The Journal of Clinical Nutrition and Metabolism

Editorial Board

Editor

Diana Cárdenas, MD, PhD.

Profesora Asistente, Facultad de Medicina, Instituto de Investigación en Nutrición, Genética y Metabolismo, Universidad El Bosque, Bogotá, D.C, Colombia.

Associate Editor

Fanny Aldana-Parra, ND, PhD.

Investigadora Pontificia Universidad Javeriana, Departamento de Nutrición y Bioquímica, Bogotá, D.C, Colombia.

Editor assistance

Lorena Montealegre Páez, MD.

Investigadora Facultad de Medicina, Instituto de Investigación en Nutrición, Genética y Metabolismo, Universidad El Bosque, Bogotá, D.C, Colombia.

Editorial Advisory Board

Jorge Eliécer Botero López, MD, MSc.

Profesor, Departamento de Pediatría, Facultad de Medicina, Universidad de Antioquia, Hospital Infantil de San Vicente Fundación, Medellín, Colombia.

Lilia Yadira Cortés Sanabria, ND, PhD.

Profesora Titular, Pontificia Universidad Javeriana, Departamento de Nutrición y Bioquímica, Bogotá, D.C, Colombia.

Olga Lucía Pinzón Espitia, ND, PhD.

Docente, Facultad de Nutrición, Universidad Nacional, Universidad del Rosario, Hospital Méderi, Bogotá, D.C, Colombia.

Sonia Echeverri, RN, MSc, FASPEN.

Fundación Santa Fe de Bogotá, Directora Fundación Conocimiento, Bogotá, D.C, Colombia.

Scientific Advisory Board

Ana María Menéndez, QF, PhD.

Investigadora y Profesora titular de Farmacia Hospitalaria y Clínica. Carrera de Farmacia, Universidad de Belgrano. Co-Directora Ejecutiva del Instituto Argentino de Investigación y Educación en Nutrición- IADEIN, Buenos Aires, Argentina.

Carlos Andrés Castro, QF, PhD.

Profesor Asistente, Facultad de Medicina, Instituto de Investigación en Nutrición, Genética y Metabolismo, Universidad El Bosque, Bogotá, D.C, Colombia.

Carlos Andrés Santacruz, MD, Especialista.

Intensivista, médico institucional, Fundación Santa Fe de Bogotá, Bogotá, D.C, Colombia.

Dan Linetzky Waitzberg, MD, PhD.

Professor Associado da Faculdade de Medicina da Universidade de São Paulo. Director Ganep Nutrição Humana, São Paulo, Brasil.

Gil Hardy, PhD, FRSC, FASPEN.

Profesor Emérito de Nutrición Clínica. College of Health, Massey University, Auckland, Nueva Zelanda.

Guillermo Ortiz, MD, PhD.

Jefe de Cuidados Intensivos del Hospital Santa Clara. Director Ejecutivo del Instituto de Simulación Médica (INSIMED), Bogotá, D.C, Colombia.

María Isabel Toulson Davisson Correia, MD, PhD.

Professora de Cirugía Universidade Federal de Minas Gerais, 

Belo Horizonte, Brasil.

José Mario Pimiento Echeverri, MD, Especialista, FACS.

Profesor Asociado, Cirugía Oncológica Gastrointestinal, Jefe de la Sección de Oncología del tracto gastrointestinal alto, Moffitt Cáncer Center and Research Institute, Tampa, Florida, USA.

Juan Bernardo Ochoa, MD, PhD.

Profesor de Cirugía y Cuidado Critico, Universidad de Pittsburg, PA, USA.

Miguel León Sanz, MD, PhD.

Jefe, Sección de Endocrinología y Nutrición. Profesor Titular de Medicina en el Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, España.

Rafael Figueredo Grijalba, MD, MSc.

Director del Instituto Privado de Nutrición Integral, Paraguay.

Rubens Feferbaum, MD, PhD.

Professor, Instituto da Criança HC, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil.

Sandra Paola Perdomo Velázquez, Bióloga, PhD.

Profesora Titular, Facultad de Medicina, Instituto de Investigación en Nutrición, Genética y Metabolismo, Universidad El Bosque, Bogotá, D.C, Colombia.

Saúl Rugeles Quintero, MD, Especialista.

Profesor Titular de Cirugía, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia.

Vanessa Fuchs-Tarlovsky, ND, MD, PhD.

Jefe del Servicio de Nutrición Clínica e Investigadora en Ciencias Médicas, Hospital General de México, Ciudad de México, México.

William Manzanares, MD, PhD.

Profesor Agregado de Medicina Intensiva, Cátedra de Medicina Intensiva. Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.

The Colombian Clinical Nutrition Association

Board of Directors 2019-2021

President: Charles E. Bermúdez, MD.

Vice president: Lina López, RN.

Executive secretary: Angélica Pérez, ND.

Treasurer: Milena Puentes, QF.

Representatives

Clara Eugenia Plata, MD.

Esperanza Moncada Parada, ND.

Martha Elena Muñoz Peláez, ND.

Justo Olaya Ramírez, MD.

Fernando Pereira, MD.

Committee of former presidents

Patricia Savino Lloreda, ND.

Jaime Escallón Mainwaring, MD.

Saúl Rugeles Quintero, MD.

Stella Moreno Vélez, ND.

Óscar Jaramillo Robledo, MD.

Álvaro Valencia, MD.

Julián Sotomayor Hernández, MD.

Mauricio Chona Chona, MD.

Arturo Vergara Gómez, MD.

Claudia Angarita Gómez, ND.

Josef Kling, MD.

Adriana Amaya, ND.

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Ethics, integrity and transparency policy

The Journal conforms to the international ethical and good practice standards in publications. The purpose is to promote an ethical and transparent publication in each one of its articles. The articles published in the Clinical Nutrition and Metabolism Journal must abide by the ethical principles of the different declarations and legislations on intellectual property and copyright specific to the country where the research was carried out.

The editor, the authors, the members of the committees, and the academic peers must comply with the international ethical rules (http://publicationethics.org and Committee on Publication Ethics Code of Conduct for Journal Publishers, validated by the ICJME).

Open access policy

The Journal in its electronic version is published in the Open Journal System editorial management developed by the Public Knowledge Project (PKP), allowing free access to articles.

Licenses of use and distribution

The Journal is published under the Creative Commons Attribution-NonCommercial 4.0 International license (CC BY-NC-SA 4.0), so the user is free to: share, copy and redistribute the material in any medium or format; and to remix, transform and build from the material with the condition of citing the original source (Journal, authors and URL). It should not be used for commercial purposes.

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The Journal of Clinical Nutrition and Metabolism (RNCM - Rev. Nutr. Clin. Metab.)

The Journal is the official organ of the Colombian Clinical Nutrition Association, published every six months (May and October).
500 copies have been printed

Avenida 15 No. 118-03 Oficinas 512 / 514, Bogotá, D.C., Colombia

Visite: www.nutriclinicacolombia.org

Correspondance: E-mail: editor-rmnc@nutriclinicacolombia.org

Editing: Sonia Echeverri, RN, MSc, FASPEN

Editing (English): Sergio Cárdenas

Layout and Printing: Grupo Distribuna

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The Journal of Clinical Nutrition and Metabolism Volume 2, Supplement 1 - december 2019.

Contents / Contenido / CONTEÚDO

EDITORIALS / EDITORIALES / EDITORIAIS

Cartagena Declaration: Date with a dream Declaración de Cartagena: cita con un sueño Declaração de Cartagena: encontro com um sonho Charles E. Bermúdez Patiño

The Cartagena Declaration from the optics of the presidency of FELANPE Declaración de Cartagena desde la óptica de la presidencia de la FELANPE Declaração de Cartagena da óptica da presidência de FELANPE Dolores Rodríguez Veintimilla

Nutrition and Clinical Nutrition as human rights Nutrición y Nutrición Clínica como derechos humanos Nutrição e nutrição clínica como direitos humanos Rocco Barazzoni

ORIGINAL ARTICLES / ARTÍCULOS ORIGINALES / ARTIGOS ORIGINALES

The International Declaration on the Right to Nutritional Care and the fight against Malnutrition, “Declaration of Cartagena” Declaración de Cartagena. Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición Declaração Internacional sobre o Direito ao Cuidado Nutricional e a Luta contra a Desnutrição Diana Cardenas, Charles Bermúdez, Sonia Echeverri, Angélica Pérez, Milena Puentes, Lina López, Isabel Correia, Juan Bernardo Ochoa, Ana María Ferreira, María Alexandra Texeira, Diego Arenas Moya, Humberto Arenas Márquez, Miguel Leon-Sanz, Dolores Rodríguez-Veintimilla

The 13 Principles of the Cartagena Declaration Los 13 Principios de la Declaración de Cartagena Os 13 Princípios da Declaração de Cartagena Diana Cardenas, Milena Puentes, Sonia Echeverri, Angélica Pérez, Lina López, Charles Bermúdez

From the right to food to the right to nutritional care Del derecho a la alimentación al derecho al cuidado nutricional Do direito à alimentação ao direito ao cuidado nutricional Diana Cardenas, Sonia Echeverri, Charles Bermúdez

Clinical nutrition and the human right-based approach Nutrición clínica y el enfoque basado en derechos humanos Nutrição clínica e a abordagem baseada nos direitos humanos Diana Cardenas

Ethical aspects of the Cartagena Declaration Aspectos éticos de la Declaración de Cartagena Aspetos éticos da Declaração de Cartagena Diana Cardenas, Sonia Echeverri

The Cartagena Declaration from interdisciplinarity La Declaración de Cartagena desde la interdisciplinariedad A Declaração de Cartagena desde a interdisciplinariedade Sonia Echeverri, Humberto Arenas Márquez, Gil Hardy, María Alejandra Texeira, Yadira Cortes, Edna Nava, Laura Joy, María Isabel Pedreira de Freitas

The Cartagena Declaration and the Sustainable Development Goals La Declaración de Cartagena y los Objetivos de Desarrollo Sostenible A Declaração de Cartagena e os Objetivos de Desenvolvimento Sustentável Diana Cardenas

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, Angélica Pérez, Milena Puentes, Lina López, Mery Guerrero, Eloísa García Velasquez, Serrana Tihista, Gertrudis Baptista, Paula Sanchez, Haydee Elena Villafana Medina, Lázaro Alfonso, Tania Palafox, Sonia Echeverri, Diana Cardenas

Information for the authors

1. Scope and aim

The Journal of Clinical Nutrition and Metabolism, the official Journal of the Colombian Clinical Nutrition Association is a peer-reviewed, Open Access journal that publishes original research articles as well as review articles on all aspects of clinical nutrition and metabolism. Therefore, the Journal publishes articles about different biochemical processes, specifically about metabolism and nutritional regulations, nutritional therapy (enteral nutrition, parenteral nutrition, oral supplements), and the relationship between nutrition and disease.

The Journal is published every six months (May and October) with a multidisciplinary approach and a content of original articles, review articles, clinical cases, controversies, opinion and others. Translations of guidelines and international consensuses are also part of the Journal. It receives works in Spanish, English, and Portuguese for publishing, and it has printed and online versions.

The Journal doesn’t charge any fee throughout the editorial process for the publication of the articles. It operates a fully open access publishing model which allows open global access to its published content.

2. Criteria for the initial acceptance of manuscripts

The Journal complies with the rules of the International Committee of Medical Journal Editors (ICJME). Every manuscript must be elaborated by following its recommendations, which can be found on its website: http://www. icmje.org

All manuscripts will be subject to complete evaluation by the editor for their initial validation. The criteria for initial acceptance by the Journal include authenticity, data validity, clarity in writing, conclusion soundness, and relevance of the work in the field of clinical nutrition and metabolism. Compliance with ICMJE publishing norms will be verified.

3. Peer review process

Reception. All the submissions must be done through the website: https://revistanutricionclinicametabolismo.org/index.php/nutricionclinicametabolismo

Editorial subject acceptance. The Journal conducts a two-step acceptance process. The first step implies the editorial acceptance of subject and content. Within a maximum period of 30 days from the article’s reception, the correspondent author will be notified via e-mail whether the assessed article fulfills the norms and requirements detailed in the Criteria for the initial acceptance of manuscripts section. The editor may request the correspondent author some adjustments or modifications before submitting the article for the second step.

Peer review. The second step consists of an external and anonymous peer review (peer review - single blind review). Each manuscript is evaluated by one or two expert independent reviewers to assess the scientific quality of the document. A third verdict may be requested to arbitrate a particular article. With one, two, or three verdicts will the editor decide on its publication. The correspondent author will receive the answer within a maximum term of four months. This may be: accepted/rejected/accepted with minor revisions/ accepted with mayor revisions.

The Journal only accepts original publications; therefore, submission of any contribution or publication for consideration of the Editorial Committee implies that it is authentic and has not been previously published nor is it being reviewed for publication by another Journal. Previously published material in indexed Journals will not be accepted. The national or international clinical Guidelines or Recommendations published by other Journals can be published with prior editor validation, and once applicable permits for its publication have been obtained.

The authors are responsible for obtaining the appropriate permits to partially reproduce the material, be it text, charts, or figures, which they must attach to the manuscript sent to the Clinical Nutrition and Metabolism Journal.

The Editor is responsible for accepting or rejecting the submission.

4. Sections of the Journal

The Journal consists of the following sections:

Editorials, Originals, Reviews, Letters to the Editor, Clinical Cases, others.

5. Format and style rules

The manuscript must be sent in Word format, in Spanish, English or Portuguese, Arial 12 size Font, and 1.5 line spacing. All figures and tables are placed at the end of the manuscript, and if necessary in a separate document. Add line numbers throughout the file.

Each component of the manuscript must begin in a new page in the following order:

1. Cover letter
2. Title page
3. Summary in Spanish and English, and keywords.
4. Text: Introduction, Materials and Methods, Results, Discussion, Acknowledgements, declaration of authorship, declaration of interests and funding
5. Bibliographical references
6. Tables and figures

For all manuscripts add line numbers throughout the file starting at the first page.

Cover letter

The cover letter must be addressed to the Editor and present the relevance and particular contribution made by the proposed work (see journal template).

6. References

Bibliography must follow Vancouver norms.

Where available, DOIs and URLs for the references should be provided.

7. Ethics, integrity and transparency policy

The Journal conforms to the international ethical and good practice standards in publications. The purpose is to promote an ethical and transparent publication in each one of its articles. The articles published in the Clinical Nutrition and Metabolism Journal must abide by the ethical principles of the different declarations and legislations on intellectual property and copyright specific to the country where the research was carried out.

The editor, the authors, the members of the committees, and the academic peers must comply with the international ethical rules (http://publicationethics.org and Committee on Publication Ethics Code of Conduct for Journal Publishers, validated by the ICJME). It is sought to avoid cases of forgery, falsification, omission of information, and plagiarism, as well as to promote the publication of research that conforms to the ethical principles of investigation.

8. Conflict of interest

Authors must describe any financial or personal relationship that might result in a conflict of interest with respect to the published article.

9. Authorship

Within the list of authors, only such individuals who fulfill each one of the following requirements must appear:

1. Having participated in the conception and completion of the work that has resulted in the article in question.

2. Having participated in the text’s drafting and possible revisions.

3. Having approved the version that will finally be published.

Bermúdez C, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):8-9.

Cartagena Declaration: Date with a dream

Declaración de Cartagena: cita con un sueño

Declaração de Cartagena: encontro com um sonho

Charles E. Bermúdez Patiño1*

https://doi.org/10.35454/rncm.v2supl1.026

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1 President ACNC 2017-2021

*Corresponding author: Charles E. Bermúdez Patiño

presidencia@nutriclinicacolombia.org

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When we took on the challenge, as the Board of Directors, of leading the course of the Colombian Clinical Nutrition Association, we established pillars on which we would work in the following years: education, research, creation and strengthening of networks, and dissemination strategies. The Declaration of Cartagena is a convincing example of the union of these four paths to fulfill the mission and vision of our Association, also succeeding in influencing the rest of Latin America in the quest to achieve a higher good, a timely medical nutritional therapy, adequate, fair, equitable and in conditions of human dignity, recognizing the patient as a fragile person with rights and committing the health team as guardians of these rights.

Taking as a reference the Declaration of Cancun, signed in 2008, a document that for the first time in Latin America proclaimed “the human right of the sick to receive timely and optimal nutritional therapy wherever they are(1)”; malnutrition in its various forms, as the most common disease, and in the clinical area related to inadequate intake, increased nutritional requirements due to disease, poor absorption of nutrients, excessive nutrient loss; or a combination of all these factors(2), becomes a global problem, with figures around 50 % of patients hospitalized according to the series studied(3-5).

If we review the nutritionDay figures in Colombia we find that the malnutrition rate in 7,994 patients evaluated from 2009 to 2015 is 38 %. Despite this data, in 2018 only 27.2% of the patients studied underwent nutritional screening, showing that there is still a long way to go in the timely detection of the risk of malnutrition. When reviewing nutritional interventions we found that by 2018 the use of nutritional supplementation was 9.9%, enteral nutrition 5.3% and parenteral nutrition 2.2%(6), remembering that malnutrition figures are around 40 % of hospitalized patients, it is pertinent to think that ultimately, something is wrong with the nutritional intervention.

The consequences of malnutrition are widely described and can be summarized as slow healing, altered immunity, increased mortality, increased hospital stay, and the direct and indirect costs of health care.

It has been documented in multiple publications that the percentage of complications is higher in malnourished patients: Waitzberg et al. in 2001, quantified this higher rate of complications in malnourished patients in 27% different from 16.8% of incidence in well-nourished patients(3); Correia et al. in 2003, indicated that in malnourished patients mortality increased by 8 % and hospital stay increased by up to 3 days(7).

Once the problem was identified, and the adverse outcomes that the problem entails, the next step, in this particular case of the Societies, Colleges and Associations belonging to FELANPE, was to assume the challenge, and the implications of declaring “Nutritional Care as a human right, and to guarantee to all persons, especially to the sick with or at risk of malnutrition, access to nutritional care and in particular to optimal and timely nutritional therapy, in order to, among others, reduce the high rates of hospital malnutrition and associated morbidity-mortality”(8). The Declaration of Cartagena establishes 13 Principles, but I consider that the most important thing is to establish an action plan that allows us to move from words to deeds, from discourse to action, committing governments to the integral treatment of our patients, understanding nutritional therapy as a human right(9) and the key to an effective and sustainable health system.

Finally, this is the moment to publicly express my gratitude to my family for their help, support and generosity with their time and in particular to Valeria Bermúdez Garzón, my daughter, who is in 11th grade at the Angloamericano School, and who despite her school obligations, decided to accompany me to achieve my dreams, to support me not only from the heart but through admirable physical work, advice, recommendations, she has walked with me these years, we have grown together, always remember “Close your eyes, focus, imagine, dream, make a wish”.

Thank you, daughter!!!

References

1. Castillo Pineda JC, Figueredo Grijalva R, Dugloszewski C, Diaz R, Reynoso JAS, Spolidoro Noroña JV, Matos A, et al. Declaración de Cancún: declaración internacional de Cancún sobre el derecho a la nutrición en los hospitales. Nutr Hosp. 2008;23(5):413-7.
2. Loch SH, Allison SP, Meier R, Pirlich M, Kondrup J, Shneider S, ven der Berghe G, Pichard C. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, Definitions and General Topics. Clin Nutr. 2006;5:180-6.
3. Waitzberg D, Caiaffa WT, Correia MI. Hospital Malnutrition: The Brazilian National Survey (IBRANUTRI): A Study of 4000 Patients. Nutrition. 2001;17(7-8):573-80.
4. Cruz V, Bernal L, Buitrago G, Ruiz AJ. Frecuencia de riesgo de desnutrición según la Escala de Tamizado para Desnutrición (MST) en un servicio de Medicina Interna. Rev Med Chile. 2017; 145: 449-57.
5. Bermudez CH, Henao A, Rodriguez P, Veloza A. Por una clínica sin malnutrición: Modelo de atención nutricional en la Clínica la Colina. Revista Médica. 2016;6(1):12-5.
6. nutritionDay reports.[Internet] (Consultado el 20 de octubre de 2019). Available: https://www.nutritionday.org/en/about-nday/national-reports/index.html
7. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22:235-9.
8. 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.
9. Cardenas D, Bermúdez CH, Echeverri S. Is nutritional care a human Rigth?. Clin Nutr Exp. 2019; 26: 1-7. https://doi.org/10.1016/j.yclnex.2019.05.002

Rodríguez D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):10-11.

The Cartagena Declaration from the optics of the presidency of FELANPE

Declaración de Cartagena desde la óptica de la presidencia de la FELANPE

Declaração de Cartagena da óptica da presidência de FELANPE

Dolores Rodríguez Veintimilla.1

https://doi.org/10.35454/rncm.v2supl1.027

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1 President of FELANPE 2019 - 2020

*Corresponding author: Dolores Rodríguez Veintimilla

dra.rodriguezv@yahoo.com

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According to the Royal Academy of the Spanish Language (RAE), Declaration is the action and effect of declaring, manifesting or explaining what others doubt or ignore, manifestation of intent or intention. On May 3, 2019, the 16 countries that make up the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) in the city of Cartagena, Colombia, raised their voices, proclaimed to the world and registered their real commitment to recognize nutritional care as a Human Right independent of the level of health care, in action against the various kinds of malnutrition and in particular that which is disease related, convinced that adequate Nutritional Therapy can correct malnutrition, improve disease prognosis, quality of life, decrease comorbidities, mortality and health costs.

The great initiative to recognize the right of patients to receive nutritional therapy as a human right, registered as the Cartagena Declaration: International Declaration on the Right to Nutritional Care and the Fight against Malnutrition, saw the light from the hand of a great professional, Dr. Diana Cardenas who with Dr. Charles Bermudez, president, and other distinguished members of the Colombian Association of Clinical Nutrition (ACNC) designed this great project and promoted this activity with the main objective of reducing the prevalence of disease-related malnutrition and promote the development of clinical nutrition. Malnutrition figures in Latin America range between 40 % and 60 %, and there are even studies that report an increase in its prevalence with a notable increase in the number of days of hospital stay and a greater frequency of comorbidities.

The question comes to mind: How to promote compliance with the Cartagena Declaration? This leads us to the last point of the Declaration in which FELANPE shares with its co-responsible organizations the concern and responsibility regarding the process of intervening in the different forms of malnutrition, due to the negative impact it has on the health of individuals, communities and societies.

It is gratifying to see the way in which the different countries of FELANPE are working together to fight hospital malnutrition, and this example of perseverance and effort has spread to other societies such as the European Society of Clinical Nutrition and Metabolism (ESPEN), the American Society of Parenteral and Enteral Nutrition (ASPEN), and the Pan American and Iberian Federation of Critical Medicine and Intensive Care (FEPIMCTI), among others.

As has been expressed on multiple occasions “no person is an island”, and the desired objectives will not be achieved if each one works alone, on his or her own. In this sense, with the signing and proclamation of the Cartagena Declaration, FELANPE leads a global effort so that finally food and nutritional security in hospitals and health systems is recognized as an indissoluble part of therapeutic success and comprehensive health management.

References

1. 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.
2. Correia MITD, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: a systematic review. Clin Nutr. 2017;36:958-67.
3. Ruiz AJ, Buitrago G, Rodríguez N, Gómez G, Sulo S, Gómez C, et al.  Clinical and economic outcomes associated with malnutrition in hospitalized patients. Clin Nutr. 2018; S0261-5614(18)30201-2. doi: 10.1016/j.clnu.2018.05.016.

Barazzoni R. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):12-13.

Nutrition and Clinical Nutrition
as human rights

Nutrición y Nutrición Clínica como
derechos humanos

Nutrição e nutrição clínica como direitos humanos

Pr. Rocco Barazzoni1*

https://doi.org/10.35454/rncm.v2supl1.028

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1 Chairman of ESPEN. Department of Medical, Surgical and Health Sciences, University of Trieste - Italy

*Corresponding author: Rocco Barazzoni

barazzon@units.it

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There is no doubt that human beings have a right to nutrition and hydration as a basic support for life. Prolonged deprivation of sufficient amounts of food results in development of malnutrition, which is incompatible with survival through deterioration of health. More specifically, disease (particularly infections through loss of immune defense), disabilities and ultimately death are common malnutrition consequences. There is strong general awareness that the right to be nourished is jeopardized by natural, social and economic hurdles that still affect a large, but fortunately decreasing proportion of humankind. Ensuring adequate food availability for all is therefore a strong priority in political agendas worldwide.

It is however much less recognized that deterioration of nutritional state and the onset of malnutrition are primarily associated with disease, independently of nutrient availability and even intake. As they become sick and vulnerable, humans often develop anorexia with reduced desire to eat, as well as profound metabolic derangements that impair the ability to utilize food and nutrients to store energy and preserve tissues and muscle mass. Most importantly, disease-related malnutrition is all the more dangerous for patient survival as it enhances disease-specific risks. The right to nutrition becomes therefore crucial in disease conditions, but nutritional components and complications of disease are unfortunately dramatically under-recognized. Food quality and food intake in hospital settings are often low due to organization choices and priorities that neglect nutritional needs, at a time when they should receive highest priority. Patients that are unable to eat adequate quantities of calories and protein could and should indeed be treated with supplemental nutrition to meet their needs and preserve nutritional status. Clinical nutrition protocols are available to this aim through oral, enteral and parenteral routes and techniques, which were introduced and refined over several decades. Clinical nutrition treatment is however dramatically under-recognized and under-implemented in all medical fields. Neglecting or even ignoring the therapeutic option of clinical nutrition is increasingly frustrating and ultimately unacceptable, since strong evidence is accumulating to show its effectiveness to reduce complications, mortality and save healthcare costs.

For these reasons, as the discipline of clinical nutrition is rapidly growing, scientific Clinical Nutrition Societies more and more recognize the need to extend their scopes beyond supporting and disseminating excellence in research, education and clinical practice. Indeed, they should increasingly promote action to enhance awareness on the importance of preventing malnutrition and its dramatic complications in all patients and clinical settings. Such actions should aim to reach not only health-care professionals but also patients, policymakers and the public at large through multi-stakeholder strategic campaigns. As this is increasingly occurring worldwide, the Latino-American Federation for Parenteral and Enteral Nutrition (FELANPE) implemented an important step that lead to the Cartagena Declaration this year, calling to formally recognize that clinical nutrition, no different from basic food, is a human right. The Cartagena Declaration was signed by all Presidents of Latino-American Parenteral and Enteral Nutrition Societies, and Presidents of the European and North-American Society were invited to Cartagena to sign as witnesses. The Cartagena Declaration also importantly provides indications to move towards implementation of its principles. Formal, widespread recognition of clinical nutrition as a fundamental human right could indeed play a relevant role in promoting awareness that disease-related malnutrition is a major clinical burden, reducing life expectancy, life quality and health-care resources in millions of patients worldwide.

The European Society for Clinical Nutrition and Metabolism (ESPEN) has recognized the need to promote initiatives to increase awareness and implementation of clinical nutrition treatment, which should also reach towards patients, public at large and policymakers. ESPEN strongly supports all efforts towards recognition of each patient’s right to nutrition and clinical nutrition, and it has therefore convincingly signed the Cartagena Declaration in its witness capacity.

Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):14-23.

The International Declaration on the Right to Nutritional Care and the fight against Malnutrition, “Declaration of Cartagena”

DECLARACIÓN DE CARTAGENA
Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición

Declaração Internacional sobre o Direito ao Cuidado Nutricional e a Luta contra a Desnutrição

Diana Cardenas1, Charles Bermúdez2, Sonia Echeverri3, Angélica Pérez4, Milena Puentes5, Lina López6,
Isabel Correia7, Juan Bernardo Ochoa8, Ana Maria Ferreira9, María Alexandra Texeira10, Diego Arenas Moya11,
Humberto Arenas Márquez12, Miguel Leon-Sanz13, Dolores Rodríguez-Veintimilla14.

Received: May 4, 2019. Accepted: October 1, 2019

Published Online: May 4, 2019

https://doi.org/10.35454/rncm.v2supl1.015

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1 Research Institute in Nutrition, Genetics and Metabolism, Faculty of Medicine, Universidad El Bosque, Bogotá, D.C., Colombia.

2 Department of Surgery, Clinica la Colina and Clinica del Country, Bogotá, D.C., Colombia. ACNC President 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 League against cancer, section Bogotá, Bogotá, D.C., Colombia. Treasurer ACNC 2017 - 2021.

6 Nutrition support team, Clinica Universitaria Colombia, Bogotá, D.C., Colombia. Vice-president ACNC 2017 - 2021.

7 Federal University of Minas Gerais, Belo Horizonte, Brazil. President of FELANPE 2015 - 2016.

8 University of Pittsburg, PA, USA. Medical Director Surgical Critical Care, Ochsner Medical Center, Jefferson Campus, USA.

9 Paraguayan Nutrition Society. Asunción,Paraguay. President of FELANPE 2021 - 2022.

10 The Human Milk Bank of Hospital Regional Salto, Salto, Uruguay. Director of the Nutrition Committee of FELANPE 2019 - 2020.

11 Clinical Nutrition and Functional Medicine, SANVITE, Guadalajara, Mexico. Director of the FELANPE Education Committee.

12 Integrated Intestinal Failure Unit, Hospital San Javier, Guadalajara, Jalisco, Mexico. President of FELANPE 2017 - 2018.

13 Department of Endocrinology and Nutrition, Hospital Doce de Octubre & University Complutense Madrid, Spain. President of SENPE.

14 Clinical Nutrition and Dietetics Service of the Ecuadorian Society to Fight Cancer, Guayaquil, Ecuador. President of FELANPE 2019 - 2020.

* Corresponding author: Diana Cárdenas,

Dianacardenasbraz@gmail.com

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Summary

Faced with the need to promote the right to nutritional care, to fight against malnutrition and to advance in education and research in clinical nutrition, all the FELANPE’s societies signed on May 3 during an extraordinary assembly in the city of Cartagena, the International Declaration on the Right to Nutritional Care and the fight against Malnutrition, “Declaration of Cartagena”.

The Declaration provides a coherent framework of thirteen principles which can serve as a guide for societies, schools and associations affiliated to FELANPE in the development of action plans. In addition, it will serve as an instrument to promote, through governments, the formulation of policies and legislation in the field of clinical nutrition. We believe that the general framework of principles proposed by the Declaration can contribute to raise awareness about the magnitude of this problem and to forge cooperation networks among Latin-American countries. Although this Declaration does not have a binding legal effect, it has undeniable moral force and can provide practical guidance to States. We will then be contributing to achieving the United Nations Sustainable Development Goals which aim to put an end to all forms of malnutrition by 2030.

Keywords: Malnutrition, Right to Health, Right to Food, Right to Nutritional Care.

Resumen

Frente a la necesidad de promover el derecho al cuidado nutricional, de luchar contra la malnutrición y de avanzar en temas de educación e investigación en nutrición clínica, las sociedades que constituyen la FELANPE firmaron la Declaración Internacional sobre el Derecho al Cuidado Nutricional y la lucha contra la Malnutrición, “Declaración de Cartagena”, en la asamblea extraordinaria que tuvo lugar el 3 de mayo del presente año en la ciudad de Cartagena.

La Declaración proporciona un marco coherente de trece principios los cuales podrán servir de guía a las sociedades, los colegios y las asociaciones afiliadas a la FELANPE en el desarrollo de los planes de acción. Además, servirá como un instrumento para que promuevan, a través de los gobiernos, la formulación de políticas y legislaciones 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. Aunque esta Declaración no tiene un efecto jurídico vinculante (obligatorio), tiene una fuerza moral innegable y puede proporcionar orientación práctica a los Estados. Estaremos entonces contribuyendo a alcanzar los Objetivos de Desarrollo Sostenible de Naciones Unidas que buscan, para 2030, poner fin a todas las formas de malnutrición.

Palabras clave: malnutrición, cuidado nutricional, derecho a la alimentación, derecho a la salud.

Resumo

Confrontados com a necessidade de promover o direito à assistência nutricional, para combater a desnutrição e favorecer o progresso na educação e na pesquisa em nutrição clínica, todas as companhias membros da FELANPE em data do 3 de maio 2019 numa reunião extraordinária, na cidade de Cartagena, reconhecem e suscrivem à Declaração Internacional sobre o Direito à Nutrição e o combate à desnutrição, “Declaração de Cartagena”.

A Declaração fornece uma estrutura coerente de treze princípios que podem servir como um guia para sociedades, escolas e associações afiliadas à FELANPE no desenvolvimento de planos de ação. Além disso, servirá como instrumento para promover, através dos governos, a formulação de políticas e legislação no campo da nutrição clínica. Acreditamos que a estrutura geral de princípios proposta pela Declaração pode contribuir para aumentar a conscientização sobre a magnitude desse problema e forjar redes de cooperação entre os países da região. Embora esta Declaração não tenha um efeito legal vinculante, tem força moral inegável e pode fornecer orientação prática aos Estados. Vamos então contribuir para alcançar os Objetivos de Desenvolvimento Sustentável das Nações Unidas que visam, até 2030, pôr fim a todas as formas de desnutrição.

Palavras-chave: Desnutrição, direito à saúde, direito à alimentação, direito ao cuidado nutricional.

INTRODUCTION

On the occasion of the tenth anniversary of the Cancún Declaration, which refers for the first time in Latin America to the right to nutrition, the Colombian Association of Clinical Nutrition (ACNC) proposes to the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) to revise and update the above-mentioned declaration(1). This proposal is based on three fundamental aspects.

First, the need to recognize nutritional care as a human right(2). We consider nutritional care as an emerging human right, which implies that governments and health systems must respect, protect and fulfill the right to regular hospital diet, therapeutic diet (i.e food modification and supplements) and medical nutrition therapy (i.e. enteral and parenteral nutrition). This could mean that the patient has the right to benefit from food or medical nutrition therapy administered by a team of experts, and the government has the duty to guarantee it. We are convinced that promoting this right in all care settings and from the level of primary care to highly complex hospital institutions is a mechanism that will allow us to fight against the problem of malnutrition and promote nutritional therapy ensuring respect for dignity of all patients(3).

Secondly, the need to go forward in clinical nutrition education and research. The lack of education and training of health professionals (doctors, dieticians, nurses and pharmacists, among others) in the field of clinical nutrition is worrying(4,5). Added to this is the lack of awareness of these professionals about the importance of adequately addressing nutritional problems with patients(6). The integration of content and a sufficient number of hours of nutrition education into undergraduate curricula is a priority(5). 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 caregivers 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 lines of research on the most frequent problems in this field is a priority. In particular, efforts to understand the pathophysiology of malnutrition and nutritional alterations through innovative technology (e.g. metabolomics) should be guided, which will be important to improve treatment and to develop new strategies in order to obtain better results.

Third, the need for tools to address bioethical questions and dilemmas. The possibility of feeding all sick people thanks to advances in science and technology leads to bioethical questions and dilemmas. We believe that the exercise of clinical nutrition must be carried out within the framework of a set of ethical principles and values which must 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(7).

Therefore, the declaration seeks through its XIII principles to provide a frame of reference to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity. The definition of these principles was consolidated after the presentation of the review, from different approaches, carried out by Latin American experts during the FELANPE congress in Guadalajara in 2018. These principles were defined by a committee of experts defined by the ACNC and submitted for discussion and validated by the presidents of the societies, colleges and associations of the member countries of FELANPE.

The Cartagena Declaration, adopted on May 3 at the extraordinary assembly of FELANPE in the city of Cartagena, provides a coherent framework of principles that can serve as a guide to the societies, schools and associations affiliated to FELANPE in the development of action plans. It will also serve as an instrument for governments to promote the formulation of policies and legislation in the field of clinical nutrition. The general framework of principles proposed by the Declaration can contribute to raising awareness of the magnitude of this problem and to forging cooperation networks among the countries of the region. We will then be contributing to achieving one of the goals of the United Nations Sustainable Development Goals(8), which seeks by 2030 to “put an end to all forms of malnutrition”.

References

1. Castillo Pineda JC, Figueredo Grijalva R, Dugloszewski C, Ruy Díaz Reynoso JAS, Spolidoro Noroña JV, Matos A, et al. Declaración de Cancún: Declaración Internacional de Cancún sobre el Derecho a la Nutrición en los Hospitales. Nutr Hosp. 2008;23(5):413-7.
2. Cardenas D. Is the right to food in hospitals a human right? Rev. Nutr. Clin. Metab. 2018;1(2):9-12.
3. Correia MITD, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clin Nutr 2016;36:958-67.
4. Cuerda C, Shneider SM, Van Gossum A. Clinical nutrition education in medical schools: Results of an ESPEN survey. Clin. Nutr. 2017; 36:915-6.
5. Arenas Márquez H. Clinical Nutrition Education. Rev. Nutr. Clin. Metab. 2018;1(2):13-16.
6. Perlstein R, McCoombe S, Shaw C, Nowson C. Medical student perceptions regarding the importance of nutritional knowledge and their confidence in providing competent nutrition practice. Public Health. 2016;140:27-34.
7. 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 abril 2019]. Disponible en: http://portal.unesco.org/es/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html.
8. Organización de las Naciones Unidas. Objetivos de Desarrollo Sostenible. https://www.un.org/sustainabledevelopment/es/energy/ [Internet]. New York: ONU; 2015 [consultado el 8 de abril 2019].

International Declaration on the Right to Nutritional Care and the Fight against Malnutrition

CARTAGENA DECLARATION

Approved on May 3, 2019 within the framework of the 33rd Colombian Congress of Metabolism and Clinical Nutrition, IV Andean Regional Congress-Center Region of the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) 2019, during the extraordinary assembly.

The Assembly,

Recognizing that the societies, colleges and associations affiliated to FELANPE have joined efforts since its creation to promote research, education and training of professionals in Clinical Nutrition, and to collaborate, if required, with the public authorities in the evaluation and solution of problems related to clinical nutrition,

Recalling the International Declaration of Cancun, 2008, on the right to nutrition in hospitals, where for the first time the Presidents of the societies, schools and associations of FELANPE declared their will to raise nutrition in hospitals to the level of basic human right,

Noting article 25 of the Universal Declaration of Human Rights of December 10th, 1948 which states that “ everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food,...” and article 11 of the International Covenant on Economic Rights, The International Covenant on Economic, Social and Cultural Rights (ICESCR) stipulates that States parties “recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food” and affirms the existence of the “fundamental right of everyone to be free from hunger”,

Invoking article 12 of the International Covenant on Economic, Social and Cultural Rights, in particular general comment No. 14 on the right to the highest attainable standard of health, which recognizes that “the right to health encompasses a wide range of socio-economic factors that promote the conditions under which individuals can lead healthy lives, and extends this right to underlying determinants of health, such as food and nutrition”,

Recognizing nutritional care as a human right inseparable from the right to health and the right to food,

Considering that the right to food must be respected in all spheres, including the clinical one, the sick person must be fed in conditions of dignity and has the fundamental right to be free from hunger,

Bearing in mind that the right to food is often disrespected in the clinical setting resulting in an unacceptable number of people suffering from disease-related malnutrition,

Recognizing that inpatient malnutrition is associated with prolonged hospital stays, reduced quality of life, increased comorbidity, and unnecessary health costs,

Stressing that advances in science and technology today make it possible to feed naturally or artificially any sick person and to actively combat malnutrition,

Aware that adequate nutritional therapy can correct malnutrition, improve disease prognosis and quality of life, reduce co-morbidities, mortality and health costs,

Aware of the need to seek, through the application of basic, clinical and public health sciences, increasingly effective nutritional solutions,

Aware that nutritional therapy may have side effects and low effectiveness in some patients such as those in a hypercatabolic state, or if not administered properly,

Convinced of the need to call upon researchers, the pharmaceutical industry and academic entities on the importance of promoting research in clinical nutrition under a new paradigm that considers nutritional therapy beyond the administration of micro and macronutrients,

Convinced of the need to appeal to public authorities and various national and international bodies on the importance of nutritional care and the fight against malnutrition,

Bearing in mind that the scientific and technological advances that have enabled the development of artificial nutrition therapy pose dilemmas and ethical problems, which should be addressed from a bioethical perspective, and respecting the principles set out in the UNESCO Declaration on Bioethics and Human Rights promulgated on 19 October 2005,

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 to all people, especially the malnourished ill people, 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 among other things.

It is proclaimed,

I. Scope

The Declaration deals with the right to nutritional care, independent of the level of health care, and the fight against various kinds of malnutrition in particular that one associated with disease, thus limited to the field of clinical nutrition. Clinical nutrition is an interdisciplinary and applied discipline and science concerned with malnutrition. The aim is to apply the principles of nutritional therapy (artificial nutrients administered through supplements, enteral and parenteral nutrition) within the framework of nutritional care in order to ensure nutritional status and to modulate other biological functions to positively influence the treatment, quality of life and outcome of patients;

This declaration is addressed to the societies, schools and associations affiliated to FELANPE and to any organization or institution that defends the right to food, the right to health and promotes the fight against malnutrition. The Cartagena Declaration should be considered to be 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.

II. Objectives

1. To promote respect for human dignity and protect the right to nutritional care, ensuring respect for human life and fundamental freedoms, in accordance with international law on human rights and bioethics;

2. To provide a frame of reference whose principles constitute the foundation for promoting the development of nutritional care in the clinical setting that allows all sick persons to receive nutritional therapy under dignified conditions;

3. Promote awareness of the magnitude of the problem of malnutrition associated with disease and the need to develop a model of nutritional care in health institutions;

4. Promote the development of research and education in clinical nutrition under a new paradigm.

III. Principles

1. Feed the ill person in conditions of dignity

The right to food must be understood as an International Human Right that allows all human beings to be fed in conditions of dignity. It is recognized that this right encompasses two distinct norms: the first is the right to adequate food; the second is that everyone be protected against hunger. In the clinical field, the fulfillment of this right also implies the respect of these two norms and it becomes concrete when the sick person receives complete nutritional care under the intervention of an interdisciplinary group of professionals specialized in clinical nutrition. 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 sick 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;

Therefore, sick people, without distinction of any kind, should enjoy the same quality of nutritional therapy under conditions of dignity, and a comprehensive approach to the malnutrition associated with the disease. The right to nutritional care is considered to be exercised when every man, woman and child, after appropriate diagnosis, receives adequate nutrition (oral, enteral or parenteral nutritional therapy) taking into account all dimensions (biological, symbolic, affective and cultural) and does not suffer from hunger. Essential elements are safety, timeliness, efficiency, efficacy, effectiveness of nutritional care and respect for bioethical principles. This is considered the minimum that must be guaranteed independent of the level of health care;

It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and health personnel have the obligation to accept this decision and not to perform futile actions.

The right to nutritional care should not be limited or restricted to energy sources, protein and other specific nutritional elements, but should guarantee the human, physical and economic mechanisms for access to nutritional therapy.

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.

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 sick people 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 is defined as the condition resulting from lack of intake, 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. > 80 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. Malnutrition associated with disease 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 nutrition plan includes nutrition therapy (or medical nutrition therapy), i.e., oral nutrition therapy, 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 dimension (quantitative and qualitative), the symbolic, affective and cultural dimension associated with food 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 and to prevent side effects. Documentation serves to track and evaluate the continuity of therapy for each patient and to ensure quality.

The three stages seek safety, timeliness, efficiency, efficacy and effectiveness of nutritional care. Health institutions should promote the development of the nutritional care model based on detecting, nourishing and monitoring.

3. Patient empowerment as a necessary action to improve nutritional care

Empowerment is defined as a process and an outcome. The first is based on the principle that increasing education improves the ability to think critically and act autonomously, while the second (outcome) is achieved through the sense of self-efficacy, the outcome of the process.

Empowerment is achieved through education, and education implies freedom. Therefore, in nutritional care, empowering patients is offering them the opportunity to be part of the nutritional process and treatment. Empowering the patient not only seeks to obtain a voice, but also to share knowledge and responsibilities with them and with the family.

Empowerment seeks to increase the freedom and autonomy of the patient (the ability to make informed decisions) about the role of malnutrition and nutritional therapy in the different phases of treatment.

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.

4. The interdisciplinary approach to nutritional care

Nutritional care should be performed by interdisciplinary teams which should include, at a minimum, nutrition professionals, nurses, physicians, pharmacists, and encourage the integration of phonoaudiology, occupational therapy, physical therapy, rehabilitation, social work, and psychology, among other disciplines that can increase the effectiveness of nutritional therapy. 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, efficiency and efficacy.

The creation of nutrition therapy teams and the result based accreditation of functioning teams should be promoted.

5. Ethical principles and values in clinical nutrition

It is important to emphasize that nutritional therapy (oral, enteral and parenteral nutrition) is considered a great scientific and technological advance that has allowed any sick person to be fed and 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. These issues should be analysed within the framework of the principles set out in UNESCO’s DUBDH, in particular the universal principles of equality, justice and equity, non-discrimination and non-stigmatization, nonmaleficence, autonomy, beneficence and respect for human vulnerability and personal integrity. Respect for cultural diversity and pluralism is fundamental to the realization of nutritional care and the debate around ethical questions.

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. Malnutrition implies physical, psychological and social deterioration (with the risk of losing one’s life and the possibility of losing one’s autonomy).

Professionalism, honesty, integrity and transparency in decision-making should be promoted, in particular the declaration of all conflicts of interest and the sharing of knowledge in accordance with article 18 of the DUBDH.

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 people’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. In this context, value in health is defined by an efficient relationship between results and costs. It is the patient, society and the health service provider who capture the value.

The sick 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 that quality programs are implemented which integrate elements of the health economy: cost minimization, cost effectiveness, cost benefit, cost effectiveness and cost utility.

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 sick 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 sick people.

Authorities, health organizations (insurers, hospitals), pharmaceutical and food companies should be required to invest more and support research in clinical nutrition.

Interdisciplinary research groups should be created, promoted and supported at the appropriate level for the purpose of:

a) research on relevant clinical nutrition issues under scientific standards of quality, evidence-based medicine and respecting the principles of bioethics;

b) developing relevant lines of research 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.

It is recognized that the interests and welfare of the individual should have priority over the sole interest of science or society (pharmaceutical industry, companies, etc.).

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;

c) appropriate institutions: accredit specialised training and promote continuing education in the field of clinical nutrition.

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.

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.

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 sick 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;

e) contributing to achieving the goals of United Nations sustainable development goals 2 and 3 (DSO 2 and 3) 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”.

12. Ethical, deontological and transparency principles of the pharmaceutical and nutritional industry

Relationships should be promoted between societies, schools and associations that defend the right to clinical nutrition with the the pharmaceutical and nutritional industry (Ph&NI), based on the ethical and transparency policies they demand:

a) 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.

To this end, each society, college and association must establish policies of ethics, integrity and transparency.

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 people, 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 among other consequences.

Cartagena, 3 May 2019,

Signed by FELANPE Presidents.

Dr. Dolores Rodríguez-Ventimilla

Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo – FELANPE 2019-2020

Dr. Ana Ferreira

FELANPE 2021 – 2022

Dr. Ma. Virginia Desantadina

Asociación Argentina de Nutrición Enteral y Parenteral – AANEP

Dr. Dan Waitzberg

Sociedad Brasileña de Nutrición Parenteral y Enteral – BRASPEN

Ms. Janett K. Rodriguez

Asociación Boliviana de Nutrición Clínica y Terapia Nutricional

Dr. Paula Sánchez

Asociación Costarricense de Nutrición Enteral y Parenteral – ACONEP

Dr. Charles Bermúdez

Asociación Colombiana de Nutrición Clínica – ACNC

Dr. Lázaro Alfonso Novo

Sociedad Cubana de Nutrición Clínica y Metabolismo – SCNCM

Dr. Karin Papaprieto

Asociación Chilena de Nutrición Clínica, Obesidad y Metabolismo – ACHINUMET

Dr. Mery Guerrero

Asociación Ecuatoriana de Nutrición Parenteral y Enteral – ASENPE

Dr. Miguel León-Sanz

Sociedad Española de Nutrición Parenteral y Enteral – SENPE

Dr. Juan Carlos Hernández

Colegio Mexicano de Nutrición Clínica y Terapia Nutricional – CMNCTN

Dr. Rosa Larreategui

Asociación Panameña de Nutrición Clínica y Metabolismo – APNCM

Dr. María Cristina Jiménez

Sociedad Paraguaya de Nutrición – SPN

MSg. Luisa Angélica Guerrero

Asociación Peruana de Terapia Nutricional – ASPETEN

Dr. Anayanet Jáquez

Sociedad Dominicana de Nutrición Enteral y Parenteral – SODONEP

Ms. Mabel Pellejero

Sociedad Uruguaya de Nutrición – SUNUT

Dr. José Guillermo Gutiérrez

Asociación Salvadoreña de Nutrición Parenteral y Enteral – ASANPEN,

Witnesses

Dr. Roberto Berni Canani

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition – SPEGHAN

Dr. Liliana Ladino

Latinamerican Society for Paediatric Gastroenterology, Hepatology and Nutrition – LASPEGHAN

Dr. Rafael Figueredo

Sociedad latinoamericana de Nutrición – SLAN

Pr. Rocco Barazzoni

European Society for Clinical Nutrition and Metabolism – ESPEN

Dr. Juan Bernardo Ochoa

American Society for Parenteral and Enteral Nutrition – ASPEN.

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

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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

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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.

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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.”

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

1. 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
2. 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.
3. 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.
4. 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].

Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):42-48.

From the right to food to the right
to nutritional care

Del derecho a la alimentación al derecho al cuidado nutricional

Do direito à alimentação ao direito ao cuidado nutricional

Diana Cardenas1*, Sonia Echeverri2, Charles Bermúdez3

Received: September 1, 2019. Accepted: October 26, 2019.

https://doi.org/10.35454/rncm.v2supl1.029

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1 Research Institute of Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia

2 Hospital Ethics Committee and Humanism and Bioethics Committee of the Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.

3 Surgery Department. Clínica la Colina y Clínica del Country. Bogotá, Colombia. President ACNC 2017-2021.

*Corresponding author: Diana Cardenas

dianacardenasbraz@gmail.com

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Summary

Malnutrition is a public health problem in the world. Malnutrition associated with socioeconomic factors falls within the scope of the right to adequate food. The approach to this type of malnutrition is achieved through the two aspects of this right: the right to be protected against hunger and the right to adequate food, wich implies the need to constitute an economic, political and social environment that allows people to achieve food security by their own means. However, disease-related malnutririon cannot be defined within the scope of the right to food. In this context, a human right to nutritional care should be considered where the person at risk or in a state of malnutrition can receive nutritional care including nutritional therapy in an optimal and timely manner. This new emerging human right must be studied and defined from the human rights approach to be recognized before international and national human rights institutions.

Keywords: Malnutrition; Public health; Right to nutritional care.

Resumen

La desnutrición es un problema de salud pública en el mundo. La desnutrición asociada a factores socioeconómicos es competencia del ámbito del derecho a la alimentación adecuada. El abordaje de este tipo de desnutrición se logra a través de las dos vertientes de este derecho: el derecho a estar protegido contra el hambre y el derecho a una alimentación adecuada que implica la necesidad de constituir un entorno económico, político y social que permita a las personas alcanzar la seguridad alimentaria por sus propios medios. Sin embargo, la desnutrición asociada a la enfermedad no puede definirse dentro del alcance del derecho a la alimentación. En este contexto, debe considerarse como un derecho humano al cuidado nutricional donde la persona en riesgo o en estado de desnutrición pueda recibir cuidado nutricional incluyendo la terapia nutricional de manera óptima y oportuna. Este nuevo derecho humano emergente debe ser estudiado y definido desde el enfoque de los derechos humanos para que sea reconocido ante las instituciones de derechos humanos internacionales y nacionales.

Palabras clave: desnutrición, salud pública, derecho al cuidado nutricional.

Resumo

A desnutrição é um problema de saúde pública no mundo. A desnutrição associada a factores socioeconómicos encontra-se no domínio do direito à alimentação adequada. A abordagem para esse tipo de desnutrição é alcançada através dos dois aspectos desse direito: o direito a ser protegido contra a fome e o direito a alimentação adequada, o que implica a necessidade de constituir um ambiente económico, político e social que permita as pessoas alcançarem a segurança alimentar por seus próprios meios. No entanto, a desnutrição associada à doença não pode ser definida no âmbito do direito à alimentação. Nesse contexto, um direito humano aos cuidados nutricionais deve ser considerado onde a pessoa em risco ou em estado de desnutrição pode receber cuidados nutricionais, incluindo terapia nutricional, de maneira ótima e oportuna. Esse novo direito humano emergente, deve ser estudado e definido a partir da abordagem de direitos humanos para ser reconhecida perante instituições nacionais e internacionais de direitos humanos.

Palavras-chave: desnutrição, saúde pública, direito ao cuidado nutricional.

Introduction

Malnutrition is a public health problem in the world due to the high impact on morbidity, mortality and costs to health systems. According to the World Health Organization (WHO) malnutrition can be of three types: overweight/obesity, malnutrition (undernutrition) and micronutrient disorders. Figure 1 shows the classification of nutritional disorders(1). Malnutrition in the International Classification of Diseases 11 (ICD-11) is found within code 5 “endocrine diseases” and as part of “nutritional disorders”. Malnutrition is defined there as “a disorder in which the body’s requirements are not met due to insufficient nutrient intake or poor absorption or utilization”. It may be due to lack of access to food or disease. Malnutrition is generally understood as a deficit in energy consumption, but can also refer to a lack of specific nutrients. It may be acute or chronic(2).

Figure 1. Diagnoses tree of malnutrition; from at risk for malnutrition, basic definition of malnutrition to etiology-based diagnoses. ESPEN, 2017(1). Phenotypic and etiologic criteria for the diagnosis of malnutrition according to The GLobal Leadership on Malnutrition (GLIM). For ESPEN, undernutrition is synonimous of malnutrition.

In this definition we can identify two main types of malnutrition due to deficit. The first is malnutrition associated with socioeconomic factors and hunger, where the starting point is inadequate access to food (Figure 2). Figures from the Food and Agriculture Organization of the United Nations (FAO) show that, in 2017, 821 million people were suffering from hunger, that is, 1 in 9 people in the world. The approach to address this problem is based on public nutrition policies and the eradication of poverty and hunger(3). The human rights approach for several decades, through the right to adequate food, has allowed States to take responsibility and act to protect populations against hunger and malnutrition.

Figure 2. Pathways from inadequate food access to multiple forms of malnutrition, FAO, 2018(8).

Second, disease-related malnutrition where the starting point is the varying degrees of acute or chronic inflammation associated with the disease or trauma, and consequent metabolic adaptations, reduced food intake, or decreased assimilation(1) (Figure 3). This leads to altered body composition, loss of lean mass, loss of adipose tissue and decreased biological function(1). To address disease-related malnutrition, nutritional care has proven to be an effective and cost-efficient process(4,5). However, despite this and the fact that it is now technically possible to administer nutritional therapy to any sick person, the prevalence of malnutrition associated with the sick person at hospital admission remains high, between 40 % and 60 % according to different studies(6). Public policies and legislation to address this issue are scarce and the human rights approach has never been studied.

Figure 3. Pathways from disease to malnutrition. Base on the definition and classification of disease-related malnutrition(1).

Faced with this problem, we ask ourselves: why is the right to food not respected in the clinical field? Surprising as it may seem, in the hospital, a privileged place for the care of the person seeking health and the highest level of well-being of people, this right is too often disrespected. Our hypothesis is that disease-related malnutrition does not fall within the scope of the concept or normative content of the right to food. In this article we will show that in the clinical context and at any level of health care, the right to food cannot be guaranteed because its normative content does not apply. Therefore, it is necessary to recognize a new emerging human right: the right to nutritional care.

The right to food

The right to adequate food as a fundamental human right was recognized for the first time, within the framework of the right to an adequate standard of living, in the Universal Declaration of Human Rights of 1948 (Article 25):

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food...”(7). This right became legally binding when the International Covenant on Economic, Social and Cultural Rights (ICESCR) entered into force in 1976. Since then, other international agreements have reiterated the right to food, including the Convention on the Elimination of All Forms of Discrimination against Women (1979), the International Convention on the Rights of the Child (1989), the Convention Relating to the Status of Refugees (1951), the Convention on the Rights of Persons with Disabilities (2006) and various regional human rights instruments. To date, 160 States have ratified the ICESCR and are therefore legally bound to implement its provisions. Article 11 of the ICESCR stipulates that States parties “recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food” and affirms the existence of the right of everyone to be free from “hunger and malnutrition”(8).

To live a life without hunger is considered as the minimum that must be guaranteed by each State independent of the level of development(14). However, the right to food is not limited to this aspect. The Committee on Economic, Social and Cultural Rights has defined the right to food in its general comment No. 12 as:

“The right to adequate food is realized when every man, woman and child, alone or in community with others, have physical and economic access at all times to adequate food or means for its procurement.”(9)

In addition, the Committee stresses that the right to adequate food “should not be interpreted restrictively or strictly as the right to a minimum ration of calories, protein or other specific nutrients”. Other elements such as food practices, hygiene education, nutrition training, health care provision and breastfeeding should also be taken into account. This implies that every person must have access to food not only to be free from hunger but also to have a good state of health and well-being. Therefore, this right encompasses two distinct norms: the first is the right to “adequate food”, the second is that “everyone is protected from hunger and malnutrition”(8).

This approach to the right to food, which has evolved since the 1990s, aims to go beyond the food security approach that has been defended until then. It is no longer just about defending and promoting agricultural production and ensuring the availability of food; it is now about a right to food that protects people from hunger and malnutrition in order to achieve good health. In other words, it seeks to protect the right to satisfy one’s own food needs, either by producing or by buying the products. It is considered a radical change of perspective: the citizen who benefits from the right to food is no longer a defenseless, passive recipient, an object of charity, and who must be “fed”, but a person who has the right to benefit from an environment that allows him to feed himself and, failing that, to receive assistance not only with dignity but also with quality(10).

In conclusion, malnutrition associated with socio-economic factors falls within the scope of the right to adequate food. Addressing this type of malnutrition is achieved through the two strands of this right. On the one hand, the right to be protected from hunger, considered as an absolute norm, and as the minimum level that must be guaranteed to all people regardless of the level of development achieved by the State. On the other hand, the right to adequate food encompasses much more, as it entails the need to create an economic, political and social environment that enables people to achieve food security by their own means.

Does disease related malnutrition have a place in the human right to food? How should the right to food be understood in the clinical context? In other words, the fundamental question is: should people be granted the right to “feed themselves” or to be “fed”?

The right to nutritional care: an emerging human right

Let us recall that in the field of public health and in the political context, the beneficiary or holder of the right to food is considered to be a person with an active role to which the State must provide an enabling environment that allows him or her to “feed himself” and, failing that, to receive assistance with dignity. In the clinical context, should individuals be granted the right to “feed themselves” or to be “fed”?

In the clinical context, the sick person is more likely to have altered nutritional status simply because he or she is sick. Therefore, every sick person in contact with a health institution should be able to receive nutritional care. That is, nutritional screening should be carried out to identify nutritional risk, an accurate diagnosis of malnutrition leading to a nutritional plan that includes feeding and nutritional therapy, its surveillance and monitoring (Figure 4). For the patient to benefit from nutritional care, a clinical nutrition professional is required to ensure a complete and adequate nutritional care process. The sick person cannot decide for themselves the type of nutrition or food they need. It is the professional who issues a recommendation and a therapeutic indication. Of course, it is the patient, who has the freedom to decide whether or not to accept the health professional’s proposal.

Figure 4. The stages of the nutritional care.

Therefore, the sick person has the right to receive a nutritional therapy i.e. “to be fed” and this must be guaranteed by the State and the caregivers. The normative content of the right to food as conceived in international human rights instruments cannot be applied in the same way in the clinical context. Thus, it is possible to recognize that patients have the right to receive optimal and timely nutritional care, and consequently, it is possible to recognize an emerging human right: the right to nutritional care (Figure 5).

Recognizing the existence of a right to nutritional care would have implications for the beneficiaries of the right (patients who are malnourished or at risk of malnutrition), and for duty bearers such as the State and legislators. For patients, this right would imply that they can claim from the state a complete nutritional care that prevents or at least limits nutritional alterations and modulates metabolic adaptations to have a positive impact on the evolution of the disease and outcomes. For States, this right would imply guaranteeing at least access, acceptability, availability and quality of food and nutritional therapy in the hospital (Figure 5).

For health professionals, the right to nutritional care should guide their actions. It is about defending the right of each sick person to receive all stages of nutritional care that lead to the patient being “fed” in conditions of dignity. More specifically, the right to benefit from nutritional care and to receive nutritional requirements through timely, optimal and quality nutritional therapy, in a context that supports the emotional, symbolic and social dimension of food. Emphasis should be placed on the fact that feeding the sick person should not be considered an act of charity, as when feeding the ill patients in hospital during the Middle Ages. On the contrary, it should be considered as a medical therapy that is integrated into the general care of patients. Nutritional therapy is a medical intervention, which requires an indication for achieving a treatment goal and the informed consent of the competent patient. Consequently, physicians, nutritionists, nurses and other health professionals must protect, respect and guarantee the right to nutritional care through the realization of all stages of nutritional care including timely and optimal nutritional therapy.

Figure 5. The right to food versus the right to nutritional care.

Conclusion

Disease-related malnutrition cannot be defined within the scope of the right to food. The right to food as considered in international human rights instruments, such as the right to “eat”, cannot be guaranteed in the same way in the clinical setting. In this context, a human right to nutritional care should be considered, where the person at risk or already malnourished receives nutritional care including nutritional therapy in an optimal and timely manner. This new emerging human right must be studied and defined from a human rights perspective so that it can be recognized before national and international human rights institutions.

Funding sources

This article was not financed.

Conflict of interests

The authors have no conflict of interest.

Author’s contributions

DC designed the article. The authors declare that they reviewed the article and validated its final version.

References

1. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49-64.
2. World Health Organization. [Internet]. International Classification of Diseases 11th Revision. The global standard for diagnostic health information ICD 11. (Consultado el 5 de septiembre de 2019). Disponible en: https://icd.who.int/en.
3. Food and Agriculture Organization of the United Nations. The state of food security and nutrition in the world. [Internet]. Roma 2018. (Consultado el 5 de septiembre de 2019). Disponible en: http://www.fao.org/3/I9553ES/i9553es.pdf.
4. Rosen BS, Maddox P, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. JPEN J Parenter Enteral Nutr. 2013;37:796–801.
5. Kris-Etherton PM, Akabas SR, Bales CW, Bistrian B, Braun L, Edwards MS, Laur C, Lenders CM, Levy MD, Palmer CA, et al. The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Am J Clin Nutr. 2014;99(Suppl.):1153S-66S.
6. Correia MITD, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clin Nutr. 2016;36:958-67.
7. Declaración Universal de Derechos Humanos de 1948. [Internet]. (Consultado el 1 de agosto 2019). Disponible en: http://www. un.org.
8. Food and Agriculture Organization of the United Nations. [Internet]. Le droit à l’alimentation. Le temps d’agir Avancées et enseignements tirés lors de la mise en application. Roma 2012. (Consultado el 1 de agosto 2019). Disponible: http://www.fao.org/docrep/016/i2250f/ i2250f.pdf.
9. Le droit à l’alimentation. Organisation des nations unies pour l’alimentation et l’agriculture, Rome 2006 [Internet]. (Consultado el 1 de agosto 2019). Disponible: http://www.fao.org/3/a-ah189f.pdf.
10. Diouf J. Droit á l´alimentation, notions generales. FAO, 2007. [Internet]. (Consultado el 1 de agosto 2019). Disponible: http://www1.montpellier.inra.fr/aide-alimentaire/images/.

Cardenas D. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):49-55.

Clinical nutrition and the human
right-based approach

Nutrición clínica y el enfoque basado en derechos humanos

Nutrição clínica e a abordagem baseada nos direitos humanos

Diana Cardenas1

Received: September 5, 2019. Accepted: October 2, 2019

https://doi.org/10.35454/rncm.v2supl1.030

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1 Research Institute of Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia

*Corresponding author: Diana Cardenas

dianacardenasbraz@gmail.com

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Summary

Introduction: Nutritional care was recognized as a human right in the Cartagena Declaration of May 3, 2019. This article defines this right and discusses the implications of the human right-based approach in clinical nutrition and the fight against disease-related malnutrition.

Methodology: An analysis was carried out with the human rights-based approach. This approach is a fundamental strategy to determine the roles and obligations of different stakeholders (governments and policy makers, health institutions, patients, health professionals and caregivers).

Results: It is possible to define nutritional care as an emerging human right. Its normative mandate is found in principle 13 of the Cartagena Declaration. Like other human rights, it is based on the principle of respect for human dignity and its content and scope are limited to the field of clinical nutrition. Although this mandate has no binding force, it does imply an important moral commitment to ensure that the patient benefits from the nutritional care process.

Conclusion: The recognition of nutritional care as a human right is the result of the effort of international scientific societies in the field of clinical nutrition that seek to fight for a minimum guarantee so that people anywhere in the world can access nutritional care. In the future, the objective is that from a legal and political point of view, states also have certain obligations, whose effective implementation can be legitimately claimed by people.

Keywords: Human Rights, Nutritional Care, Malnutrition

Resumen

Introducción: el cuidado nutricional fue reconocido como un derecho humano en la Declaración de Cartagena del 3 de mayo de 2019. En este artículo se define este derecho y se analizan las implicaciones del enfoque basado en los derechos humanos en la nutrición clínica y la lucha contra la malnutrición asociada a la enfermedad.

Metodología: se realizó un análisis con el enfoque basado en los derechos humanos (Human rights-based approach). Este enfoque es una estrategia fundamental para determinar el papel y las obligaciones de las diferentes partes interesadas (gobiernos y responsables políticos, instituciones de salud, pacientes, profesionales de la salud y cuidadores).

Resultados: el cuidado nutricional es un derecho humano emergente, cuyo mandato normativo se encuentra en el principio 13 de la Declaración de Cartagena. Al igual que otros derechos humanos, se fundamenta en el principio del respeto a la dignidad humana, su contenido y alcance se limitan al campo de la nutrición clínica. Aunque este mandato no tiene fuerza vinculante, sí implica un compromiso moral importante para asegurar que el paciente se beneficie del proceso de cuidado nutricional.

Conclusión: el reconocimiento del cuidado nutricional como derecho humano es el resultado del esfuerzo de las sociedades científicas internacionales en el campo de la nutrición clínica que pretenden luchar por un mínimo de garantía para que las personas en cualquier parte del mundo puedan acceder al cuidado nutricional. A futuro, el objetivo es que desde el punto de vista legal y político, los estados también tengan ciertas obligaciones, cuya implementación efectiva puede ser legítimamente reclamada por las personas.

Palabras clave: derechos humanos, cuidado nutricional, malnutrición

Resumo

Introdução: cuidado nutricional foi reconhecido como um direito humano na Declaração de Cartagena de 3 de maio de 2019. Este artigo define esse direito e discute as implicações da abordagem baseada nos direitos humanos, na nutrição clínica e na luta contra a desnutrição associada à doença.

Metodologia: foi realizada uma análise, com a abordagem baseada nos direitos humanos. Essa abordagem é uma estratégia fundamental para determinar o papel e as obrigações das diferentes partes interessadas (governos, responsáveis políticos, instituições de saúde, pacientes, profissionais de saúde e cuidadores).

Resultados: O cuidado nutricional é um direito humano emergente, cujo mandato normativo é encontrado no princípio 13 da Declaração de Cartagena. Como outros direitos humanos, é baseado no princípio do respeito à dignidade humana, o seu conteúdo e alcance são limitados ao campo da nutrição clínica. Embora este mandato não tenha força vinculativa, implica um compromisso importante para garantir que o paciente beneficie do processo do cuidado nutricional.

Conclusão: o reconhecimento do cuidado nutricional, como um direito humano é o resultado do esforço das sociedades científicas internacionais no campo da nutrição clínica, que tem como objetivo lutar por uma garantia mínima para que as pessoas em qualquer lugar do mundo possam aceder ao cuidado nutricional. No futuro, o objetivo é que, do ponto de vista jurídico e político, os estados também tenham certas obrigações, cuja implementação efetiva possa ser legitimamente reivindicada pelas pessoas.

Palavras-chave: direitos humanos, cuidado nutricional, malnutrição.

Introduction

There is an inextricable link between health and human rights. According to Jonathan Mann, health is a human rights issue and, inversely, human rights are a health issue(1). Over the past 70 years, human rights have developed under international law, as bases for public health, offering a universal framework for promoting justice in public health, elaborating the freedoms and rights that are necessary to attain dignity for everyone.

Human rights are philosophical, legal and political concepts claiming that every human being possesses inalienable and universal rights, which are independent of the current legal framework and of other factors such as ethnic origin or nationality(1). Human rights are a variety of personal prerogatives of an individual that democratic societies, generally, enshrine in the law, either through their political constitutions or as a consequence of adhering to international conventions, thereby guaranteeing that all figures, including the State, respect their primacy. The centrality of human rights in health issues is found in well-known public health policies, programs, and practices. In fact, growing evidence shows that norms that enshrine respect, protection and fulfillment of human rights can be translated into better public health(2).

The relationship between human rights and nutrition is also bidirectional. On the one hand, the human rights-based approach contributes to the field of nutrition. It has done so for several decades, from the field of public nutrition, through the human rights instruments and institutions which form the basis for formulation and implementation of nutrition policies and programs. This means that, from the public health perspective, those interested in nutrition enforce the states’ obligation to promote the human right to adequate food and therefore not to be hungry. They also recognize that other human rights (civil, political, economic, social and cultural) must be implemented to allow the right to food to be a reality, founded on a sustainable basis. In other words, efforts have focused on using human rights laws and institutions to unite the efforts aimed at improving human nutrition, as a “moral imperative and as a precondition for sustainable social, economic, and human development.”(3) On the other hand, the way in which nutrition can impact human rights and thus have positive, sustainable effects for human beings and society has recently been put into question. In other words, public nutrition can contribute to the sustainable development agenda through human rights.

However, nutrition in the clinical context has not yet explored the path of the human rights-based approach sufficiently. Until now, it has limited itself to promote and claim the right to food in the clinical context(4,5). The Declaration of Cancun, signed in 2008 by FELANPE was based on the right to food and nutrition in hospitals(6). Another example, the Resolution ResAP (2003)3 on Food and Nutritional Care in Hospitals, adopted by the Committee of Ministers of the Council of Europe, was based on the right to food, as stated in the introduction: “access to a safe and healthy variety of food is a fundamental human right.”(7)

By invoking the right to food and nutrition in hospitals, the right to be protected against hunger and the right to adequate food would be promoted. However, we consider that the problem of disease-related malnutrition goes further and cannot be considered only within the scope of this right, nor its normative content applied in the clinical context; consequently, a proposal is made to recognize a new human right: the right to nutritional care(8). Therefore, the International Declaration on the Right to Nutritional Care and the fight against Malnutrition, Cartagena Declaration, is innovative when it recognizes that nutritional care must be considered an emerging human right. This declaration emerges from the need to take a new look at the Declaration of Cancun. Its starting point is the need to move forward on key issues such as the promotion of clinical nutrition research and education, patient empowerment, recognition of the health value in nutritional care and the promotion of an optimal nutritional care to impact on the prevalence of disease-related malnutrition and its impact on the disease burden. To make progress in this matter, public policies and legislation on clinical nutrition are needed, and the promotion of the right to nutritional care is a way to achieve this.

In these circumstances, it is necessary to define nutritional care as a human right. In other words, we want to answer the following question: How can the human rights-based approach contribute to the development of clinical nutrition and the fight against disease-related malnutrition? In this article, the right to nutritional care is defined under this approach and the implications for clinical nutrition are analyzed.

Methods

The human rights-based approach

The human rights-based approach has been developed by the United Nations as the conceptual framework that places the respect, protection and guarantee of human rights as the foundation, the objective and the tools to make a sustainable human development feasible(9). The human rights approach is a popular conceptual framework and it carries considerable rhetorical and legal power. Furthermore, this approach can help mobilize the strength of public opinion to achieve change. However, frequently, both the meaning of human right claims and the way in which they are justified might cause confusion. The lack of a definition of human rights fosters the promotion of this approach for whatever cause is deemed useful, with the resulting indiscriminate proliferation of claims and subsequent depreciation. Therefore, defining nutritional care as a human right is necessary.

The right to nutritional care has been considered an emerging human right by the international scientific societies in the clinical nutrition field since May, 2019. The ultimate goal is that this human right, beyond civil society, is recognized by national and international institutions such as the United Nations Human Rights Council. It is an ambitious goal, and the first step towards achieving it is to have clarity and precision on the definition and contents of this right. The human rights-based approach can serve this purpose. Our hypothesis is that this approach makes it possible to define the right to nutritional care not as an extension of the right to health or to food but as a human right in itself. This article answers the following questions: How is the right to nutritional care classified? What are the basis, content and scope of this right?

Results and discussion

Nutritional care is an emerging human right

Emerging human rights are legitimate social claims aimed at the formulation of new or renewed human rights(10). Emerging human rights have a starting point in 2004 in the Universal Declaration of Emerging Human Rights(11). This Declaration “pretends to fill the existing gaps and contribute to designing a new horizon of rights that serves as a guide for social movements, for the agendas of political leaders, in order to foster a new relationship between global civil society and power.”(10)

Emerging human rights are, on the one hand, those rights that arise in the face of the rapid and constant evolution of globalized societies and, on the other hand, a set of rights that emerge after having remained “submerged” in oblivion or the indifference of states and the international system as a whole. As part of the emerging human rights there are some innovative ones, such as the right to a basic income, or new interpretations of classic rights, like for example the right to access medications, considered an extension of the classic right to health.

In the case of clinical nutrition, the application of the human rights-based approach allows us to define nutritional care, not as an extension of the right to health or the right to food, but as a new human right(8). It is a claim by civil society (in this case, scientific societies in the field of clinical nutrition) aspiring that all patients have access to an optimal and timely nutritional care, and that disease-related malnutrition and hunger, in the clinical context, be a visible issue. Therefore, and according to this approach, it is necessary to define the basis, content and scope, the way it has been done for other emerging human rights(12) (Table 1).

Table 1. Characteristics of the human right to nutritional care

Emerging Human Right

Foundation Human dignity

Duty-bearers The Cartagena Declaration morally commits scientific societies in the field of clinical nutrition to promote the right to nutritional care Rights-holders Patients at risk or in a state of malnutrition

Content and scope Nutritional care is related to the duty of identifying the risk, diagnosing the nutritional state and feeding sick patients by natural or artificial means in order to prevent or treat disease-related malnutrition and contribute to health and improving outcomes. The content of this human right must be conceived in close relationship with the right to health and the right to food.

Human dignity: the foundation of the right to nutritional care

Human dignity is the fundamental value of human rights. The notion of human dignity from its philosophical dimension means, according to Immanuel Kant, the fact that the person should never be treated as a means, but rather as an end in itself. People do not have a price, they have dignity (13). Dignity refers to a quality that would be linked to the very essence of each human being, which would explain why this quality has to be equal for everyone and not admit levels or degrees. In this sense, it means that all human beings deserve unconditional respect, regardless of their age, physical or mental health, gender identity or sexual orientation, religion, social status or ethnical origin. However, it is necessary to recognize that dignity can be an ambiguous concept: pro-euthanasia and anti-euthanasia movements exist in the name of respect for human dignity. This ambiguity can lead to important philosophical and legal debates mainly about their operative value in decision making and in the legal field. This is why it is necessary to define what it means to feed the person in conditions of dignity as proposed by the Cartagena Declaration.

The respect for human dignity, understood as a person’s right to be treated ethically, to be valued and respected for who they are, is attained by feeding the sick person, when their individual autonomy, religious beliefs and sociocultural environment are taken into consideration. This implies recognizing the intrinsic value of each human being, as well as the respect for the integrity, the diversity of moral, social and cultural values during the stages of the nutritional care process.

The absence of an optimal nutritional care can threaten human dignity. But prolonging nutritional therapy beyond what’s medically necessary, might also be considered as a lack of respect for human dignity since the person’s physical integrity would be being harmed. Hence, it must be considered that nutritional therapy is a medical treatment, the patient has the right and the autonomy to refuse it, and the caregivers have the obligation to accept this decision and not perform futile actions.

Content and scope of the right to nutritional care

The content and scope of human rights refer to the interests that the rights defend (for example, health and knowledge) and the duties generated by these underlying interests. Nutritional care as a human right implies the duty of guaranteeing all people, especially those at risk or in a state of malnutrition, access to nutritional care and, in particular, to optimal and timely nutritional therapy with the purpose, among other things, of reducing the high rates of disease-related malnutrition and associated morbidity and mortality(8). The right to nutritional care is considered to be exercised when every man, woman or child, after a timely diagnosis, receives adequate nutrition (therapeutic diet, oral, enteral or parenteral nutritional therapy) taking into account their dimensions (biological, symbolic, affective and cultural) and does not suffer from hunger. Essential elements include safety, timeliness, efficiency, efficacy, effectiveness of nutritional care and the respect for bioethical principles. This is considered the minimum that must be guaranteed, regardless of the level of health care.

Nutritional care is part of overall patient care, and it encompasses a process that begins with the identification of the nutritional risk and whose objective is to prevent and treat disease-related malnutrition by providing a wide range of products, from food to nutritional therapy. The latter is considered as a medical intervention that requires a therapeutic indication with a treatment objective and that requires the patient’s informed consent. Promoting the right to nutritional care does not mean being in favor of administering compulsorily nutritional therapy to all sick people during every stage of their disease, including the terminal phase.

Therefore, nutritional care has to do with the duty of feeding sick patients by natural or artificial means in order to prevent or treat disease-related malnutrition and contribute to health and improving outcomes. The content of this human right must be conceived in close relationship with other human rights. It is considered possible to frame this duty within the scope of two well-recognized rights: the right to food and the right to health.

The human rights approach makes it possible to identify duty-bearers. In the case of nutritional care, the duty-bearers are States and other interested parties, and also healthcare service managers, the scientific society and the caregivers. The issue at stake is the capacity for health care systems to provide optimal nutritional care.

Human rights indicators

Human rights indicators provide “specific information on the state or condition of an object, event, activity or outcome that can be related to human rights norms and standards, and that can be used to assess and monitor the promotion and implementation of human rights.”(14) They are used to assess and monitor the promotion and protection of human rights. The importance of these indicators rests on their usefulness for making more concrete situation analyses, identifying and defining issues and difficulties that need to be addressed. Additionally, they serve to review strategies and set objectives and goals, follow progress and assess outcome impact(14). The use of indicators contributes to improve the effective implementation of human rights.

Indicators can be quantitative or qualitative. Quantitative indicators include statistic type indicators, while the latter encompass any information articulated descriptively or in a “categorical” manner. Indicators can also be structural, process or outcome indicators.

After a thorough analysis, indicators of the right to nutritional care have been proposed. The starting point was the description of attributes or characteristics that detail the normative standards of the right to nutritional care proposed by the Cartagena Declaration. The specification of the attributes of the right to nutritional care helps make the content of that right concrete and makes explicit the link between the defined indicators of this right on the one hand and the normative standards regarding that right on the other(14).

In general, the attributes are defined according to the normative framework of the right in question. In our case, the only normative (not legally binding) is the Cartagena Declaration, which is complemented by the normative related to the right to health and the right to food, defined in the preamble of this Declaration (Table 2).

The identified attributes of the right to nutritional care were:

• Nutritional care is a process
• Optimal and timely nutritional therapy for at risk or malnourished patients
• Education of the patient in clinical nutrition
• Education of caregivers in clinical nutrition
• Clinical nutrition research

Table 3 shows the structural, process and outcome indicators. These were defined on the basis of the Declaration’s Mandate.

Table 2. Normative on the right to health and the right to food in the Declaration of Cartagena

Preamble

Article 25 of the Universal Declaration of Human Rights from December 10, 1948 which establishes that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food […]” Article 11 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) which stipulates that the States Parties to the Covenant “recognize the right of everyone to an adequate standard of living for himself and his family, including [adequate] food” and affirms the existence of the “fundamental right of everyone to be free from hunger.” Article 12 of the International Covenant on Economic, Social and Cultural Rights, particularly General Comment No. 14 on the right to the highest attainable standard of health recognizing that “the right to health embraces a wide range of socio-economic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as food and nutrition.”

Principle 13

The Declaration of Cartagena’s Mandate 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 people, 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.

Table 3. Right to nutritional care indicators

	Attributes
	Nutritional care process	Optimal and timely nutritional therapy	Education of the patient in clinical nutrition	Education of caregivers in clinical nutrition	Clinical nutrition research
Structural indicator	Legislation on nutritional care
	Public policies to improve nutritional care and fight against disease-related malnutrition
Process indicator	Proportion of hospitals that implement the three stages of nutritional care: Screening, nourish, watch.	Proportion of hospitals with interdisciplinary nutritional therapy groups.	Development of empowerment and therapeutic education to patients with nutritional therapy in the hospital and at home.	Improved nutritional curriculum in medical faculties and others. Creation of postgraduate programs.	Creation of groups or lines of research in clinical nutrition and metabolism.
Outcome indicators	Prevalence of nutritional risk and disease-related malnutrition
	Prevalence of nutritional risk upon hospital admission.	Proportion of patients at nutritional risk who received nutritional therapy.	Proportion of patients with knowledge of nutritional care.	Teaching hours of nutrition at the undergraduate level of medicine and other health professions. Creation of postgraduate programs.	Number of original publications on clinical nutrition.

Conclusion and perspective

Recognizing that all patients have the right to nutritional care is an important advance in clinical nutrition. The human rights-based approach allows the identification of the main priorities and objectives in order to fight against malnutrition and implement an optimal nutritional care for everyone. Among these priorities and objectives, it is possible to identify the need to improve medical research and education, highlight economic aspects, create an institutional culture that values nutritional care and promote patient empowerment as necessary actions to improve nutrition.

Nutritional care must be considered an emerging human right. By being recognized only in the Cartagena Declaration, and even though it has no legally binding force, it does harbor a very important moral strength that implies the ethical responsibility to promote nutritional care.

This right is the result of the efforts of international scientific societies in the field of clinical nutrition that seek to achieve a minimum guarantee that people, anywhere in the world, can access nutritional care. In the future, the objective is that, from a legal and political point of view, States also have certain obligations, the effective implementation of which can be legitimately claimed by people. Therefore, States and other duty-bearers would be bound to “respect, protect, and fulfill” the right to benefit from the entire nutritional care process. This means that the patient has the right to benefit from nutritional screening and for his nutritional state to be diagnosed, to receive regular hospital diet, therapeutic diet (food modification and supplements) and nutritional therapy (enteral and parenteral nutrition) administered by a team of experts, and the State has the duty to guarantee it.

Funding sources

This article was not financed.

Conflict of interests

The author has no conflict of interest.

References

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Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):56-62.

Ethical aspects of the Cartagena Declaration

Aspectos éticos de la Declaración de Cartagena

Aspetos éticos da Declaração de Cartagena

Diana Cardenas1, Sonia Echeverri2

Received: September 25, 2019. Accepted: October 26, 2019.

https://doi.org/10.35454/rncm.v2supl1.032

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1 Research Institute of Nutrition, Genetics and Metabolism, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia

2 Hospital Ethics Committee and Humanism and Bioethics Committee of the Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.

*Corresponding author: Diana Cardenas

dianacardenasbraz@gmail.com

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Summary

Introduction: Nutritional care was recognized as a human right in the Cartagena Declaration on May 3, 2019. This article analyzes the Cartagena Declaration from the ethical approach.

Methodology: An analysis was made based on the four principle approach and on the principles of the UNESCO Declaration of Bioethics and Human Rights.

Results: it is recognized that the right to nutritional care implies feeding the sick person in conditions that respect their dignity, considering the vulnerability of the malnourished person or at risk of malnutrition and respecting the principles of bioethics. Therefore, the principles of autonomy, beneficence, non-maleficence and justice must be respected. Recognizing this right and the ethical basis of the Declaration does not imply that the obligation to feed all patients at any stage of life and at any cost is being accepted. On the contrary, recognizing this right implies from an ethical point of view that the best decision for the patient must be taken and this may include the decision not to feed.

Conclusion: The Cartagena Declaration has a fundamental structural ethical component which is based on the concepts of dignity and vulnerability, respect for autonomy, beneficence, non-maleficence and justice as a condition for the practice of clinical nutrition. In addition, it promotes the values of justice and equity in nutritional care.

Keywords: Human rights; Ethics; Bioethics; Malnutrition.

Resumen

Introducción: el cuidado nutricional fue reconocido como un derecho humano en la Declaración de Cartagena del 3 de mayo de 2019. Este artículo analiza la Declaración de Cartagena desde la perspectiva y fundamentación ética.

Metodología: se hace un análisis desde la ética teniendo en cuenta los principios de la bioética o “principialismo” y los de la Declaración de Bioética y Derechos Humanos de la UNESCO.

Resultados: se reconoce que el derecho al cuidado nutricional implica alimentar a la persona enferma en condiciones que respeten su dignidad, teniendo en cuenta la vulnerabilidad de la persona desnutrida o en riesgo de desnutrición y respetando los principios de la bioética. Por lo tanto, se deben respetar los principios de autonomía, beneficencia, no maleficencia y justicia. Reconocer este derecho y el fundamento ético de la Declaración no implica que se esté aceptando la obligación de alimentar a todos los pacientes en cualquier etapa de la vida y bajo cualquier costo. Por el contrario, reconocer este derecho implica desde el punto de vista ético, que se debe tomar la mejor decisión para el paciente y esto puede incluir la decisión de no alimentar.

Conclusión: la Declaración de Cartagena tiene un componente ético estructural fundamental el cual se basa en los conceptos de dignidad y vulnerabilidad, el respeto a la autonomía, la beneficencia, la no maleficencia y la justicia como condición para el ejercicio de la nutrición clínica. Además, promueve los valores de justicia y equidad en el cuidado nutricional.

Palabras clave: derechos humanos, ética, bioética, malnutrición.

Resumo

Introdução: o cuidado nutricional foi reconhecido como um direito humano na Declaração de Cartagena de 3 de maio de 2019. Este artigo analisa a Declaração de Cartagena sob a perspetiva e o fundamento ético.

Metodologia: é feita uma análise da ética, levando em consideração os princípios da bioética ou “principialismo” e os da Declaração da UNESCO de Bioética e Direitos Humanos.

Resultados: a Declaração de Cartagena tem como fundamento ético os princípios da Declaração da UNESCO de Bioética e Direitos Humanos. Reconhece-se que o direito ao cuidado nutricional implica alimentar a pessoa doente em condições que respeitem sua dignidade, levando em consideração a vulnerabilidade da pessoa desnutrida ou em risco de desnutrição e respeitando os princípios da bioética.

Portanto, os princípios de autonomia, beneficência, não maleficência e justiça devem ser respeitados. O reconhecimento deste direito e da base ética da Declaração não implica que a obrigação de alimentar todos os pacientes em qualquer fase da vida e a qualquer custo seja aceite. Pelo contrário, reconhecer esse direito implica, do ponto de vista ético, que a melhor decisão para o paciente deve ser tomada e isso pode incluir a decisão de não alimentar.

Conclusão: a Declaração de Cartagena possui um componente ético estrutural fundamental, baseado nos conceitos de dignidade e vulnerabilidade, respeito à autonomia, beneficência, não maleficência e justiça como condição para a prática da nutrição clínica. Além disso, promove os valores de justiça e equidade no cuidado nutricional.

Palavras-chave: direitos humanos, ética, bioética, desnutrição.

Introduction

On May 3, 2019, in the city of Cartagena, Colombia, the 16 associations, societies and schools that comprise the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE), after signing the Cartagena Declaration, committed themselves to defend the right to nutritional care and to fight against malnutrition. The Cartagena Declaration seeks through its thirteen principles to provide a frame of reference to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity. It also works as an instrument for the societies that are members of FELANPE and all the institutions that work in favor of nutritional care to promote, through governments, the formulation of policies and legislations in the field of clinical nutrition. It is a non-binding instrument, i.e. one that does not legally bind, but has an undeniable moral strength which commits the parties to join efforts in this common fight. Knowing its ethical foundations is key to the implementation of the declaration’s principles, the development of the implementation program and the formulation of policies in clinical nutrition. The objective of this article is to carry out an analysis on the ethical aspects and principles that lay the foundations for the Cartagena Declaration.

Methods

Ethics is a branch of philosophy whose objective is to carry out an intellectual analysis of the human moral dimension in all its complexity (1). Ethics has to do with principles that allow us to make decisions about what is morally right and wrong. It refers to a judgment of behaviors, good or bad. Bioethics is part of ethics and its objective is to reflect on and provide answers to the ethical problems and questions or dilemmas introduced by the advances in science and technology, including decision-making in the field of healthcare. This article analyzes the ethical foundation of the Cartagena Declaration taking into account the principles of bioethics (autonomy, beneficence, nonmaleficence, and justice) as well as the principles established in UNESCO’s Universal Declaration on Bioethics and Human Rights signed by 191 countries in the city of Paris on October 19, 2005 (DUBDH)(2).

Results - Analysis

Artificial nutrition is considered to be a great advance in 20th century medicine, because thanks to the administration of nutrients through enteral or parenteral routes today we can feed sick people who require it, and have an impact on malnutrition, outcomes and quality of life. However, this advance leads to ethical questioning in particular situations such as palliative care and the end of life, cancer, patients with advanced Alzheimer’s, patients in intensive care, etc.(3). The difficulties in decision-making and ethical dilemmas in this field arise mainly due to a lack of clarity on the role of artificial nutrition. It is a medical therapy that has to have an indication, a precise therapeutic objective, and must have the patient’s, their family’s, or their legal representative’s consent. Like every medical therapy, artificial nutrition has precise medical indications but can also have side effects and complications that can be more important than the possible benefit and can cause harm to the patient. This is why the decision of withholding or withdrawing nutritional therapy in specific situations must be made after an analysis of each case and after an interdisciplinary consultation with the treating medical team and the family.

By recognizing the right to nutritional care as a human right, the Cartagena Declaration is promoting a commitment and a very important ethical responsibility for all of the scientific societies or persons who push and defend it. It must be made clear that this does not mean that the obligation to feed every person under any circumstance or during every stage of life, including the terminal phase, is being defended. On the contrary, recognizing this right implies, from the ethical point of view, that an agreement must be reached together with the patient and their family, on the best decision for the patient, and this includes the option of not feeding. Therefore, the feeding of the sick person must be promoted under conditions that respect their dignity, taking into account and respecting the principles of bioethics.

UNESCO’s Universal Declaration on Bioethics and Human Rights

The Cartagena Declaration is based on the respect for the principles established in the UDBHR(2) . It is an ethical reference that encompasses matters related to medicine, life sciences, and the use of technology associated to human beings, taking into account the ethical, social, legal and environmental dimensions.

The UDBHR aims to provide a universal structure of principles and procedures to guide States in the formulation of policies, laws and diverse tools applied to the field of bioethics. It is an instrument whose central axis is the respect for human dignity, human rights and is based on 15 principles (Table 1).

The Cartagena Declaration recognizes and applies them in the field of clinical nutrition, so that Principle 5 “Ethical principles and values in clinical nutrition”, states:

“It is important to emphasize that nutritional therapy (oral, enteral and parenteral nutrition) is considered a great scientific and technological advance that has allowed any sick 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. These issues should be analysed within the framework of the principles set out in UNESCO’s UDBHR, in particular the universal principles of equality, justice and equity, non-discrimination and non-stigmatization, nonmaleficence, autonomy, beneficence and respect for human vulnerability and personal integrity.”

Table 1. Principles of the UDBHR, UNESCO 2005

Human dignity and human rights

Benefit and harm

Autonomy and individual responsibility

Consent

Persons without the capacity to consent

Respect for human vulnerability and personal integrity

Privacy and confidentiality

Equality, justice and equity

Non-discrimination and non-stigmatization

Respect for cultural diversity and pluralism

Solidarity and cooperation

Social responsibility and health

Sharing of benefits

Protecting future generations

Protection of the environment, the biosphere and biodiversity

Human dignity

Respect for the person’s dignity is the cornerstone upon which the values of both the UDBHR and the Cartagena Declaration are based, and it is also the guiding thread of their statements.

The concept of human dignity and respect for human rights are closely related. The approach based on human rights allows the identification of priorities and objectives in order to fight against malnutrition and implement an optimal nutritional care for everyone. It also allows to understand that human dignity is a central axis in the ethical foundation of feeding the sick person. The notion of human dignity from its philosophical dimension means, according to Immanuel Kant, the fact that the person should never be treated as a means, but rather as an end in itself. People do not have a price, they have dignity (4). Dignity refers to a quality that would be linked to the very essence of each human being, which would explain the reason why this quality has to be equal for everyone and not admit levels, degrees or exceptions. In this sense, it means that all human beings deserve unconditional respect, regardless of their age, physical or mental health, gender identity or sexual orientation, religion, social status or ethnical origin.

The first principle of the Cartagena Declaration is focused exclusively on recognizing the importance of feeding the sick person in conditions of dignity. The respect for human dignity, understood as a person’s right to be treated ethically, to be valued and respected for who they are, is attained when by feeding the sick person (by means of nutritional therapy), their individual autonomy, religious beliefs and sociocultural environment are considered. This implies recognizing the intrinsic value of each human being, as well as the respect for integrity, and the diversity of moral, social and cultural values during the stages of the nutritional care process.

The absence of an optimal nutritional care can threaten human dignity. But prolonging nutritional therapy beyond what’s medically necessary, might also be considered as a lack of respect for human dignity since the person’s physical integrity would be harmed. Hence, it must be considered that nutritional therapy is a medical treatment, sick people have the right and the autonomy to refuse it, and healthcare personnel have the obligation to accept this decision and not perform futile actions.

The vulnerability of the malnourished patient

The notion of vulnerability is central to the ethical component of clinical nutrition. The Cartagena Declaration states:

“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. Malnutrition implies physical, psychological and social deterioration (with the risk of losing one’s life and the possibility of losing one’s autonomy).”

The word vulnerable comes from the Latin vulnerabilis, formed by vulnus (wound) and the suffix abilis or -able which indicates possibility, that is, that can be wounded. Hence the word vulnerability in its common use means “capable of” being wounded. A vulnerable person is a person who can be hurt easily and who cannot defend themselves expeditiously. It is in this way the field of law considers vulnerable people, whom the State has the obligation of protecting to avoid, for example, them from becoming objects of research. In the ethical field, the notion of vulnerability is based on the Levinasian notion that suggests a non-intellectual morality whose origin is an individual’s vulnerability and subjectivity, defined by bodily sensitivity and not by conscience, or reason, or the rational deliberation of freedom(5). Thus, according to the ethics of vulnerability, the matter of respect for and the support of the vulnerable person goes beyond the protection of a category of individual and the difficult problem of informed consent (6). In these conditions, the respect for the person is not reduced to the assessment of their legal competence nor to the examination of their cognitive abilities. Likewise, the response to specific needs cannot turn into deciding for the other which would be a dismissal of their will. Furthermore, what situations of vulnerability highlight is the need of considering the fact that the person needs the other, needs medical care and health care structures, and the de facto reality that they wish to be considered a person, a human being whose dignity is intact despite being at risk of physical or cognitive aggression.

Therefore, the deepest ethical sense of vulnerability implies a commitment to responsibility towards others, the “care for others”(6). Vulnerability implies “the responsibility for the other” and that means we need the other. In the case of malnutrition, a malnourished patient is doubly vulnerable because on the one hand, their integrity is compromised, and on the other hand, they are fragile due to their relationship of dependence with the professional who must feed them artificially. Malnutrition implies, the same way the illness does, the loss of control over the body, of the vital processes that are necessary for health and of autonomy. In the case of malnutrition this is even more serious because its diagnosis is difficult due to the lack of consensus on its definition and the methods to determine it; in addition to the scarce action of doctors that can be due to insensitivity per se or due to lack of education on the subject of malnutrition and its consequences. Therefore, it is possible to consider that the malnourished patient is a doubly vulnerable patient. In particular situations, the person with disease-related malnutrition loses the ability to feed themselves. They are then dependent on a caregiver, on their technical and scientific qualifications, but also on their moral qualities to satisfy the medical treatment that is nutritional therapy.

The bioethical principles in the Declaration of Cartagena

Principlism, according to Tom Beauchamp and James Childress, is based on four principles: the respect for the person’s autonomy, the principle of nonmaleficence, the principle of beneficence and the principle of justice(7). These four principles constitute a common frame of reference for the analysis of bioethical problems.

Autonomy

Patients must be treated as autonomous agents, i.e. recognize their capacity to make independent and authentic decisions about how they want to be fed, whether they want to be fed or not, based on their knowledge, values and personal beliefs. Autonomy does not mean that a patient has the right to obtain any treatment they desire or request if this treatment in particular is not medically indicated. Autonomy can only be excercised after having gathered complete and appropriate information, as well as having understood it. The decision must be made without any kind of pressure or coercion.

These aspects are manifested in Principles # 1 and # 3 of the Cartagena Declaration. On the one hand, Principle 1 states that:

“It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and caregivers have the obligation to accept this decision.”

This is complemented by Principle # 3 which recognizes the importance of the patient’s empowerment to ensure truly autonomous decisions by the patient:

“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.”

Beneficence

The principle of beneficence imposes the obligation of acting for the patient’s benefit. Caregivers must comply with professional obligations and standards. Each decision must be made at the individual level. Health professionals have the obligation of maximizing the potential benefits for their patients and simultaneously minimizing the potential harm for them.

This means that an adequate nutritional therapy must be provided in response to a medical indication and following the patient’s consent, the screening of malnutrition risk must be done using a validated tool that is adequate for all people that come into contact with health services. Nutritional assessment must be conducted on all subjects identified as being at risk by the nutritional risk detection. Monitoring of the nutritional therapy must be carried out on all patients.

Respect for the principle of beneficence in the Declaration is implicit in the preamble:

“Aware that adequate nutritional therapy can correct malnutrition, improve disease prognosis and quality of life, reduce comorbidities, mortality and health costs,”

And in Principle # 2 which recognizes that:

“Nutritional care is part of the patient’s overall care, and should therefore be an inherent component of their care.”

Nonmaleficence

The principle of nonmaleficence imposes the obligation not to inflict harm on others. Medical nutritional therapy must minimize possible harm. If the risk of administering nutritional therapy to a specific patient outweighs the potential benefits, then the caregivers have the obligation of not providing (withholding) said therapy. If the nutritional therapy is useless and it only prolongs suffering or is postponing death, it must be suspended. Additionally, respect for this principle implies avoiding the hospitalized patient’s prolonged and unnecessary fasting. Withholding or withdrawing nutritional therapy if it is considered useless: in a situation where it would only prolong suffering, or at the terminal stage of an incurable or untreatable disease, situations in which nutritional therapy would not be medically indicated.

Respect for this principle is recognized in the preamble of the Declaration of Cartagena:

“Aware that nutritional therapy may have side effects and low effectiveness in some patients such as those in a hypercatabolic state, or if not administered properly,”

Emphasis is also placed on not performing futile actions in Principle # 1:

“It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and caregivers have the obligation to accept this decision and not perform futile actions.”

Justice

The principle of justice refers to an equal access to healthcare for everyone. Limited resources, including the time that doctors and other healthcare professionals dedicate to their patients, must be allocated uniformly in order to achieve a true benefit for the patient. The resources must be allocated justly without any discrimination. This means that all patients must have the best nutritional care available. This implies that nutritional therapy must always be administered, like any other therapy, only when there is a medical indication. This is explicit in the preamble of the Cartagena Declaration:

“Aware of the need to seek, through the application of basic, clinical and public health sciences, increasingly effective nutritional solutions,”

And in Principle # 6 of the Declaration where emphasis is placed on the value-based approach in healthcare:

“Under this approach, the aim is to reorient health services to improve the satisfaction of people’s health needs, particularly nutritional care, while maintaining an optimal relationship with costs and outcomes.”

Principle # 11 acknowledges the importance of the values of justice and equity in nutritional care.

Table 2 shows the ethical contents of the Cartagena Declaration.

Conclusion

The Cartagena Declaration has a fundamental structural ethical component which is based on the concepts of dignity and vulnerability. The principles established by this Declaration recognize the importance of Principlism and promote the respect for autonomy, beneficence, nonmaleficence and justice as a condition for the practice of clinical nutrition. In addition, it promotes the values of justice and equity in nutritional care.

Table 2. Ethical Contents of the Declaration of Cartagena

Ethical Foundation	Declaration of Cartagena
Feed the ill person in conditions of dignity	Principle 1
Vulnerability of the person at risk of malnutrition or in a state of malnutrition	Principle 5
Respect for the principle of autonomy	Principle 1 Principle 3
Respect for the principle of beneficence	Preamble Principle 2
Respect for the principle of nonmaleficence	Preamble Principle 1
Respect for the principle of justice	Preamble Principle 6

Financing

This article was not financed.

Conflict of interests

The authors declare that they have no conflict of interest.

Author’s contributions

DC and SE designed the article. The authors declare that they read and approved the final manuscript.

References

1. Ricoeur P, Éthique, Dictionnaire d’éthique et de philosophie morale, M Canto-Sperber ed., Paris, PUF, 2004, p. 689.
2. Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura. Declaración Universal sobre Bioética y Derechos Humanos.[Internet]. Paris: Unesco; 2005 [consultado el 29 ocubre 2015]. Disponible en: http://portal.unesco.org/es/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html.
3. Druml CH, Ballmer P.E, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr. 2016;35:545-56.
4. Fiat E. Petit traité de dignité. Paris: Ed. Larousse. 2012. p. 234.
5. Levinas E. Autrement qu’être ou au-delà de l’essence, Martinus Nihjoff, The Hague, 1974. [Internet]. [Consultado el 1 de agosto 2019]. Disponible en : https://monoskop.org/images/8/89/Levinas_Emmanuel_Autrement_qu_etre_ou_au_dela_de_l_essence_1974.pdf
6. Pelluchon C. L´autonomie brisée. Bioéthique et philosophie, philosophie. Paris: PUF, 2009. p. 99.
7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th edition. New York: Oxford University Press, 2013. p. 416.

Echeverri S, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):63-75.

The Cartagena Declaration from
interdisciplinarity

La Declaración de Cartagena desde la interdisciplinariedad

A Declaração de Cartagena desde a interdisciplinariedade

Sonia Echeverri1*

Received: November 1, 2019. Accepted: November 13, 2019.

https://doi.org/10.35454/rncm.v2supl1.031

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1 Hospital Ethics and Humanism Committee, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia. Vice-president FELANPE Central Region

*Corresponding author: Sonia Echeverri

info.fundacionconocimiento@gmail.com

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Summary

The Latin American Federation of Nutrition Therapy, Clinical Nutrition and Metabolism (FELANPE), in its general assembly held last May in the city of Cartagena, raised the right to nutritional care and the fight against malnutrition to the category of human right. The Cartagena Declaration, which through 13 Principles addresses the worrying problem of malnutrition, in all its forms, indicates how to raise awareness about this scourge that is much talked about, investigated, assumed, palliated, we obtain some results, but we can rarely beat it.

Thus, it is recognized that malnutrition is a complex problem, requiring complex treatments, which are optimized when disciplines related to nutritional activity such as medicine, nursing, nutrition, pharmacy and rehabilitation, among others, decide to join efforts based on their knowledge and respecting the disciplinary competences, as was explicit in Principle # 4 of the Cartagena Declaration focused on the interdisciplinarity of nutritional care, and as reflected by Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, authors who integrate this article which is about this Principle.

In conclusion, by signing the Cartagena Declaration, the societies, associations and schools that make up FELANPE, pledged to recognize the importance of promoting equitable disciplinary integration to provide optimal nutritional care, both in healthcare and academia, as scientific evidence proves.

Keywords: Cartagena Declaration; Mal-nutrition; Interdisciplinary; Principles.

Resumen

La Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo (FELANPE), en su asamblea general realizada en el pasado mes de mayo en la ciudad de Cartagena, elevó a la categoría de derecho humano el derecho al cuidado nutricional y a la lucha contra la malnutrición. En la Declaración de Cartagena, la cual a través de 13 Principios aborda el preocupante problema de la desnutrición, en todas sus formas, indica la manera de crear conciencia sobre este flagelo del que mucho se habla, se investiga, se asume, se palia, se obtienen escasos resultados, pero al que pocas veces se consigue vencer.

Se reconoce, entonces, que la malnutrición es un problema complejo, que requiere tratamientos complejos, los cuales logran ser optimizados cuando disciplinas relacionadas con la actividad nutricional como medicina, enfermería, nutrición, farmacia y rehabilitación, entre otras, deciden sumar esfuerzos basados en sus conocimientos y respetando las competencias disciplinares, como quedó explícito en el Principio # 4 de la Declaración de Cartagena enfocado en la interdisciplinariedad del cuidado nutricional, y como lo reflejan Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, autores que integran este artículo que trata sobre dicho Principio.

En conclusión, al firmar la Declaración de Cartagena, las sociedades, asociaciones y colegios que conforman la FELANPE, se comprometieron a reconocer la importancia de promover la integración disciplinar equitativa para brindar un óptimo cuidado nutricional, tanto en la asistencia como en la academia, según lo demuestra la evidencia científica.

Palabras clave: Declaración de Cartagena, desnutrición, interdisciplinariedad, principios.

Resumo

A Federação Latino-Americana de Terapia Nutricional, Nutrição Clínica e Metabolismo (FELANPE), em sua assembleia geral realizada em maio passado na cidade de Cartagena, elevou o direito ao cuidado nutricional e o combate à desnutrição à categoria de direito humano, Declaração de Cartagena, que através de 13 princípios aborda o preocupante problema da desnutrição, em todas suas formas, indica como aumentar a conscientização sobre esse flagelo que é muito comentado, investigado, assumido, aliviado, com poucos resultados, mas raramente é abatido.

Reconhece-se, então, que a desnutrição é um problema complexo, que requer tratamentos complexos, otimizados quando disciplinas relacionadas à atividade nutricional, como medicina, enfermagem, nutrição, farmácia e reabilitação, entre outras, decidem unir esforços com base em seus conhecimentos. e respeitando as competências disciplinares, como foi explicitado no Princípio nº 4 da Declaração de Cartagena, focado na interdisciplinaridade do cuidado nutricional, e refletido por Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, autores que integram este artigo que trata deste Princípio.

Concluindo, ao assinar a Declaração de Cartagena, as sociedades, associações e escolas que compõem a FELANPE comprometeram-se a reconhecer a importância de promover uma integração disciplinar equitativa para oferecer um atendimento nutricional ideal, tanto no atendimento quanto na academia, de acordo com evidências científicas.

Palavras-chave: Declaração de Cartagena, desnutrição, interdisciplinaridade, princípios.

Introduction

Principle # 4 of the Cartagena Declaration correctly guides nutritional care towards interdisciplinarity: “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, efficiency and efficacy.”(1)

Malnutrition, in all its forms, is an alteration with a high degree of complexity and uncertainty, and should be addressed as such. This complexity makes it necessary for diverse disciplines to participate, focusing their attention and actions to interact with one another sharing knowledge, experience and objectives.

For over four decades, when Dr. Stanley J. Dudrick used parenteral nutrition with the known outcomes, he did so with the help of a health team conformed by nursing, pharmaceutical and nutrition professionals, an initially multidisciplinary one which then began to migrate to interdisciplinarity. Since then, it has been recognized that the contribution of each discipline is, to a great extent, responsible for the success of nutritional therapy: saving lives, enabling patients condemned to die due to the impossibility of using the digestive tract to be nourished, to recover, progress.

Interdisciplinary Nutritional Care

Interdisciplinary, a term coined by sociologist Louis Wirtz and first published in 1937. Interdisciplinarity, whose prefix inter anticipates that a relationship will be established between the disciplines, one in which every one of them will contribute, within their field and competence, the different conceptual analysis schemes, subjecting them to comparison, critical judgement and, finally, incorporating and integrating results with the purpose of solving a concrete problem in all its complexity, in this case malnutrition, object of study and care(2).

As proposed by Mario Tamayo y Tamayo, interdisciplinarity is an internal demand of sciences. Let us take the case of medicine, nursing, nutrition, pharmacy, rehabilitation, psychology, each of them considered particularly, can be considered a level of science, whose purpose is to maintain health, prevent, treat, cure or palliate diseases, among others, applies structured processes, which respond to a dynamic of their own and which develops as each system, of its own discipline, connects to, relates to and coexists with the other disciplines(2).

Therefore, confronting the scourge of malnutrition (undernourishment or obesity), a broad and complex phenomenon, requires the concurrence of various health disciplines, each of which has specific competences within their curricular context and with a common structure or base whose reality is defined, studied, researched and developed from an own perspective. With this foundation (for the issue that concerns us, in research and assistance), disciplines start intertwining, being integrated, giving each other a cohesion of knowledge, forming groups or teams that enrich each discipline at a personal level, professionally, optimizing the nutritional care provided to the patient, family, caregivers and the community.

However, disciplines adopt diverse ways of coexisting, of working as a team, of producing knowledge, such as multidisciplinarity, pluridisciplinarity, interdisciplinarity, intradisciplinarity and transdisciplinarity, each type having its own characteristics, specific dynamics and different nuances. In general, Nutritional Support Teams (NST) embrace multidisciplinarity: “a set of disciplines with common objectives that do not maintain collaborative relationships with each other.”

Some scholars of economic issues related to health policies propose that transdisciplinarity, defined as “the transformation and integration of knowledge from all interested perspectives to define and address complex problems” or “Process according to which the limits of individual disciplines are transcended to address problems from multiple perspectives with the aim of generating emerging knowledge”, might increase the benefits, in financial terms(1).

The Cartagena Declaration approaches the subject of nutritional care from the Interdisciplinarity perspective due to all the advantages it brings along with it among which is its essence: it is the sum of knowledges, scientific methods, abilities and disciplinary skills that allow solving complex problems that surpass the limits and competences of each discipline, creating new knowledge, finding certainty in situations of uncertainty, complementing deficiencies with the objective of optimizing nutritional care and fighting against malnutrition, contributing to society’s well-being and therefore economic progress(1,3).

Consequently, recognizing the importance of the interdisciplinary approach in nutritional care has implications that are mainly academic, but also for health organizations and institutions. The administration of nutritional therapy must be done within the framework of nutritional therapy 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, complement each other, but most importantly that it should be done with ethics, humanism, recognizing the other as equal, respecting differences, diversity, nutritional care should be provided valuing and appreciating the sick person’s vulnerability and human dignity (Figure 1).

In 1999, Dr. Óscar Jaramillo, in a communication to FELANPE, in support of the creation of the Interdisciplinary Course on Critical Nutrition, CINC, wrote: “The problems that must be solved day after day, do not present themselves to us – for our fortune or our disgrace- classified in disciplinary blocks. Nature, in its admirable wisdom, does not allow – with very few exceptions – only one of its individuals to be responsible for changing its course”. “... The intention is for an interdisciplinary work to originate –by spontaneous generation- from a non-interdisciplinary education given to students, forgetting that university formation rarely offers students the opportunity to interact with other disciplines”. In this sense, the Cartagena Declaration recommends that: From the academic point of view, not only should the professionals in these disciplines be formed in the field of clinical nutrition, but specific disciplinary competences should also be defined and respected.

Figure 1. Teamwork models for nutritional care.

Importance of the Cartagena Declaration on the right to nutritional care and the fight against malnutrition. From the medical perspective

Importancia de la Declaración de Cartagena sobre el derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la perspectiva médica

Importância da Declaração de Cartagena sob o direito ao cuidado nutricional e a luta contra a desnutrição. Do ponto de vista médico

Acad. Dr. Humberto Arenas Márquez, FACS-FASPEN*.

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1 Director of the Integrated Intestinal Failure Unit, Hospital San Javier , Guadalajara, Jalisco, México. President of FELANPE 2017 – 2018.

*Corresponding author: Humberto Arenas Márquez

arenas50@hotmail.com

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Evidence shows that the rate of prevalence of hospital malnutrition is alarming and that its associated care costs increase exponentially(4,5); undoubtedly, optimal nutrition is intimately related to the positive outcome in disease management(6) ; therefore, it would be ideal for a nutritional plan to be applied to every sick person who enters a hospital(7,8). However, reality is different; the doctor leading the care team has not been trained to face this challenge and, what is worse, is not conscious of this need.

Based on the Hippocratic ethical principle “First, do no harm”, the FELANPE has presented the Cartagena Declaration in 2019 and defined 13 principles to raise awareness, especially among doctors and Health System leaders in Latin America, about the right held by patients to an optimal in-hospital nutrition through the creation of an Institutional Culture that values nutritional care(9).

The doctor, as the leader of the interdisciplinary health team, through his or her attitude and making use of his or her competences such as intelligence, effort and charisma must be able to improve his or her self-awareness and that of his or her collaborators to create a coalition capable of transforming its hospital environment, and thus integrate the process of nutritional care into the Institutional Safety Culture(10) whose objectives are: the identification and control of risks that can cause nutritional harm to patients, the prevention of harm and providing a safe environment to supply optimal nutrition at all times and under any circumstances.

On the other hand, the culture of safety is a matter of ethics and is linked to efficiency, given that a safe doctor is not the one that is most competent in a skill, but rather the one that is most honest in recognizing their own competence and ability limitations and that has enough courage to ask for help and is committed to learn beyond their limitations, especially in the nutritional area(11).

Such cultural shift is a precondition for action that will lead to a policy to improve the patient’s nutritional care process with a policy of measuring outcomes and with them the capacity to act in the political field(12).

Undoubtedly, trust is the cornerstone of the doctor-patient relationship(13). The concept of vulnerability is particularly relevant when the state of dependency is related to the disease; therefore, the sick person trusts us medical professionals to provide them a responsible and dignified care by recognizing their integrity to maintain their health and coordinate a care focused on the patient’s needs so that patients perceive that they are protected when they are most vulnerable.

Although we have significant advances in the medical sciences, practices have not evolved. In order to achieve the objectives of the Cartagena Declaration, we need a unified goal that allows all actions to be aligned.

An objective that has been discussed in debates on healthcare and that can be defined and measured is the addition of value to systems. Porter has developed the theory of value in which the center of attention, and therefore of value, are patients. Value in health is defined as the achieved result for every unit of money invested and is created by a full cycle of care of the person’s medical conditions. Value can be measured using scientific tools (14,15).

Shared responsibility will be achieved through the development of integrated practice units. These integrated systems of care would replace our autonomous and individualistic culture, in which specific departments and specialties work independently and focus on providing a limited range of interventions.

Conclusions

In order to achieve the goals of the Cartagena Declaration, it is essential for a cultural shift to be produced among doctors. Systems must invest in a comprehensive healthcare model that includes optimal nutrition. Investigation of the doctors’ attitude through measurements of their results and costs, as well as patient satisfaction, will allow the identification of interdisciplinary care teams that five value to the patient by including the nutritional process in the institutional culture. This cultural shift will lead to achieving quality care, operational efficiency and financial health for the institution and care providers for the patient’s benefit (16).

The Cartagena Declaration: The role of the Pharmacist

La Declaración de Cartagena: el papel del farmacéutico

A Declaração de Cartagena: o papel do farmacêutico

Prof. Gil Hardy, PhD, FRSC, FASPEN*

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1 Profesor Emérito de Nutrición Clínica. College of Health, Massey University, Auckland, Nueva Zelanda.

*Corresponding author: Gil Hardy

gil.hardy50@gmail.com

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The Cartagena Declaration: The Role of the Pharmacist

The Cartagena Declaration(9) on the right to nutritional care, outlines 13 important Principles, including the fact that nutritional care should be a continuous process encompassing; Screening, Nourishment and Monitoring. Nourishment by oral, enteral nutrition (EN) or parenteral nutrition (PN) is considered a medical intervention, which like any therapy with side effects, risks and benefits should be monitored and documented. Moreover, the sterile nutrition products used for PN are categorised as pharmaceutical drugs. Principle 4 of The Declaration recognises “The interdisciplinary approach to nutritional care”. It specifically recommends that nutritional care [in hospitals] should be performed by interdisciplinary teams, i.e. a nutrition support team (NST) which should include at a minimum, nutrition professionals (dietitians), nurses, physicians and pharmacists.

A Technical Role

The nutritional care process involves several stages. Pharmacists are well placed and professionally qualified to play a major part in each step, using the knowledge and technical skills developed during their professional training and post graduate experience. In many locations, the formulation and compounding of PN regimens remains the cornerstone of this technical pharmaceutical role. Since the early pioneering days of PN, pharmacists have had responsibility for the preparation of PN. As experts in pharmacology, microbiology, asepsis and pharmaceutical compatibility/stability, pharmacists have contributed significantly to the successful use of nutritional therapy, by formulating stable PN regimens to safely meet individual patient requirements. It is well recognised that safe administration is key to efficacious PN therapy. Many PN components and admixtures are excellent growth media for bacteria and moulds, but any such risks can be minimised when the processes are supervised be pharmacists. Optimum quality can be assured when PN admixtures are prepared by competent technical staff in appropriate aseptic facilities that are routinely monitored.

A substantial body of research data, frequently generated by hospital, academic and industry pharmacists, are available to facilitate judgements on stable and safe formulations. In the absence of pharmaceutical input, poor understanding of all the issues that influence stability can lead to serious, even fatal consequences (17).
On-going training programs for pharmacists and pharmacy technicians must involve understanding the principles and limitations of aseptic techniques, overcoming the belief that any operation carried out under laminar flow automatically results in a sterile product or that a good validation overrides an incorrectly designed or poorly audited facility. There may be a statistical risk of producing ‘infected’ PN bags in a poorly designed, uncontrolled Aseptic Unit operated by inadequately trained personnel. On the other hand, safety and quality can be assured if suitably trained pharmacists, who fully understand the technical processes involved, can nullify the potential microbiological risks by following standard operating procedures and by taking professional responsibility for their actions.

A Clinical Role

Pharmacy participation in daily NST rounds provides a useful forum to help identify unexpected events, such as pyrexia, avoid the unnecessary removal of central lines and improve the likelihood of rapidly identifying the causes of such events that can threaten patient outcomes. His/her specialist knowledge concerning limits for chemical compatibility within which the PN prescription can be formulated is invaluable (18).

The pharmacist can also review the concurrent administration of other drugs and advise ward staff on pharmaceutical aspects of safe administration techniques. The pharmacist’s understanding of drug pharmacokinetics, drug-nutrient interactions (DNI), stability and compatibility will ensure that the most convenient and safe PN admixture can be prescribed for the patient(19). Knowledge of the products available in the hospital formulary and their relative costs can also ensure cost effectiveness of PN therapy. Interdisciplinary collaboration during patient selection and monitoring, catheter placement and catheter care, PN prescription and preparation is essential. In all these operations there are elements of risk and elements of benefit for patients. If the correct balance is found, then the so called ‘hazards of PN’ can be minimised or even eliminated. Involving pharmacists in the patient assessment and prescribing processes, allows these important clinical issues to be addressed.

Multi- Chamber Bags (MCB)

One of the most significant PN developments in recent decades has been the move from multiple bottle systems to single ‘Big Bags’ containing all the daily nutrients. Many PN regimens are still compounded into Big Bags in hospital Aseptic Units, but latterly industry has been able to provide a wide variety of regimens in 2- and 3- chamber bags (MCB). The benefits of delivering PN in a single MCB have been well documented and accepted as the optimum means of safe administration. An unfortunate consequence of the ready availability of MCB with long shelf lives coupled with the increasing regulatory pressures on GMP etc has been the abandonment of PN compounding by many hospital pharmacies and closure of their Aseptic Units. Nevertheless, MCB as supplied by the manufacturer, are not ‘All-in-One’ regimens and still require daily aseptic addition of micronutrients. Pharmacists must therefore be vigilant and ensure that all PN additives are made aseptically, under pharmaceutically controlled conditions.

Pharmaconutrition

With continuing clinical interest in ‘nutraceuticals’ for immuno-/pharmaco-nutrition it is likely that there will be expanding focus on the parenteral administration of specific amino acids, such as glutamine, arginine, novel lipid sources, such as fish and olive oils, individual trace elements and antioxidant vitamins, at concentrations greater than RDA. The American Nutraceutical Association has defined ‘nutraceuticals’ as “naturally occurring dietary substances in pharmaceutical dosage forms”(20). This definition certainly encompasses PN components and pharmaconutrients, but it has been estimated that 75% of home users of nutraceutical supplements do not inform their doctor or NST and may not regard them as ‘medicines’. In fact, many nutraceuticals are potent medications with some health benefits but may have potentially adverse effects when interacting with PN or EN. We are already aware of interactions between thiamine/bisulfite, cysteine/copper, selenite/ascorbic acid, lipids/peroxides. We know that glutamine effects methotrexate pharmacokinetics in cancer patients and methionine increases the incidence of oxoprolinuria in females on low protein diets. Increasing clinical demands for supplementing EN and PN regimens with pharmacological doses of these nutraceuticals for treatment of specific diseases will require even more pharmaceutical involvement for aseptic compounding of patient specific pharmaconutrition regimens. Not Less!

A Teaching Role

Pharmacist’s expertise and training in pharmacokinetics, DNI and microbiology makes them a principle source of knowledge, advice and education for health professionals and PN patients. As a key member within the interdisciplinary NST, the pharmacist can ensure colleagues develop better awareness of potential medication risks at the patient assessment stages. Expertise in medication counselling, allows the pharmacist to educate and advise patients on preparation, storage and administration of PN at home (HPN). Education and on-going training of fellow NST members and HPN patients in aseptic techniques for handling PN and co-administration of other medications is a key pharmaceutical responsibility. Centralisation of all prescription-derived records and patient monitoring records in the pharmacy, can form an essential part of the PN patient’s care plan and will facilitate regular audits for constantly improving team performance in the fight against disease related malnutrition, as advocated by The Cartagena Declaration.

The right to nutritional care and the fight against malnutrition. From the Nutritionist’s point of view

El derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la óptica del Nutricionista

O direito ao cuidado nutricional e a luta contra a desnutrição. Do ponto de vista do Nutricionista

María Alejandra Texeira ND., MSc.1*, Yadira Cortes ND., Ph.D.2, Edna Nava3, Laura Joy, ND., Ph.D.4

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1 Head of the Human Milk Bank, Hospital Regional Salto, Salto, Uruguay. Head of the Nutritionist Committee of FELANPE 2019 - 2020.

2 Nutrition and biochemistry department, Pontificia Universidad Javeriana, Bogotá, D.C., Nutritionist Committee of FELANPE, central region, 2019 - 2020.

3 Universidad Autonoma de Nuevo León, México. Nutritionist Committee of FELANPE, north region, 2019 – 2020

4 Instituto Nacional de Cáncer, Paraguay. Nutritionist Committee of FELANPE, southern region, 2019 – 2020

*Corresponding author: María Alejandra Texeira

alejandratexeira@gmail.com

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The reflection focused on the Cartagena Declaration(9) by the Committee of Nutritionists of the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) leads us to ask ourselves: What is our responsibility as professionals and as a group with regard to these rights?

The answer, undoubtedly, is that as professionals and as group we have the responsibility of contributing to the promotion of the right to nutritional care and the fight against malnutrition, and to the advancement in terms of education and research in clinical nutrition, so that they become a reality and not just theoretical statements that are not put into practice.

While the statements of principles and norms are important, without feelings, attitudes and inner conviction, we will not achieve the expected outcomes. As nutrition professionals, we believe that knowing the Declaration is not enough, but that it is necessary to embrace its spirit and implement it.

As a collective, it is our duty to defend this right not only by complying with it from the exercise of our daily practice, but, additionally, we must ensure that it is respected and fulfilled, avoiding falling into a situation of complicity or failure by omission.

JL Aranguren raises the following question: can the man who accepts, at least with his passivity and his silence, an unjust social situation be considered a truly good man?(21)

Transferring Aranguren’s question to the context of the Cartagena Declaration, we ask ourselves: can the Nutritionist who accepts, at least with his passivity, the violation of the right to nutritional care and everything this implies, be considered good?

It is the Nutritionist’s responsibility to participate in the formulation and implementation of policies for the positive fulfillment of the principles of the Cartagena Declaration, to analyze governmental structures and policies and, simultaneously, to carry out research in nutrition and health that contributes data for the elaboration of these policies.

Demonstrating, through clinical research, that the interventions of the nutrition professional solve problems and help people have full enjoyment of their rights to adequate nutritional and health status, is an individual commitment as professionals and additionally a matter of guild and social responsibility.

We nutritionists must perform a practice that prioritizes the preservation of people’s rights and promotes the acknowledgement of nutrition and health as a human right, advocating for the people who are under our care.

We believe that, driven by the Cartagena Declaration, we must form academic and ethics study groups, with professors, researchers and clinicians, with the purpose of achieving a higher convergence between theory and practice, committing ourselves not only to be a good Nutritionist, but also a prepared, updated, ethical, guild-conscious and professional Nutritionist.

International declaration on the right to nutritional care and the fight against malnutrition. From the Nursing perspective

Declaración Internacional sobre el derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la perspectiva de Enfermería

Declaração internacional sobre o direito aos cuidados nutricionais e o combate contra à desnutrição. Na perspetiva da Enfermagem

María Isabel Pedreira de Freitas1*

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1 Past president of the Nurse Committee of FELANPE

*Corresponding author: María Isabel Pedreira de Freitas

>beloca4@yahoo.com.br

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In May 2019, the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE), in a general assembly, approved the International Declaration on the Right to Nutritional Care and the Fight Against Malnutrition, named the Cartagena Declaration.

The nursing personnel daily witness patients who develop malnutrition during their hospitalization or who arrive at health institutions in a deplorable state of malnutrition(22). This situation largely afflicts people who remain 24 hours a day next to those who seek an answer to their health needs. There are publications of evidence-based studies(23), in which patients who remain fasting for surgery, for a longer time than is recommended, put their recovery at risk(24). However, in many health institutions, there is still resistance to making modifications to this practice that may compromise the surgical patient’s life.

As nurses, what do we have to do with this Declaration, knowing that together with patients and their families, we act in the same field as doctors?

We have a lot to do!

It is a fortune to know that States around the world, presided over by Dr. Tedros Ghebreyesus, Director-General of the World Health Organization, WHO, and the International Council of Nurses, ICN, during the opening of the 72nd World Health Assembly, established 2020 as the Year of the Nurse and midwife, giving birth to Nursing Now.

This campaign states that “While it is true that the WHO recognizes the crucial role that nurses play on a daily basis, 2020 will be dedicated to highlight the enormous sacrifices and contributions of nurses and midwives, and… seeks to train nurses to take their place at the heart of the health challenges of the 21st century and maximize their contribution to achieve Universal Health Coverage.”(25)

Walking next to health professionals that support the Cartagena Declaration, means that Nursing can optimize every step towards meeting the challenges that healthcare demands, taking into account that “to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity”(9) is one of the objectives of the Declaration.

Who better than the nursing team that accompanies the patient in their hospitalization at different moments in which their clinical conditions change, causing changes in the therapeutic behaviors that will affect their recovery and overall status?

Nurses are able to observe and act on “factors as diverse as education, economic status, social capital and the physical environment profoundly affect the health and well-being of individuals and populations” as stated by one of the principles of the document Nursing Now(25).

By conceiving nutritional care as “a continuous process consisting of several stages which can be summarized as follows: 1. Screening, 2. Nourish and 3. Watch”, as proposed by the Cartagena Declaration, the caregiver who is closest to the patient and can act immediately upon detecting the alterations present in the patient’s evolution and consequently provide care, is the Nurse. The Nurse acts throughout the entire assistance process with a strong post-operative care teaching approach, directly associated with a better patient recovery, in the same way that continuous assessment and monitoring are very well defined in the nurse’s role(26).

As stated by the Cartagena Declaration, “Nutrition therapy should be monitored and documented. Monitoring seeks to verify that the different dimensions of nutrition therapy are met and to prevent side effects. Documentation serves to track and evaluate the continuity of therapy for each patient and to ensure quality.”(9) It will be the nurse’s leadership in assistance what will favor the fulfillment of this record and the monitoring of the complications that occur during the patient’s hospitalization process. It is these actions, based on the results obtained in successful experiences lived in the day-to-day life with patients, citizens, caregivers, what made the proposals recorded in the document Nursing Now and the Cartagena Declaration possible, which pleasingly walk towards the same objective, shoulder to shoulder, optimizing the outcomes that must be achieved.

Being aware that “clinical nutrition research is a pillar for the realization of the right to food in the clinical field and the fight against malnutrition” makes it necessary to promote “the teaching of clinical nutrition in health careers (medicine, nutrition, nursing, pharmacy, etc.).”(9) Therefore, interdisciplinary action in the formation of students in health areas is fundamental, since the beginning of curricular formation, to achieve an effective and coherent interaction in order to obtain the best results in clinical practice.

In order for the patient to be fed and adequately nourished, it is necessary for each person to carry out concrete actions. Caregivers must act knowing the cultural level of each patient and their family, with the purpose of empowering them so that they can continue the health recovery process at home. They will be able to make the best decisions based on the freedom that knowledge provides, identifying what is best for them and their health. That freedom can be attained by incorporating the training and teaching that the nurse developed with their team and transmitted to the patient during their hospitalization process, thus optimizing the obtained results during the teaching-learning process(27).

The Cartagena Declaration strengthens the actions that health teams must develop together with people who seek to improve their health when it is compromised.

Financing

This article was not financed.

Conflict of interests

The author declares that he has no conflict of interest.

Author’s contributions

SE designed the article. All the authors wrote the manuscript and read and approved the final version.

References

1. Barrocas A. Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams? Nutr Clin Pract. 2019;34:806–21.
2. Tamayo y Tamayo M. El Método, la interdisciplinariedad y la universidad. Universidad ICESI, 1995. (Consultado el 26 de octubre de 2019). Disponible en: https://books.google.pt › books
3. McCauley SM, Barrocas A, Malone A. Malnutrition quality improvement initiative yields value for interdisciplinary patient care and clinical nutrition practice. J Acad Nutr Diet. 2019;119(9):S1-S72.
4. Correia MI, Hegari RA. Addressing Disease -Related Malnutrition in Healthcare: A Latin-American Perspective. JPEN J Parenter Enter Nutr. 2016;40(3):319-25.
5. Arenas D, Plascencia A, Ornelas D, Arenas H. Hospital Malnutrition Related to Fasting and Underfeeding Is It an Ethical Issue? Nutr Clin Pract. 2016;31(3):316-24.
6. Yeh DD, Fuentes E, Quraishi SA, Cropano C, Kaafarani H MA, et al. Adequate Nutrition May Get You Home: Effect of Caloric/ Protein Deficits on the Discharge Destination of Critically Ill Surgical. Patients. JPEN J Parenter Enteral Nutr. 2016;40(1):37-44.
7. Malone A. Addressing Hospital Malnutrition- The Time Is Now! JPEN J Parenter Enteral Nutr. 2013;37:439-40.
8. Tapenden KA. The value of Nutrition Intervention. JPEN J Parenter Enteral Nutr. 2013;37(2):160.
9. 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.
10. McLean S. Transformation: A New Kind of Academic Health Center and the Pursuit of High Self-Mastery. J Am Coll Surg. 2016;222(4): 337-46.
11. Thurunavukarasu P. Do more requirements make better surgeons? External vs. Internal motivators: Against increasing requirements. Bull Am Coll Surg. 2011; 96(8):50-1.
12. Leape L, Berwick D, Clancy C, Conway J. Gluck P, Guest J, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18:424–8.
13. Pellegrini C. Trust: The Keystone of the Patient-Physician Relationship. J Am Coll Surg. 2017;224(2):95-102.
14. Porter ME, Teisberg EO. Redefining Healthcare: Value-based Competition on Results. Boston, MA: Harvard Business School Press; 2006.
15. Hoyt DB. Looking forward. Bull Am Coll Surg. 2011;96(12):4-6.
16. Knight A. Pride and Joy. Linney Group Ltd 2014. Chapter Five. Crocodiles. p. 21-31.
17. Allwood M, Hardy G, Sizer T. Roles and functions of the pharmacist in the nutrition support team. Nutrition. 1996;12(1): 63-4.
18. Allwood MC, Ronchera-Oms CL, Sizer T, McElroy B and Hardy G. From pharmaceutics to pharmaceutical care in nutritional support. Clin Nutr. 1995:14 (1);1-3.
19. Ayers P, Boullata J, Sacks G. Parenteral Nutrition Safety: The Story Continues. Nutr Clin Pract. 2018;33(1): 46-52.
20. Mannion M. Nutraceutical revolution continues at Foundation for Innovation in Medicine Conference. Am J Nat Med. 1998;5:30–3.
21. Aranguren JL. Ética. Barcelona: Altaya; 1994. p. 38.
22. Correia MITD, Campos AC; ELAN Cooperative Study. Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study. Nutrition. 2003; 19(10):823-5.
23. Correia MITD, Silva RG. Paradigms and evidence of perioperative nutrition. Rev. Col. Bras. Cir. 2005; 32(6):342-347. http://dx.doi.org/10.1590/S0100-69912005000600012
24. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-41.
25. World Health Organization. Nursing Now campaign: empowering nurses to improve global health. [internet] 27.02.2018. (Consultado el 30 de octubre 2019) Disponible en: https://www.who.int/hrh/news/2018/nursing_now_campaign/en/
26. Nursing Now – Brasil. Onde há pesquisa há enfermagem. [Internet] (Consultado el 30 de octubre 2019). Disponible en: http://nursingnowbr.org/principios-internacionais
27. Crosson JA. Enhanced Recovery After Surgery – The Importance of the perianesthesia Nurse on Program Success. J Perianest Nurs. 2018; 33(4):366-74.

Cardenas D. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):76-81.

The Cartagena Declaration and the Sustainable Development Goals

La Declaración de Cartagena y los Objetivos de Desarrollo Sostenible

A Declaração de Cartagena e os Objetivos de Desenvolvimento Sustentável

Diana Cardenas1*

Received: September 1, 2019. Accepted: October 26, 2019.

https://doi.org/10.35454/rncm.v2supl1.034

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1 Instituto de Investigación en Nutrición, Genética y Metabolismo, Facultad de Medicina, Universidad El Bosque, Bogotá, D.C., Colombia.

*Corresponding author: Diana Cardenas

dianacardenasbraz@gmail.com

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Summary

The Sustainable Development Goals (SDGs) seek to end all forms of hunger and malnutrition by 2030 and ensure the access of all people, especially children, to sufficient and nutritious food throughout the year. However, the goals of SDG 2 “Zero Hunger,” and the other 16 SDGs do not include the problem of disease-related malnutrition. Malnutrition (underweight, overweight and obesity, micronutrient deficiencies) associated with socio-economic factors (poor diet, hunger and poverty) and disease-related malnutrition have different pathophysiological origins and mechanisms and therefore need different approaches. The Cartagena Declaration is an instrument where nutritional care is elevated for the first time as a human right and can be considered as a strategy to give visibility and draw the attention of public policy makers on the need to advance in this field. By including this type of malnutrition within the global approach to the problem of population malnutrition, we would be contributing to achieving the SDG targets and, in particular, to the sustainable development of countries.

Keyword: Sustainable Development Goals; Human Rights; Malnutrition.

Resumen

Los Objetivos de Desarrollo Sostenible (ODS) buscan terminar con todas las formas de hambre y desnutrición para 2030 y velar por el acceso de todas las personas, en especial los niños, a una alimentación suficiente y nutritiva durante todo el año. Sin embargo, las metas del ODS 2 “Hambre Cero”, y de los otros 16 ODS no incluyen la problemática de la desnutrición asociada a la enfermedad. La malnutrición (bajo peso, sobrepeso y obesidad, carencia de nutrientes) asociada a factores socio económicos (mala alimentación, hambre y pobreza) y la desnutrición asociada a la enfermedad tienen orígenes y mecanismos fisiopatológicos distintos; y por lo tanto, necesitan abordajes diferentes. La Declaración de Cartagena es un instrumento en que, por primera vez, el cuidado nutricional es elevado a categoría de derecho humano y puede ser considerado como una estrategia para dar visibilidad y llamar la atención de los formuladores de políticas públicas sobre la necesidad de avanzar en este campo. Al incluir este tipo de desnutrición dentro del abordaje global del problema de la malnutrición de las poblaciones estaríamos contribuyendo a lograr las metas de los ODS y en concreto al desarrollo sostenible de los países.

Palabras clave: objetivos de desarrollo sostenible, derechos humanos, malnutrición.

Resumo

Os Objetivos de Desenvolvimento Sustentável (ODS) buscam acabar com todas as formas de fome e desnutrição até 2030 e garantir o acesso de todas as pessoas, especialmente crianças, a alimentos suficientes e nutritivos ao longo do ano. No entanto, os objetivos do ODS 2 “Fome Zero” e os outros 16 ODS não incluem o problema da desnutrição associado à doença. A desnutrição (baixo peso, sobrepeso e obesidade, carência de nutrientes) associada a fatores socioeconômicos (má alimentação, fome e pobreza) e a desnutrição associada à doença têm origens e mecanismos fisiopatológicos diferentes e, portanto, precisam de abordagens diferentes. A Declaração de Cartagena é um instrumento em que, pela primeira vez, o cuidado nutricional é elevado à categoria de direito humano e pode ser considerado uma estratégia para dar visibilidade e chamar a atenção dos formuladores de políticas públicas sobre a necessidade de avançar neste campo. Ao incluir esse tipo de desnutrição na abordagem global do problema da desnutrição populacional, estaríamos contribuindo para alcançar as metas dos ODS e, em particular, para o desenvolvimento sustentável dos países.

Palavras-chave: objetivos de desenvolvimento sustentável, direitos humanos, desnutrição.

Introduction

According to the United Nations, sustainable development is defined as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs. Sustainable development requires concerted efforts to build an inclusive, sustainable and resilient future for people and the planet”(1). Sustainable development takes into account three basic elements: economic growth, social inclusion and environmental protection. These elements are interrelated and essential for the well-being of individuals and societies(1). Extreme hunger and malnutrition remain a major obstacle to sustainable development. Hunger and malnutrition make people less productive and more prone to disease, so they are often unable to increase their incomes and improve their lives.

In September 2015, more than 150 heads of state and governments met at the historic Summit on Sustainable Development, at which they approved the United Nations Agenda 2030. This Agenda contains 17 goals and 169 universally applicable targets that, from 1 January 2016, govern countries’ efforts to achieve a sustainable world(1). The Sustainable Development Goals (SDGs) replace the Millennium Development Goals (MDGs), and seek to achieve those targets that were not achieved. What is innovative about the SDG is that it calls on all countries, without distinction, to take a series of measures to promote development while protecting the planet. They recognize that efforts to address issues such as hunger must go hand in hand with strategies that support economic growth and address a range of social needs, including education, health, social protection and employment opportunities, while combating climate change and promoting environmental protection. SDGs are not legally binding, but countries set targets to be achieved through national actions and policies.

Objective 2: Hunger zero

Ending hunger, achieving food security and improving nutrition, and promoting sustainable agriculture are the focus of Goal 2 “Zero Hunger”. A world without hunger and in good nutritional status can have a positive impact on the economy, as well as on overall health, education, equality and social development. This Zero Hunger goal is a central point in building a better future for all countries. Hunger and malnutrition, by slowing human development, would prevent the achievement of the other Sustainable Development Goals, such as education, health and gender equality (2) (Table 1, Figure 1).

Table 1. Goal 2 Targets: Zero Hunger

2.1 By 2030, end hunger and ensure access for all people, in particular the poor and vulnerable, including infants, to healthy, nutritious and adequate food throughout the year

2.2 By 2030, end all forms of malnutrition, even by achieving, by 2025, the internationally agreed goals on growth stunting and emaciation of children under five years of age, and address the nutritional needs of adolescents, pregnant and lactating women and older persons

2.3 By 2030, double the agricultural productivity and incomes of small-scale food producers, particularly women, indigenous peoples, family farmers, pastoralists and fisherfolk, including through secure and equitable access to land, other productive resources and inputs, knowledge, financial services, markets and opportunities for value-added generation and non-agricultural employment

2.4 By 2030, ensure the sustainability of food production systems and implement resilient agricultural practices that increase productivity and production, contribute to the maintenance of ecosystems, strengthen resilience to climate change, extreme weather events, droughts, floods and other disasters, and progressively improve soil and land quality.

2.5 By 2020, maintain the genetic diversity of seeds, cultivated plants and farm and domesticated animals and their related wild species, including through the sound management and diversification of seed and plant banks at the national, regional and international levels, and promote access to the benefits arising from the utilization of genetic resources and traditional knowledge and their fair and equitable sharing, as agreed internationally. 2.a Increase investments, including through enhanced international cooperation, in rural infrastructure, agricultural research and extension services, technological development and gene banks of plants and livestock in order to improve agricultural production capacity in developing countries, in particular in the least developed countries. 2.b To correct and prevent trade restrictions and distortions in world agricultural markets, including through the parallel elimination of all forms of agricultural export subsidies and all export measures with equivalent effect, in accordance with the mandate of the Doha Development Round. 2.c. Take measures to ensure the proper functioning of markets for food commodities and their derivatives and facilitate timely access to market information, particularly on food stocks, in order to help limit extreme food price volatility.

Source: https://www.un.org/sustainabledevelopment/es/.

Figure 1. Including disease-related malnutrition and promoting nutritional care in the clinical setting would contribute to the sustainable development of countries. From: https://www.un.org/sustainabledevelopment/es/.

Figure 2. A: Pathways from inadequate food access to multiple forms of malnutrition (Except disease related malnutrition) According to the FAO, 2018(15); B: Pathways from disease to malnutrition. Figure according to the classifications and definitions of ESPEN(4).

Disease related malnutrition and SDG

Disease related malnutrition, a specific type of malnutrition caused by a concomitant disease, is highly prevalent in all countries of the world (3,4). In Latin America the prevalence of malnutrition at hospital admission is higher than in other regions of the world, according to a review of the literature is 40 % to 60 %(5), and increases with the length of hospital stay. Disease related malnutrition is associated with a reduced quality of life for patients and an increase in infectious and non-infectious comorbidities, the length of stay and the costs which impose a considerable economic and health burden on these countries(6,7).

The risk of malnutrition at the time of admission has been correlated with several factors including metabolic alterations, the impact of the disease on nutritional requirements, decreased food intake, organizational problems and lack of awareness and medical education. We believe that whatever the reason, the higher prevalence of disease-related malnutrition in Latin America could be influenced by the higher prevalence of hunger and malnutrition in the general population. This means that socio-economic conditions and public health conditions (access and health coverage) may influence the higher prevalence of hospital nutritional risk in the region.

The burden of malnutrition was investigated in Colombia in hospitalized patients with cardiovascular or pulmonary disease in a multicenter study by Ruiz et al (8). This study showed that the risk of malnutrition detected with the Malnutrition Screening Tool (MST) was associated with a 1.6-day increase in the average length of hospital stay, with a relative increase of 30.13% in the average cost associated with hospitalization. It was also associated with an increased risk of mortality up to 30 days after discharge from hospital.

Numerous studies have shown that nutritional care can improve clinical outcomes and reduce health care costs in different areas of the disease, such as critically ill patients (9,10), pancreatitis (11), older adults (12), patients with dysphagia (13), and patients with chronic obstructive disease (14).

Despite this evidence, disease related malnutrition is not often detected and, therefore, is not treated in hospitals, alerts are not generated, and there is no concern among policy-makers. Few countries have legislation and public policies on this issue. In addition, none of the targets of Goal 2, nor of any of the other 16 SDGs, mentions malnutrition associated with disease (Table 1). This means that governments will focus on addressing undernutrition and food security without taking into account this specific type of disease-related malnutrition.

Goal 2 “Zero Hunger” and the Cartagena Declaration

In order to include the problem of disease related malnutrition in the national and international political agenda and to increase the probability of formulating policies to combat this problem, particularly in the hospital setting, it is necessary as a first step to give visibility to the problem and generate awareness of its importance. The Cartagena Declaration is an instrument where, for the first time, nutritional care is elevated to the category of a human right. Although this Declaration commits only societies to work in its defense, it is a first step towards giving visibility and attracting the attention of public policy makers. Raising nutritional care to the rank of human right will serve as a strategy so that when evaluating and seeking solutions to the problem of malnutrition of the population, disease-related malnutrition will also be considered. This is essential if we bear in mind that malnutrition (underweight, overweight and obesity) associated with socioeconomic factors (poor nutrition, hunger and poverty) and disease-related malnutrition have different origins and physiopathological mechanisms, and therefore, need a different approach (Figure 2).

In this way, by making the problem visible and fighting for nutritional care for all patients, we would be contributing to the sustainable development of countries.

Conclusion

When scientific societies and health professionals assume the defense of the right to nutritional care, they promote the visibility of this issue. The objective is to ensure that disease-related malnutrition is included in the global approach to the problem of population malnutrition. In this way, the science of clinical nutrition is contributing to the achievement of the goals of the United Nations Agenda 2030 and in particular to the sustainable development of the countries.

Funding sources

This article was not financed.

Conflict of interests

Authors declare that they have no conflict of interest.

References

1. Naciones Unidas. Objetivos de Desarrollo Sostenible. [Internet]. [consultado el 29 ocubre 2015]. Disponible en: https://www.un.org/sustainabledevelopment/es/.
2. Naciones Unidas. Objetivos de Desarrollo Sostenible. ODS 2: Hambre Cero. [Internet]. [consultado el 29 ocubre 2015]. Disponible en https://www.un.org/sustainabledevelopment/es/wpcontent/uploads/sites/3/2016/10/2_Spanish_Why_it_Matters.pdf.
3. Sobotka L. Editor. Basics in clinical nutrition. 4th ed. Galen , Prague, 2012.
4. Cederholm CT, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49-64. doi: 10.1016/j.clnu.2016.09.004.
5. Correia MITD, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clin Nutr. 2017;36:958-67.
6. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27:5-15.
7. Rodriguez-Manas, Abizanda P, Barcons N, Lizán L. Malnutrition in Institutionalized and Community-Dwelling Older Adults in Spain: Estimates of Its Costs To the National Health System. Value Health. 2014;17(7):A507.
8. Ruiz AJ, Buitrago G, Rodríguez N, Gómez G, Sulo S, Gómez C, Partridge J, Misas J, Dennis R, Alba MJ, Chaves-Santiago W, Araque C. Clinical and economic outcomes associated with malnutrition in hospitalized patients. Clin Nutr. 2019;38(3):1310-6 doi: 10.1016/j.clnu.2018.05.016
9. Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009;35(12):2018–27.
10. Visser J, Labadarios D, Blaauw R. Micronutrient supplementation for critically ill adults: a systematic review and meta-analysis. Nutrition. 2011;27(7–8):745–58.
11. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006;30(2):143–56.
12. Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE, Nelson JL, et al. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial. Clin Nutr. 2016;35(1):18-26.
13. Cook IJ. Treatment of oropharyngeal dysphagia. Curr Treat Options Gastroenterol. 2003;6(4):273–81.
14. Snider JT, Jena AB, Linthicum MT, Hegazi RA, Partridge JS, LaVallee C, et al. Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among medicare patients with COPD. Chest. 2015;147(6):1477-84.
15. Food and Agriculture Organization of the United Nations. The state of food security and nutrition in the world. [Internet]. Roma 2018. (Consultado el :5 september 2019). Disponible en: http://www.fao.org/3/I9553ES/i9553es.pdf.

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

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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

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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.

Introduction

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

1. Cardenas D, Bermudez CH, Echeverri S. Is nutritional care a human right? Clin Nutr Exp. 2019;26:1-7.
2. Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health. 2019; 3: e379–89.