 19 October 2005, served as a reference for the development of these principles.
In this article we will present the general guidelines of the program of implementation of the Cartagena Declaration, in particular the development of the toolbox.
Objectives of the implementation program
1. To define the necessary mechanisms to promote the Cartagena Declaration in the academic sphere, with national and international scientific societies, in health institutions, with the pharmaceutical industry and governments. Actions to achieve this objective have been determined since the signing of the Declaration and will be maintained on an ongoing basis.
2. Develop the necessary tools for the implementation of the principles of the Cartagena Declaration. Dissemination of the tools will begin in the third quarter of 2019 and extend to 2020.
3. Adopt the strategy to measure, through indicators, compliance with the implementation of the Cartagena Declaration. In the first instance, the indicators will be defined and developed in order to later promote their implementation.
Working group
The implementation program and the development of the program’s tools will be carried out by three working groups made up of experts in clinical nutrition from Latin America.
- Research and education
- Ethics
- Promoting Nutritional Care
Each working group will focus on the development of tools that consider the principles of the Declaration. The relationship of working groups to the principles of the Cartagena Declaration is shown in Table 1.
Table 1. Working groups and the principles of the Cartagena Declaration
|
Principles of the Cartagena Declaration |
Working groups |
|||
|
Promotion of nutritional care |
Research and Education |
Ethics |
||
|
1 |
Nutrition in conditions of dignity of the sick person |
x |
x |
|
|
2 |
Nutritional care is a process |
x |
||
|
3 |
Patient empowerment as a necessary action to improve nutritional care |
x |
x |
|
|
4 |
The Interdisciplinary Approach to Nutritional Care |
x |
x |
x |
|
5 |
Ethical principles and values in nutritional care |
x |
x |
x |
|
6 |
Integrating value-based health care (economic aspects) |
x |
||
|
7 |
Clinical nutrition research is a pillar for the fulfillment of the right to nutritional care and the fight against malnutrition. |
x |
||
|
8 |
Clinical nutrition education is a fundamental axis for the fulfillment of the right to nutritional care and the fight against malnutrition. |
x |
||
|
9 |
Strengthening clinical nutrition networks |
x |
x |
x |
|
10 |
Creating an institutional culture that values nutritional care |
x |
x |
|
|
11 |
Justice and equity in nutritional care |
x |
x |
|
|
12 |
Ethical, deontological and transparency principles of the nutritional pharmaceutical industry (NPh&I) |
x |
x |
|
|
13 |
International Call to Action |
x |
x |
x |
The toolbox
It will be made up of the following nine tools:
1. Nutritional Care Process Implementation Guide and Manual
The objective of this manual is to provide the guidelines and basic tools necessary to implement the nutritional care model in institutions and at the different levels of nutritional care in Latin America. It will include recommendations on the use of screening, diagnostic, nutritional therapy and surveillance tools. In addition, it will facilitate economic and scientific arguments to promote the development of nutritional care in institutions or health systems. This tool seeks to provide detailed guidance for improving nutritional care in clinical practice and for institutions that do not yet have a nutritional care structure to implement it. That is, this tool also aims to provide methodological assistance to develop the nutritional care model, recommendations on planning, implementation and monitoring of nutritional care.
2. Guide to promoting the creation of interdisciplinary nutrition therapy groups
This tool aims to provide detailed guidance for the creation of interdisciplinary nutritional therapy groups. It will provide methodological and operational assistance to develop them.
3. Manual for Patient Education and Empowerment
The purpose of this manual is to provide the basic guidelines and tools necessary to educate and empower the patient. The development of this manual will be based on a literature review and an expert consensus meeting.
4. Ethics and transparency policy for nutrition societies
Its objective is to develop a model document defining a policy of ethics and transparency based on the principles of the Declaration. The main objective is to promote ethical and more transparent relations between scientific societies and different actors, such as the pharmaceutical industry, among others.
5. Guideline on Ethical Principles in Nutrition
Explanatory and academic materials will be produced on ethical principles to facilitate addressing ethical problems and dilemmas in nutrition. The development of this manual will be based on a literature review and an expert consensus meeting.
6. Manual of Principles of Clinical Nutrition Research
The purpose of this manual is to provide the basic guidelines and tools necessary to promote research in clinical nutrition.
7. Core curriculum for undergraduate clinical nutrition education (medicine, nutrition, nursing, pharmacy, etc.).
The undergraduate core curriculum aims to establish the competencies, attitudes and skills needed by health professionals. It will begin with the core curriculum for physicians. The curriculum will be developed after a literature review and an expert consensus meeting.
8. Nutrition curriculum and competencies for postgraduate education
The curriculum shall include recommendations and minimum curriculum content as well as competencies for the health professional who wishes to develop in the areas of clinical nutrition and nutritional therapy. The curriculum will be developed after a literature review and an expert consensus meeting.
9. Strategies and guidelines for the creation of public policies and legislation in clinical nutrition
This directive will have the key elements to bring the issue of malnutrition onto the political and public health agenda. A survey will be carried out to find out the current state of legislation and public policies on clinical nutrition in all the countries that are part of FELANPE.
Conclusion
The mission of the implementation program is to translate the principles of the Cartagena Declaration into concrete actions. The toolbox represents an important step for nutritional care to be recognized as a human right. While the Cartagena Declaration contains the principles on what should be done, the toolbox shows how this can be done. It will include a series of analytical, practical and educational tools that offer guidance and advice on the practical aspects of the 13 principles. The program comes at an opportune time. Clinical nutrition societies and associations are looking for ways to improve the rates of disease-related malnutrition and to promote education and research in clinical nutrition. In that sense, these tools represent valuable guidance. FELANPE remains committed to continue supporting these efforts.
Financing
This article was not financed.
Conflict of interests
The authors declare that they have no conflict of interest.
Author’s contributions
CB and DC designed the article. The authors declare that they read and approved the final manuscript.
References
- Cardenas D, Bermudez CH, Echeverri S. Is nutritional care a human right? Clin Nutr Exp. 2019;26:1-7.
- Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health. 2019; 3: e379–89.